The Centers for Disease Control and Prevention is examining a cluster of rare and serious brain abscesses in children in and around Las Vegas, Nevada, and doctors from other regions of the country are reporting an increase in cases as well. In 2022, the number of brain abscesses in children in Nevada increased, from four to five per year to 18.
“In my 20 years’ experience, I’ve never seen anything like it,” said Dr. Taryn Bragg, an associate professor at the University of Utah who treated the cases.
Pediatric neurosurgeons like Bragg are in short supply. She is the only one in Nevada, and because she treated all of the cases, she was the first to detect the trend and warn local public health officials.
“After March of 2022, there was just a huge increase,” in brain abscesses, Bragg said. “I was seeing large numbers of cases and that’s unusual.”
“And the similarities in terms of the presentation of cases was striking,” Bragg said.
Doctors across the US report rise in brain abscesses in children
In almost every case, children would present with a common childhood symptom, such as an earache or a sinus infection, along with a headache and fever, but within a week, it became evident that something more serious was going on, according to Bragg.
Doctors from other parts of the country stated they are finding similar rises in brain abscesses in children after hearing a presentation on the Nevada cases at the Epidemic Intelligence Service Conference on Thursday.
“We’re just impressed by the number of these that we’re seeing right now,” said Dr. Sunil Sood, a pediatric infectious disease expert at Northwell Health, a New York-based healthcare facility. He believes they are seeing at least twice as many as usual, though no formal count has been conducted. He asked the CDC to continue its investigation and spread the message.
Brain abscesses are not reportable conditions in and of themselves, thus clinicians are not compelled to notify public health departments when they encounter them. They usually come to the attention of public health officials only when doctors notice an increase and contact them.
Disease investigators are on the case.
Brain abscesses are infected pus-filled pockets that progress to the brain. Seizures, visual abnormalities, or changes in vision, speech, coordination, or balance can all result from them. The first signs are headaches and intermittent fever. Abscesses frequently necessitate many surgeries, and children may spend weeks or even months in the hospital recovering after having one.
In the Clark County cluster, about three-quarters of the cases were in boys, with the majority being around the age of twelve. Dr. Jessica Penney is a CDC Epidemic Intelligence Service officer, or “disease detective,” assigned to the Southern Nevada Health District, which investigated the cases. On Thursday, she presented her findings from the Clark County cluster at the CDC’s annual Epidemic Intelligence Service meeting.
Penney said that in order to determine what was causing the spike, they looked at a variety of criteria, including travel, a history of Covid-19 infection, underlying health, and any shared activities or exposures, but they found nothing that linked the cases. Then, she claims, they decided to go back in time, searching for brain abscess cases in children under the age of 18 dating back to 2015.
“I felt like that helped us get a better sense of what might be contributing to it,” Penney said in an interview with CNN.
According to Penney, the number of instances of brain abscesses in Clark County remained relatively stable between 2015 and 2020, at roughly four per year. In 2020, the number of brain abscesses in children decreased, most likely due to efforts such as social distancing, school closures, and masking, all of which slowed the spread of respiratory diseases other than Covid-19. As restrictions began to be lifted in 2021, the number of these events returned to normal levels, followed by a large spike in 2022.
Is there a link to the pandemic?
“So the thoughts are, you know, maybe in that period where kids didn’t have these exposures, you’re not building the immunity that you would typically get previously, you know with these viral infections,” Penney said. “And so maybe on the other end when we you had these exposures without that immunity from the years prior, we saw a higher number of infections.”
This is known as the immunity debt theory. A number of dangerous children’s diseases, such as invasive group A strep, have recently witnessed extraordinary rises, according to doctors. Some believe that because children were not exposed to the number of viruses and bacteria they would normally encounter during the pandemic, their immune systems were less able to fight infections.
Sood is not convinced that there is some sort of immunity debt at work. Instead, he believes Covid-19 temporarily displaced other infections, effectively crowding them out. Now that Covid-19 cases have decreased, he believes that other childhood infections are on the rise, citing an unprecedented increase in RSV cases last fall and winter as an example.
According to Sood, brain abscesses occur in a very tiny percentage of children who have sinus infections or inner ear infections. The number of brain abscesses has increased proportionally to the growth of those infections.
Causes and risk factors for brain abscesses in children
If a lack of immunity or a higher infection burden were to blame, it stands to reason that brain abscesses would have increased in other regions as well. Last year, the CDC worked with the Children’s Hospital Association to find and count brain abscesses in kids, to see if there was any sort of national spike. According to research released in the Morbidity and Mortality Weekly Report last fall, data collected until May 2022 did not show any form of broad increase.
However, Bragg believes that the study’s data cutoff was too early. She claims that incidents in her area really took up in the spring of 2022. She said the CDC is still collecting data on brain abscesses and analyzing local and national patterns.
A third of the brain abscesses in the Clark County cluster were caused by Streptococcus intermedius, a form of bacteria that ordinarily lives harmlessly in the nose and mouth, where the human immune system keeps it in check. However, when it gets into places it shouldn’t, such as the blood or the brain, it can cause problems. That can happen after dental work, for example, or if someone has an underlying health condition like diabetes that weakens their immunity.
That was not the case for the children in the Clark County cluster
“These are healthy children. With no prior significant medical history that would make them more prone…there wasn’t any known immunosuppression or anything like that,” Bragg says.
Sood notes that, like the incidents in Clark County, the majority of the children they are seeing are older, in grade school and middle school. He claims that until children reach this age, their nasal cavities are immature and haven’t fully formed. This may render them especially susceptible to infection. He fears that these little areas will fill with pus and rupture. When this occurs above the brow or behind the ear, where the barrier between the brain and the sinuses is thinner, the infection can spread to the brain.
According to Sood, the symptoms of a sinus infection in children might be subtle, and parents aren’t usually aware of what to look for. If a child has a cold or a congested nose and then wakes up the next day with a red and swollen eye, or an eye that is swollen shut, it is best to seek medical assistance. They may also complain of a headache and point to the area above their brow as the source of their discomfort.
Keep an eye out for new cases
Bragg says she’s treated two more children with brain abscesses in 2023, but the number of new cases appears to be slowing – or so she hopes. To clear their infections, several of the youngsters she treated required multiple brain and head, and neck procedures.
Sood says doctors in his hospital have a woman who has been there for two to three months and has had five procedures, but he describes her as an extreme case. According to Penney, the CDC is keeping a close eye on the situation.
“We’re going to continue to monitor throughout the year working very closely with our community partners to see you know what, what happens down in Southern Nevada,” she said.