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Brain abscess due to Streptococcus intermedius in a 3‐year‐old child

A 3-year-old girl with no history of severe congenital or acquired diseases was brought to the emergency room (ER) of our department because she had experienced an increase in temperature for 8 h (37.8°C) and had suffered six episodes of vomiting without diarrhea. No signs or symptoms possibly related to neurological disease were found. The girl was given an 8-h intravenous (i.v.) saline infusion along with ceftriaxone, and was sent home with a prescription for ceftriaxone. Emesis in the absence of fever re-appeared after 1 week, and she was again brought to the ER of the same department. The results of a physical examination were normal and she was discharged without any prescription. Fifteen days later, she was brought to the ER for a third time, in this case because of vomiting and headache. Upon admission, she showed a decreased level of consciousness (Glasgow Coma Scale = 14) with no other neurological sign. Her body temperature was 37.5°C and no episode of diarrhea was reported. Contrast-enhanced computed tomography (CT) of the head revealed a very large hypodense lesion (6 ¥ 5.6 cm) suggesting a brain abscess (Fig. 1a). A craniotomy with excision was immediately performed, and 110 mL of evacuated purulent material was sent to the laboratory for bacteriology and fungi detection. After craniotomy, the patient was empirically treated with ceftriaxone and metronidazole, together with sodium valproate for seizure prophylaxis. The surgical drainage cultures grew Streptococcus intermedius sensitive to the administered b-lactam antibiotic, whereas the blood cultures were negative. In a search for predisposing factors for the development of a brain abscess, all diagnostic evaluations showed negative results. A contrastenhanced CT carried out 2 weeks after surgery demonstrated the shrinking of the lesion (3 ¥ 3.4 cm) (Fig. 1b). In our case, S. intermedius was the only isolated infectious agent, thus confirming that, even though it is usually a commensal, it can become a pathogen under particular conditions. It was cultured in the purulent material evacuated from the abscess but not in blood, which highlights that the cause of a brain