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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 54, Num. 1, 2006, pp. 108-109

Neurology India, Vol. 54, No. 1, January-March, 2006, pp. 108-109

Letter To Editor

Enterococcus avium cerebellar abscess

Correspondence Address: Department of Microbiology, All India Institute of Medical Sciences, New Delhi - 29, India, E-mail:

Code Number: ni06035


A right-handed 5-year-old boy was admitted to the hospital with a 10-day history of severe headache (aggravated by coughing and sneezing), vomiting and high-grade fever. His past history was unremarkable except for left-sided otitis media of three years duration. On examination, the patient had a blood pressure of 100/70 mm Hg, a pulse rate of 84/minute and a temperature of 37.8°C. Otoscopic evaluation revealed exudation of fresh pus from the left ear.

Laboratory examination revealed a hemoglobin level of 144g/L, a total leucocyte count of 8.6 x 10 9/L (76% polymorphs, 22% lymphocytes, 2% eosinophils) and platelet count of 391 x 10 9/ L. Routine blood chemistry and coagulation tests were normal. The patient underwent a contrast enhanced computed tomography scan of the brain which showed a cerebellar abscess on the left side. Left paramedian suboccipital craniectomy was performed with excision of left cerebellar abscess. Pus aspirate was sent for bacterial culture. Thereafter, cavity was irrigated, wound drainage done and the patient placed on parenteral antibiotics (cefoperazone/sulbactam and metronidazole).

Culture of the pus aspirate revealed pure growth of Enterococcus avium identified by conventional biochemical tests.[1] The organism (gram positive cocci) was catalase negative, hydrolysed bile-esculin and grew in 6.5% sodium chloride. In carbohydrate utilization tests performed in purple broth[1] (brain heart infusion broth with bromocresol purple as indicator), the organism fermented arabinose, lactose, mannitol, sorbitol and sucrose but not raffinose. It did not hydrolyse arginine and did not reduce potassium tellurite. Identification of the isolate was confirmed as Enterococcus avium by the API 20 Strep system (Bio-Mérieux, Marcy l′Etoile, France).

In a standard Kirby-Bauer sensitivity test, the organism was susceptible to penicillin, erythromycin, gentamicin, ciprofloxacin, teicoplanin, vancomycin and linezolid. Antibiotic therapy consisting of cefoperazone/sulbactam (2 gm i.v. 8 hrly) and metronidazole (100ml i.v. 8 hrly) was continued for 2 weeks and the patient improved. He was discharged on the 14th postoperative day in a stable condition with a healthy wound and was advised to come for follow-up in the otorhinolaryngology clinic.

Brain abscesses are intracerebral infections arising from microbial introduction, leading to cerebritis followed by an encapsulated focal collection of pus. The usual routes of infection include contagious spread from sinus, dental, and otogenic infections.[2] Brain abscess due to an otogenic source is rare (1 in 10,000) in the post-antibiotic era, largely due to prompt therapy of otitis media.[2] Untreated or chronic otogenic infections, however, may lead to intracranial complications such as brain abscess.[3] Enterococcus avium (formerly known as group Q Streptococcus), the etiologic agent of brain abscess in our patient, is a rare pathogen in humans.[1] Other cases of Enterococcus avium induced abscesses in human beings include those of pancreas,[4] gall bladder[5] and spleen.[6] Prior to this case, we have recently reported another case of brain abscess due to E.avium.[7] The patient was an immunocompetent adult with a history of chronic otitis media and the abscess was located in the temporal lobe.[7] Apart from abscesses, other cases of E.avium -induced human infections include bacteremia, endocarditis, osteomyelitis, meningoencephalitis and infection of a breast prosthesis.[7]

Since strains of E.avium are usually susceptible to beta-lactams and aminoglycosides,[1],[5],[7] it cannot be excluded that at least some of the infections previously reported as caused by sensitive enterococci may in fact have been unrecognized infections by E.avium .

In summary, E.avium is an uncommon cause of brain abscess; however, its incidence may be rising, and it should be considered in the differential of causative organisms. This shall enable proper selection of antimicrobial agents, a key to the successful management of brain abscess.


1.Facklam RR, Teixeira LM. Enterococcus. In: Lollier L, Balows A, Sussman M, editors. Topley and Wilson's Microbiology and Microbial Infections, 9th ed. New York: Oxford University Press; 1998. pp. 669-82.  Back to cited text no. 1    
2.Crum NF. Group A Streptococcal brain abscess. Scan J Infect Dis 2004; 36: 238-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Kangsanarak J, Fooanant S, Ruckphaopunt K, Navacharoen N, Teotrakul S. Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol 1993; 107: 999-1004.   Back to cited text no. 3  [PUBMED]  
4.Suzuki A, Matsunaga T, Aoki S, Hirayama T, Nakagawa N, Shibata K et al. A pancreatic abscess 7 years after a pancreatojejunostomy for calcifying chronic pancreatitis. J Gastroenterol 2002; 37: 1062-7.  Back to cited text no. 4    
5.Verhaegen J, Pattyn P, Hinnekens P, Colaert J. Isolation of Enterococcus avium from bile and blood in a patient with acute cholecystitis. J Infect 1997; 35: 77-8.  Back to cited text no. 5  [PUBMED]  
6.Farnsworth TA. Enterococcus avium splenic abscess: a rare bird. Lancet Infect Dis 2002; 2: 765  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Mohanty S, Dhawan B, Kapil A, Das BK, Pandey P, Gupta A. Brain abscess due to Enterococcus avium . Am J Med Sci 2005; 329: 161-2  Back to cited text no. 7  [PUBMED]  [FULLTEXT]

Copyright 2006 - Neurology India

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