A brain abscess is a focal, intracerebral infection that develops into a collection of pus surrounded by a well-vascularized capsule. Although fungi and protozoa (particularly Toxoplasma) can also cause brain abscesses, bacterial causes are much more common. Streptococci are found in 70% of bacterial abscesses and are usually from oropharyngeal infection or infective endocarditis, whereas Staphylococcus aureus accounts for 10% to 20% of isolates and is more often found after trauma. Community-associated MRSA strains have been increasing. Enteric gram-negative bacilli (e.g., E. coli; Proteus, Klebsiella, and Pseudomonas spp.) are isolated in 23% to 33% of patients, often in patients with ear infection, septicemia, or immunocompro-mise and those who have had neurosurgical procedures.
Most clinical symptoms are caused by the size and location of the abscess rather than the systemic signs of an infection. Headache is the most common complaint and may be accompanied by fever, mental status changes, evidence of increased intracranial pressure (nausea, vomiting, papilledema), or focal neurologic deficits. Diagnosis is usually made by CT scan with IV contrast showing the characteristic hypodense center with a peripheral uniform ring enhancement, with or without a surrounding area of brain edema. MRI is becoming the preferred imaging modality because of increased sensitivity, particularly for detecting satellite lesions. Additional testing depends on risk factors and the likely underlying source of infection and may include blood cultures, chest imaging, testing for HIV and antibodies to Toxoplasma, and transesophageal echogram. Empiric therapy typically involves vancomycin, ceftriaxone, and metronida-zole. Optimal management also includes surgical drainage for most abscesses, both to find an etiologic microorganism and to improve chances of cure (Turkel, 2010).
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