P1001 - An Unlikely Telemedicine Diagnosis: A Case Report of Rhizobium Radiobacter Brain Abscess

Introduction: Rhizobium radiobacter is a gram negative bacillus commonly found in soil. The frequency of reported infections in the pediatric population is rare and typically affects immunocompromised patients. This case highlights the incidence of a Rhizobium Radiobacter infection, prompted by a telemedicine consultation, in a healthy pediatric patient with no known risk factors.

Case Description: A 12-year-old male with a history of chronic sinusitis and renal agenesis presented to the emergency department after a new-onset generalized seizure. The patient complained of having intermittent fevers for 5 days and left ear pain as well as left sided periorbital swelling. He was febrile with elevated leukocytosis and inflammatory markers, and found to have extensive left-sided sinusitis with no focal neurological deficits. He was subsequently discharged with antibiotics and instructions to follow-up in one month with a pediatric neurologist.

Three days after the initial presentation, he returned to the emergency department with persistent fever and headache. He was determined to have a sinus headache and instructed to complete the antibiotic course. The following day, he was evaluated by pediatric neurology via telemedicine. Secondary to the new onset seizures and changes in neurological status, he was referred for emergent inpatient admission. Just prior to arrival, the patient had a 20-minute nonverbal episode, prompting rapid video EEG placement which was suggestive of seizure activity. The patient received a loading dose of levetiracetam and began maintenance dosing. Despite AEDs, the patient continued to have multiple subclinical seizures in the frontal lobe. MRI brain was indicative of meningoencephalitis involving the left hemisphere, left frontal lobe cerebritis,and a multilocular extra-axial abscess. At this time intravenous antibiotics were begun at meningitic dosing. The patient was taken for emergent craniotomy for abscess evacuation, and cultures were found to be positive for Rhizobium Radiobacter.

Discussion: In the setting of fever and new-onset seizure in an otherwise healthy patient, meningitis should be high on the differential. Infectious etiology cannot be excluded and necessitates further investigation including lumbar puncture with cerebrospinal fluid cultures. The delay in ascertaining a spinal tap, alongside the late-onset of IV antibiotic use, propagated the formation of a bacterial abscess.

Conclusion: During the COVID-19 pandemic, the availability of telemedicine proved to be a lifesaving service. The clinical acumen of the neurologist prompted admission to the hospital for further evaluation and the eventual diagnosis of a bacterial brain abscess. A telehealth consultation with the patient in his home setting allowed for the thorough history-taking required to develop the connection between the neurological changes and recent sinusitis. This case exemplifies the functionality of pediatric telemedicine and serves to highlight a unique pathogen in this patient population.