Rapid Development of Brain Abscess Caused by Streptococcus Pyogenes Following Penetrating Skull Injury via the Ethmoidal Sinus and Lamina Cribrosa

Abstract

Objective: Streptococcus pyogenes is a beta-hemolytic bacterium that belongs to Lancefield serogroup A, also known as group A streptococci (GAS). There have been five reported case in terms of PubMed-based search but no reported case of brain abscess caused by Streptococcus pyogenes as a result of penetrating skull injury. We present a patient who suffered from penetrating skull injury that resulted in a brain abscess caused by Streptococcus pyogenes.

Methods: The patient was a 12-year-old boy who fell down from his bicycle while cycling and ran into a tree. A wooden stick penetrated his skin below the right lower eyelid and advanced to the cranium. He lost consciousness on the fifth day of the incident and his body temperature was measured as 40. While being admitted to our hospital, a cranial computed tomography revealed a frontal cystic mass with a perilesional hypodense zone of edema. There was no capsule formation around the lesion after intravenous contrast injection. Paranasal CT showed a bone defect located between the ethmoidal sinus and lamina cribrosa.

Results: Bifrontal craniotomy was performed. The abscess located at the left frontal lobe was drained and the bone defect was repaired.

Conclusion: Any penetrating lesion showing a connection between the lamina cribrosa and ethmoidal sinus may result in brain abscess caused by Streptococcus pyogenes. These patients should be treated urgently to repair the defect and drain the abscess with appropriate antibiotic therapy started due to the fulminant course of the brain abscess caused by this microorganism.

Keywords: Brain abscess; Penetrating head injury; Skull base repairing; Streptococcus pyogenes; Surgical evacuation.

Fig. 1

Preoperative contrasted computed cranial tomography and noncontrasted cranial magnetic resonance image scan. A : Contrasted cranial computed tomography showing mild shift and hypodense lesion causing shift from the left to the right at left frontal lobe and no capsule formation. B : On the fourth day of the incident, preoperative noncontrast cranial magnetic resonance image showing hypointense abscess cavity in T1WI images and hyperintense abscess cavity in T2WI images.

Fig. 2

Preoperative and postoperative paranasal computed tomography and postoperative three-dimensional cranial computed tomography. A : Preoperative paranasal computed tomography showing the defective area of the bone located between ethmoidal sinus and lamina cribrosa. B : Postoperative paranasal computed tomography scan showing the repaired part of the bone defect and resolution of the edema and hemorrhage around the ethmoidal sinus. C : Postoperative three dimensional cranial computed tomography showing the repaired part of the bone defect.

Fig. 3

Intraoperative appearence of the bone defect located between ethmoidal sinus and lamina cribrosa.

Fig. 4

Changing of the body temperature overtime.

Fig. 5

Changing of the white blood cell count overtime.

Fig. 6

Changing of the C-reactive protein levels overtime.

Fig. 7

Contrasted computed cranial tomography scan on the third day of the operation, showing no shift and no contrast enhancement around the lesion, but there is edema formation around the hypodense abscess cavity.

Fig. 8

Contrasted computed cranial tomography scan on the 10th day of the operation showing contrast enhancement around the abscess cavity and edema formation in the frontal lobe and no shift.

Fig. 9

Contrasted computed cranial tomography scan on the 22 nd day of the operation showing contrast enhancement around the abscess cavity and edema formation in the frontal lobe and no shift.

Fig. 10

Contrasted computed cranial tomography scan on the 32 nd day of the operation showing contrast enhancement around the abscess cavity and edema formation in the frontal lobe and no shift. In addition, the edema formation decreased.

Fig. 11

On the 43rd day of the operation, contrasted computed cranial tomography scan showing no contrast enhancement and no abscess cavity, but very little edema formation at left frontal lobe.