An Unusual Bacterium Causing a Brain Abscess.

To the Editor: Intracranial abscesses are an important cause of illness and death in a neurologic/neurosurgical unit. Early presumptive clinical diagnosis supported by radiologic evidence (computerized axial tomography [CAT] scan and magnetic resonance imaging) is the mainstay of diagnosis (1). Abscess contents are aspirated under stereotaxic guidance and cultured to isolate causative organisms and determine their antibiotic sensitivities. Organisms isolated from brain abscesses are usually streptococci, anaerobic and facultative gram-negative bacilli, staphylococci, or pseudomonads (2).

A 24-year-old male farmer came to us with progressive headache, dizziness, and a low-grade fever of 2 weeks' duration. He had had a pimple on his right cheek approximately 3 weeks before, which had discharged "bluish" pus on forcible evacuation and subsequently healed without treatment. No focal neurologic signs were detected on physical examination. Because an intracranial space-occupying lesion was suspected, a lumbar puncture was withheld. Later, a CAT scan of the patient's head revealed a right-sided temporoparietal space-occupying lesion approximately 3 cm in diameter, suggestive of a unilocular brain abscess. The abscess was needle aspirated under stereotaxic guidance, and the pus was cultured aerobically and anaerobically. After 24 hours of aerobic incubation on MacConkey agar at 37 [degrees] C, a pure growth of violet-colored colonies appeared, identified as Chromobacterium violaceum by the 20E API system (Biomerieux, France).

Other initial laboratory findings were as follows: blood leukocyte count, 16,200 cells/[micro]L (84% neutrophils, 15% lymphocytes, 1% eosinophils); erythrocyte sedimentation rate (Westergren method), 22 mm/hour; C-reactive protein concentration, 96 mg/L; and fasting blood sugar concentration, 5.1 mmol/L. Blood urea and C-reactive protein concentrations after 3 weeks of antibiotic treatment were 4.6 mmol/L and [is less than] 6 [micro]g/L, respectively.

The organism was sensitive to imipenem and ciprofloxacin and resistant to cefotaxime and ceftriaxone, by the Stokes comparative disk-diffusion antibiotic sensitivity testing method (3). Ciprofloxacin (as lactate) was administered intravenously, 400 mg twice a day, for 4 weeks. Repeated CAT scans, clinical symptoms, and serial C-reactive protein levels indicated rapid regression of the abscess followed by complete cure.

C. violaceum is a gram-negative bacillus present in soil and aquatic environments of tropical and subtropical countries or regions such as Trinidad, Guyana, India, Malaysia, Florida, and South Carolina. It is a bacterium of low virulence, occasionally causing skin infections and disseminated disease involving multiple organs in immunocompromised patients. In such cases the disease can mimic septicemic melioidosis (4,5).

In this previously healthy patient, infection probably originated from the facial abscess. The patient was negative for HIV antibody (Serodia), had no history of diabetes mellitus or other compromising illnesses, and had no evidence of immunodeficiency. In a previous case of disseminated C. violaceum infection in a young patient, postmortem findings revealed numerous cortical infarcts and hemorrhages (6). Our isolate from a brain abscess is yet another case of a relatively avirulent saprophytic microorganism resulting in a deep-seated infection in a well-nourished, previously healthy person.

Dhammika Nanda Atapattu,(*) Dhammika Priyal Jayawickrama,(*)([dagger]) and Vasanthi Thevanesam(*)

(*) University of Peradeniya, Peradeniya, Sri Lanka; ([dagger]) General Hospital, Kandy, Sri Lanka

References

(1.) Mathisen GE, Johnson JP. Brain abscess. Clin Infect Dis 1997;25:763-81.

(2.) Mandell GL, Bennett J, Dolin R. Principles and practice of infectious diseases. 4th ed. New York: Churchill Livingstone; 1995: p. 887-99.

(3.) Stokes EJ, Ridgway GL, Wren MWD. Clinical microbiology. 7th ed. London: Edward Arnold; 1993: p. 239-50.

(4.) Murray PR, Baron EJ, Pfaller MA, Tenover FC. Manual of clinical microbiology. 6th ed. Washington: ASM press; 1995: p. 503.

(5.) Mitchell RG. In: Parker MT, Duerden BI, editors. Miscellaneous bacteria. Topley and Wilson's principles of bacteriology, virology and immunity, Vol. 2.8th ed. London: Edward Arnold; 1990: p. 589-91.

(6.) Ti TY, Tan WC, Chong APY. Non fatal and fatal infections caused by Chromobacterium violaceum. Clin Infect Dis 1993;17:505-7.