Aap Grand Rounds 2004 Neurology 15_2

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2004;12;15 AAP Grand RoundsPrevalence, Symptoms, and Prognosis of Intracerebral Abscess

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Print ISSN: 1099-6605.Village, Illinois, 60007. Copyright 2004 by the American Academy of Pediatrics. All rights reserved.

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6. American Aca emy o Pe iatrics Committee on Drugs anCommittee on Bioethics. Pediatrics . 1997;99:122-129.

NEUROLOGY

Prevalence, Symptoms,and Prognosis ofIntracerebral AbscessSource: Goodkin HP, Harper MB, Pomeroy SL. Intracerebralabscess in children: historical trends at Childrens HospitalBoston. Ped atr cs. 2004;113:1765-1770.

O f the 386 patients identied by databases as havingbeen treated for intracerebral abscess at ChildrensHospital, Boston, Mass, between 1981 and 2000, 55had the diagnosis conrmed by cranial imaging or autopsyreports. A retrospective review o t e recor s o t ese 55patients was performed. The age of patients ranged from 5

ays to 34 years; 7 were younger t an 8 wee s at presentationand 5 were younger than 1 month. Nine children were clas-si e as immunosuppresse , 6 a organ transp antations,2 were treated for acute lymphoblastic leukemia, and 1 hadhyperimmunoglobulin M syndrome. Abscesses were singlein 37 and multiple noncontiguous in 18. Cultures obtainedby aspiration, resection, or biopsy on 42 occasions identi-ed pathogens in 36 (86%), with 2 or more organisms in 14.Streptococcus milleri was the most frequent isolate. Of the 9patients with fungal infections, 7 were immunosuppressed,and all died. Presenting symptoms included headache in 27(50%), vomiting in 12 (22%), photophobia in 5 (9%), fever in 16(29%), seizures in 15 (27%), changes in mental status (lethargyto coma) in 17 (31%), paresthesias in 4 (7%), hemiparesis in4 (6%), and increasing head circumference in 3 (6%). All but

1 patient received antimicrobial therapy, either alone or incombination with surgery. Surgical treatment (aspiration in39 and resection in 3) was performed in 42 (76%) cases, with20 patients requiring 2 or more procedures. Thirteen (24%)patients ie , wit t e most common cause o eat eingmultisystem failure. Of the 24 patients followed after discharge(16 ost to o ow-up), 7 recovere , 10 a eve opmenta e ayor learning disorders, 6 had epilepsy, and 3 developed hydro-cep a us requiring a ventricu operitonea s unt.

The 55 patients in this 1981-2000 series were compared toa similar study of the natural history of intracerebral abscessin 94 patients treated between 1945 and 1980. 1 Congenitalheart disease was the most common predisposing factorduring both time periods, with the rate of cerebral abscesssimilar in both time periods (2.75 per year for 1981-2000versus 2.68 per year for 1945-1980). When compared to theearlier era, the more recent case series revealed a decreasein the frequency of abscesses associated with sinus or otiticinfection (11% in 1981-2000 versus 26% in 1945-1980), anincrease in infants affected (18% versus 7%), an increasednumber associated with acute immunosuppressive diseases(16% versus 1%), an increase in cases treated with antibioticsalone (22% versus 1%), no signicant change in mortality(24% versus 27%), previously unrecognized Citrobacter caus-ative organism (only in 3 neonatal cases), and fungus infec-tion (pre ominant y in immunosuppresse patients) notencountered in the 1945-1980 era. Despite improvements in

iagnosis ue to neuroimaging, rain a scess continues toresult in high rates of neurologic impairment and death.

ommentary by J. Gordon Millichap, MD, FAAPNeurology, Childrens Memorial Hospital, Northwestern University Medical

chool, Chicago, IL

A brain abscess consists of localized pus within the brainsu stance. Organisms enter t e rain via t e oo streamfrom a distant infection, such as a contiguous spread fromt e mi e ear or paranasa sinuses, rom a penetrating wound, or in association with cyanotic congeni tal heart

isease wit rig t-to- e t s unt. A scesses resu ting romhematogenous spread may be localized in any part of thebrain, most commonly at the junction of gray and whitematter, whereas those arising from contiguous sources areusually supercial and close to the infected bone or dura.During the initial cerebritis (septic encephalitis) stage, theclinical picture is nonspecic. A patient with heart diseasedevelops headache, vomiting, seizures, and fever. As theabscess forms, the neurologic signs become more apparentand lateralizing, with hemiparesis, hemianopia, papill-edema, and localized percussion tenderness of the skull.The electrocardiogram shows focal slowing and computedtomography conrms the diagnosis.

In the differential diagnosis, thromboses of arteries, veins,and dural sinuses are common in cyanotic infants and symp-toms may mimic an a scess except t at t e onset is moreabrupt. Thromboses are rare in infants older than 2 years of

age. Hypoxic attac s occur in 12 to 15% o patients wit cya-notic heart disease and are common during the rst 2 yearso i e. Meningitis may a so mimic an a scess e ore symp-toms and signs become lateralized. 3 The diagnosis of braina scess s ou e consi ere wit new-onset ea ac e anseizure, especially in a child with congenital heart disease orrecent sinus or ear infection, or in an acutely immunosup-pressed patient with fungal disease.

Re erences1. Fischer EG, et al. Am J Dis Child . 1981;135:746-749.2. Raimondi AJ, et al. J Neurosurg. 1965;23:588 (cited by Menkes,

1980).3. Men es JH. Text oo o C Neuro ogy . 2n e . P i a e p ia,

Pa: Lea & Febiger; 1980:345.

ALLERGY AND IMMUNOLOGY

Risk of EnvironmentalExposure to Peanut Allergen in Schools Appears to be Low

Source: Perry TT, Conover-Walker MK, Poms A, et al. Distri-bution of peanut allergen in the environment. J Allergy ClinImmunol. 2004;113:973-976.

Because ingestion of even minute amounts of peanut bya sensitize c i can cause anap y axis, parents eartheir children will be inadvertently exposed to peanutsin schools, restaurants, and other public settings. Researchersat Johns Hopkins University, Baltimore, Md, measured theamount of major peanut allergen, Arachus hypogea allergen1 (Ara h 1), present on cafeteria tables and other surfaces inschools, tested for airborne peanut allergen under a varietyof simulated conditions, and examined the effectiveness of

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2004;12;15 AAP Grand RoundsPrevalence, Symptoms, and Prognosis of Intracerebral Abscess

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4/638 AAP Grand Rounds

economic status of these 2 neighborhoods were comparable.Surveys were conducted by trained interviewers at 6 high-trafc locations in each neighborhood at various times in or-der to maximize the likelihood of obtaining a representativesample of the target population of 15- to 30-year-olds. Thenal sample consisted of 285 individuals, of whom 51% werefemale, 81% were African-American, and 13% were Hispanic.The average age of respondents was 20.3 years.

T e ma ority o respon ents (65%) a computer accesseither at home, at school, or at a community organization. Younger members of the group (15 to 18 years of age) had

more access (up to 91%), because of computer availability atsc oo s, t an o er mem ers o t e samp e (19 to 30 years oage). Two-thirds of all respondents used the Internet at leasta few times a week. Across all age groups, 55% reported usingthe Internet to obtain health information.

T e secon report, rom t e Center on A iction anSubstance Abuse (CASA), is derived from an ongoing studyof how prescription drugs are diverted from legal distribu-tion channels into illegal ones. During the week of January15, 2004, researchers found 495 websites selling controlleddrugs (Schedules II-V). Analysis of these sites revealed thefollowing:

68% (338) were portal sitesconduits to other websites where drugs were offered and sold.

32% (157) were anchor siteswebsites where you couldactually purchase drugs.

Benzodiazepines were the most frequently offered drugs,followed by opioids.

Of the anchor sites, 90% did not require a prescription. None of the sites had mechanisms to deter children from

purc asing rugs.

ommentary by Stanley I. Fisch, MD, FAAPPrivate Practice, Harlingen, TX

Is t ere a pro em? T e Wa Street Journa reports t at in April, 2004, 64% of all e-mail was spam. 1 Combine this fact with these reports of pervasive access to the Internet andseemingly ready, direct access to prescription drugs, and youhave to change your mental image of a drug pusher.

Earlier reports about the digital divide highlighted dis-parities in access to such information because of class differ-ences in Internet access. 2,3 The rst report suggests the divideno longer exists, that Internet access is now pervasive, andemphasizes the positive aspects of Internet access: youngpeople use the Internet to obtain health information. TheCASA report points us to t e ar si e o t ese eve op-ments and is cause for great concern.

Figure: Representation of an Internet ad received as spam4/25/04*

*Content and format modied to mask the identity of the advertiser.

Fe era an state regu ations ave not ept up wit e-velopments in cyberspace. Issues of privacy and free speechconfound legislators attempts to impose controls on this

new realm of information and communication. In the end,as with most things important to families and children, it willbe up to parents to set controls and supervise their childrensuse of the Internet, albeit a challenging task, particularlyfor older adolescents. We pediatricians can help by alertingparents to the potential dangers.

References1. Tam P. Fruitcake debutantes dened by O, and other spam

ric s. T e Wa Street Journa . May 28, 2004:B1.2. Brodie M, et al. Health Aff. 2000;19:255-265.3. Becker HJ. Future of Children. 2000;10:44-75.

CME QuestionsThe following continuing medical education ques-

tions cover the content of the September 2004 issue of AAP Grand Rounds . Please keep this issue. Each yearsmaterial is worth up to 18 Category 1 credits toward the AMA Physicians Recognition Award.

1. Accor ing to t e stu y y James et a on a sc oo - aseintervention to re uce c i oo o esity:

a. sc oo - ase intervention stu ies ave s ownuni orm e ects on re ucing o esity.

. sc oo - ase interventions are genera y ine ective inpu is e o esity prevention tria s.

c. t eir intervention a no impact on eit er car onaterin inta e or o esity.

. t eir intervention resu te in ot ower car onaterin inta e an re uce percentage o overweig t

an o ese c i ren. e. t eir intervention resu te in ess car onate rin in-

ta e ut no c ange in t e percentage o overweig t ano ese c i ren.

CME Objectives: AAP Grand Rounds presents important new studiesfrom the medical literature, selected by a panel of expert clinicians andeditors. Selection criteria include clinical signicance, methodologicalquality, and the importance of the research question. The CME activity isdesigned to introduce new knowledge, reinforce the critical assessmentof the evidence, and provide insights into the clinical application of newresearch. The activity is also designed to help clinicians hone their criticalassessment skills, increase awareness of the current research environ-ment, and stimulate further learning and investigation. Participants in thismonths activity should be able to, upon completion: Assess the impact of sugar-sweetened drinks on childhood obesity; Consider the benets of zinc supplementation in the treatment of severe

pneumonia; and Discuss whether pulse oximetry is a reliable indicator for continued hos-

pitalization of bronchiolitis patients.

Erratumn the August 2004 issue of AP Grand Rounds , page 15 in

he commentary by J. Gordon Millichap on intracerebral ac-cess, the second sentence of the rst paragraph should readOrganisms enter the brain via the blood stream from a distantinfection, by continuous spread from the middle ear or parana-al sinuses, from a penetrating wound, or in association with

cyanotic congenital heart disease with right-to-left shunt.The last line of the same paragraph should read The elec-

roencephalogram shows focal slowing and computed tomog-raphy conrms the diagnosis.

e regret the errors

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2. Broo s et a s stu y o young c i ren wit pneumonia inBang a es s owe an association etween w ic o t eo owing?

a. Decrease oo zinc eve s an increase ris o severepneumonia

. Decrease pu monary zinc eve s an increase ris osevere pneumonia

c. Supp ementa ora zinc an a ecrease ris o recurrentpneumonia

. Supp ementa ora zinc an more rapi recovery romsevere pneumonia

3. Accor ing to t e artic e y Sc roe er et a , w ic o t eo owing statements regar ing pu se oximetry is true? a. Hospita isc arge s ou e ase so e y on oxygen

saturation. . Over-re iance on pu se oximetry may pro ong

ospita stays. c. Pu se oximetry i not a ect ospita isc arge rates.

. Pu se oximetry is t e most re ia e measurement ooxygen saturation.

4. The study by Shultz et al shows that early intervention with video-assisted thoracic surgery (VATS) as adjunctivetreatment of pleural empyema can:

a. decrease the length of hospitalization and durationof fever.

b. increase the morbidity of pleural empyema. c. increase the risk of infection with methicillin-resistant

Staphylococcus aureus . d. obviate the need for antibiotics.

5. An 11-year-old girl is evaluated with a complaint of feverassociated with a cough for a 5-day duration. Physicalexam reveals a fever of 102.2F (39.0C), tachypnea, andfocal crepitations. Which is the most likely cause of thepatients pneumonia?

a. Chlamydia pneumoniae b. Mycoplasma pneumoniae c. Parainuenza 1 d. Parainuenza 2 e. Streptococcus pneumoniae

6. T e ana ysis o t e Nationwi e Inpatient Samp e con-ucte y Bar er an co eagues supports w ic o t e

o owing statements a out t e treatment o pe iatricrain tumors?

a. A c i wit a ma ignant rain tumor is more i e y to ecure i t at c i gets care at a c i ren s ospita .

. Functiona outcome a ter treatment or me u o as-toma is compromise y postponement o inpatient re-

a i itation unti ra iation t erapy as een comp ete . c. Surgeons w o per orm a ig annua vo ume o crani-

otomy or a u t rain tumor ave outcomes equa tope iatric neurosurgeons in t e per ormance o crani-otomy or pe iatric rain tumor.

. Surgeons w o per orm a ig annua vo ume o craniot-omy or a u t rain tumor ave outcomes in erior tope iatric neurosurgeons in t e per ormance o crani-otomy or pe iatric rain tumor.

e. T e perioperative morta ity rates or craniotomy orpe iatric rain tumor are ower at usy c i rens os-pita s t an at ospita s w ere c i ren wit t is con i-tion are se om treate .

7. A 12-year-o c i eve ops persistent cognitive an e-aviora seque ae o owing cere e ar astrocytoma re-

section. W ic o t e o owing is inc u e in t e cere e -ar cognitive a ective syn rome?

a. Dysca cu ia . Dys ia oc o inesia c. Impaire visua spatia s i s . Mutism

8. Accor ing to t e stu y y Va ent et a , t e impact o t eenvironment on c i ea t :

a. is neg igi e. . is sta e across a socioeconomic groups. c. may e arge y a eviate y e ucation o pe iatricians

an parents. . requires government po icy c anges to e su stantia y

improve .

9. During t e we c i exam o a 6-year-o oy an 8- year-o gir , t e parents vo unteer t at t ey wi e goingon a s i vacation next wee . In provi ing anticipatory

gui ance or t is trip, w ic o t e o owing representst e est a vice? a. Since most ata injuries occur among gir s, t e aug ter

is at ig er ris o a ata injury rom s iing. . Since most ata injuries occur in t e evening, t e c i -

ren s ou not s i a ter 4 PM. c. Since most ata injuries resu t rom a s, t e c i ren

s ou e accompanie y an a u t on t e s i i t. . Since most ata injuries resu t rom ea trauma, t e

c i ren s ou wear s i e mets. e. Since most ata injuries resu t rom ypot ermia, t e

c i ren s ou wear warm c ot ing.

10. When performing computed tomography to evaluate ab-dominal injury in blunt trauma, what is a reasonable de-cision for bowel visualization?

a. Barium provides good bowel contrastb. Hypaque must be used to visualize bowel

c. No contrast is necessary d. Water is equally as effective as dilute Hypaque for

visualization

11. Which of the following neurologic disorders is signi-cantly more prevalent with celiac disease compared tocontrols?a. Double vision

b. Migraine headaches c. Obsessive compulsive disorder d. Stuttering e. Tics

12. T e stu y y Benn et a o a Danis nationa irt co orts owe t at:

a. aving 3 or more in ections prior to age 6 mont s wasassociate wit a ecrease ris o atopic ermatitis.

. in ants younger t an 6 mont s w o atten e ay carea an increase ris o atopic ermatitis.

c. in ections prior to age 6 mont s were not protectiveagainst atopic ermatitis.

. t e majority o in ants i not eve op in ections uringt e rst 6 mont s o i e.

e. t e majority o in ants eventua y eve ope atopicermatitis.

13. T e O etani met o o reast massage was s own in astu y y Fo a et a to:

a. ave no e ect on reast mi composition. . increase t e energy content o reast mi . c. increase t e ree water content o reast mi . . increase t e protein content o reast mi . e. increase t e vitamin content o reast mi .14. W ic o t e o owing statements a out c i ren in

oster care is true? a. A sma num er o t e c i ren in oster care account or

most o t e menta ea t costs. . C i ren ess t an 6 years o age at entry into oster care

are at greater ris o requiring menta ea t servicest an c i ren o er t an 6 years o age.

c. C i ren wit ig er p ysica ea t care costs are essi e y to receive menta ea t services.

. C i ren wit mu tip e oster care p acements are un-i e y to receive menta ea t services.



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EDITORIAL BOARD

Editors-in-Chief Lewis R. First, Burlington, VT Edgar K. Marcuse, Seattle, WA

Consulting EditorsJosep D. Dic erman, Burlington, VT Douglas Diekema, Seattle, WA

Editorial BoardM. Doug as Ba er, Wood ridge, CT Leslie Barton, Tucson, AZ Ro ert H.A. Has am, oronto, Virginia Moyer, ouston,Gary Ona y, Dayton, OH Richard A. Polin, New York, NY Jo n Sny er, San Francisco, CA Bern ar Wie ermann, Was ington, DC

Contributing Section Editors A ministration an Practice Management:

Jera L. Zarin, Houston, TX A o escent Hea t : Ric ar R. Broo man, Glen Allen, VA Allergy and Immunology: Mitchell Lester, Westport, CT Anest esio ogy an Pain Me icine:

T omas Mancuso, Boston, MA Bioethics: Brenda Jean Mears, Dallas, TX Breastfeeding: Wendelin Slusser, Los Angeles, CA Car ioogy an Car iac Surgery: Davi Dan or , Oma a, NE C i A use an Neg ect: Betty Spivac , Louisville, KY Children with Disabilities: Pasquale Accardo, Richmond, VA C inica P armaco ogy an T erapeutics:

Ian M. Pau , Hers ey, PA Community Pe iatrics: Stan ey I. Fisc , Harlingen, TX Critical Care: Susan L. Bratton, Ann Arbor, MI Dermato ogy: A ert C. Yan, P iladelp ia, PA Deve opmenta an Be aviora Pe iatrics:

Rona L. Lin say, Colum us, OH Emergency Medicine: Ronald L. Paul, Louisville, KY

En ocrino ogy: Suren ra Varma, Lu oc , TX Epi emio ogy: Danie R. Neuspie , New Yor , NY Gastroentero ogy an Nutrition: Nea LeLei o, Providence, RI Genetics, Birth Defects: Lawrence R. Shapiro, New York, NY Hospita Care: Brian M. Pate, Kansas City, MO In ectious Diseases: Mo een Rat ore, Jac sonville, FL Injury an Poison Prevention: Murray L. Katc er, Madison, WI International Child Health: Brian Bramson, Raleigh, NC Me icine-Pe iatrics: Brett Ro ins, Roc ester, NY Nep ro ogy: Aaron Frie man, Madison, WI Neurological Surgery: Joseph H. Piatt, Jr., Philadelphia, PA Neuro ogy: J. Gor on Mi ic ap, C icago, IL Op t a mo ogy: Wa ter M. Fierson, Pasadena, CA Ort ope ics: Fre eric Dietz, Iowa City, IA Otolaryngology: Daniel L. Wohl, Jacksonville, FL

Pe iatric Dentistry: Jo n E. Nat an, Oa Broo , IL Perinata Practice: Ric ar A. Po in, New Yor , NY P astic Surgery: Fernan o D. Burstein, Atlanta, GA Pulmonology: Jeffrey Wagener, Denver, CO Ra io ogy: Bever y Woo , Los Angeles, CA Resi ents: Ric Foc t, Crestview Hills, KY R eumato ogy: Susan Ba inger, Indianapolis, IN School Health: Linda Grant, Boston, MA Senior Mem ers: Dona W. Sc i , Littleton, CO Sports Me icine: E.F. Luc stea , Amarillo, TX Surgery: C inton Cavett, Roano e, VA Transport Medicine: Monica Kleinmann, Sharon, MA Uni orme Services: Mic ae Du i , San Diego, CAUro ogy: Danie McMa on, A ron, OH

A n s w e r s :

1 . d

2 . d

3 . b

4 a

5 . e

6 . e

7 . c

8 . d

9 . d

1 0 . d

1 1 . b

1 2 . c

1 3 . b

1 4 . a

1 5 . a

1 6 . a

1 7 . a

1 8 . a

ME INFORMATION

AAP Grand Rounds is an e uca-tional publication.

The American Academy of Pediatricsis accre ite y t e Accre itation Coun-

il for Continuing Medical Education(ACCME) to provide continuing medical

ucation or p ysicians. AAP GrandRounds is p a nne a n pro uce in ac-ordance with ACCME Essentials.

T e American Aca emy o Pe iatricsesignates t is e ucationa activity or

up to 18 Category 1 credits toward the AMA P ysic ian s Recogn itio n Awar .Eac p ysician s ou c a im on y t oseredits that he/she actually spent in theducational activity.

he AMA has determined that non-US licensed physicians who participatein t is CME activity are e igi e or AMAPRA Category 1 cre it.

A CME Quiz Sheet is included in theJanuary issue of AAP Grand Rounds. The

ea ine or su mitting t e 2004 quizs eet or 2004 cre it is January 31, 2005.

This is a scientic publication designedto present updates and opinion to healthcare pro essiona s. It does not provide

edical advice for any individual case,and is not intended for the layman.

15. W ic one o t e o owing anatomic an p ysio ogica norma ities was most consistent y i enti e in t estu y group o prepu erta c i ren suspecte o avings eep isor ere reat ing?a. A norma Respiratory Distur ance In ex on po ysom-

nograp y . Hypertrop ic tonsi s an a enoi s c. Increase vertica istance (over ite) etween man i u-

ar an maxi ary incisors. Long so t pa ate, wit re un ant tissue

e. Nasa septa eviation

16. W ic o t e o owing is t e most accurate met o oriagnosing He ico acter py ori in ection in c i ren? a. Antra iopsy

. H pylori serum immunoassay c. H pylor stoo antigen test . H pylori urinary IgG anti o ies e. Urea reat test

17. A 3-year-old child is evaluated in the emergency depart-ment for a knee injury. The parent saw the child trip andfall down 3 steps, landing hard on his knee. Following thefall, he refused to bear weight. X-ray reveals a buckle frac-ture of the distal femur at the junction of diaphysis andmetaphysis. Which of the following statements about themechanism of this injury are correct?

a. The injury results from axial loading and is consistent with the proposed history.

b. The injury results from axial loading and is inconsistent with the proposed history.

c. The injury results from complex loading and is consis-tent with the proposed history.

d. The injury results from shearing forces and is consistent with the proposed history.

e. The injury results from torsional forces and is inconsis-tent with the proposed history.

18. A website selling prescription drugs will probably: a. not require a doctors prescription. b. only sell drugs which are under consideration by the

Food and Drug Administration for reclassication toover-the-counter status.

c. reach fewer lower-income people since they have lessaccess to the Internet than those with higher incomes.

d. screen out most children from making purchases.


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Aap Grand Rounds 2004 Neurology 15_2