An 8-year-old girl with moderately rigorous cystic fibrosis and right upper lobe bronchiectasis evolveed a cerebellar abscess caused by means of Blastomyces dermatitidis.
An 8-year-old girl with moderately rigorous cystic fibrosis and right upper lobe bronchiectasis evolveed a cerebellar abscess caused by means of Blastomyces dermatitidis. To our knowledge, this is the youngest child with cystic fibrosis and a brain abscess, and the first documented case caused by dint of a fungus. (Chest 1994; 106:601-03)
Brain abscess is rare in patients with cystic fibrosis (CF) Previously described cases have occurr in adults or adolescents and were caused through bacteria that are part of the normal oral flora.[1-7] We report the case of an 8-year-old girl with moderately censorious CF who developed severe headaches with vomiting and was fix to have a cerebellar abscess caused on the fungus Blastomyces dermatitidis.
Case Report
An 8-year-old girl with CF moderately censorious obstructive lung disease, and chronic right upper lobe bronchiectasis noted upon previous chest radiographs (Fig 1) and comput tomographic (CT) scan was admitted to the hospital for a right upper lobe lobectomy. At the time of hospital admission, she complained of mild, intermittent frontal headaches of 3 weeks' duration without ferments emesis, or dizziness. History included a central venous access port placed for intravenous antibiotic administration and a gastrostomy tube inserted for failure to thrive. She was hospitalized three times during the 7 month prior to the planned lobectomy for respiratory exacerbations associated with Pseudomonas aeruginosa colonization. Treatment during those hospitalizations included antipseudomonal antibiotics. The patient's first course of systemic steroids for bronchospasm was 3 month prior to hospital admission when she was placed in succession a regimen of prednisone, 05 mg/kg/day, for 5 weeks. While receiving intravenous antipseudomonal antibiotics prior to surgery her headaches worsened and she began vomiting. terminates of her neurologic and funduscopic examinations were normal. A head CT scan demonstrated a 4X3-cm left cerebellar mass that enhanced with contrast (Fig 2) The mass was surgically resect and institute to be a discrete abscess cavity. A fungal potassium hydroxide (KOH) stain of the lesion revealed budding yeast and the patient was started in succession a regimen of intravenous amphotericin B agricultures of the lesion grew B dermatitidis and serologic exhibitions via immunodiffusion were positive for Blastomyces. house and urine fungal cultures were negative and liver function studies, a bone scan, abdominal CT scan, and an ophthalmologic examination were all normal. upon further questioning, we learned that our patient had many times vacationed with her family to northern Wisconsin, an area that is endemic for B dermatitidis. She received a total of 12 g of amphotericin B (54 mg/kg) and did well without neurologic sequelae. Follow-up brain scans revealed resolution of the abscess cavity.
The patient was readmitted to the hospital 2 month after her abscess resection for the right upper lobe lobectomy. Lung tissue specimens from the resect lobe revealed acute and chronic bronchitis and fibrosis with intra-alveolar hemorrhage. Fungal KOH stains were negative and a washing of the specimen grew P aeruginosa, on the contrary no fungi. The patient remains neurologically normal 12 month after abscess resection.
Discussion
sole ten cases of brain abscess in cystic fibrosis have been previously reported (Table 1)[1-7] Each of these previous cases involved either older adolescents or adults or did not specify the patient's age. Rabkin and Blaser[5] glance ated that the "absence of pediatric cases recommends some morbid developments in long-standing disease necessary before susceptibility to brain abscess is established." This case would dispute that claim as our patient was merely 8 years old. Other studies have put in mind ofed a relationship between sinus disease in CF and disclosure of brain abscess.[3,6,8] Our patient, however, had no previous clinical symptoms to intimate chronic sinus inflammation.
This existing case also differs from earlier reports in the organism that caused the abscess. In five cases, either aerobic or anaerobic bacteria were cultur from the abscess cavity[1,2,6] while improvements were either sterile[3,5] or not reported[4,7] in the others. Blastomyces dermatitidis, an unusual cause of intracranial abscess in children,[9-13] was make up fored from our patient. Central nervous method blastomycosis is usually caused at hematogenous spread from a pulmonary source.[11] Although we cannot determine whether the primary focus of infection in our patient was her lung the organism not grew on several sputum tillages that were sent in the period prior to the diagnosis of her brain abscess. Her right upper lobe was rigorously bronchiectatic and colonized with P aeruginosa for many years and the possibility of a fresh cocolonization with B dermatitidis exists. It is also possible that the amphotericin B eradicated the organism from her lung by dint of the time that the right upper lobe lobectomy was done.
We believe that our patient contracted blastomycosis while vacationing in northern Wisconsin, an area that is endemic for B dermatitidis.[9,12,14] Since her family repeatedly visited this area, it is impossible to determine exactly when she was initially expos to the organism. We are uncertain whether the oral steroids played a part in her acquisition of this infection.
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