Introduction Brain abscess is a rare but life-threatening condition in children which may result from contiguous site infection, haematogenous seeding, penetrating traumatic injury, neurosurgical procedure or cryptogenic source.

Clinical case A twelve-year-old girl presented to the emergency department with severe, progressive left-sided frontal headache of 3 weeks’ duration associated with increased somnolence of three days’ duration and one episode of vomiting. These symptoms were associated with a left sided periorbital cellulitis, five days after the onset of headache, which was treated in the community with two weeks of oral flucloxacillin and had resolved at the time of presentation. This child’s medical history was unremarkable. Neurological examination including gait assessment and fundoscopy were normal. Emergent imaging (CT and MRI) revealed a thick-walled, rim enhancing lesion in the left anterior inferior frontal lobe with associated oedema and mass effect. Left ethmoid and frontal sinusitis were also apparent on MRI. The patient underwent transfer to a neurosurgical facility for emergency burr hole aspiration of left frontal lobe abscess and subsequent naso-endoscopy and sinus decongestion. Streptococcus intermedius was isolated from microbiological samples. She completed five weeks IV antimicrobial therapy followed by three weeks high dose oral therapy. Follow-up imaging revealed a small residual area of enhancement without evidence of persistent abscess. Clinically she remains well without sequelae.

Conclusions The presentation of brain abscess is diverse with headache (70%), nausea and vomiting (50%), fever (40%), seizures (25%), focal neurological signs (50%), and nuchal rigidity (25%). Only 10% of children with a brain abscess will have an absent underlying medical condition that increases their risk of brain abscess. 15% will have a preceding Frontal sinusitis and only 2.5% a preceding Ethmoid sinusitis. In children with chronic progressive headaches sinister aetiologies must be excluded and appropriate neurological imaging performed.