Year : 2007 | Volume
: 2 | Issue : 2 | Page : 94--95
Unusual cause of brain abscess in an infant
Vinu A Thomas1, T Sathish Kumar1, Indira Agarwal1, Ari G Chacko2,
1 Department of Child Health Unit II, Christian Medical College and Hospital, Vellore - 632 004, India
2 Department of Neurology Unit I, Christian Medical College and Hospital, Vellore - 632 004, India
Department of Child Health Unit II, Christian Medical College, Vellore - 632 004
|How to cite this article:|
Thomas VA, Sathish Kumar T, Agarwal I, Chacko AG. Unusual cause of brain abscess in an infant.J Pediatr Neurosci 2007;2:94-95
|How to cite this URL:|
Thomas VA, Sathish Kumar T, Agarwal I, Chacko AG. Unusual cause of brain abscess in an infant. J Pediatr Neurosci [serial online] 2007 [cited 2020 Oct 29 ];2:94-95
Available from: https://www.pediatricneurosciences.com/text.asp?2007/2/2/94/36776
Morganella morganii is a gram-negative rod classified within the Enterobacteriaceae family. These bacteriae are usually found in the environment and in the intestinal tracts of humans, mammals and reptiles as normal flora.  Morganella species are commonly isolated in clinical laboratories and have been clearly implicated in sporadic clinical infections. M. morganii has remained a rare cause of central nervous system (CNS) infections such as meningitis and brain abscess. We describe an infant with Morganella brain abscess who was aggressively treated by both surgical and medical modalities.
A 2-month-old male infant presented with enlarging head circumference since 45 days of age. He was the first child born to non-consanguineous parents by normal vaginal delivery. His mother did not have any antenatal risk factors such as urinary tract infection, chorioamnionitis or puerperal sepsis. The child had been somewhat irritable, but he had no prior history of fever, skin infection, ear discharge, diarrhea or urinary tract infection and was not administered with antibiotics.
His weight was 5 kg and length was 55 cm. His head circumference was 45 cm. His vital signs were stable. There was a prominent bulge over the right frontal region and a sun-setting sign was present. The anterior fontanel was 8 × 8 cm , and the posterior fontanel was wide open. Central nervous system did not reveal any cranial nerve palsy or focal neurological deficit. He had increased tone and brisk reflexes in both lower limbs. Cardiovascular and respiratory system were within the normal limits.
His blood investigations revealed a total count of 19500 cu. mm with neutrophilic predominance and reactive thrombocytosis. Suspecting the presence of hydrocephalus, computed tomography (CT) of the brain [Figure 1] was done. This demonstrated a right frontal lobe (8 × 6.5 cm) ring-enhancing lesion with multiple loculations , mass effect and extensive cerebral edema.
By the radiological diagnosis of a pyogenic abscess, around 30 ml of pus was aspirated through the edge of the anterior fontanel, and he was empirically started on intravenous cloxacillin, cefotaxime and metronidazole. CSF analysis revealed a total count of 29500/cu.mm with a differential of N70% and L30% with raised CSF protein (1.9 g%) and low sugar (49 mg%). Unexpectedly, the pus culture grew M. morganii , which was sensitive to cefotaxime, gentamicin, chloramphenicol and ceftazidime. Antibiotics were changed to cefotaxime and gentamicin. The blood culture was sterile. As it was an unusual organism, HIV ELISA and immuoglobulins were sent, both of which were normal.
Despite 2 weeks of antibiotics, repeat CT scan showed only minimal decrease in the size of the brain abscess. We decided to treat this child with multiple aspirations and appropriate antibiotics due to the young age and the fact that an organism was isolated that was sensitive to the antibiotics. He underwent multiple serial aspiration of abscess by neurosurgeons, and intravenous cefotaxime and gentamicin were continued for a total of 6 weeks.
The third CT scan [Figure 2] showed marked reduction in size of the brain abscess. As the child improved clinically, he was discharged on oral chloramphenicol. Unfortunately, he was not brought back for review, and hence the final outcome is not known.
Nosocomial epidemics with M. morganii have been reported previously in the setting of urinary tract infection, postoperative wound infection or bacteremia.  Sporadic case reports have linked this organism to rare complications such as chorioamnionitis,  septic arthritis  and liver and gallbladder abscess.  The risk factors for M. Morganii are the prior exposure to ampicillin and other beta lactamase antibiotics, diabetes mellitus, advanced age, surgical procedure and perinatal exposure.
In comparison to citrobacter, M. morganii is an extremely rare cause of meningitis and brain abscess.  It has only occasionally been described in the neonatal population and adults.  The usual presentation in the newborn is the early onset of neonatal sepsis.  The presentation as brain abscess in this age group is extremely rare.  This child who presented with an enlarging head circumference did not have any predisposing illness or risk factors and had no signs of sepsis.
The treatment of brain abscess requires a combination of antimicrobial therapy, surgical intervention and eradication of primary foci.  The twist drill aspiration of pus is an attractive surgical option that can be performed at the bedside for neonates, children with cyanotic heart disease or those in a moribund state with a high risk for general anaesthesia. Moreover, the aspirations may have to be repeated based on the subsequent radiological imaging conducted every 2 weeks. The advantages of aspiration are simplicity, reduced morbidity as a consequence of surgical trauma and its utility in the early stages of the disease.  On the other hand, abscesses loculated in the cerebellum or in noneloquent supratentorial areas are probably best excised during open surgery.
Appropriate antibiotic therapy is also instituted based on the sensitivities of the organism isolated. Morganella is usually sensitive to third generation cephalosporins and aminoglycosides. M. morganii typically has an inducible beta-lactamase and develops resistance to multiple antibiotics. Drug resistance should be considered in children who are not responding to the initial treatment. The outcome depends upon the early institution of appropriate antibiotics and surgical intervention.
We report this case to increase awareness among pediatricians that M. morganii, even though uncommon, is a cause of brain abscess and meningitis. As it may have a slow insidious onset with minimal signs and symptoms, a high index of suspicion is required. Prompt and appropriate antibiotic treatment along with aggressive surgical drainage is required to treat this infection.
|1||O'Hara CM, Brenner FW, Miller JM. Classification, identification and clinical significance of Proteus, Providencia and Morganella. Clin Microbiol Rev 2000;13:534-6.|
|2||Williams EW, Hawkey PM, Penner JL, Senior BW, Barton LJ. Serious nosocomial infection caused by Morganella morganii and Proteus mirabilis in a cardiac surgery unit. J Clin Microbiol 1983;18:5-9.|
|3||Johnson JR, Feingold M. Case of chorioamnionitis in an immunocompetent woman caused by Morganella morganii. J Matern Fetal Med 1998;7:13-4|
|4||Gautam V, Gupta V, Joshi RM, Sawhney G, Duhan S. Morganella morganii- associated arthritis in a diabetic patient. J Clin Microbiol 2003;41:3451.|
|5||Tseng LJ, Tsai CC, Mo LR, Lin RC, Kuo JY, Chang KK, et al . Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy. Hepatogastroenterology 2000;47:932-6.|
|6||Rau CS, Chang WN, Lin YC, Lu CH, Liliang PC, Su TM, et al . Brain abscess caused by aerobic Gram-negative bacilli: Clinical features and therapeutic outcomes. Clin Neurol Neurosurg 2002;105:60-5.|
|7||Sinha AK, Kempley ST, Price E, Sharma BK, Livermore DM. Early onset Morganella morganii sepsis in a newborn infant with emergence of cephalosporin resistance caused by depression of AMPC beta-lactamase production. Pediatr Infect Dis J 2006;25:376-7.|
|8||Dutta S, Narang A. Early onset neonatal sepsis due to morganella morganii. Indian Pediatr 2004;41:1155-7.|
|9||Verboon-Maciolek M, Vandertop WP, Peters AC, Roord JJ, Geelen SP. Neonatal brain abscess caused by Morganella morganii. Clin Infect Dis 1995;20:471.|
|10||Rau CS, Chang WN, Lin YC, Lu CH, Liliang PC, Su TM, et al . Brain abscess caused by aerobic Gram-negative bacilli: Clinical features and therapeutic outcomes. Clin Neurol Neurosurg 2002;105:60-5.|
|11||Chacko AG, Chandy MJ. Staged computed tomography guided stereotactic aspiration of multiple bihemispheric brain abscesses. Surg Neurol 1997;48:278-83.|