Pediatric Brain Abscesses, Epidural Empyemas, and Subdural Empyemas Associated With Streptococcus Species

Abbreviations: ED = emergency department; MRSA = methicillin-resistant Staphylococcus aureus; RSV = respiratory syncytial virus; URI = upper respiratory infection.
*Percentages calculated using nonmissing data.
^†Other underlying conditions included: Alice in Wonderland syndrome (i.e., dysmetropsia, a rare neurologic disorder characterized by distortions in perception, especially of body image); allergies (seasonal, nonseasonal, and peanut); autism; Castleman disease; cerebral palsy (including spastic quadriplegic); cerebral infarction; chronic nasal congestion; cystic encephalomalacia; epilepsy; frequent nosebleeds; gallstone pancreatitis; global developmental delay; Hashimoto disease; headaches, insomnia; intellectual disability; microcephaly; migraines; MRSA infection; myringotomy tubes; neurofibromatosis type 1; nonaccidental trauma to child; oropharyngeal dysphagia; retinal hemorrhage of both eyes; right spastic hemiparesis; sinusitis; snoring; traumatic brain injury at birth; and Trisomy 21.
^§Including COVID-19, influenza, sinusitis, upper respiratory infection, and other respiratory infections.
^¶Other respiratory infections included otitis media (five); parainfluenza (two); cough and fever of unspecified cause (one); URI symptoms but no diagnosis (one); RSV (one); and otitis externa (one).
**In ED, outpatient primary care, or urgent care.
^††Viral respiratory pathogens detected during hospitalization included: SARS-CoV-2 (nine), rhinovirus/enterovirus (four), RSV (two), influenza virus (one), adenovirus (one), and parainfluenza virus (one).
^§§ Actinomyces sp. (one), Clostridium sp. (one), Candida parapsilosis (one), Cutibacterium acnes (one), Haemophilus influenzae (one), Klebsiella pneumoniae (one), Mycoplasma hominis (one), Staphylococcus capitis (one), Staphylococcus hominis (one), Gemella morbillorum (one), and unspecified streptococci (three).
^¶¶Orbital abscess (two), forehead abscess (one), middle meatus (one), ear aspirate (two), and sinuses (eight).

Authors and Disclosures

Emma K. Accorsi, PhD^1,2, Sopio Chochua, MD, PhD¹, Heidi L. Moline, MD^1,2, Matt Hall, PhD³, Adam L. Hersh, MD, PhD⁴, Samir S. Shah, MD⁵, Amadea Britton, MD^1,2, Paulina A. Hawkins, MPH¹, Wei Xing, MSTAT¹, Jennifer Onukwube Okaro, MPH¹, Lindsay Zielinski, DO^1,2, Lesley McGee, PhD¹, Stephanie Schrag, DPhil¹ and Adam L. Cohen, MD<sup>1

1</sup>Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC; ²Epidemic Intelligence Service, CDC; ³Children's Hospital Association, Lenexa, Kansas; ⁴Department of Pediatrics, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah; ⁵Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Corresponding author
Emma K. Accorsi, vgi0@cdc.gov.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Adam L. Hersh reports grants from the Agency for Health Research and Quality, participation on the National Institutes of Health Data and Safety Monitoring Board, and leadership or fiduciary roles in the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Lesley McGee reports support from the American Society for Microbiology and the International Symposium on Pneumococci and Pneumococcal Diseases for attending meetings and travel. Samir S. Shah reports grants from the Patient Centered Outcomes Research Institute and Children's Hospital Association. No other potential conflicts of interest were disclosed.

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Summary

What is already known about this topic?

Recent reports have suggested a possible increase in pediatric streptococcal brain abscesses, epidural empyemas, and subdural empyemas.

What is added by this report?

After a decline in cases at the onset of the COVID-19 pandemic, cases increased during summer 2021, peaked in March 2022, and then declined to baseline levels. Clinical presentation and microbiological features were stable during this period.

What are the implications for public health practice?

Initial reports from clinicians are consistent with seasonal fluctuations and a redistribution of cases over time during the COVID-19 pandemic. No evidence of increased case severity, genetic relatedness of streptococcal isolates from different cases, or increased antimicrobial resistance was identified. Epidemiologic monitoring is continuing.

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