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Pathology Research International

Volume 2011, Article ID 583139, 12 pages
doi:10.4061/2011/583139

Research Article
Microbiological Spectrum of Brain Abscess at a Tertiary Care
Hospital in South India: 24-Year Data and Review
V. Lakshmi,1 P. Umabala,1 K. Anuradha,1 K. Padmaja,1 C. Padmasree,1
A. Rajesh,2 and A. K. Purohit2
1 Department

of Microbiology, Nizams Institute of Medical Sciences, Panjagutta, Hyderabad,

Andhra Pradesh 500082, India
2
Department of Neurosurgery, Nizams Institute of Medical Sciences, Panjagutta, Hyderabad,
Andhra Pradesh 500082, India
Correspondence should be addressed to V. Lakshmi, [email protected]
Received 24 November 2010; Accepted 15 September 2011
Academic Editor: S. K. Shankar
Copyright 2011 V. Lakshmi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Intracranial abscesses are life-threatening infections that pose a diagnostic challenge not only to the neurosurgeon but also to
the microbiologists. Detailed studies documenting the spectrum of infecting agents involved in brain abscesses are limited from
India. Materials and Methods. This is a retrospective analysis of 352 samples from 1987 to 2010 analyzed at a tertiary care hospital
in South India from 1987 to 2010, to document the changing trends with time. Results. The age of the patients ranged from
2 to 80 years, a larger number of males being aected. Otogenic infections were the most common cause while cryptogenic
abscesses were 20%. Gram stain and culture positivity were 78% each. Gram-positive and negative facultative aerobes and
obligate anaerobes were also on the rise. Unusual organisms, like Burkholderia pseudomallei, Salmonella typhi, Nocardia species,
Cladosporium bantiana, Fonsecaea pedrosoi, Entamoeba histolytica, and Acanthamoeba were also isolated and/or detected from
the brain abscesses aspirate or resected tissue. Summary. New and emerging pathogens associated with brain abscess, especially
in immunosuppressed individuals, have renewed the necessity of an early detection, and it will be of great value in appropriate
management of patients with brain abscess.

1. Introduction
Intracranial abscesses (usually referred to as brain abscess),
though uncommon in developed countries, are serious, lifethreatening infections [13]. Major advances, such as stereotactic neurosurgical procedures, discovery of newer antibiotics, especially metronidazole against anaerobes and ceftriaxone which eectively crosses the blood brain barrier,
and newer imaging techniques for early detection of brain
abscesses [3], have lead to a substantial reduction in the mortality [4, 5]. Despite these advances, brain abscess remains a
potentially fatal central nervous system (CNS) disease, especially in developing countries [39].
Diculties in the diagnosis of intracranial abscess are
mainly due to protean clinical manifestations and similarities
in the imaging and morphologic appearance of some intracranial mass lesions, like cystic gliomas and metastases.

The frequent delay in making the diagnosis renders this

condition a significant challenge for the neurosurgeon [8
10] in the management of the case.
New and emerging pathogens, especially in immunosuppressed individuals, have renewed concern about the diagnosis and treatment of brain abscess and equally pose a challenge to the clinical microbiologist [1, 3, 7, 11]. Meticulous
microbiological investigations, including critical microscopic
examination for all possible infectious agents and employing
detailed microbial investigative armamentarium for the isolation of the organism(s) from the abscess material and from
the probable primary site of origin of the infection elsewhere
in the body, will definitely aid in the identification of the
etiological agent(s) [2, 911]. These findings will enable
the neurosurgeon and the infectious disease (ID) specialist
to treat the brain abscess more rationally and appropriately
[5, 7, 8, 10].

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It is well worth stating that a brain abscess is not only

a neurosurgical emergency but also a microbiological emergency and a diagnostic challenge to both the disciplines [1,
10, 12].
The objectives of this retrospective study were to analyze the microbiological findings in the purulent aspirates
and/or tissue obtained from the brain abscesses and discuss
the changing and evolving spectrum of infectious agents
observed over the past 24 years with a brief review of other
studies.

2. Materials and Methods

This is a hospital-based retrospective microbiological analysis of 352 brain abscess materials (purulent aspirates and/or
tissue) that were received between 1987 and 2010, by the
Microbiology Laboratory, at the Nizams Institute of Medical
Sciences, a tertiary care and a teaching hospital, in South
India. The data was analyzed in two groupsgroup I,
between 1987 and 1993 (published data) [12] and group II
between 1994 and 2010, to document the changing trends in
the microbial flora and treatment strategies.
(1) The demographic and clinical information of the patients was retrieved from the medical records section.
Relevant data recorded included the age and sex of
the patients, intracranial location of the abscess(es),
the probable primary source of the infectious agents
leading to the formation of the abscess(es).
(2) The microbiology data was retrieved from the microbiology records maintained as a database in the Microbiology Department.
(3) Wherever the resected brain abscess tissue was received, the histopathological features were corroborated to complement the culture results.

3. Microbiological Investigations
Specimen collected from a brain abscess (either through a
burr hole or craniotomy) during any time of the day and
submitted for microbiological investigations was considered
as an emergency specimen and was processed immediately in
the microbiology laboratory, on priority.
Specimen received between the years 1987 and 1993
(study group I) [12] was processed only for bacteria (aerobic
and anaerobic), by routine microbiological procedures [13].
(i) Grams stain was carried out on all specimens for
bacteria, while Zeihl Neelsens (ZN) stain for acid fast
bacilli (AFB) was done in only one case of tuberculous brain abscess.
(ii) Aerobic cultures were performed on 7% sheep blood
agar and McConkey agar and incubated at 37 C for
48 hours, before being declared as sterile. All positive
cultures were further processed for identification and
antibiotic susceptibility patterns [13].
(iii) Anaerobic culture was performed on 7% sheep blood
agar plates and incubated in the Dynamicro Gaspak

system. Metronidazole disc (5 g) was placed to observe for antibiotic susceptibility of anaerobes. Isolates susceptible to metronidazole were considered to
be anaerobes. Grams stain of such isolates was carried out to confirm the morphology and the genus
of the isolate. Aerotolerance test was performed to
demonstrate that these isolates were obligate anaerobes.
(iv) The specimen from the tuberculous abscess showed
AFB on ZN stain. The material was inoculated on
Lowenstein Jensens (LJ) medium, and the isolate was
identified as Mycobacterium tuberculosis (M.tb) based
on its rate of growth and susceptibility to para nitro
benzoic acid [12].
The rest of the 302 brain abscess specimens (study group
II) were processed for detection of bacteria (aerobes and
anaerobes), mycobacteria, fungal pathogens including Nocardia and Actinomycetes, and parasites, by standard microbiological procedures [13] and by semiautomated identification
systems (Mini API and the Vitek 2, bioMerieux, USA).
Various detection procedures used were as per standard
guidelines [13]. The anaerobic isolates were identified up to
the genus level only.

4. Results
The average number of brain abscess specimens received for
microbiological analysis was 21 per year.
Brain abscesses were diagnosed in all decades of life, with
the ages ranging from 2 years to 80 years (mean of 28.5
17.6) and a male preponderance (male to female ratio was
2.7 : 1). The youngest patient (2 years) developed a frontal
lobe abscess with an underlying septicemia and was referred
to our institute for further management. The oldest patient
was an 80-year-old lady, with chronic suppurative otitis
media (CSOM) and a parietal lobe abscess.
Table 1(a) shows a comparison between the two study
groups in terms of the location and source of infection of the
brain abscess. Tables 1(b) and 1(c) highlight the topographic
distribution of the abscesses and the probable source of
infection documented in study group II.
There were 310 (88.1%) nontraumatic and 42 (11.9%)
posttraumatic brain abscesses in our study. Though solitary
abscesses (313/352; 88.9%) were more common, multiple
abscesses (39/302; 12.9%), predominantly otogenic, were
noted only in the study group II. There were 6 cases of subdural empyema and 3 cases of extradural abscesses. The rest
of the brain abscesses were intracranial, involving the brain
parenchyma. The majority of these intracerebral abscesses
were located in the parietal region 102/352 (28.9%), followed
by the frontal and the temporal lobes (21%).

5. Microbial Spectrum
Staining and microscopy of the brain abscess material (pus
and/or tissue) revealed the pathogens in 41/50 (82%) [12]
and 221/302 (73.1%) of the cases in the 2 groups, respectively. In the rest of the cases, only polymorphonuclear cells

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Table 1: (a) Neuroanatomical location and source of infection of brain abscess comparison between the two study groups. (b) Neuroanatomical location and source of infection of solitary brain abscess in study group II (n = 263). (c) Location and source of infection of multiple
brain abscesses in study group II (n = 39).
(a)

Location
Group
Parietal
Frontal
Temporal
Cerebellar
Occipital
Subdural
Total

CSOM
I
8
4
6
4
2

24

II
4
20
46
15
5
1
91

CHD
I
4
2
1

1
1
9

II
11
3
3

18

Primary source of infection

Pulm
Trauma
I
II
I
II
4
1
1
23

6
3
1
32

I
5
2
2

10

Cryptogenic
II
23
33
11
2
2

71

Total
I
22
8
9
4
4
3
50

II
62
63
63
18
8
1
215

Crypto
23
33
11
2
2

1
71

Total
80
73
72
22
8
3
3
1
1
263

CSOM: chronic suppurative otitis media, CHD: congenital heart disease, and Pulm: pulmonary.
Group I: 19871993 and Group II: 19942010.
(b)

Location
Parietal
Frontal
Temporal
Cerebellar
Occipital
Subdural
Epidural
Thalamus
Medullary
Total

ASOM

CSOM
4
20
46
15
5
1

91

PNS

6
2

CHD
11
3
3

18

Primary source of infection

Sepsis
Odont
Pulm
Trauma
17
1
1
9
4

1
2
3
1

1
1

30
2
3
13

Op trauma
14
4
2

20

Misc
1

3
2

ASOM: acute suppurative otitis media, CSOM: chronic suppurative otitis media, PNS: paranasal sinusitis, CHD: congenital heart disease, Odont: odontogenic, Pulm: pulmonary, Op trauma: operative trauma, Misc: miscellaneous, and Crypto: cryptogenic.
E. hystolytica and Acanthamoeba cases not included in analysis.
(c)

Location
FP
FT
FO + SD
F + SD
PO
TP
T + SD
TOTAL

ASOM

CSOM
5
2
1

5
5
1
19

PNS

CHD
1
1

Sepsis
1

Odont

Pulm

Trauma
3
1

1
3

Op trauma

Misc

Crypto

Total
10
4
1
1
12
10
1
39

CSOM: chronic suppurative otitis media, PNS: paranasal sinusitis, CHD: congenital heart disease, Odont: odontogenic, Pulm: pulmonary, Op trauma:
operative trauma, Misc: miscellaneous, Crypto: cryptogenic, FP: frontoparietal, FT: frontotemporal, FO: fronto-occipital, SD: subdural, F: frontal, PO:
parieto-occipital, TP: temperoparietal, and T: temporal.

were seen, indicating an inflammatory process. Microscopy

was positive on all the fungal, mycobacterial, Nocardial, and
parasitic abscesses. However, the microscopy was negative in
12 bacterial culture-positive cases in group II.
Microbiological cultures for bacteria, mycobacteria, and
fungi (included in the study group II only) revealed the
etiological agent(s) in 44/50 (88%) [12] and 203/302 (67.2%)

cases in the two groups. The spectrum of organisms isolated

from the brain abscesses in both of the groups is compared
in Tables 2(a), 2(b), and 2(c).
Gram-positive facultative aerobes were isolated more frequently than the gram-negative aerobes. Among the isolates, 35/44 (79.5%) and 158/203 (77.83%) were facultative
aerobes, 7/44 (15.9%) and 32/203 (15.8%) were obligate

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Table 2: (a) Single and polymicrobial aerobic bacterial isolates from brain abscess. (b) Single and polymicrobial anaerobic isolates from brain
abscess. (c) Miscellaneous bacterial and fungal isolates from brain abscess.
(a)

No. of isolates

Type of organism

Group I (n = 35)

Group II (n = 158)

Gram-positive facultative aerobes

Staphylococcus aureus

11

51

Enterococci species (avium, faecium, and faecalis)

32

Beta haemolytic Streptococci

17

Alpha haemolytic Streptococci

Streptococcus pneumoniae

Diphtheroids

Escherichia coli

Klebsiella pneumoniae

10

Enterobacter species

Proteus species

Morganella morganii

Citrobacter freundii

Pseudomonas aeruginosa

Acinetobacter species

Gram-negative facultative aerobes

Salmonella typhi

Burkholderia pseudomallei

Neisseria meningitides

Total

30

150

Facultative aerobes-polymicrobial
Klebsiella + Proteus

BH Streptococci + Proteus

S. aureus + Proteus

Pseudomonas + Klebsiella

Klebsiella + E. coli

Klebsiella + S. aureus

Pseudomonas + S. aureus

Klebsiella + Acinetobacter + Enterococci

S. aureus + Acinetobacter

Enterococci + Strep. pneumonia

S. aureus + E. coli

Total
(b)

Type of organism
Gram-positive obligate anaerobes
Peptococcus species
Peptostreptococcus species
Gram-negative obligate anaerobes
Bacteroides fragilis
Veillonella
Total

No. of isolates
19871993 (n = 7)

19942010 (n = 32)

3
11

3
1
18

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(b) Continued.

No. of isolates

Type of organism

19871993 (n = 7)

19942010 (n = 32)

Mixed anaerobic isolates

Peptostreptococcus + B. fragilis
Prevotella melaninogenicus + Peptostreptococcus
Total

2
1
3

Mixed aerobic and anaerobic isolates

Pseudomonas + B. fragilis + Peptostreptococcus
Strep. pneumonia + Proteus + B. fragilis
Pseudomonas +B. fragilis
S. aureus + Peptostreptococcus
Proteus + Peptostreptococcus
S. aureus + B. fragilis
BH Streptococci + B. fragilis
Pseudomonas +Veillonella
Veillonella+ Providencia stuartii
Total

1
1

2
1
2
1
1
1
1
11

(c)

Type of organism
Mycobacterial and Nocardial isolates from brain abscess
Mycobacterium tuberculosis
Mycobacterium fortuitum
Nocardia brasiliensis
Nocardia asteroides
Fungal isolates from brain abscess
Nocardia asteroides + Aspergillus terreus
Aspergillus flavus
Aspergillus flavus + BHS
Cladosporium bantiana
M. tb + Fonsecaea pedrosoi
Total

No. of isolates
19871993 (n = 2)

19942010 (n = 13)

1
1

1
1

1
1
1
1
1
13

E. histolytica and Acanthamoeba cases not included in analysis.

anaerobes, and 2/44 (4.5%) and 7/203 (3.4%) were mycobacteria. Nocardia species 3/203 (1.5%) and fungal isolates
5/203 (2.5%) were seen only in group II, probably due to
the extensive methods employed. The obligate anaerobes
were isolated mainly from the brain abscesses originating
from the ear, paranasal, and oral infections. Mixed aerobic
and anaerobic abscesses were also frequently encountered.
There were 30 microscopy-positive abscesses with very small
Gram-positive cocci in pairs and or chains, on Grams stain,
resembling anaerobic cocci. However, no organisms could
be recovered by any of the culture methods used from these
specimens.
5.1. Bacterial Isolates (Tables 2(a) and 2(b)).
5.1.1. Facultative Aerobes (180 Single and 13 Mixed Aerobes,
Total 193) (Table 2(a)). Staphylococcus aureus (S. aureus)

(68/192, 35.2%) was the most common isolate, often as a single isolate. Compared to the group I, the incidence of S.
aureus infections was about 4 times more (Table 2(a)). These
isolates were usually from brain abscesses associated with
CSOM and trauma cases, in the study group II. There were
6/55 methicillin-resistant S. aureus (MRSA) isolates, from
brain abscesses following a road trac accident (RTA), and
they were sensitive to vancomycin. The rest of the isolates
were methicillin-sensitive S. aureus (MSSA) and sensitive to
a broad range of antibiotics.
Enterococcus species (34/193, 17.6%) were isolated frequently from the cases with CSOM. Compared to the study
group I, Enterococcus species appeared to be significant
emerging pathogens of brain abscess at our centre. The
species isolated were E. avium, E. faecalis, and E. faecium.
All the isolates demonstrated a high susceptibility to betalactams and vancomycin. The high rates of isolation could

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be due to the use of chromogenic media for primary culture

of the pus and automated identification systems like the
Vitek 2.
Beta haemolytic Streptococci (22), alpha haemolytic Streptococci (8), and S. pneumoniae (5) were mostly otogenic and
were highly susceptible to penicillin and other betalactams.
The isolation of these important pathogens was more in the
study group II, often as single isolates.
Aerobic Gram-negative bacilli (62/193, 32.1%) though
mainly otogenic, these organisms were also frequently isolated from the postcraniotomy and hematogenic abscesses.
The enteric bacilli, such as Escherichia coli (E. coli), Klebsiella
pneumoniae (K. pneumoniae), Enterobacter species, Proteus
species, Morganella morganii, and Providencia stuartii were
the frequent isolates. Like the Gram-positive pathogens, the
incidence of the Gram-negative bacilli, especially of multidrug-resistant and nosocomial pathogens, was seen to increase. E. coli and K. pneumoniae were highly resistant organisms producing extended-spectrum -lactamase (ESBL).
Nosocomial pathogens such as Pseudomonas aeruginosa
(P. aeruginosa) and Acinetobacter baumannii (A. baumannii)
were also isolated.
5.1.2. Obligate Anaerobes (22 Single and 17 Mixed, Total 39).
An increasing incidence of polymicrobial anaerobic abscesses
was documented. The spectrum of anaerobes in this study is
shown in Table 2(b).
5.1.3. Uncommon Gram-Negative Bacilli
(i) B. pseudomallei (2 cases): One patient with melioidosis had presented with fever and abdominal pain
and developed calvarial osteomyelitis and multiple
parietal and sagittal sinus abscesses [14]. Another
patient with a splenic abscess due to B. pseudomallei
developed a frontal lobe brain abscess. However, the
organism could not be isolated on culture from the
brain abscess pus.
(ii) S. typhi was isolated from the brain abscess pus in a
case of septicemia.
5.1.4. Mycobacterial Species (8/352, 2.2%). All the 8 TB
abscesses revealed AFB on microscopy, and M. tb was isolated
by culture on LJ Medium (study group I) and BACTEC 460
TB system (Becton Dickinson, USA). In our study group
I, two cases of mycobacterial abscesses, (M. tb (1) and M.
fortuitum (1) [12] were documented, while there were 6 cases
of tuberculous brain abscesses and one was a mixed fungal
and TB abscess [15], in the study group II.
5.1.5. Nocardial Species (3/302, 1%). There were 2 parietal
lobe abscesses caused by N. asteroides in our group (one in a
postrenal transplant patient and the other in a case of atopic
dermatitis on steroids). We also reported a case of a young
female with mycetoma on the back, who presented with an
epidural abscess. N. brasiliensis was isolated from the sinuses
on the skin and from the epidural abscess pus [16].

5.2. Fungal Agents. There were 5 (1.7%) cases of fungal brain

abscess in our series, that occurred in various clinical settings. The cases with Aspergillus abscesses had a fatal outcome.
We reported a case of a 23-year-old immunocompetent
male who sustained a head injury and developed a capsuloganglionic region abscess due to the neurotropic fungus,
Cladophialophora bantiana [17]. Diagnosis was made based
on the microscopy, mycology, and histopathology findings
of the aspirate obtained from the abscess. The patient
responded clinically to amphotericin B.
5.3. Protozoa
(a) E. histolytica abscess: the trophozoites of E. histolytica
were demonstrated on microscopy in a patient with
cerebral amoebiasis. There was no evidence of diseases elsewhere. Patient had a complete recovery following a total excision of the abscess and Metronidazole therapy [18].
(b) A fatal case of an acute frontal lobe abscess due to
Acanthamoeba, in an immunocompetent patient
with meningoencephalitis, was documented. The cerebrospinal fluid (CSF) from the patient showed the
Acanthamoeba (polygonal) cysts on Gram stain and
calcofluor white stain. However, a coculture with E.
coli was unsuccessful in isolating the organism [19].

6. Discussion
Brain abscesses have been well known and reported from the
beginning of the Hippocratic era [10, 11]. Essentially, a brain
abscess is a focal intraparenchymal collection of pus and is
classified based on the anatomical location or the etiologic
agent causing it. It begins as a localized area of cerebritis and
evolves into a collection of pus surrounded by a vascularized
capsule [5, 20].
Our data shows that the incidence of brain abscess continues to be significant in the neurosurgical clinical setting.
The average incidence of brain abscess among all the spaceoccupying lesions in our institute is about 25%. Recent
studies from India have reported an average of 9 to 15 cases
per year [1, 7, 8], while studies from developed countries
recorded a lower number, 512 cases per year [10, 21, 22].
As per our data and other studies, brain abscesses occur in
all decades of life, with a male preponderance [1, 6, 21, 22].
However, the reasons for the male preponderance, are not
clear [1].
The spectrum of organisms seen in brain abscess usually
depends on the primary source of infection. Gram-positive
cocci, especially the Enterococci, and Gram-negative bacilli,
especially E. coli and K. pneumoniae, were more frequently
isolated in group II than in the earlier group I. This is
probably due to the use of the Bact/alert system and direct
inoculation of the purulent aspirates into the bottles. A larger
number of antibiotic-resistant Gram-negative bacilli were
isolated from cases in group II, probably due to the increased
number of trauma cases in this group.

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6.1. Otogenic Abscesses. CSOM continues to be the most frequent predisposing condition in all age groups (24/50 (48%)
and 118/302 (39%) in both the groups), respectively, time
groups. Other studies from India also documented CSOM
as a major source of brain abscess, 49% [1], 31.4% [7],
and 40% [8]. Though middle ear suppurative disease was
seen to extend to temporal lobe or cerebellum [1, 23, 24],
multiple otogenic abscesses, often involving the frontal and
parietal lobes, were seen in the study group II, probably due
to arterial dissemination of infective emboli. Direct extension
may also occur through osteomyelitis in the posterior wall of
the frontal sinus, sphenoid, and ethmoid sinuses. This direct
route of intracranial extension is more commonly associated
with subacute and chronic otitic infection and mastoiditis
than with sinusitis [4]. Frontal or ethmoid sinus infections
generally spread to the frontal lobes. Odontogenic infections
can spread to the intracranial space via direct extension or a
route, generally to the frontal lobe [4].
All the otogenic abscesses, in our study, were of bacterial
etiology (aerobic and/or anaerobic), with culture positivity
of 85%. Gram-positive facultative aerobes were the most
frequent isolates from these abscesses, as also recorded in
other studies [1, 6, 7, 23, 24]. An unusual case of concomitant
TB (M. tb) and fungal (Fonsecaea pedrosoi) infections
involving the middle ear cleft extending and destroying the
craniovertebral junction at the skull base was successfully
managed and treated at our centre [15]. Our study and others
from India clearly suggest that middle ear infections need
to be treated aggressively to reduce the incidence of brain
abscesses [1, 24].
6.2. Odontogenic Abscesses. The oral and dental florae, mainly from the subgingival sites, are documented to be frequent
sources of brain abscesses [25]. These sites are usually
comprised of Streptococcus milleri and the Gram negative
anaerobic bacilli. Two cases of odontogenic abscesses were
noted in the study group II caused by S. aureus and Prevotella
melaninogenica.
6.3. Cardiogenic Abscesses. Cyanotic congenital heart diseases
such as tetralogy of Fallot (10/23, 43.5%), transposition of
the great vessels (3/23, 13%), and dextrocardia (2/23, 0.08%)
are documented as risk factors for brain abscess [1, 8, 26,
27] and congenital pulmonary arteriovenous malformations
[28]. We documented cardiogenic abscesses in 18% (9/50) in
the study group I [12] and 7.6% (23/302) in the study group
II. The age of the patients with cardiogenic abscess was less
than 20 years though there was one 45-year-old patient with
an S. aureus abscess.
Patients with cyanotic heart disease have a right to left
shunt of venous blood in the heart, bypassing the pulmonary
circulation, thus leading to bacteremia, septicemia, and
infective thromboembolism, usually in the brain. These patients also have low-perfusion areas in the brain due to
chronic hypoxemia and secondary polycythemia. The abscesses, often multiple, occur at the junction of the gray and
white matter. The parietal lobes are most commonly aected
due to the large caliber and direct continuation of the middle

7
cerebral artery [9]. The congenital arteriovenous anomalies
become a nidus for the organisms, especially Gram-positive
ones, spread to the brain leading to the development of
brain abscess [1, 9]. Nineteen of the 23 (82.6%) cardiogenic abscesses in our series were positive for bacteria by
microscopy and Gram-positive cocci, including facultative
aerobes, and obligate anaerobes were isolated.
6.4. Traumatic Abscesses. Trauma to the skull, either following road trac accident (21/302; 7.2%) or a craniotomy
(20/302; 6.6%), is an important risk factor in the study group
II, which was not encountered in the study group I, probably
related to increase in speeding vehicles and availability of
neurosurgical facilities. Thirty six of the forty one abscesses
were solitary, and the parietal lobe was the most commonly
aected site.
Microscopy revealed organisms in 92.7% abscesses, while
80.5 of them were culture positive. S. aureus infection was
common in the RTAs, probably due to the direct implantation of the organism derived from the normal flora of
the calvarial skin. On the other hand, the postcraniotomy
abscesses had a spectrum that is predominantly of gramnegative facultative aerobes and was often a nosocomial
infection. These isolates, most commonly E. coli and K. pneumoniae, had a high level of resistance to antibiotics. Strict
aseptic measures during the postoperative management of
the surgical wound and care of the intravascular catheters in
these patients is very important and cannot be underscored
[6, 11].
Postcraniotomy brain abscesses due to C. bantiana were
reported by other centers [2931]. The portal of entry of the
fungus is either due to direct inoculation following trauma
to the skull, either following RTA or craniotomy, inhalation
of the spores, or a haematogenous spread to the brain [31].
6.5. Hematogenic Abscesses. Septicemia and/or sepsis elsewhere in the body is a probable cause for the spread of the
organism from the primarily involved organ to the brain.
We documented 10.9% hematogenic abscesses in the study
group II. Twelve of the abscesses (36.4%) had no detectable
organisms on microscopy and were sterile on culture. Menon
et al. recorded 40% sterile abscesses in patients on prior
antibiotics [1].
Also calling metastatic abscesses from a remote site, the
hematogenic abscesses are the commonest type in developed countries [3]. They are often multiple and typically
occur at the junction of the white and gray matter, where
the capillary blood flow is the slow [9]. They are more
commonly seen along the distribution of the middle cerebral
arteries and the parietal lobes, where the regional blood
flow is the highest. The common systemic sources of infection are chronic pulmonary infections, skin pustules, bacterial endocarditis, and osteomyelitis. Those with a right to left
vascular shunt as a result of congenital heart disease or pulmonary arteriovenous malformations are particularly susceptible. Being hematogenous, any lobe of the brain can be
aected, and some of them could be multiple [9, 28]. Though
these abscesses are reported to contain a mixed flora [32],

8
in the present series, the infected hematogenic brain abscesses were monomicrobial, since the septicemia is usually monomicrobial. Gram-negative pathogens were more
frequently isolated from these abscesses, though unusual
Gram-negative organisms such as S. typhi and B. pseudomallei were isolated from the hematogenic brain abscess
pus.
6.6. Preexisting Pulmonary Lesions. Primary infections or
secondarily infected pulmonary cavities can be a predisposing cause of brain abscess, especially in the immunocompromised patients [4]. Six cases of brain abscesses of a probable
pulmonary origin were recorded in group I which include 1
M.tb, 1 M. fortuitum, and 4 bacterial abscesses [12]. In the
study group II, there were 3 abscesses of proven pulmonary
origin (organisms were isolated from the respiratory tract),
which grew N. asteroides (a case of postrenal transplant) and
M.tb (2 cases), respectively.
6.7. Urosepsis. The urinary tract infections are an important
primary source of brain abscess. We documented an abscess
in lower midbrain in a patient with urosepsis. The abscess
was sterile, probably due to prior antibiotic therapy. A similar
report of brain abscess due to urosepsis was reported in
literature [33].
6.8. Intracranial and Meningeal Lesions. Brain abscess has
been documented to occur following a contiguous spread
from infected foci within the brain or meninges or a secondary infection of preexisting intracranial lesions [4, 33].
Two brain abscesses from a primary infective focus within
the brain or the meninges were documented in our study.
One was a case of neurocysticercosis developing a temporal
abscess due to Neisseria meningitides, probably a secondary
infection of the cystic lesion. The other case was a case of
pyogenic meningitis developing a frontoparietal abscess due
to Peptostreptococcus species.
6.9. Osteomyelitis of the Calvarium. Osteomyelitis of the skull
bones can be a primary focus with a contiguous spread to
the underlying parenchyma [4] as noted in our study [14].
We documented an unusual case of B. pseudomallei calvarial
osteomyelitis that had spread to both the parietal lobes
and medially extended up to the sagittal sinus [14]. There
were two other cases of calvarial osteomyelitis with sterile
abscesses in the study group II.
6.10. Immunosuppression. Immunosuppression can predispose patients to the development of brain abscesses. With the
increasing number of transplant surgeries, especially renal,
in the recent times, it is a significant emerging problem [9].
Immunosuppression induced by steroids also may predispose the patients in developing brain abscess.
The spectrum of organisms noted in the immunosuppressed patients may not be found in immunocompetent
individuals, and because of this, empirical therapy in these
patients should be avoided [9]. Since, the imaging features
of the abscess on computerized tomography or magnetic

Pathology Research International

resonance imaging (MRI) also do not help in the diagnosis,
attention should be directed to obtaining a microbiological
diagnosis, whenever possible, so that appropriate antimicrobial therapy can be initiated without delay. The pus obtained
from the abscess should be subjected to microbiological
examination for fungal elements, AFB including Nocardia
and parasites besides the routine aerobic and anaerobic
cultures [1, 7, 9]. These compromised hosts with impaired
T-lymphocyte or macrophage function are prone to develop
infections with intracellular pathogens such as fungi (particularly Aspergillus species) and bacteria like Nocardia
species [6, 11, 34], especially emerging Nocardial species (N.
cyriacigeorgica) [35].
Brain abscess was documented in 3 cases of renal transplantation. The aspirated materials on microscopy, and culture revealed growth of A. flavus, N. asteroids, and S. pneumoniae along with S. aureus in the 3 cases, respectively
(Table 2(c)). Another fatal case of mycotic brain abscess in
a case of atopic dermatitis on immunosuppressive therapy
with steroids in a 5-year-old female child and multiple
parietal abscesses secondary to A. terreus and N. asteroides,
probably originating from the ears or the lungs, were noted.
Dias et al. documented a case of Nocardial brain abscess
in an elderly male with undetected diabetes mellitus [34,
36].
6.11. Cryptogenic Brain Abscesses. This group comprises of
those abscesses where there would be no obviously demonstrable primary focus of infection elsewhere in the body nor
any underlying predisposing condition leading to infection.
The reported incidence of such cryptogenic abscesses, as per
several studies ranges between 15 and 22% [1, 10, 34]. The
organisms in the cryptogenic abscesses have been shown to
be derived from the upper respiratory tract and oral flora,
comprising mainly of Streptococcal species and anaerobic
cocci [1, 10]. In one of the studies, a patent foramen ovale was
identified by echo cardiogram and was proposed as a possible
way of migration and seeding of the oral flora to the brain
[37].
We documented 23.3% brain abscesses as cryptogenic.
Though the majority were solitary and sterile abscesses
(53/82, 64.6%), the culture-positive cryptogenic abscesses
(19/82, 26.4%) were caused mainly by a single Gram-positive
facultative aerobe (12/19), among which S. aureus (MSSA)
was the predominant isolate. The remaining cases were
polymicrobial.

7. Microscopy versus Culture

The sensitivity of microscopy depends on the number of
organisms in the specimen (103 CFU/mL). In our study, the
Grams stain was positive in 30 culture-negative cases, while
it was negative in 12 culture-positive cases. There is a need
to adopt methods to improve the detection rates especially
by microscopy, which includes fluorescent staining using
acridine orange (sensitivity (102 CFU/mL)) [13], calcoflour
white for fungal filaments, and by auramine rhodamine
fluorescent stain for mycobacteria.

Pathology Research International

8. Culture for Various Organisms

All the culture methods used in our study were to optimize
the isolation of the various possible and cultivable etiologic
agents. It has been shown that a direct inoculation and use
of automated methods of culturing the pus, immediately
after its aspiration, enhances the yield of organisms [7, 38].
Direct inoculation of the pus specimen into a standard
anaerobic BacT/Alert bottle (bioMerieux, USA) facilitated
early and better yield of the organisms. The unvented, bottled
anaerobic medium facilitates the growth of both facultative
aerobes and the obligate anaerobes, and the yield is further
enhanced by the shaking incubator, inbuilt in the bacT/alert
system [38].
Despite the meticulous conventional microbiological
procedures, 6/50 (12%) and 99/302 (32.8%) abscesses were
sterile, in our group, respectively. The reported incidence of
sterile abscesses, from other centers, has ranged between 0%
and 43% [1, 7, 39]. The yield of organisms by culture also
directly depends on the prior use of antibiotics [11]. This
could be one of the reasons for an increased incidence of
sterile abscesses in group II of our study.
Infections with P. aeruginosa and A. baumannii are
caused by contiguous extension to brain and meninges from
an ear, mastoid, paranasal sinus surgery, or diagnostic procedures. In some patients, the involvement of the CNS is
due to spread of the organism from infective endocarditis,
pneumonia, or urinary tract infection [3]. These organisms
have emerged as important and highly resistant nosocomial
pathogens in recent years.
Brain abscess due to unusual Gram-negative bacilli was
observed in the study group II only, probably due to the
improved microbiological diagnostic techniques and automated identification systems used.
(i) Salmonella typhi is a rare pathogen in brain abscess
and probably spreads to the brain hematogenously
[40].
(ii) B. pseudomallei (agent of Melioidosis): brain abscess
is a complication of a neurological infection [11]. Isolation of B. pseudomallei from the specimen remains
the gold standard in diagnosis. The microbiologist
should be well versed with the colony morphology
and the antibiogram of these important yet not very
fastidious organisms. Ceftazidime remains the drug
of choice in the early phase of treatment, followed by
a prolonged therapy with cotrimoxazole [14].
Anaerobic brain abscesses: the earlier studies on brain
abscesses from India were specifically on anaerobic infections
[4143]. The obligate anaerobes are significant pathogens of
a brain abscess and often occur as mixed infection either
with another anaerobe or a facultative aerobe, as seen in our
group. They are generally associated with otogenic and odontogenic infections.
Anaerobes are highly susceptible to metronidazole [41].
Subsequent to its addition to the antibiotic treatment regimen of a brain abscess and widespread use, the incidence
of anaerobic infections has declined [1, 12, 41]. Attention
to proper anaerobic isolation techniques is essential for

9
a good recovery [11, 13] as is evidenced in the increased
yield of anaerobes in our study group II (Table 2(c)).
Since conventional anaerobic cultures require 2-3 days of
incubation, it is essential to use alternative techniques for
their early detection [44, 45]. Gas liquid chromatography
(GLC) is a routine method used in the identification and
dierentiation of anaerobes from aerobes in clinical samples
on the basis of the presence of volatile and nonvolatile
fatty acids on the chromatogram. Computer-aided GLC is
commercially available and is a means of rapid microbial
identification [44, 45]. However, the equipment and cost are
the limiting factors for a routine use of GLC in resourcerestricted conditions.
Tuberculous brain abscess results when mycobacteria gain
entry to the brain parenchyma, by a hematogenous route
from a remote site, usually the lungs, unlike TB Meningitis,
which occurs via lymphatic spread from cervical lymph
nodes. The TB bacilli are immobilized in end arteries,
which lead to formation of submeningeal tuberculous foci
and either result in a tuberculoma or undergo a central
caseation and liquefaction to form an abscess [4649]. This
phenomenon is very rare and commonly occurs in patients
with cell-mediated immunity and is mostly focal and usually
secondary to a primary focus in the lungs. Histologically
and clinically, these abscesses are devoid of a granulomatous
reaction, similar to pyogenic abscesses [19].
For appropriate therapy and clinical management, a TB
abscess must be dierentiated from a tuberculoma. The
criteria for the diagnosis of a TB brain abscess, laid down
by Whitener in 1978, should be fulfilled in the diagnosis
of a TB brain abscess [50]. These include (i) evidence of a
true abscess formation within the brain, as confirmed during
surgery, (ii) histological proof of the presence of inflammatory cells in the abscess wall (histologically, the abscess
walls are usually devoid of epitheloid and giant cells, unlike
in a tuberculoma [13], and (iii) demonstration of AFB and
isolation of M.tb from the abscess pus. Though not included
in this data, we had reported a case of calvarial tuberculous
osteomyelitic abscess, which was successfully managed [51].
Nocardial brain abscesses are rare and account for about
1-2% of all cerebral abscesses [5254]. The entity is being
increasingly reported in the present era of transplant surgeries and immunosuppressive therapies. The infection may
occur as an isolated lesion or as a part of a disseminated
infection of a pulmonary or a cutaneous infection [6, 11, 16,
34, 52, 53, 55]. Almost all the patients with Nocardial brain
abscesses have a defective cell-mediated immunity [11]. An
early detection and treatment are very important since the
mortality is three times higher than that of other bacterial
brain abscesses. Though N. asteroides and N. brasiliensis are
the common species, other species are also being isolated
from brain abscess [52]. The diagnosis of Nocardial brain
abscess requires a high index of clinical suspicion, with an
attempt for an early tissue and microbiological diagnosis
[34].
Invasive fungal infections remain a life-threatening complication in children with hematological malignancies. The
brain is a common site of haematogenously disseminated
fungal infections from an extracranial focus [56]. Cerebral

10

Pathology Research International

aspergillosis occurs in about 10 to 20% of all cases of invasive

aspergillosis and has a very poor prognosis. The outcome
depends on the early recognition of the causative organism
and prompt initiation of antifungal treatment. Hence, every
attempt should be made to detect fungal filaments in the
brain abscess material submitted [11].

9. Alternative and Advanced

Techniques to Improve Detection of
the Infecting Pathogen(s)
Microscopy-positive but culture-negative abscesses, especially the bacterial, are not unusual and pose a challenge to
the microbiologist(s). The organisms, often the nutritionally
demanding Streptococcus species and the anaerobic cocci,
generally will not be recovered on routine culture media.
Also cultures will be negative when the number of organisms
in the abscess pus is less. Such specimen should ideally be
processed for the etiologic agent by more sensitive assays.
At present, these highly sensitive and sophisticated assays
are being increasingly used in advanced centers for research
purposes.
(1) Broad range real-time polymerase chain reaction (RT
PCR) using 16srRNA or DNA will help amplify and
detect the probable bacterial nucleic acid, as shown
by several studies [5762]. A subsequent sequencing
of the amplified product is performed to further
improve the specificity. With the recent advances,
the molecular methods are gradually making inroads
into routine diagnostic laboratories and in the coming years may become important primary tools in the
early detection of the etiologic agent. However, the
specificity and the cost of these assays are important
limiting factors [63] in the underdeveloped and
developing countries.
(2) In vitro nuclear magnetic resonance (NMR) used for
detecting the specific spectral pattern of the amino
acids and other volatile substances released by metabolic processes of the bacteria has been applied as a
means of dierentiating abscesses from other spaceoccupying lesions in the brain [6466]. However, the
need for NMR with very high Tesla and an expert
analysis and interpretation of the spectral patterns are
the limiting factors.
(3) Gas liquid chromatography (GLC) on the pus sample
is also an alternative method, especially for the anaerobic abscesses.

10. Conclusions
As evidenced by our data, the microbiology of intracranial
abscesses is complex. The detection and identification of the
causative pathogen(s) are the cornerstones of diagnosis for
an appropriate management and therapeutic optimization.
The value of a promptly evaluated microscopy coupled with
meticulous and elaborate culture methods of the abscess

material cannot be under-estimated. The high yield of positive cultures will then enable the neurosurgeon and the infectious disease specialist to treat brain abscess more rationally
and appropriately. Abscesses rarely arise de novo within the
brain [4, 11]. There is almost always a primary lesion elsewhere in the body that must be sought assiduously, since
failure to treat the primary lesion will result in relapse [11].
The need to sample the primary source of the brain abscess,
especially lungs, when unusual pathogens are isolated from
the brain abscess (even in cryptogenic abscesses), is emphasized through our series.
It is advisable for the neurosurgeon to co-ordinate closely
with the microbiologist and ensure application of advanced
microbiological and molecular techniques, to detect the new
and emerging agents of intracranial abscesses.

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