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6CLINICAL CASE FROM PRACTICE Ziyakhodzhaeva L.U., Khamidova N.A.
Tashkent Pediatric Medical Institute, Department: Neurology, Child Neurology and medical
genetics, Tashkent, Uzbekistan https://doi.org/10.5281/zenodo.8367870
Abstract. Brain abscesses in pediatric practice are of particular importance due to the high incidence of otitis in children, diseases of the paranasal sinuses and the lesser ability of the child's body to localize the inflammatory process due to the imperfection of the immune system. An abscess is characterized by a triad of signs: headache, fever, focal neurological symptoms (hemiparesis, aphasia, hemianopsia), but in full it occurs in less than half of the patients.
Key words: Abscess, hemiparesis, aphasia, epileptic seizures, depression of consciousness, congestive optic discs.
Аннотация. Абсцессы головного мозга в педиатрической практике имеют особое значение в связи с высокой частотой отитов у детей, заболеваниями околоносовых пазух и меньшей способностью детского организма локализовать воспалительный процесс из-за несовершенства иммунной системы. Для абсцесса характерна триада признаков: головная боль, лихорадка, очаговая неврологическая симптоматика (гемипарез, афазия, гемианопсия), но в полном объеме он встречается менее чем у половины больных.
Ключевые слова: абсцесс, гемипарез, афазия, эпилептические припадки, угнетение сознания, застойные диски зрительных нервов.
Аннотация. Педиатрик амалиётда болалардаги отит, буруннинг ёндош аъзолари касалликлари ва болалар иммун тизимининг тулиц такомиллашмаганлиги туфайли яллигланиш жараёнининг мауаллийлашиш хусусиятининг пастлиги натижасида мия абсцессининг юцори учраш частотаси билан ауамиятли. Бош мия абсцессига триада симптоми хос: бош огриги, уароратнинг ошиши, учогли неврологик белгилар (гемипарез, афазия, гемианопсия), аммо бу тулиц куринишда нисбатан кам беморларда учрайди.
Калит сузлар: Абсцесс, гемипарез, афазия, эпилептик талваса, эс уушнинг бузилши, курув нерви дискининг димланиши.
Brain abscess is an encapsulated accumulation of pus in the body of the brain that occurs by contact (with otitis, sinusitis, mastoiditis, osteomyelitis), as a result of hematogenous spread from a distant source or direct infection (with TBI or neurosurgical interventions). Brain abscesses in pediatric practice are of particular importance due to the high incidence of otitis in children, diseases of the paranasal sinuses and the small ability of the child to localize the inflammatory process due to the imperfection of the immune system. An abscess often occurs in children and young adults (mean age 30-40 years). A common cause of abscesses is penetrating head injuries, depressed skull fractures, and neurosurgical operations. In about 20% of cases, the source of infection remains unknown. Diabetes mellitus, malignant neoplasms, leukemias, lymphomas, sarcoidosis, AIDS, chronic liver and kidney diseases predispose to abscess.
Etiology and pathomorphology. Most often, a brain abscess occurs as a result of direct contact spread of infection. Purulent inflammation of the paranasal sinuses leads to the formation of abscesses in the frontal lobe, inflammation of the middle ear, mastoiditis - to the formation of abscesses in the temporal lobe and cerebellum. The spread of infection occurs due to local osteomyelitis or phlebitis of emissary veins. The most common single.
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An abscess is characterized by a triad of signs: headache, fever, focal neurological symptoms (hemiparesis, aphasia, hemianopsia), but in full it occurs in less than half of the patients. With the formation of the capsule (by the end of 1-2 weeks), general infectious manifestations usually decrease. Frequent meningeal symptoms, epileptic seizures, depression of consciousness, congestive optic disc. A lethal outcome is possible due to the wedging or breakthrough of pus into the ventricles. If a brain abscess or subdural empyema is suspected, MRI, CT, or radioisotope scintigraphy are indicated. At an early stage of abscess formation, CT reveals a homogeneous zone of low density (cerebritis), and along its periphery there is a zone of low density corresponding to perifocal edema. With the introduction of contrast, it accumulates along the periphery of the focus. In some cases, hemorrhages or hydrocephalus are detected. ECHO-ES can detect midline displacement, but its data is not reliable.
The bacterial pathogens that cause brain abscesses differ depending on the location of the primary infection, age, and underlying disease. In the neonatal age, if an MRI cannot be obtained, bedside ultrasound of the skull is an alternative. The patient's history and physical examination can help identify predisposing factors for infection.
We present a clinical case. Patient S.Yu. was observed in the department of pediatric neurology at the TashPMI clinic. 11 years old with main complaints of fever, seizures, headache and nausea. According to the anamnesis, according to the mother, the child has been sick for a week, seizures were noted at home against the background of high temperature. Upon admission, the patient showed depression of consciousness to moderate stupor. On physical examination, seizures were observed. Meningoencephalitis was initially suspected, MSCT of the brain was performed: Signs of pansinusitis. The MSCT picture is more consistent with left-sided subdural empyema.
The operation was performed: Left-sided maxillary ethmoid frontotomy and right-sided frontotomy. Objectively: the general condition of the patient is severe. Neurostatus: Consciousness at the level of moderate stun. Answers questions in one word. Moderately severe cerebral symptoms. From the side of FMN: The sense of smell is not broken. Follows the movement of objects. The palpebral fissures on the left are reduced due to swelling of the upper eyelid. The pupils are equal in size, of medium width, the photoreaction is lively. Corneal, conjunctival reflexes are evoked. The face is symmetrical. Hearing is not broken. Swallowing saved. Muscle hypotension is noted in the extremities, on the right hemiparesis with muscle strength of 3-4 points. Motor aphasia is noted. Meningeal symptom stiff neck.
Locally: there is a postoperative wound in the frontal region, which is primarily healing.
The patient, after surgical intervention by ENT doctors, was re-examined in the department, a clinical diagnosis was made: Subdural empyema of the left fronto-parietal-temporal region of the brain. Pansinusitis. SPO. Left-sided sinusitis and right-sided frontatomy. Donkey Meningoencephalitis?
Given the severity of the neurological status, we recommended MRI of the brain. Conclusion MRI of the brain: Empyema of the right hemisphere of the brain with a mixture of median structures.
According to urgent indications, the patient was again scheduled for surgery by neurosurgeons.
Indication for surgery:
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1. Clinical and neurological symptoms - depression of consciousness to the point of stunning.
2. Brain MRI data.
3. Large volume of empyema.
4. Pronounced stagnation of the optic disc.
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An MRI study of the brain was performed on 11/14/2021.
Produced decompensated trepanation of the fronto-parietal-temporal region on the left with the removal of a multi-chamber abscess of the brain.
Diagnosis after surgery: multi-chamber subdural abscess of the left fronto-parietal-temporal region of the brain. Pansinusitis. SPO. Left-sided maxillary ethmoid frontatomy and right-sided frontatomy. Complicated meningoencephalitis.
Objectively: the general condition of the patient is moderately severe. Neurostatus: Clear consciousness. Answers questions in one word. Mental condition. There is contact with others, orientation in time, place is not broken. Meningeal symptoms: moderate stiff neck. Higher cortical functions: motor aphasia. No pathology was detected from the side of CCN. Motor functions: on the right, hemiparesis with a force of 3-4 is preserved, muscle hypotension D>S is noted in the limbs, tendon reflexes BR, TR, PR, AR are brisk D>S, pathological Babinski reflexes are positive with D. Sensitivity is not impaired.
Conclusion:
1. During the operation, a subdural abscess of the fronto-parietal-temporal region of the brain was found. When the capsule was released, pus of a thick consistency, green in color, odorless, was also aspirated in the amount of 140 ml.
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2. The patient was examined during repeated outpatient treatment after discharge one month later. In the neurological status: there is no pathology on the part of craniocerebral insufficiency. The movements in the right limbs were restored, muscle strength was 4 points, the upper and lower Bare's symptom were positive. VKF: motor speech recovered. The patient receives neurological therapy and is under outpatient observation.
3. Brain abscesses in children are serious and life-threatening conditions that require timely and appropriate treatment. Although this is a rare condition, intracranial complications of frontal sinusitis, frontal sinusitis, sinusitis, and ethmoiditis should be considered clinically.
Early surgical intervention is critical given the risk of neurological complications.
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