Brain Abscess Developing After Lobar Pneumonia: A Rare Complication in Unvaccinated Child Caused by Streptococcus pneumoniae Serotype 14

To the Editors: In this report, we would like to share our clinical experience of an unusual presentation of streptococcal brain abscess in an unvaccinated immunocompetent child with lobar pneumonia. An 8-year-old male patient presented with 10 days of fatigue, poor appetite, fever, productive cough and respiratory distress. A typical lobar pulmonary infiltration without evidence of a pulmonary effusion was seen on chest radiography. High levels of acute-phase reactants supported the diagnosis of bacterial pneumonia (white blood cell: 22.02 × 103/μL, neutrophil count: 18.6 × 103/μL, C-reactive protein: 159 mg/L, procalcitonin: 4.1 μg/L). The patient was started on treatment with vancomycin and cefotaxime. On follow-up, the patient showed clinical and laboratory improvement. However, no pathogen was detected in the blood culture. At follow-up, the physical examination revealed intermittent esotropia in the right eye without any evidence of other neurological findings. For further research, the patient had a cranial magnetic resonance imagining that demonstrated approximately 10 × 9 mm abscess, with peripheral vasogenic edema in the left temporal region (Fig. 1A,B). A diagnosis of a temporal abscess was made and vancomycin and cefotaxime treatment was continued with the addition of metronidazole. The case was operated by neurosurgery for abscess drainage. The histopathology findings in the abscess supported the clinical preliminary diagnosis. Periodic acid-Schiff (PAS) and Grocott-Gomori methenamine silver staining of the sample did not reveal any microorganisms. The tissue culture that was sent from the operation specimens was negative for any organism. However, the blood culture that was sent during the operation was positive and the isolate was identified as Streptococcus pneumoniae. Antibiogram showed penicillin susceptibility. Vancomycin and metronidazole were stopped and cefotaxime was continued. The isolate, sent to the laboratory for typing, was reported as serotype 14. After surgery, the patient was conscious and well-orientated with no deficits. Antibiotherapy was completed for 8 weeks.FIGURE 1.: Coronal (A) and axial (B) T2-weighted cranial magnetic resonance imagings reveal cortical cystic lesion with surrounding edema in left temporal lobe.Brain abscess caused by S. pneumoniae is more commonly associated with a focus of infection namely chronic suppurative otitis, sinusitis and mastoiditis.1 Previous studies of pediatric brain abscesses in children have shown that immunodeficiencies and congenital cyanotic heart diseases are the most common predisposing factors.2 With this article, we wanted to draw attention to brain abscess, which was an unexpected complication in our immunocompetent patient who was followed up for lobar pneumonia, contrary to known predisposing factors. Another important issue we want to emphasize is the importance of vaccination. The patient was an immigrant who had not been vaccinated against pneumococcal disease due to parental refusal, and unfortunately, the organism detected in the blood culture was a vaccine-preventable serotype (serotype 14). Vaccines remain the most effective preventive measure, but their widespread use in developing countries is reportedly limited by cost. On the contrary, for vaccine-preventable diseases such as this one, vaccination will always remain a cost-effective approach. It is known that the incidence of brain abscess is higher in developing countries due to various factors such as socioeconomic inequalities, nutritional deficiencies and delayed treatment.3 Improvements in living conditions and increased awareness about vaccination will have the greatest positive impact on both incidence and prognosis.

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