Introduction Intracerebral abscess during pregnancy is an exceptionally rare but potentially life-threatening condition requiring urgent diagnosis and coordinated multidisciplinary management.1 Clinical presentation may overlap with more common obstetric emergencies such as eclampsia, preeclampsia, or hemolysis, elevated liver enzymes and low platelet syndrome, thereby delaying recognition and definitive treatment.2–4 Because available evidence is limited largely to isolated case reports, management decisions frequently rely on extrapolation from non-pregnant populations and individualized balancing of maternal neurological priorities with fetal well-being. We report the successful third-trimester management of a frontal lobe abscess caused by Streptococcus intermedius (S. intermedius), a pathogen that, to our knowledge, has been seldom described in the context of pregnancy-associated disease. The case highlights the importance of prompt neuroimaging, timely neurosurgical source control, pregnancy-compatible antimicrobial therapy, and multidisciplinary decision-making that enabled continuation of pregnancy to term and uncomplicated vaginal birth. Written informed consent for publication was obtained from the patient. Institutional ethical approval was obtained or waived according to local policy for anonymised case reports. Case presentation A 32-year-old previously healthy primigravida at 33+1 weeks of gestation was found unconscious at home by her husband, with drooling, tongue biting, and urinary incontinence, strongly suggestive of recent seizure activity. After spontaneous recovery of consciousness, she was able to mobilize but remained disoriented. At emergency department admission, blood pressure was 75/40 mmHg, heart rate 105 beats/min, and Glasgow Coma Scale score 14/15 because of temporal disorientation. No focal neurological deficits were initially observed. Laboratory investigations were unremarkable apart from mild leukocytosis (10.7 × 109/L) and elevated C-reactive protein (44 mg/L). Urgent brain magnetic resonance imaging demonstrated a left frontal intra-axial lesion measuring 24 × 22 × 15 mm, surrounded by vasogenic oedema and associated with local mass effect (Supplementary Fig. 1A, https://links.lww.com/MFM/A132). During observation, the patient developed rightward ocular deviation with clonic jaw movements lasting approximately four minutes, consistent with focal seizure recurrence. Given the simultaneous onset of uterine contractions, tocolysis with hexoprenaline was initiated. Empirical intravenous antibiotic therapy with ceftriaxone (2 g twice daily) and metronidazole (500 mg twice daily) was commenced, together with levetiracetam (1000 mg daily) for seizure prophylaxis and dexamethasone (4 mg twice daily) for cerebral oedema. Because of the risk of preterm delivery, antenatal betamethasone was administered for fetal lung maturation. Electroencephalography performed under treatment showed no active epileptiform abnormalities (Supplementary Fig. 2, https://links.lww.com/MFM/A132). Neurosurgical drainage of the lesion was subsequently undertaken, evacuating approximately 4 mL of frank purulent material. Culture identified S. intermedius as fully susceptible to ceftriaxone. Further investigations included transthoracic echocardiography, which excluded valvular vegetations, and otorhinolaryngology assessment after incidental detection of a left maxillary mucosal retention cyst; this was not considered the infectious source. Human immunodeficiency virus testing was negative. Clinical evolution was favourable. Uterine activity resolved, and tocolysis was gradually discontinued. The patient was discharged after 10 days of hospitalisation. Intravenous antibiotics were continued for four weeks following drainage. Corticosteroids were progressively tapered and stopped after 15 days. Antiepileptic therapy was maintained until the postpartum period. Follow-up magnetic resonance imaging (MRI) performed two weeks after discharge demonstrated marked reduction of perilesional oedema and improvement of the frontal lesion (Supplementary Fig. 1B, https://links.lww.com/MFM/A132). At 36 weeks of gestation, superficial thrombosis of the left forearm developed, and prophylactic low-molecular-weight heparin was initiated. At 39+6 weeks, labour was induced using a cervical ripening balloon and low-dose misoprostol. Labour progressed uneventfully, and at 40+0 weeks, a female infant weighing 3770 g was delivered vaginally, with Apgar scores of 9, 10, and 10. Arterial cord pH was 7.20. The postpartum course was uncomplicated. Subsequent neurological and infectious disease follow-up remained normal, and an MRI performed five weeks after delivery showed further radiological resolution (Supplementary Fig. 1C, https://links.lww.com/MFM/A132). Discussion This case offers several clinically relevant lessons. First, an intracerebral abscess during pregnancy may present abruptly with seizures and altered consciousness, features that commonly trigger an obstetric differential diagnosis centred on eclampsia.2,3 However, persistent confusion, focal semiology, inflammatory markers, or absence of typical hypertensive findings should prompt urgent reconsideration and early neuroimaging.4 In our patient, a timely MRI rapidly established the diagnosis and enabled definitive management before neurological deterioration occurred. Second, this report highlights how the immunological adaptations induced by pregnancy, which are essential for maternal tolerance of the semi-allogeneic fetus, may also alter susceptibility to infection. Indeed, during pregnancy, a dynamic modulation of innate and adaptive immune responses, including shifts in T-helper cell balance, changes in cytokine profiles, altered neutrophil function, and progressive hormonal influences on host defence mechanisms that may reduce the efficiency of pathogen clearance in selected settings and potentially facilitate the development or progression of deep-seated infections, including intracerebral abscesses.5 Although causality cannot be directly established in individual cases, such pregnancy-related immune remodelling may partly explain why severe suppurative infections occasionally arise in otherwise healthy women with no evident predisposing factors. Third, this report supports the safety and value of MRI in pregnant patients with unexplained acute neurological symptoms.6 Magnetic resonance imaging avoids ionising radiation and provides excellent characterization of intracranial lesions, oedema, and mass effect. In rare high-risk presentations such as this, diagnostic delay likely represents a greater threat than imaging itself. Fourth, management illustrates the importance of multidisciplinary coordination involving maternal-fetal medicine specialists, neurologists, neurosurgeons, infectious disease physicians, anaesthetists, and neonatologists. The simultaneous presence of seizure recurrence, preterm uterine contractions, intracranial infection, and evolving maternal-fetal priorities required parallel rather than sequential management. Tocolysis, fetal lung maturation, seizure control, antimicrobial treatment, and neurosurgical intervention were integrated successfully. Fifth, the case reinforces that pregnancy alone should not delay indicated neurosurgical treatment: instead, the treatment strategy is primarily guided by abscess size, mass effect, and neurological status. Surgical drainage provided microbiological diagnosis, reduced infectious burden, relieved local mass effect, and facilitated targeted therapy. In selected stable patients with small lesions, conservative treatment may be appropriate; however, lesions associated with oedema, seizures, diagnostic uncertainty, or clinical progression generally favour invasive management.6 Sixth, antimicrobial selection during pregnancy must balance efficacy with fetal safety. Empirical 3rd-generation cephalosporin plus metronidazole offered broad coverage for community-acquired brain abscess while remaining compatible with pregnancy.7 Culture-directed continuation of ceftriaxone after identification of S. intermedius exemplifies the importance of microbiological confirmation whenever feasible. The duration of therapy varies depending on the surgical approach, rather than the causative microorganism itself.6 Of particular interest, S. intermedius belongs to the Streptococcus anginosus group and is strongly associated with abscess formation because of its tissue-invasive properties.8,9 Although well recognized in non-pregnant brain abscesses, to our knowledge, this case represents a rare instance of a pregnancy-associated intracerebral abscess caused by S. intermedius. This expands the microbiological spectrum clinicians should consider when treating pregnant patients with intracranial suppurative disease. Finally, the obstetric outcome is noteworthy. Once maternal stabilization was achieved, pregnancy continuation allowed term delivery and avoided iatrogenic prematurity. Intracerebral abscess itself does not mandate cesarean section, only indicated when maternal or fetal conditions begin to deteriorate. In neurologically stable patients without raised intracranial pressure or urgent obstetric indication, vaginal birth may remain feasible, as demonstrated here. Conclusion Intracerebral abscess in pregnancy is a rare neurosurgical emergency that may mimic more common hypertensive or seizure-related obstetric disorders. Early neuroimaging, prompt antimicrobial therapy, timely surgical drainage when indicated, and coordinated multidisciplinary management are essential to optimize maternal and fetal outcomes. This case additionally represents, to our knowledge, the first reported S. intermedius brain abscess during pregnancy and demonstrates that successful continuation of pregnancy to term with vaginal delivery is achievable after maternal stabilization. Acknowledgements We would like to thank the patient for her participation in this study. Funding None. Author Contributions All authors contributed to clinical management, manuscript preparation, revision, and approval of the final version. Conflict of Interest The authors declare no conflicts of interest. Data Availability The data supporting the findings of this study are included within the article. Additional details are available from the corresponding author upon reasonable request, subject to ethical and privacy considerations.
Mosca et al. (Fri,) studied this question.
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