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Other CNS Infections
Goals of Treatment
The goal is to rapidly identify infections which may result in intracranial extension, and to recognize that the
empiric antibiotic selection in these cases must include antibiotics that are both bactericidal and achieve adequate
CNS penetrance.
CLINICAL PEARLS AND PITFALLS
The most common comorbidity in children with brain abscesses is congenital heart disease.
Staphylococci and streptococci are the most common organisms isolated.
One common regimen to treat suspected CNS invasion from contiguous structures is the combination
of vancomycin, ceftriaxone or cefotaxime, and metronidazole, all at meningitic doses. If multiply
resistant gram-negative organisms have been isolated from a child previously, empiric meropenem
can be considered after consultation with infectious diseases.
Fewer data exist for other antibiotics (e.g., piperacillin-tazobactam, ampicillin-clavulanate) crossing
the blood–brain barrier.
Brain Abscesses
Brain abscesses can result from contiguous spread from head and neck infections (e.g., mastoiditis, sinusitis,
odontogenic) or from direct seeding from septic emboli, most commonly in children with congenital heart disease.
The latter remains the most common risk factor for pediatric brain abscesses. The most common organisms are
streptococci (aerobic and anaerobic streptococci, GAS, and pneumococcus) and S. aureus, followed by fungal
(primarily Aspergillus ) and Enterobacteriaceae. Early symptoms are nonspecific and can include fever, malaise,
vomiting, and headache. The most common signs are focal neurologic deficits (particularly cranial nerve VI),
papilledema, meningeal signs, hemiparesis, and ataxia, although symptoms will vary by abscess location (cerebral
hemisphere is the most common location) and size. Mental status changes are late signs with ominous prognoses.
LP rarely yields an organism, and blood cultures infrequently are positive. ED-based diagnosis can be made by
contrast CT of the brain, although magnetic resonance imaging (MRI) will better delineate brainstem and
cerebellar abscesses. Early neurosurgical intervention is critical. Empiric antibiotics should be broad-spectrum
antibiotics with CNS penetrance covering staphylococci, streptococci, and anaerobes. One regimen would be
vancomycin, cefotaxime, and metronidazole, all at meningitic doses. Standard precautions should be used.

Acute Flaccid Paralysis
Acute flaccid myelitis (AFM) has historically been caused by polio, transmitted via the fecal–oral route. Polio is

now only endemic in Afghanistan and Pakistan. More recently, other enteroviruses (A71, D68), adenovirus,
herpesviruses, and flaviviruses have been causing AFM on an every-other-year pattern. A prodromal upper
respiratory tract infection, with or without pyrexia, is often noted within 4 weeks of the development of acuteonset extremity weakness. MRI shows gray matter spinal cord lesions and a CSF pleocytosis often is noted. The
differential diagnosis includes acute transverse myelitis and Guillain–Barré syndrome. In addition to routine
studies on CSF, PCR for enteroviruses, EBV, CMV, HSV, and arboviruses should be considered.
Sinusitis
Sinusitis is an inflammation of the paranasal sinuses. While the ethmoid and maxillary sinuses are present at birth,
the frontal and sphenoid sinuses do not develop until children are school aged. The most common etiologies mimic
those causing acute otitis media and include pneumococcus, nontypeable H. influenzae, Moraxella, and GAS. The
most common signs and symptoms of acute sinusitis are listed in e-Table 94.3 . Children with chronic sinusitis
can have milder, more indolent symptoms, such as cough that is often worse when the child is supine and
rhinorrhea; pyrexia is less common in this group of children, and physical examination often is normal. The
diagnostic criteria are summarized in
e-Table 94.4 . Complications of sinusitis include orbital cellulitis, brain
abscess, epidural or subdural empyema, and cavernous sinus thrombosis.
Most sinusitis is managed solely with medical therapy in the outpatient setting. Amoxicillin (80 to 90
mg/kg/day) remains the mainstay of therapy; a 10-day course is recommended for most cases of uncomplicated
acute sinusitis. Two- to 3-week courses may be needed for chronic sinusitis or for immunocompromised or