A 3-year-old girl is brought to the emergency department due to worsening fever and lethargy. Her parents report that she has had recurrent upper respiratory illness and recently had been irritable and pulling at her ears. She has also been eating poorly and vomiting, and has progressively become more lethargic. The patient has no chronic medical conditions and has received all recommended vaccinations. While being evaluated in the emergency department, she has a generalized tonic-clonic seizure. CT scan of the head shows a solitary 2-cm, ring-enhancing lesion in the left lateral temporal lobe. The pathogen responsible for this patient's current condition most likely gained access to the brain from which of the following structures?

Question

A 3-year-old girl is brought to the emergency department due to worsening fever and lethargy.  Her parents report that she has had recurrent upper respiratory illness and recently had been irritable and pulling at her ears.  She has also been eating poorly and vomiting, and has progressively become more lethargic.  The patient has no chronic medical conditions and has received all recommended vaccinations.  While being evaluated in the emergency department, she has a generalized tonic-clonic seizure.  CT scan of the head shows a solitary 2-cm, ring-enhancing lesion in the left lateral temporal lobe.  The pathogen responsible for this patient's current condition most likely gained access to the brain from which of the following structures?

Quizplus · Accepted Answer

Brain abscess is a contained area of liquefactive necrosis with a surrounding inflammatory capsule and marked vasogenic edema. It usually appears on imaging as a ring-enhancing lesion and often presents with headache, fever, and/or focal neurologic findings (eg, seizure). Most cases are bacterial in origin (eg, viridans streptococcus, Staphylococcus aureus) and stem from an underlying adjacent or distant infection. The number and location of lesions helps differentiate the likely underlying source, as follows: Single abscess is usually due to the direct invasion of a contiguous infection. This patient who was pulling at her ears likely had otitis media that spread to the mastoid air cells and then invaded the adjacent temporal lobe leading to temporal lobe abscess. In contrast, frontal lobe abscess is generally due to direct spread of ethmoid or frontal sinusitis (Choices A and B) Multiple abscesses usually arise due to hematogenous dissemination of a distant infection, most commonly the heart (eg, endocarditis) or lungs (eg, abscess, empyema) (Choice D) Maxillary sinusitis can spread contiguously to the orbit and cause periorbital or orbital cellulitis and abscess. Unlike the frontal and ethmoid sinus, the maxillary sinus is not adjacent to the brain. (Choice E) Facial infections in the area around the eyes and nose drain into the opthalmic veins and can lead to cavernous sinus thrombosis, which usually presents with headache, fever, oculomotor deficits, and eye swelling. (Choice F) Peritonsillar abscess usually presents with fever, sore throat, and a muffled voice. Complications include airway obstruction and spread of the infection to the deep neck spaces or mediastinum. Educational objective: A single brain abscess is usually caused by direct spread of a contiguous infection. Temporal lobe abscess is usually a result of otitis media that has spread to the mastoid air cells, while frontal lobe abscess is usually due to ethmoid or frontal sinusitis. Multiple brain abscesses typically indicate hematogenous dissemination of a distant infection (eg, endocarditis, empyema).

A 3-Year-Old Girl Is Brought to the Emergency Department Due