brain abcess case

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  • 1. Case 11786 Brain abscess in a drug abuser with history of cocain sniffing Muhammad Asim Rana, Ahmed F. Mady, Abdulrehman Alharthy, Omar E. Ramadan, Waleed T. Hashim, Sameh A. Ashmawi, Mohammed A. Alodat, Mahmoud H. AlKurdi, Mohammed M. Gharba, Ahmed Ragab, Mazen A. Hallak King Saud Medical City, Riyadh Saudi Arabia NeuroradiologySection: 2014, May. 12Published: 37 year(s), malePatient: Authors' Institution King Saud Medical City, Riyadh, Saudi Arabia Email:drasimrana@yahoo.com Clinical History An adult male with history of sniffing the substance of abuse, presented with 14 days history of progressive fever and confusion. Examination revealed a highly febrile drowsy patient with swollen left eye, external ophthalmoplegia and weakness of right arm. Ehcocardiography was normal. Blood cultures showed no bacterial growth. Imaging Findings CT Brain plain and with contrast done on presentation showed collection in left frontal lobe with few air locules and marked perilesional edema with mass effect causing midline shift along with effacement of left lateral ventricle. Subdural collection was also noted on right side representing subdural empyema however no significant enhancement is seen post contrast. CT Paranasal sinuses show opacification involving left frontal as well as left ethmoidal air cells and left maxillary sinus suggestive of sinusitis. Erosions in the roof of the left extra-orbital frontal and
  • 2. sphenoidal sinus indicate intracranial extension. In post craniotomy follow up plain and contrast enhanced CT brain showed left fronto parietal bone plate missing with subgaleal hematoma and surgical emphysema and there was large outwards bulging of parenchyma and pulling of midline associated with diffuse edema with effaced ipsilateral ventricle as well as cortical sulci. However, no defined abscess was noted. Discussion Brain abscess is a focal collection within the brain parenchyma, which can arise as a complication of a variety of infections, trauma, or surgery. Bacteria can invade brain directly or through blood[1, 2]. Direct spread is from adjacent sites like teeth, mastoid sinuses and results in a localized single focus of abscess while haematogenous spread usually results in multiple foci[3, 4]. Usual causes of haematogenous spread include chronic lung supperative conditions like cystic fibrosis and broncheactasis, skin, pelvic, intra-abdominal infections and infective endocarditis[5]. Different procedures like endoscopy [6] and neurosurgery have also been associated with development of brain abscess[7]. Location of brain abscess in decreasing order of frequency is frontotemporal, frontoparietal, parietal, cerebellar and occipital lobes [8]. A wide variety of bacteria can cause brain abscess depending upon site of infection, age and immune status of the patient. These include aerobic bacteria like Streptococci and Staphylococi, pneumococci are associated with emphysema (also seen in our case fig1C). While anerobes include anaerobic streptococci, Bacteroides like B. fragilis[9, 10]. Immunocompromised hosts may have broader range of opportunistic organisms and fungi[11]. Patients may present with fever, headache, and decreased sensorium or focal neurological symptoms. Examination may show neck stiffness, papilledema or cranial nerve palsies. Diagnosis can be established by brain imaging. Contrast enhanced CT brain is useful mdality as it is readily available although the sensitivity is less than MRI. Early cerebritis appears as non-enhancing irregular area of low density (see frontal lesion in this case Fig 2C). Older lesion becomes surrounded with enhancing ring because of breakdown of blood brain barrier and development of inflammatory capsule. MRI with gadolinium causes more prominent enhancement of lesions than CT and is more sensitive for early cerebritis. Diffusion weighted MR images differentiate between abscess and neoplasms[12, 13]. Lumbar puncture usually is contraindicated in cases of focal neurological signs but when performed shows high proteins and PMN cells. Cultures should be performed from the specimens as well as histopathology to establish definitive diagnosis. Successful management of a brain abscess usually requires a combination of antibiotics and surgical drainage. The antibiotic regimen is dependent on Gram stain, if available and the likely source of abscess. Antibiotics should be given for four to eight weeks. Glucocorticoids are used when substantial mass effect can be demonstrated on imaging and the mental status is significantly depressed.[14, 15] Mortality ranges from zero to 30 percent. In neurologic sequelae, seizures are the most common, occur in 30 to 60 percent of patients[16].
  • 3. Final Diagnosis Brain abscess in a drug abuser with history of cocain sniffing. Differential Diagnosis List Epidural and subdural empyema, Septic dural sinus thrombosis, Mycotic cerebral aneurysms, Septic cerebral emboli with associated infarction, Acute focal necrotizing encephalitis, Metastatic or primary brain tumors, Pyogenic meningitis Figures Figure 1 Brain Abscess Pre-operative Plain CT CT Brain without contrast showing opacification of left maxillary sinus Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess;
  • 4. CT Brain without contrast showing left frontal lobe hypodense lesion with some extradural collection. Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; CT Brain Plain with well defined left lobe collection with air pockets. Usually seen in cases of pneumoccocal cerebral abcess. Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences;
  • 5. Special Focus: Abscess; CT Brain Plain shows the extension of lesion to cortex and left parieto-occipital area. Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; Figure 2 Contrast enhanced CT Brain Cerebral Abscess CECT Brain with opaque sinuses Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia
  • 6. Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; CECT Brain extent of lesion with mass effect Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; Left frontal lobe collection seen with compression of left lateral ventricle. Post contrast enhancement is not seen in left frontal lobe because of element of cerebritis (abcess was
  • 7. recent). Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; mass effect with mid line shift Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; Figure 3 Post operative Plain CT Brain
  • 8. Post craniotomy follow up CT with subgalial hematoma and pneumocephalus Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; brain protrusion from bone defect with pneumocephaly Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess;
  • 9. Post operative changes Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; Bone defect with extension of brain into the defect, some local edema Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences;
  • 10. Special Focus: Abscess; Figure 4 Follow up contrast enhanced CT brain (post operative) Bone defect secondary to craniotomy with subgalial hematoma Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; left fronto parietal bone plate missing with subgaleal hematoma and surgical emphysema and there is large outwards bulging of parenchyma and pulling of midline associated with diffuse
  • 11. edema and effacement of lateral ventricle. Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Procedure: Imaging sequences; Special Focus: Abscess; large outwards bulging of parenchyma with diffuse edema effaced cortical sulci. No defined abscess is seen. Rana M. A. King Saud Medical City, Riyadh, Saudi Arabia Area of Interest: Head and neck; Imaging Technique: CT; Proce