Clinical Brief

Amebic Cerebral Abscess Mimicking Bacterial Meningitis

S. Sayhan Emil, D. Altinel1, U. Bayol1, O.O. Ozcolpan, A. Tan and O. Ganiusmen2
R.T.M.H Izmir Tepecik Teaching Hospital, Department of Pathology
1
Emory University Hospitals, 2R.T.M.H Izmir Tepecik Teaching Hospital, Department of Neurosurgery, Clifton,
Atlanta

ABSTRACT
We report a case of an amebic brain abscess in a 2-year-old girl, with symptoms mimicking bacterial meningitis with no
evidence of disease elsewhere. Histological evaluation of the abscess revealed the organisms, and the abscess regressed
in response to specific medical treatment. This article reviews the rarity of these abscesses and difficulty in the diagnosis.
[Indian J Pediatr 2008; 75 (10) : 1078-1079] E-mail : denizaltinel@gmail.com
Key words : Amebic abscess; Cerebral; Meningitis

Entamoeba histolytica is a well-known cause of infectious

colitis, typically producing diarrhea and occasionally
frank dysentery. This organism may also spread to
involve extraintestinal sites such as the liver, lung, central
nervous system, usually in the form of amebic abscess 1, 2.
Cerebral amebiasis is a rare and dreadful complication of
E. histolytica infection, most likely occurs in low
socioeconomic status.3 This report presents a case of a
two-year-old-girl with cerebral abscess due to E. histolytica
with no evidence of disease elsewhere.
CASE REPORT
The patient is a two-year-old girl who is coming from a
low socioeconomic status. She had week long history of
convulsions and tendency to sleep at the time she
attended the hospital. Biochemical analysis of
cerebrospinal fluid revealed an elevation of protein (303
mg/dl), potassium (3.58 mmol/L) and calcium (8.8 mgr/
dl), a decrease of glucose (4 mg/ dl). Clor (111.9 mmol/L)
was within normal limits. The patient was diagnosed as
meningitis. On the second day of her hospitalization,
though she had been treated with nonspecific antibiotics
(imipenem and vancomysin), pitosis, left sided
hemiparesia and unconsiousness have developed. She
was transferred to our institution based on the brain CT

Correspondence and Reprint requests : Dr. Deniz Altinel, M.D.,

Emory University Hospitals, Department of Pathology, 1364 Clifton
Rd. NE, Atlanta, GA 30322. Phone:+1 404 712 4770
[Received November 30, 2007; Accepted February 18, 2008]
[DOI10.1007/ S1209800801827]

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scan, presenting an intracranial abscess. On the physical

examination; unconsiousness, pitosis and left sided
hemiparesia had been observed. Admission laboratory
parameters presented with an elevated erythrocyte
sedimentation rate (ESR 83mm in the first hour), mild
signs of liver dysfunction (ALT 10u/L, AST 26u/L). Her
white cell count showed a neutrophilic leucocytosis (13,6/
ml) and esinophilia (0.1/ml). Platelets, BUN, serum
creatinine, and electrolytes were all within normal limits.
No serological tests have been performed. On the 6th day
of hospitalization, brain CT scan revealed multiple
abscesses in the right cerebral pedincle and in both
cerebral hemispheres (Fig. 1). Conservative medical
treatment with wide spectrum antibiotherapy
(vancomycin, ceftriaxone) associated with anti-edema
agents was insufficient to reduce the volume of the

Fig. 1. T1-weighted images of the brain after intravenous

gadolinium contrast showing multiple ring enhancement
typical for absess

Indian Journal of Pediatrics, Volume 75October, 2008

Amebic Cerebral Abscess Mimicking Bacterial Meningitis

masses. So the abscesses had to be drained surgically. The
microbiological evaluation of the drained purulent
material was negative as regards to micro-organisms.
Despite the continuation of the multi-agent
antibiotherapy, postoperative control CT scans showed
that multiple new brain abscesses have developed
bilaterally. Second surgical exploration was carried out.
On gross examination, the abscess was measured
approximately 7x6.5x1.5 cm and filled with greenish
yellow purulent material. Multiple sections of the cyst
walls revealed the necrotic material with a diffuse
infiltrate of PMN leucocytes, lymphomononuclear cells,
foamy histiocytes , rare esinophils and multiple spheric
structures, amebic trophozoites, measuring 20-25 in size
with eccentrically placed nucleus and a few
pathognomonic ingested erythrocytes within the
cytoplasm (Fig. 2). Trophozoites were periodic acid-Shiff
(PAS)-positive (Fig. 3). Metranidazole treatment for 14

Fig. 2. HEX400 Amoebic trophozoites, spheric structures

measuring 20-25 in size with eccentrically placed nucleus
and a few ingested erithrocytes within the cytoplasm
(ARROW) Note the neutrophilic and lymphomononuclear
infiltrate.

Fig. 3. PASX400 Trophozoites presenting PAS-positive, vacuolated

cytoplasm (ARROW).

Indian Journal of Pediatrics, Volume 75October, 2008

days alongwith systemic antibiotherapy was followed by

the complete resolution of the infective process.
DISCUSSION
E. histolytica is an obligate parasite which is dependent on
a human host. Primary reproduction takes place in the
colon and transmission is usually by the fecal-oral route4.
Although intestinal involvement is the common form of
the disease, amebic dysentery may be absent in some
patients. Though clinical symptoms of cerebral
amoebiasis are usually preceded by gastrointestinal,
hepatic or respiratory symptoms, Lombardo et al5 found
intestinal symptoms in only a little over 50% of the
cerebral amebiasis cases , they reviewed. History of
headache or sensorial disturbances are the most common
initial presentations of cerebral amebiasis. Symptoms and
signs of meningitis may also occur. Cranial nerve
involvement is frequent.6, 7 In the present case, the patient
had the symptoms of week history of convulsions and
tendency to sleep. Pitosis has developed as the result of
CN-III involvement with left hemiparesia and
unconsiousness. These symptoms lead the physicists to
the diagnosis of bacterial meningitis at the first admission
to the hospital. As there was no history of intestinal
involvement of the disease, neither serologic nor stool
analyses and cultures have been performed.
Amebic brain abscesses may be single or multiple and
commonly involve cortical and deep gray matter. The
most common sites of involvement of the brain are the
frontal lobes and basal ganglial regions. Occupation of the
left brain is more common than the right one with a ratio
of 2.3:1.5 The CT images of E. histolytica absesses are
indistinguishable from any other causes of brain
abscess.8, 9
Rarely, a mass of granulation tissue caused by
localized amebic infection (anameboma) may be the
only presenting lesion and may be confused with
malignancy.1 In the present case multiple brain abscesses
have been determined with CT scans in the right cerebral
pedincle and bilateral supratentorially in the cerebral
hemispheres. There were no significant signs for amebic
etiology as has been mentioned above.
Pathologically, stages of evaluation of amoebic abscess
have been well defined. These range from early lesions
which are poorly defined with irregular borders, to
mature lesions where true abscess with central tissue
necrosis and inflammatory cells (made up mainly round
cells) are seen. 5 Trophozoites typically measure
approximately 25 in diameter and contain a single,
round nucleus (5 ) as well as vacuolated PAS-positive
cytoplasm. The presence of ingested red blood cells is
considered to be pathognomonic for E. histolytica.1, 2 In the
present case, the microscopic examination revealed the
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S. Emil S et al
presence of trophozoites, as well. Metranidazol is the
recommended antibiotic agent for the treatment of amebic
abscess.10, 11 Surgical decompression was undertaken in
the present case, because of the significant mass effect.
Cerebral amebiasis is an important condition in the
differential diagnosis of the brain abscesses . This case
report points out that the patients with cerebral amebic
abscess may present any clinical evidence of extracerebral amebic involvement which is important for early
diagnosis. Great care must be exercised in the application
and interpretation of the available diagnostic tests. As it is
demonstrated by the present case, the alert surgical
pathologist has the potential to be the first one to suspect
and establish the diagnosis.
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Indian Journal of Pediatrics, Volume 75October, 2008