Bacterial Brain Abscess and Life-Threatening Intracranial Hypertension Requiring Emergent Decompressive Craniectomy After SARS-CoV-2 Infection in a Healthy Adolescent

Abstract

Acute coronavirus 2 (SARS-CoV-2) infection usually results in mild symptoms, but secondary infections after SARS-CoV-2 infection can occur, particularly with comorbid conditions. We present the clinical course of a healthy adolescent with a brain abscess and life-threatening intracranial hypertension requiring emergent decompressive craniectomy after a SARS-CoV-2 infection. A 13-year-old healthy immunized male presented with invasive frontal, ethmoid, and maxillary sinusitis and symptoms of lethargy, nausea, headache, and photophobia due to a frontal brain abscess diagnosed three weeks after symptoms and 11 days of oral amoxicillin treatment. Coronavirus disease 2019 (COVID-19) reverse transcription-polymerase chain reaction (RT-PCR) was negative twice but then positive on amoxicillin day 11 (symptom day 21), when magnetic resonance imaging revealed a 2.5-cm right frontal brain abscess with a 10-mm midline shift. The patient underwent emergent craniotomy for right frontal epidural abscess washout and functional endoscopic sinus surgery with ethmoidectomy. On a postoperative day one, his neurological condition showed new right-sided pupillary dilation and decreased responsiveness. His vital signs showed bradycardia and systolic hypertension. He underwent an emergent decompressive craniectomy for signs of brain herniation. Bacterial PCR was positive for Streptococcus intermedius, for which he received intravenous vancomycin and metronidazole. He was discharged home on hospital day 14 without neurological sequelae and future bone flap replacement. Our case highlights the importance of timely recognition and treatment of brain abscess and brain herniation in patients with neurological symptoms after SARS-CoV-2 infection, even in otherwise healthy patients.

Keywords: bacterial; brain abscess; child and adolescent; elevated intracranial pressure; infection; intracranial hypertension; sars-cov-2; sinusitis.

Figure 1. Clinical course.

CT: computerized tomography; HR: heart rate; BP: blood pressure; BT: body temperature; GCS: Glasgow Coma Scale Score; bpm: beats per minute; RT-PCR: reverse transcription-polymerase chain reaction; HMC: Harborview Medical Center.

Figure 2. Admission (symptom day 21) computed tomography of the maxillofacial sinuses without contrast. (A) Complete opacification of both frontal and maxillary sinuses. (B) Opacification of ethmoid sinuses.

Figure 3. Admission (symptom day 21) magnetic resonance imaging of the brain with contrast. (A) 2.5 cm rim-enhancing fluid collection in the right frontal lobe. (B) 10 mm of anterior midline shift.

Figure 4. Postoperative day one computed tomography of the brain without contrast showed a mild increase in right anterior frontal lobe vasogenic edema and subfalcine herniation with a right to left midline shift before decompressive craniectomy (symptom day 23).

Figure 5. Change in Glasgow Coma Scale score and pupillary findings.

GCS: Glasgow Coma Scale; BP: blood pressure; HR: heart rate; RR: respiratory rate; mm: millimeters; bpm: beats per minute.

Figure 6. Repeat MRI of the brain at five weeks post-discharge with the craniectomy flap (arrow).

MRI: magnetic resonance imaging.