Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Brain Abscess
Glenn E. Mathisen and J. Patrick Johnson From the Infectious Disease Service, UCLA–Olive View Medical
Center, Sylmar, and the UCLA Neurosurgery Service, UCLA Center for
Health Sciences, Los Angeles, California
Before the late 1800s, brain abscess was an almost uniformly antimicrobial therapy. The brain is remarkably resistant to bac-
fatal condition that was rarely diagnosed before autopsy. The terial and fungal infection; brain abscesses in humans are quite
pioneering work of the English surgeon William Macewan led uncommon despite the frequency of both overt and occult bac-
to remarkable breakthroughs in the treatment of this condition teremia. This resistance is due in part to the brain’s abundant
[1]. With an improved knowledge of cranial surgical anatomy blood supply and the relatively impermeable blood-brain bar-
and the development of new surgical techniques, he showed rier formed by the capillary-endothelial tight junctions. A simi-
that selected patients could be cured with drainage of the ab- lar situation is seen by researchers working with experimental
* Suggested antimicrobial therapy for initial empiric treatment; antibiotic selection will vary depending on clinical situation and culture results.
†
Recommended antibiotic dosages for a 70-kg patient (dosing may need adjustment in patients with underlying renal or liver disease): penicillin, 2 – 4 million
units iv q4h; metronidazole, 500 mg iv q6h; cefotaxime, 1 – 2 g iv q4 – 8h (maximum dose, 12 g/d); ceftazidime, 1 – 2 g iv q4 – 8h (maximum dose, 12 g/d);
nafcillin, 2 g iv q4h; vancomycin, 1 g iv q12h.
‡
Demonstrated efficacy in two studies with limited numbers of patients.
Experimental models of brain abscess have increased our important in subsequent discussions about antimicrobial ther-
understanding of the neuropathology and the clinical evolution apy and the timing (and nature) of surgical intervention.
of these lesions. With use of CT scanning techniques, a series
of stages has been described that parallels the human situation
[9]. In the ‘‘early cerebritis stage’’ (days 1 – 3), direct inocula- Clinical Presentation
tion of organisms into brain parenchyma leads to a focal area
of inflammation and edema. Expansion of the cerebritis and The clinical presentation of brain abscess is influenced by a
the beginning development of a necrotic central focus are seen number of factors including the size and location of the abscess,
in the ‘‘late cerebritis stage’’ (days 4 – 9). The establishment the virulence of the infecting organism(s), and the presence of
of a ring-enhancing capsule of well-vascularized tissue with any underlying systemic conditions. In a typical case of pyo-
early appearance of peripheral gliosis and/or fibrosis is seen in genic brain abscess, headache is clearly the most common
the ‘‘early capsule stage’’ (days 10 – 14). Finally, during the presenting symptom and is seen in almost all patients who are
‘‘late capsule stage’’ (beyond day 14), host defenses act to able to give a history. The nature of the headache has no
wall off the abscess, and a well-formed capsule develops. Al- particular distinguishing features, although it is often character-
though the mechanisms and timing of these events in humans ized by a dull aching that is poorly localized. This initial,
may be different, findings with use of modern scanning tech- somewhat nonspecific presentation accounts for the frequent
niques suggest a similar progression, and these insights are delays in diagnosis and the difficulty in distinguishing early
it a less attractive agent for first-line therapy. Metronidazole for CNS infections should probably be limited to the treatment
has an excellent pharmacokinetic profile, with good oral ab- of brain abscess due to more-resistant pathogens when few
sorption and excellent penetration into CSF and brain abscess other therapeutic options are available. Meropenem is a new
cavities [32]. Metronidazole’s excellent bactericidal activity carbapenem antimicrobial that is related to imipenem. It has a
against strict anaerobes makes it an important component of similar broad antimicrobial spectrum and is reportedly associ-
most antimicrobial regimens for brain abscess. It should be ated with a lower incidence of neurotoxicity. A recent case
used in combination with an antibiotic active against microaer- report documented its use in the successful treatment of an
ophilic streptococci (e.g., penicillin), since polymicrobial infec- Enterobacter cloacae brain abscess in a 7-year-old child with
tion is common in cases of brain abscess, and streptococci and leukemia [44]. Although limited data are available, meropen-
aerotolerant anaerobes are resistant to metronidazole. Since em’s usefulness in the treatment of bacterial meningitis sug-
neurotoxic side effects (seizure, somnolence, and peripheral gests that the drug may play a useful role in therapy for brain
neuropathy) may occasionally occur during therapy with metro- abscess, particularly in cases due to more-resistant pathogens
nidazole, careful attention should be paid to dosing in patients [45]. Additional studies are needed before it can be recom-
with hepatic failure. mended for routine cases.
The specific role of the newer antimicrobial agents in the Quinolones have good CNS penetration and have shown
management of brain abscess is evolving, but recent studies excellent antibacterial activity against gram-negative faculta-
suggest that these drugs may be acceptable alternatives in many tive anaerobes such as Enterobacteriaceae and Pseudomona-
penetration, if possible, and selection of the antibiotic(s) should For the freehand procedure, a preoperative CT scan must
be based on available culture and susceptibility results. Follow- be obtained to initially plan localization with the placement
up should include clinical examinations and serial CT or MRI of scalp markers over the approximate location of the abscess.
scans (obtained bimonthly or monthly) to document resolution A repeated scan obtained with the scalp markers in place
of the abscess. Although most lesions completely disappear allows exact localization of the underlying lesion. The scalp
when therapy is prolonged, a small area of enhancement on overlying the abscess is prepared sterilely, and a small inci-
the CT scan may remain despite adequate therapy [17]. sion is infiltrated with local anesthetic. A 5-mm incision is
There have been a number of more-recent case reports dem- made precisely over the abscess, and a twist drill (4 – 5 mm
onstrating successful nonoperative treatment of brain abscess bore) is used to make a small hole in the cranium, just deep
with antibiotics alone [47 – 49]. This approach may be appro- enough to penetrate the dura. A 13-gauge (3-mm bore) Field-
priate for clinically stable patients who are poor candidates for Lee brain-biopsy needle is placed through the incision, paral-
surgery or for patients with surgically inaccessible lesions. lel to the plane of the CT scanner, and advanced a predeter-
Small lesions (õ2 cm) located in the better-vascularized corti- mined distance (measured on the CT monitor) into the abscess
cal areas are more likely to respond to antibotics alone [50, cavity. The exact position of the biopsy needle in the abscess
51]. The major drawbacks to this approach appear to be the is confirmed by obtaining a repeated CT scan through the
uncertainties (and potential toxicities) involved in prolonged area of interest. The biopsy needle can be repositioned or
administration of empirical antimicrobial therapy and the possi- redirected if necessary.
into the abscess cavity for postsurgical drainage and antibiotic large abscesses located close to the ventricular system may
irrigation [57, 58]; however, this procedure is probably not benefit from early surgical intervention to prevent intraven-
necessary in most cases, given the current availability of more tricular rupture.
powerful antimicrobial therapy. Intracavitary administration of Adjunctive therapy. The use of corticosteroids to control
antimicrobials may be of value only in patients with large, the cerebral edema associated with brain abscess has not been
poorly resolving abscesses that remain culture positive despite studied in humans in a well-controlled, randomized clinical
the administration of parenteral therapy [57, 59]. Intracavitary trial. Studies of the use of corticosteroids in experimental ani-
amphotericin B may also be of use for the treatment of fungal mal models of brain abscess have provided potentially conflict-
brain abscess [60]. ing results. An early study of corticosteroid use in a model of
Recent studies suggest that needle aspiration is as effective S. aureus brain abscess showed that administration of dexa-
as abscess excision in the management of most cases of brain methasone interfered with granulation tissue formation as well
abscess [13, 55, 61]. In the modern era, most patients can as bacterial clearance [62]. A later study showed that the use
be treated initially with closed-needle aspiration, and surgical of corticosteroids tended to reduce the concentration of certain
excision can be reserved for abscesses that fail to resolve or polar antibiotics (e.g., benzylpenicillin) in infected tissue [63];
that are caused by resistant pathogens. more-lipophilic antimicrobials (e.g., metronidazole) were not
The availability of CT scanning and modern stereotactic affected by corticosteroid use.
techniques has greatly enhanced the detection of multiple A more recent trial on the effect of dexamethasone in experi-
be continued for longer periods is a question that is difficult often afebrile, and neurological signs and symptoms may be
to answer. more suggestive of tumor or demyelinating disease. The classic
For patients followed up for long periods (£30 years in one findings of a well-defined brainstem syndrome are frequently
study), the incidence of subsequent seizures approached 70% lacking because the abscess is more likely to extend longitudi-
[66]. We currently recommend that patients undergo neurologi- nally along fiber tracts in the brainstem rather than expand
cal evaluations several months after antibiotic treatment of the transversely. The microbiology of brainstem abscesses is simi-
abscess is completed and the symptoms have resolved. If the lar to that of cortical pyogenic abscesses. In countries with a
results of an electroencephalogram are normal, consideration high prevalence of tuberculosis, there is an increased incidence
can be given to slow withdrawal of medication, with close of brainstem abscess due to Mycobacterium tuberculosis [69].
observation for the recurrence of seizures. Patients whose elec- This entity is quite rare in developed countries but should be
troencephalograms are markedly abnormal should probably considered in patients from areas where tuberculosis is en-
continue taking medication indefinitely. These decisions should demic. Brainstem infection with organisms such as Listeria
be made in consultation with a neurologist and neurosurgeon monocytogenes and Propionibacterium acnes may produce
who are observing the patient. Although some authors have brainstem encephalitis (rhomboencephalitis) that closely mim-
suggested that the incidence of seizures is higher among pa- ics a brainstem abscess [70].
tients who have undergone open craniotomy with abscess exci- MRI scanning is essential for the diagnosis of brainstem
sion (rather than needle aspiration), more recent series have abscess because MRI scanning is the best technique for imaging
Enterobacteriaceae species) [73], anaerobes [27], and Nocardia diversus, Proteus species, Serratia marcescens, or Enterobac-
species [74] may also be recovered. Abscesses that develop ter species) is infrequent, it is associated with concomitant
following trauma are frequently multiloculated and may con- brain abscess in a high percentage (ú75%) of cases [88 – 90].
tain foreign bodies such as bone fragments, scalp hair, or other The risk of brain abscess is sufficiently increased that children
debris introduced at the time of injury. These features make it should be evaluated for brain abscess if they develop bacter-
difficult to cure this condition with antimicrobial therapy and emia or meningitis with these organisms. This condition has a
needle aspiration alone. Most cases require open craniotomy high associated mortality (ú75%), and the majority of survi-
with abscess excision or debridement to effect a cure [26]. vors have significant long-term intellectual impairment. The
A special type of posttraumatic brain abscess occurs in chil- management of these cases requires aggressive surgical drain-
dren who develop frontal lobe abscess following penetrating age in addition to antimicrobial therapy.
orbital trauma from pencils or wooden toys. The seriousness Cyanotic congenital heart disease (CCHD) is a significant
of these injuries often goes unrecognized, since healing of the predisposing factor for brain abscess in children and accounts
external wound over the eye occurs rapidly, and the possibility for 6% – 50% of cases in published series [91]. The highest
of brain injury is initially overlooked [75, 76]. The superior incidence of this complication appears to be among children
orbital roof is very thin and affords little resistance to a pene- with cardiac defects such as tetratology of Fallot or transposi-
trating injury into the frontal lobe. There is a high frequency tion of the great vessels; however, any condition resulting in
of subsequent brain abscess because foreign bodies introduced a significant right-to-left shunt appears to increase the risk.
rounding vasogenic edema than are similar lesions in noncom- Mucormycosis is an infection due to fungi of the order Mu-
promised patients. This lack of ring enhancement on CT scan- corales, including Mucor species, Rhizopus species, and Ab-
ning is believed to be an indication of an inadequate sidia species, and is typically seen in patients with diabetic
inflammatory response and a poor prognostic factor [19, 96]. ketoacidosis, patients receiving corticosteroids, intravenous
In general, CNS fungal infection in immunocompromised pa- drug users, and patients who are severely immunocompromised
tients is associated with a high mortality rate despite aggressive with prolonged neutropenia [105]. In diabetic patients with
surgery and antifungal therapy. Nevertheless, early recognition rhinocerebral mucormycosis (diabetic ketoacidosis, orbitofacial
of this infection can lead to successful treatment, particularly cellulitis, or nasal eschar), extension of the Mucor species from
if leukocyte counts return to normal or the dosage of immuno- infected sinuses into the vasculature of the cavernous sinus
suppressive agents can be reduced. region and frontal lobes typically produces localized cerebral
Aspergillus species are the most common cause of fungal infarcts. A fungal brain abscess or cerebritis is a common
brain abscess in transplant recipients and other severely immu- complication of this process, especially in patients who survive
nosuppressed patients [94, 95, 97]. Although the course of for any length of time. The presentation of mucormycosis in
the disease may be subacute or chronic in some cases, CNS patients with lymphoma or leukemia may be similar; however,
aspergillosis is usually characterized by rapid progression and CNS signs may be overshadowed by more widespread pulmo-
a high mortality rate [98]. Because of the organism’s propensity nary, cutaneous, or gastrointestinal involvement in these pa-
to cause vascular thrombosis, a clinical presentation suggesting tients [106].
should be made to identify all potential pathogens. When infec- corticosteroids or transplant patients), ú50% of patients have
tion due to these organisms presents as a brain abscess, surgical no apparent predisposing risk factor [131]. The signs and symp-
excision and aggressive antifungal therapy are usually required toms of cerebral nocardiosis can sometimes be subtle; however,
to achieve a cure. all patients with suspected pulmonary nocardia infection should
Tuberculosis. M. tuberculosis is a rare cause of brain undergo brain imaging to rule out subclinical CNS disease.
abscess; however, this organism should be considered in The presence of cavitary lung lesions in patients at risk for
patients with disseminated tuberculosis or in individuals nocardiosis should prompt aggressive attempts to obtain spu-
from areas where tuberculosis is endemic. Changes in public tum samples to help confirm the presence of the disease. Nocar-
health policies during the 1970s and the emergence of the dia species can be difficult to culture, and they grow relatively
AIDS epidemic have led to a resurgence in all forms of CNS slowly on conventional media. If nocardiosis is suspected, the
tuberculosis, including tuberculomas and tuberculous brain laboratory should be notified so that proper measures can be
abscess [119 – 121]. A tuberculoma is not considered a true taken to isolate the organism.
abscess; it is a focal mass of dense granulomatous inflamma- The therapy for nocardia infections is difficult because pa-
tory tissue that contains epithelioid cells and giant cells. A tients frequently lack adequate immunologic defenses and the
tuberculous brain abscess (TBA) is a focal collection of pus organism is relatively resistant to many antimicrobials. Oral
containing abundant acid-fast bacilli (AFB) surrounded by sulfadiazine (6 – 12 g/d) remains the treatment of choice for
a dense capsule consisting of vascular granulation tissue. most patients. The combination trimethoprim-sulfamethoxa-
Brain abscess in patients with AIDS. HIV testing should on a brain scan, in association with an appropriate exposure
be considered for all patients with unexplained cerebral mass history, should allow differentiation of these lesions from pyo-
lesions. The most common cause of a brain mass in patients genic brain abscess in most cases [151]. Serology (e.g., ELISA)
with AIDS is toxoplasmosis, and antimicrobial therapy (e.g., is quite sensitive and fairly specific for this condition and is of
pyrimethamine/sulfadiazine or pyrimethamine/clindamycin) additional help in confirming the diagnosis. On rare occasions,
should be started pending results of serological testing [140]. parasitic larvae from organisms such as Strongyloides stercor-
Patients who fail to respond to therapy or have negative serol- alis or Ascaris lumbricoides that are migrating through the
ogies may still have toxoplasmosis but should be reevaluated brain may cause a brain abscess, particularly if the larvae are
for the presence of other infections or CNS neoplasms. In this colonized with intestinal bacteria [152]. Although extremely
situation, consideration should be given to performing CT- rare, such a phenomenon may account for some otherwise
guided needle aspiration for establishing a definitive diagno- inexplicable cases [153].
sis. Although radiographic patterns may suggest specific
pathogens, there is considerable overlap, and it may be diffi-
cult to differentiate toxoplasmosis from other pyogenic pro- Outcome
cesses [141]. The most successful predictor of clinical outcome for pa-
Patients with AIDS will occasionally develop brain abscess tients with brain abscess is the extent of neurological compro-
due to the common bacterial pathogens [142, 143]; however, mise at the time of presentation and diagnosis. The mortality
4. Chen S-T, Tang L-M, Ro L-S. Brain abscess as a complication of stroke. 29. Kramer PW, Griffith RS, Campbell RL. Antibiotic penetration of the
Stroke 1995; 26:696 – 8. brain: a comparative study. J Neurosurgery 1969; 31:295 – 302.
5. Bert F, Maubec E, Gardye C, Branger C, Lambert-Zechovsky N. Staphy- 30. De Louvois J, Gortvai P, Hurley R. Antibiotic treatment of abscesses of
lococcal brain abscess following hematogenous seeding of an intrace- the central nervous system. Br Med J 1977; 2:985 – 7.
rebral hematoma [letter]. Eur J Clin Microbiol Infect Dis 1995; 14: 31. Levy RM, Gutin PH, Baskin DS, Pons VG. Vancomycin penetration of
366 – 7. a brain abscess: case report and review of the literature. Neurosurgery
6. Shimomura T, Hori S, Kasai N, Tsuruta K, Okada H. Meningioma associ- 1986; 18:632 – 6.
ated with intratumoral abscess formation — case report. Neurol Med 32. Ingham HR, Selkon JB. Metronidazole and brain abscess [letter]. Lancet
Chir (Tokyo) 1994; 34:440 – 3. 1982; 2:613 – 4.
7. Saba MI. Surgical management of missile injuries of the head. In: Schmi- 33. Sjölin J, Ericksson N, Arneborn P, Cars O. Penetration of cefotaxime
dek HH, Sweet WH, eds. Operative neurosurgical techniques. Vol. 1. and desacetylcefotaxime into brain abscesses in humans. Antimicrob
3rd ed. Philadelphia: W.B. Saunders, 1995:89 – 104. Agents Chemother 1991; 35:2606 – 10.
8. Dethy S, Manto M, Kentos A, et al. PET findings in a brain abscess 34. Sjölin J, Lilja A, Eriksson N, Arneborn P, Cars O. Treatment of brain
associated with a silent atrial septal defect. Clin Neurol Neurosurg abscess with cefotaxime and metronidazole: prospective study on 15
1995; 97:349 – 53. consecutive patients. Clin Infect Dis 1993; 17:857 – 63.
9. Britt RH, Enzmann DR, Yeager AS. Neuropathological and computerized 35. Gómez J, Poza M, Martinez M, Martinez-Lage J, Hernández JL, Valdés
tomographic findings in experimental brain abscess. J Neurosurg 1981; M. Use of cefotaxime and metronidazole for treating cerebral ab-
55:590 – 603. scesses. [letter]. Clin Infect Dis 1995; 21:708.
10. Zeidman SM, Geisler FH, Olivi A. Intraventricular rupture of a purulent 36. Yamamoto M, Jimbo M, Ide M, Tanaka N, Umebara Y, Hagiwara S.
brain abscess: case report. Neurosurgery 1995; 36:189 – 93. Penetration of intravenous antibiotics into brain abscesses. Neurosur-
52. Itakura T, Yokote H, Ozaki F, Itatani K, Hayashi S, Komai N. Stereotactic 77. Miller, CF II, Brodkey JS, Colombi BJ. The danger of intracranial wood.
operation for brain abscess. Surg Neurol 1987; 28:196 – 200. Surg Neurol 1977; 7:95 – 103.
53. Lunsford LD. Stereotactic drainage of brain abscesses. Neurol Res 1987; 78. Green BF, Kraft SP, Carter KD, Buncic JR, Nerad JA, Armstrong D.
9:270 – 4. Intraorbital wood: detection by magnetic resonance imaging. Ophthal-
54. Stapleton SR, Bell BA, Uttley D. Stereotactic aspiration of brain ab- mology 1990; 97:608 – 11.
scesses: is this the treatment of choice? Acta Neurochir (Wien) 1993; 79. Woods CR Jr. Brain abscess and other intracranial suppurative complica-
121:15 – 9. tions. Adv Pediatr Infect Dis 1995; 10:41 – 79.
55. Mampalam TJ, Rosenblum ML. Trends in the management of bacterial 80. Brook I. Brain abscess in children: microbiology and management. J
brain abscesses: a review of 102 cases over 17 years. Neurosurgery Child Neurol 1995; 10:283 – 8.
1988; 23:451 – 8. 81. Singh B, Maharaj TJ. Radical mastoidectomy: its place in otitic intracran-
56. Laborde G, Klimek L, Harders A, Gilsbach J. Frameless stereotactic ial complications. J Laryngol Otol 1993; 107:1113 – 8.
drainage of intracranial abscesses. Surg Neurol 1993; 40:16 – 21. 82. Rosenfeld EA, Rowley AH. Infectious intracranial complications of si-
57. Broggi G, Franzini A, Peluchetti D, Servello D. Treatment of deep brain nusitis, other than meningitis, in children: 12-year review. Clin Infect
abscesses by stereotactic implantation of an intracavitary device for Dis 1994; 18:750 – 4.
evacuation and local application of antibiotics. Acta Neurochir (Wien) 83. Johnson DL, Markle BM, Wiedermann BL, Hanahan L. Treatment of
1985; 76:94 – 8. intracranial abscesses associated with sinusitis in children and adoles-
58. Mahmood A, Abad RM, Updegrove JH. Brain abscess treated by continu- cents. J Pediatr 1988; 113:15 – 23.
ous antibiotic perfusion: technical note. Neurol Res 1993; 15:63 – 7. 84. Yen P-T, Chan S-T, Huang T-S. Brain abscess: with special reference
59. Gentile G, Vagnozzi R, Giuffre R, Venditti M, Martino P. Instillation of to otolaryngologic sources of infection. Otolaryngol Head Neck Surg
metronidazole into a brain abscess cavity [letter]. Eur J Clin Microbiol 1995; 113:15 – 22.
102. Haruda F, Bergman MA, Headings D. Unrecognized candida brain ab- 126. Schutte C-M, Van der Meyden CH, Labuscagne JH, Otto D. Lymph node
scess in infancy: two cases and a review of the literature. Johns Hopkins biopsy as an aid in the diagnosis of intracranial tuberculosis. Tuber
Med J 1980; 147:182 – 5. Lung Dis 1996; 77:285 – 6.
103. Kamitsuka MD, Nugent NA, Conrad PD, Swanson TN. Candida albicans 127. Monno L, Angarano G, Romanelli C, et al. Polymerase chain reaction for
brain abscesses in a premature infant treated with amphotericin B, non-invasive diagnosis of brain mass lesions caused by Mycobacterium
flucytosine and fluconazole. Pediatr Infect Dis J 1995; 14:329 – 31. tuberculosis: report of five cases in human immunodeficiency virus –
104. Epelbaum S, Laurent C, Morin G, Berquin P, Piussan C. Failure of positive subjects. Tuber Lung Dis 1996; 77:280 – 4.
fluconazole treatment in Candida meningitis [letter]. J Pediatr 1993; 128. Ildan F, Gürsoy F, Gül B, Boyar B, Kihiç C. Intracranial tuberculous
123:168. abscess mimicking malignant glioma. Neurosurg Rev 1994; 17:
105. Sugar AM. Mucormycosis. Clin Infect Dis 1992; 14(suppl 1):S126 – 9. 317 – 21.
106. Nussbaum ES, Hall WA. Rhinocerebral mucormycosis: changing patterns 129. Filice GA, Simpson GL. Management of Nocardia infections. Curr Clin
of disease. Surg Neurol 1994; 41:152 – 6. Top Infect Dis 1984; 5:49 – 64.
107. Bañuelos AF, Williams PL, Johnson RH, et al. Central nervous system 130. Lerner PI. Nocardiosis. Clin Infect Dis 1996; 22:891 – 905.
abscesses due to Coccidioides species. Clin Infect Dis 1996; 22: 131. Mamelak AN, Obana WG, Flaherty JF, Rosenblum ML. Nocardial brain
240 – 50. abscess: treatment strategies and factors influencing outcome. Neuro-
108. Roos KL, Bryan JP, Maggio WW, Jane JA, Scheld WM. Intracranial surgery 1994; 35:622 – 31.
blastomycoma. Medicine (Baltimore) 1987; 66:224 – 35. 132. Overkamp D, Waldmann B, Lins T, Lingenfelser T, Petersen D, Eggstein
109. Walpole HT, Gregory DW. Cerebral histoplasmosis. South Med J 1987; M. Successful treatment of brain abscess caused by Nocardia in an
80:1575 – 7. immunocompromised patient after failure of co-trimoxazole. Infection
110. Venger BH, Landon G, Rose JE. Solitary histoplasmoma of the thala- 1992; 20:365 – 6.
148. Solari A, Saavedra H, Sepúlveda G, et al. Successful treatment of Trypa- Rosenblum ML, Mampalam TJ, Pons VG. Controversies in the management
nosoma cruzi encephalitis in a patient with hemophilia and AIDS. Clin of brain abscess. In: Little J, ed. Clinical neurosurgery. Baltimore: Williams
Infect Dis 1993; 16:255 – 9. and Wilkins, 1986:603 – 32.
149. Ohnishi K, Murata M, Kojima H, Takemura N, Tsuchida T, Tachibana Swartz MN. Central nervous system infections. In: Finegold SM, ed. Anaerobic
H. Brain abscess due to infection with Entamoeba histolytica. Am J infections in humans. San Diego: Academic Press, 1989:155 – 212.
Trop Med Hyg 1994; 51:180 – 2. Wispelwey B, Dacey RG, Scheld WM. Brain abscess. In: Scheld WM, Whitley
150. Campbell S. Amebic brain abscess and meningoencephalis. Semin Neurol RJ, Durack DT, eds. Infections of the central nervous system. 2nd ed.
1993; 13:153 – 60. Philadelphia: Lippincott-Raven, 1997:463 – 93.
151. White AC Jr. Neurocysticercosis: a major cause of neurological disease
worldwide. Clin Infect Dis 1997; 24:101 – 15.
152. Masdeu JC, Tantulavanich S, Gorelick PP, et al. Brain abscess caused
by Strongyloides stercoralis. Arch Neurol 1982; 39:62 – 3.
The ‘‘Conflict-of-Interest Policy’’ of the Office of Con-
153. Kean BH. One doctor’s adventures among the famous and infamous from tinuing Medical Education, UCLA School of Medicine,
the jungles of Panama to a Park Avenue practice. New York: Ballantine requires that faculty participating in a CME activity dis-
Books, 1990:316 – 26. close to the audience any relationship with a pharmaceu-
tical or equipment company which might pose a poten-
Additional Reading
tial, apparent, or real conflict of interest with regard to
their contribution to the program. The author reports no
Pauker SG, Kopelman RI. A rewarding pursuit of certainty. N Engl J Med
conflict of interest.
1993; 329:1103 – 7.