Case reportA four month old baby girl was brought to our department with a history of progressive decrease in movements of the left lower limb of three weeks duration and right lower limb of one day duration. The baby was intermittently febrile since three days prior to hospital admission and also had retention of urine of one day duration. The baby did not have any seizures, altered sensorium, vomiting or any history suggestive of central nervous system (CNS) involvement or raised intracranial tension. Parents noticed decreased sensations in lower limbs. The mother also reported that when pinched on the left leg she was not wincing or crying. She had a birth mark with a dimple in the lower back from which a recurrent discharge of white fluid was present since one and a half months of age. The parents had consulted multiple doctors including a neurosurgeon for the same but was reassured and sent back.On examination at the time of admission, the baby was conscious and alert, but irritable. The cranial nerves and upper limbs were normal. She had dorsolumbar scoliosis with convexity to the left, lax anterior abdominal wall on the left side and flaccid anal sphincter. There was a pale pink patch (3×3cm) with a central dimple in the lumbosacral area, approximately 3.5cm above the gluteal cleft suggestive of a congenital dermal sinus with neuro-_________________________________________ The authors declare that there are no conflicts of interest Personal funding was used for the project. Open Access Article published under the CreativeCommons Attribution CC-BY License.cutaneous marker (Figure 1). Her lower limbs were hypotonic with complete paralysis (power 0/5). Bilateral knee jerks, ankle jerks and plantar responses were absent. There was no response to pain in the lower extremities. Laboratory investigations showed leucocytosis with neutrophilia (White blood cell count 23,000/µL with 60% neutrophils) and elevated C-reactive protein (22.5 mg/L; normal <5 mg/L). X-ray of lumbosacral spine showed dorsolumbar scoliosis. Magnetic resonance imaging (MRI) of spine showed absent posterior elements at S1 and S2 with tethered cord and enlarged conus. There was an intramedullary abscess extending from D3 to S2 with a sinus tract extending to the skin from the thecal sac attached to the conus (Figure 2).She underwent L3 to S2 laminoplasty with excision of the dermal sinus. The intramedullary abscess was evacuated and the tethered cord released (Figure 3). An epidermoid tumour associated with the CDS noticed intraoperatively was also excised (Figure 4).
Reporting 40 day old child referred from a private clinic to our hospital with CT Brain showing intracranial space occupying lesion. Child had fever since day 7 of birth and was evaluated for sepsis in the nearby hospital and CSF study showed features of bacterial Meningitis and was treated for 14 days with inj. cefotaxime and amikacin. After 3 days of IV medication fever subsided. CSF culture outside did not shown any growth. We have not got the detail of blood investigation outside. CT brain was taken in that private clinic to rule out post meningitic complication. Surprisingly they found intracranial space occupying lesion. So the child was referred to our hospital for further management.On examination child was alert, active feeding well, no any neurological deficit anterior fontanelle was level. Blood investigation showed normal total count (13,000 with polymorphs predominance 70%), CRP was 7 and blood culture has not grown any bacteria. Serum calcium 8mg/dl, potassium 4meq, sodium 130 mEq.CT Brain (taken outside) showed well encapsulated calcified mass in right temporal lobe 3x3 cm with no midline shift. So child was operated (open surgery) and biopsy of the lesion showed abscess with calcification. Pus culture revealed pseudomonas aeruginosa. Child was treated with IV ceftazidime for 10 days. Child went home with no neurological deficit. On follow up he is doing well.DISCUSSION: Calcified brain abscess 1 in infancy is rare and only few cases were reported with abscess and calcification. Brain abscesses can occur in children of any age but are most common in children between 4 and 8 yr and neonates. The cause of brain abscess include embolization due to congenital heart disease with right to left shunts, meningitis, chronic otitis media, sinusitis, orbital cellulitis, dental infection, immunodeficiency and infection of ventriculoperitoneal shunts.Our patient had CSF proven meningitis treated with antibiotic for 14 days. He did not have any neurological symptoms inspite of this large lesion. Intrauterine viral infection followed by calcification has been very well documented, but bacterial infection followed by calcification is very rarely reported.In literature only few cases of brain abscess with calcification is reported and pseudomonas brain abscess in infants has not been reported till now as per available literature, so we are reporting this rare case, from our institution.Auvichayapat et al 2 reviewed the clinical features and outcomes of treatments of 107 infants and children with brain abscesses. Congenital heart diseases and chronic otitis media were the most common predisposing factors. The common signs and symptoms were fever, headache, vomiting, alteration of consciousness, and focal neurologic deficit. The overall mortality rate was 10.7%. Calcified brain abcess in a 6 year old child reported by Kabre et al 3 . Pus culture showed staph aureus.
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