Nikhil Organti, MD, FACP
Intensivist
Mercy Hospital St. Louis
Saint Louis
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Title: A Rare case of Streptococcus intermedius brain abscess with ventriculitis in a pregnant patient.
Case Report Body:
Introduction: Streptococcus intermedius (S. intermedius) species is a part of Streptococcus anginosis group, a subgroup of viridans streptococci. This group is unique due to their ability to cause abscesses. We report a rare case of a 38-year-old immunocompetent pregnant woman with S. intermedius brain abscess.
Case Description: A 38 year-old female at 13 weeks pregnant, with history of migraines, presented with intractable headache associated with nausea, vomiting, photophobia and right homonymous hemianopsia for 4 days. This presentation was not typical of her past migraines. Additional history was unremarkable for significant infectious exposure. Magnetic resonance imaging (MRI) of the head revealed left occipital region mass with peripheral enhancement, extending from ventricle into occipital lobe with associated surrounding edema, most consistent with a brain abscess and ventriculitis. She was started on seizure prophylaxis, empiric antibiotics and steroids. Neurosurgery and infectious disease specialties were consulted. She underwent stereotactic left parieto-occipital needle biopsy, revealing frank pus. Extensive infectious work-up was done, including blood/fungal cultures, toxoplasmosis, HIV and tuberculosis, were all negative. Echocardiography was negative for valvular vegetations. Ultrasound of liver was negative for abscess. Intra-operative cultures were positive for S. intermedius. She was discharged home on intravenous antibiotics. Follow up MRI 4 weeks later showed decrease in size and enhancement of the abscess.
Discussion: Brain abscess during pregnancy carry a high mortality rate of 30%. Headache is the most common symptom (75% of patients), followed by neurological abnormalities (67%) and altered consciousness (58%). Early initiation of treatment with steroids, antibiotics and anti-epileptics, guided by advanced imaging techniques with stereotactic biopsy, significantly effect morbidity and mortality. Upon review of literature, to our knowledge there are only 9 documented cases of brain abscess complicating pregnancy. We present the 10th case of brain abscess and the 1st case secondary to S.intermedius. The case we describe is a unique and rare presentation of brain abscess due to S. intermedius in a pregnant patient with negative blood cultures and no discernible primary source of infection.