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Undiagnosed cerebral abscess

01 February 2004

Ms C was a young woman with learning difficulties admitted to hospital in the late 1980s with a history of frontal headaches, dizziness and staggering gait. The clerking doctor noted that she had been discharged from the ENT ward 19 days earlier after treatment for chronic otitis media.

He also recorded a history of many episodes of bile-stained vomit, anorexia, weight loss, constipation and frontal headaches. On examination, the only finding of note was tenderness on deep palpation of the epigastrium and left upper quadrant of the abdomen.

Dr T, an SHO, saw Ms C later the same day. He noted pus in the right ear with a pink tympanic membrane. There was no neck stiffness. He diagnosed an upper respiratory tract infection with right otitis media, ordered FBC, ESR, right ear swab, throat swab and MSU, and started Ms C on a broad-spectrum penicillin.

At review the following day, Dr T discovered that a right ear swab taken at the ENT outpatient’s had grown pseudomonas resistant to penicillin, so he put Ms C on gentamicin and asked that the gentamicin levels be monitored.

Over the next four days, Ms C was reviewed regularly by several SHOs. A lumbar puncture revealed white cells in the CSF, prompting one of the doctors to prescribe penicillin. There was no growth on culture at 48 hours. Ms C’s headaches persisted, her temperature was normal and her fundi NAD, but she had an abnormally slow pulse.

Ms C collapsed suddenly in respiratory arrest. She was resuscitated, but her pupils remained fixed and dilated and she was transferred with all speed to a neighbouring hospital for a CT scan.

The scan revealed a ruptured cerebral abscess. Ms C never regained consciousness and died the following day. Her family brought a claim against the hospital and all the attending doctors, some of whom were MPS members.

Experts reporting on the case concluded that Ms C’s recent history and condition on admission should have alerted her doctors to the possibility of an intracranial infection and arranged an urgent referral.

On causation, although earlier detection and draining of the abscess would probably have spared Ms C’s life, it was likely that she would have been a victim of epilepsy thereafter.

The claim was settled.

Learning points

  • For a quick guide to examining patients with headaches, see Kavanagh’s article in Casebook 2003 (3).
  • This case was settled because the doctors concerned had failed to recognise the patient’s severe symptoms and make the necessary urgent referral – in particular, her abnormally slow pulse rate should have set alarm bells ringing.
  • The patient had learning difficulties, which made her not only more susceptible to a cerebral abscess but also more vulnerable as a patient. Patients who cannot communicate clearly are often not taken as seriously as they should be.
  • A cerebral abscess is a medical emergency. In a patient with a chronic ear infection presenting with a history of headaches, a cerebral abscess should be ruled out before considering other diagnoses. Although the onset can be sudden, the features of a cerebral abscess more usually develop over a couple of weeks. The symptoms are progressive, but there may be a transient improvement if the patient has been given antibiotics.

History:

  • ‘Typically, patients present … with headache, low-grade fever, and a focal neurologic defect or seizure.
  • None of these symptoms are pathognomonic for brain abscess, and patients often present early in their course with only headache (seen in at least 70–90% of patients with brain abscess).
  • Patients may complain of nausea, vomiting, or stiff neck.

Physical:

  • Fever is typically low grade. [Only present in 50% of patients.]
  • Altered mental status ranges from subtle personality changes, to drowsiness, to full-blown coma.
  • Nuchal rigidity occurs in about 25% of cases.
  • Focal neurologic signs can signal increasing cerebral edema around the abscess.
  • Seizures are typically grand mal.
  • Papilledema indicates the disease process is well advanced.’

(Ernoehazy W ‘Brain Abscess’, Emedicine July 2003)

emedicine.medscape.com/article/781021-overview