Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 51, Num. 1, 2003, pp. 131-132

Neurology India, Vol. 51, No. 1, Jan-Mar, 2003, pp. 131-132

Letter to Editor

Brain abscess due to Streptococcus sanguis

B. Dhawan, V. Lyngdoh, V. S. Mehta, R. Chaudhry

Dept. of Microbiology, AIIMS, New Delhi-110029, India.

Accepted on 19.09.2001.

Code Number: ni03048

Sir,

A right-handed 30-year-old male suffered an injury in a road traffic accident. On admission, his neurological condition was graded on Glasgow coma scale as E₁ M₅ V₂.There was a 10 cm-long lacerated wound in the right frontonasal region. Investigations showed a fracture of the right frontal bone, orbital rim, nasal and ethmoid bones. Exploration revealed a a large defect in the basal dura. The right frontal lobe contusion was excised and repair of the basal dural tear was done with temporalis fascia and fibrin glue. The patient was then placed on broad spectrum antibiotics. Following surgery the patient developed CSF rhinorrhoea and had to undergo therapeutic lumbar drainage of CSF. The patient was discharged on the 18^th day in a stable condition (Glasgow coma scale=E₄ V₄ M₆).

The patient was readmitted two weeks later for high-grade fever, vomiting, severe headache, urinary incontinence and altered sensoruim for 3 days. A contrast enhanced CT scan showed a left frontal brain abscess. Pus aspirate demonstrated growth of S. sanguis which was sensitive to ceftriaxone .This organism produced alpha hamolytic colonies on 5% sheep blood agar. The organism was non-motile, catalase negative and insoluble in bile. It was positive for arginine decarboxylase and hydrolyzed aesculin. It fermented trehlose, raffinose, salicin and inositol but failed to ferment mannitol and sorbitol and was negative for pyrrolidonyl peptidase. Identification of the isolate as S. sanguis was further confirmed by the API 20 STREP system (biomerieux, Vitek, Inc, Hazlewood, USA). The patient continued to improve on antibiotic therapy.

Streptococcus sanguis is a member of the `viridans group' of streptococci, which has been increasingly recognized as a pathogen of endocarditis and prosthetic joint infections.^1,2 S. sanguis does not have a propensity to create parenchymatous abscesses and has not been recognized as a specific pathogen of brain abscess. We report a case of brain abscess caused by S. sanguis following a neurosurgical procedure for management of head trauma.

S. sanguis constitutes part of the normal flora of the human oral cavity. Although it has been increasingly recognized as an important pathogen of endocarditis, S. sanguis is a rare cause of brain abscess. In a retrospective study on the microbial spectrum of brain abscess conducted at our institute, we did not encounter S. sanguis in any sample.⁴ We reviewed the medical literature from 1966 for S. sanguis and intracranial infections. The search revealed 3 other cases; 2 cases of brain abscess^5,6 and one case of cerebral botromycosis.⁷ The events that triggered the abscess formation were prosthetic valve endocarditis and multiple pulmonary fistulas in the first two cases. In the third case of cerebral botryomycosis, actinomycosis was suspected initially from clinical findings, response to penicillin therapy, and demonstration of "sulfur granules" in the surgical specimen, but anaerobic cultures were negative for Actinomyces. Aerobic cultures yielded S. sanguis and Pseudomonas cepacia. An association with intermittently treated jaw disease, was also established. In summary, it is important to recognize S. sanguis, a previously unrecognized species of Streptococcus in the etiology of brain abscess and to be aware of its predisposing factors. This shall enable proper selection of antimicrobial agents, a key to the successful management of brain abscess.

B. Dhawan, V. Lyngdoh, V. S. Mehta, R. Chaudhry

Dept. of Microbiology, AIIMS, New Delhi-110029, India.

References

1. Bartzokas CA, Johnson R, Jane M, Martin MV, Pearce PK, Saw Y. Relation between mouth and haematogenous infection in total joint replacements. BMJ 1994;309:506-8.
2. Parker MT, Ball LC. Streptococci and Aerococci associated with systemic infection in man. J Med Microbiol 1976;9:275-302.
3. Ross PW. In: Collee JG, Fraser AG, Marmion BP, Simmons AM, eds. Streptococcus and Enterococcus. Mackie and McCartney, Practical Medical Microbiology, 14^th Edn. Edinburgh: Churchill Livingstone; 1996. pp. 131-49.
4. Chaudhry R, Dhawan B, Laxmi BVJ, Mehta VS. The microbial spectrum of brain abscess with special reference to anaerobic bacteria. Br J Neurosurg 1998;12:127-30.
5. Nakamura A, Yamada Y, Hattori T, Kojima Y, Yamamoto T, Matsuura T, et al. A case of brain abscess due to Streptococcus sanguis in association with multiple pulmonary arteriovenous fistulas. Kansenshogaku Zasshi 1993;67: 680-5.
6. Young SG. Davee T, Fierer J, Morey MK. Steptococcus sanguis II (viridans) prosthetic valve endocarditis with myocar splenic and cerebral abscesses. West J Med 1987;146:479-81.
7. Gillock CB, Sahni KS, Mumaw VR, Meier FA. Cerebral botryomycosis: case study. J Infect Dis 1990;162:765-7.

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