Pediatric Brain Abscess and Pyoderma after Penetrating Cranial Trauma in Gaza

Annisa Anjani Ramadhan; Eka B Satyawardhana; Alaa Y Abu Halima

doi:10.56744/irchum.v5i1.116

Authors

Annisa Anjani Ramadhan Rumah Sakit Ibu dan Anak Tambak
Eka B Satyawardhana Rumah Sakit Umum Daerah Indramayu
Alaa Y Abu Halima Al-Quds University

DOI:

https://doi.org/10.56744/irchum.v5i1.116

Keywords:

brain abscess, Gaza, humanitarian health, penetrating brain injury, pyoderma

Abstract

Children injured during armed conflict are particularly vulnerable to infectious complications when trauma occurs in settings characterized by disrupted healthcare services, poor sanitation, malnutrition, and limited access to antimicrobial therapy. This report describes a 2-year-old Palestinian girl who sustained penetrating cranial trauma from shrapnel during an explosion in Gaza and subsequently developed a left frontoparietal brain abscess accompanied by multiple pustular skin lesions. Non-contrast computed tomography demonstrated a large intracranial abscess, which was treated by percutaneous aspiration and systemic antimicrobial therapy. Culture of the intracranial aspirate yielded coagulase-negative Staphylococcus (CoNS), whereas the cutaneous lesions yielded Staphylococcus aureus. The patient showed clinical improvement following systemic antibiotics and topical mupirocin. Follow-up imaging later demonstrated residual structural abnormalities requiring continued surveillance. The differing microbiological findings do not establish a direct causal relationship between the cutaneous infection and brain abscess; penetrating trauma and subsequent wound contamination remain plausible pathways. This case illustrates how resource constraints, disrupted referral systems, limited diagnostics, and restricted antimicrobial availability complicate the management of pediatric neurotrauma in humanitarian emergencies.

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References

Aarabi, B. (1988). Traumatic aneurysms of the brain due to high velocity missile head wounds. Neurosurgery, 22(6 Pt 1), 1056–1063.

Aarabi, B. (1989). Causes of infections in penetrating head wounds in the Iran-Iraq War. Neurosurgery, 25(6), 923–926.

Aarabi, B. (1990). Surgical outcome in 435 patients who sustained missile head wounds during the Iran-Iraq War. Neurosurgery, 27(5), 692–695.

Aarabi, B., Taghipour, M., Alibaii, E., Kamgarpour, A., & John, C. F. (1998). Central nervous system infections after military missile head wounds. Neurosurgery, 42(3), 500–507.

Aarabi, B., Taghipour, M., Haghnegahdar, A., Farokhi, M., & Mobley, L. (2000). Prognostic factors in the occurrence of posttraumatic epilepsy after penetrating head injury suffered during military service. Neurosurgical Focus, 8(1), Article e1.

Abu Hamdeh, S., Lytsy, B., & Ronne-Engstrom, E. (2014). Surgical site infections in standard neurosurgery procedures: A study of incidence, impact, and potential risk factors. British Journal of Neurosurgery, 28(2), 270–275.

Abu-Zant, A., Zabadi, H. A., Hassan, M., Abu-Zant, A., Ghadban, M., Alkowni, R., & Zyoud, S. H. (2025). Surgical site infection among hospitalized patients in Palestine: Association with in-hospital preoperative time stay, biological and clinical characteristics. BMC Research Notes, 18, Article 317. https://doi.org/10.1186/s13104-025-07392-z

Agarwalla, P. K., Dunn, G. P., & Laws, E. R. (2010). An historical context of modern principles in the management of intracranial injury from projectiles. Neurosurgical Focus, 28(5), Article E23.

Alao, T., Munakomi, S., & Waseem, M. (2024, January 30). Penetrating head trauma. StatPearls Publishing.

Alvis-Miranda, H., Castellar-Leones, S. M., Elzain, M. A., & Moscote-Salazar, L. R. (2013). Brain abscess: Current management. Journal of Neurosciences in Rural Practice, 4(Suppl 1), S67–S81.

Bell, R. S., Mossop, C. M., Dirks, M. S., Stephens, F. L., Mulligan, L., & Ecker, R. (2010). Early decompressive craniectomy for severe penetrating and closed head injury during wartime. Neurosurgical Focus, 28(5), Article E1.

Bell, R. S., Vo, A., Neal, C., Tigno, J., Roberts, R., Mossop, C., & Armonda, R. (2009). Military traumatic brain and spinal column injury: A 5-year study of the impact of blast and other military grade weaponry on the central nervous system. Journal of Trauma, 66(4 Suppl), S104–S111.

Benson, C., & Paul, M. (2016). Staphylococcal and streptococcal pyodermas. In S. Tyring, O. Lupi, & U. Hengge (Eds.), Tropical dermatology (2nd ed., pp. 243–251). Elsevier.

Borchardt, R. A., & Tzizik, D. (2018). Update on surgical site infections: The new CDC guidelines. Journal of the American Academy of Physician Assistants, 31(4), 52–54. https://doi.org/10.1097/01.JAA.0000531052.82007.42

Boregard, I.-L., Arvidsson, L., Bringman, S., Leo Swenne, C., & von Vogelsang, A. C. (2025). What factors are associated with surgical site infections after intracranial neurosurgical procedures? An exploratory register study. Journal of Hospital Infection, 160, 81–87. https://doi.org/10.1016/j.jhin.2025.02.013

Bowen, A. C., Mahe, A., Hay, R. J., Andrews, R. M., Steer, A. C., Tong, S. Y. C., & Carapetis, J. R. (2015). The global epidemiology of impetigo: A systematic review of the population prevalence of impetigo and pyoderma. PLoS ONE, 10(8), Article e0136789. https://doi.org/10.1371/journal.pone.0136789

Dewan, M. C., Rattani, A., Gupta, S., Baticulon, E. R., Hung, Y. C., Punchak, M., Agrawal, A., Adeleye, A. O., Shrime, M. G., Rubiano, A. M., Rosenfeld, J. V., & Park, K. B. (2019). Estimating the global incidence of traumatic brain injury. Journal of Neurosurgery, 130(4), 1080–1097.

Elshami, M., Bottcher, B., Awadallah, I., Alnaji, A., Aljedaili, B., Sulttan, A. H., & Hwaihi, M. (2020). Determinants of surgeons’ adherence to preventive intraoperative measures of surgical site infection in Gaza strip hospitals: A multi-centre cross-sectional study. BMC Surgery, 20(1), Article 135. https://doi.org/10.1186/s12893-020-0684-4

Fuglestad, M. A., Tracey, E. L., & Leinicke, J. A. (2021). Evidence-based prevention of surgical site infection. Surgical Clinics of North America, 101(6), 951–966. https://doi.org/10.1016/j.suc.2021.05.027

Ginsburg, J., & Smith, T. (2025, February 17). Traumatic brain injury. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557861/

Google. (n.d.). Patient Friend's Benevolent Society, Gaza [Map]. Google Maps. Retrieved August 29, 2025, from https://www.google.com/maps/place/%D8%AC%D9%85%D8%B9%D9%8A%D8%A9+%D8%A7%D8%B5%D8%AF%D9%82%D8%A7%D8%A1+%D8%A7%D9%84%D9%85%D8%B1%D9%8A%D8%B6+%D8%A7%D9%84%D8%AE%D9%8A%D8%B1%D9%8A%D8%A9+Patient+Friend's+Benevolent+Society%E2%80%AD/@31.517509,34.4428247,17z/data=!3m1!4b1!4m6!3m5!1s0x14fd7f144f99cf6b:0x35765c31e855e0c4!8m2!3d31.517509!4d34.4453996!16s%2Fg%2F11c5360d2n?entry=ttu&g_ep=EgoyMDI1MTAwNy4wIKXMDSoASAFQAw%3D%3D.

Jamali, M., Ahrari, I., Eghbal, K., Saffarrian, A., Rakhsha, A., & Ghahramani, S. (2021). Multiple brain abscesses by an air gun shot: A case report. Arquivos Brasileiros de Neurocirurgia, 40(4), e404–e407.

Jeong, T. S., & Yee, G. T. (2018). Prospective multicenter surveillance study of surgical site infection after intracranial procedures in Korea: A preliminary study. Journal of Korean Neurosurgical Society, 61(5), 645–652. https://doi.org/10.3340/jkns.2018.0021

Kazim, S. F., Shamim, M. S., Tahir, M. Z., Enam, S. A., & Waheed, S. (2011). Management of penetrating brain injury. Journal of Emergencies, Trauma and Shock, 4(3), 395–402.

Lin, H. S., Lin, P. T., Tsai, Y. S., Wang, S. H., & Chi, C. C. (2021). Interventions for bacterial folliculitis and boils (furuncles and carbuncles). Cochrane Database of Systematic Reviews, 2021(2), Article CD013099. https://doi.org/10.1002/14651858.CD013099.pub2

Linz, M. S., Mattappallil, A., Finkel, D., & Parker, D. (2023). Clinical impact of Staphylococcus aureus skin and soft tissue infections. Antibiotics, 12(3), Article 557. https://doi.org/10.3390/antibiotics12030557

Liu, J., Liu, J., Wu, X., & Jiang, E. (2024). Risk factors for central nervous system infection after craniotomy. Journal of Multidisciplinary Healthcare, 17, 3637–3648.

Mahabeer, Y., Khumalo, A., Kiratu, E., & Mlisana, K. (2014). Posttraumatic brain abscess caused by Aeromonas hydrophila. Journal of Clinical Microbiology, 52(5), 1796–1797.

Mahwati, T., & Nanda, A. R. (2022). Analysis of the Palestinian and Israeli conflict in the perspective of international humanitarian law. International Law Discourse in Southeast Asia, 1(1), 23–42. https://doi.org/10.15294/ildisea.vlil.56873

Menon, D. K., Schwab, K., Wright, D. W., & Maas, A. I. (2010). Position statement: Definition of traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 91(11), 1637–1640. https://doi.org/10.1016/j.apmr.2010.05.017

Miller, L. S. (2019). Superficial cutaneous infections and pyodermas. In S. Kang, M. Amagai, A. L. Bruckner, A. H. Enk, D. J. Margolis, A. J. McMichael, & J. S. Orringer (Eds.), Fitzpatrick’s dermatology (9th ed., pp. 2719–2740). McGraw-Hill Education.

Murray, G. D., Butcher, I., McHugh, G. S., Lu, J., Mushkudiani, N. A., Maas, A. I., Marmarou, A., & Steyerberg, E. W. (2007). Multivariable prognostic analysis in traumatic brain injury: Results from the IMPACT study. Journal of Neurotrauma, 24(2), 329–337. https://doi.org/10.1089/neu.2006.0035

Nicolai, M., Safi, S. S. S., Casera, M., Dekhili, D., Hook, C., Gaudron, C., Cilliers, A. E., & Baidjoe, A. Y. (2025). War wounds caused by explosive weapons in Gaza: Data from a 2024 study by Médecins Sans Frontières. The Lancet, 406(10504), 687–688. https://doi.org/10.1016/S0140-6736(25)01386-8

Perhimpunan Dokter Spesialis Kulit dan Kelamin Indonesia (PERDOSKI). (2021). Panduan praktik klinis. PERDOSKI.

Ragel, B. T., Klimo, P., Jr., Martin, J. E., Teff, R. J., Bakken, H. E., & Armonda, R. A. (2010). Wartime decompressive craniectomy: Technique and lessons learned. Neurosurgical Focus, 28(5), Article E2.

Rosenfeld, J. V., Bell, R. S., & Armonda, R. (2015). Current concepts in penetrating and blast injury to the central nervous system. World Journal of Surgery, 39(6), 1352–1362.

Sakr, A., Bregeon, F., Mege, J. L., Rolain, J. M., & Blin, O. (2019). Staphylococcus aureus nasal colonization: An update on mechanism, epidemiology, risk factor, and subsequent infection. Frontiers in Microbiology, 9, Article 2419.

Sakr, S., Azzazi, A., Elsayed, A., & Fathalla, H. (2016). Surgical management of penetrating intracranial bullet injuries. Neurosurgery Quarterly, 26(1), 37–41.

Savitri, Q. M., Putri, C. P., Gunawan, K. J., Hapsari, D. L., Sidharta, I., & Wicaksono, P. (2020). Localized asymptomatic cerebellar abscess after penetrating brain injury by wooden foreign object with adequate antibiotics administration: A case report. International Journal of Surgery Case Reports, 72, 85–90.

Stephens, F. L., Mossop, C. M., Bell, R. S., Tigno, T., Jr., Rosner, M. K., Kumar, A., & Armonda, R. A. (2010). Cranioplasty complications following wartime decompressive craniectomy. Neurosurgical Focus, 28(5), Article E3.

Swedish Institute for Standards. (2015). Microbiological cleanliness in the operating room — Preventing airborne contamination — Guidance and fundamental requirements (Technical Specification SIS-TS 39:2015). SIS.

UNICEF. (2024, October 7). A year of tears: 12 months of war on children – UNICEF report. United Nations. https://www.unicef.org/sop/reports/year-tears

Wilson, M. H., Ashworth, E., & Hutchinson, P. J. (2022). A proposed novel traumatic brain injury classification system: An overview and inter-rater reliability validation on behalf of the Society of British Neurological Surgeons. British Journal of Neurosurgery, 36(5), 633–638.