low grade astrocytoma associated with abscess f : c … · 2016. 12. 12. · low-grade astrocytoma...

Kaohsiung J Med Sci May 2008 • Vol 24 • No 5262© 2008 Elsevier. All rights reserved.

Low-grade astrocytomas are slow-growing astrocyticneoplasms with a high degree of cellular differentiation.These lesions generally affect young adults and havea tendency to progress to higher-grade astrocytomas[1–3].

Brain abscess is the most common infectious lesionand can be caused by many different types of patho-gens, usually bacteria. Brain abscesses frequently arisesecondary to hematogenous dissemination of an ex-tracranial site, by direct extension from a contiguoussuppurative focus, or secondary to meningitis [4,5].

Abscess formation within a brain tumor is un-common. Astrocytoma with abscess is extremely rare.Intrasellar or parasellar tumors are among the mostcommon neoplasms that develop such a complicationas the result of direct extension of microbial flora fromcontiguous infected sinuses [6]. We present a rare caseof low-grade astrocytoma associated with abscessformation.

CASE PRESENTATION

A 52-year-old man had underlying diseases includingnon-insulin dependent diabetes mellitus and hepati-tis B virus-related cirrhosis. He could understand whatpeople said but had difficulty with speech for 10 days.He had no history of fever, trauma or hypertension.Physical examination revealed jaundice. Neurologic

Received: Sep 4, 2007 Accepted: Oct 5, 2007Address correspondence and reprint requests to:Dr Ann-Shung Lieu, Department of Neurosur-gery, Kaohsiung Medical University Hospital,100 Tzyou 1st Road, Kaohsiung 807, Taiwan.E-mail: [email protected]

LOW-GRADE ASTROCYTOMA ASSOCIATED WITH

ABSCESS FORMATION: CASE REPORT AND

LITERATURE REVIEW

Tai-Hsin Tsai,1 Yan-Fen Hwang,1 Shiuh-Lin Hwang,1,2 Chen-Hsiang Hung,1 Cheng-Wei Chu,1

Boon-Kee Lua,1 Chih-Lung Lin,1,2 Kung-Shing Lee,1,2 Joon-Khim Loh,1,2 Aij-Lie Kwan,1,2

Chih-Jen Wang,1,2 Tzuu-Yuan Huang,1,2 Shen-Long Howng,1,2 and Ann-Shung Lieu1,2

1Department of Neurosurgery, Kaohsiung Medical University Hospital, and 2Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

A rare case of low-grade astrocytoma associated with abscess formation occurred in a 52-year-oldman presenting with Broca’s aphasia. He underwent craniotomy and tumor removal under the im-pression of brain tumor with necrotic cystic change. Abscess accumulation within the intra-axialtumor was found intraoperatively. Literature related to brain abscess with brain tumor is reviewed,with an emphasis on abscesses with astrocytoma. We discuss the common brain tumors that areassociated with abscess, pathogens that coexist with brain tumor, and the pathogeneses of coex-isting brain abscess and tumor. It is very important to know how to differentiate between anddiagnose a brain abscess and tumor, or brain abscess with tumor, preoperatively from clinical pre-sentation and through the use of computed tomography, conventional magnetic resonance imaging,diffusion-weighted imaging or magnetic resonance spectroscopy.

Key Words: astrocytoma, brain abscess, magnetic resonance spectroscopy(Kaohsiung J Med Sci 2008;24:262–9)

Low-grade astrocytoma associated with abscess formation

Kaohsiung J Med Sci May 2008 • Vol 24 • No 5 263

examination revealed Broca’s aphasia. Hematologicexamination and biochemistry demonstrated coagu-lopathy, hyperbilirubinemia and thrombocytopenia,but no leukocytosis or elevated C-reactive protein.

Under the impression of cerebrovascular disease,computed tomography (CT) scan was performed.Noncontrast CT demonstrated a left temporal hypo-dense lesion with perilesional edema (Figure 1A), andcontrast-enhanced CT demonstrated mild hyperdensesoft tissue components with mild enhancement in theleft temporal lobe (Figure 1B). Magnetic resonanceimaging (MRI) demonstrated a mass lesion in the lefttemporal lobe with hyperintensity on T2-weightedimages and hypointensity on T1-weighted images.After the administration of contrast medium, the le-sion showed a thickened, enhanced wall (Figure 2).Diffusion-weighted imaging (DWI) demonstratedhyperintensity and apparent diffusion coefficient(ADC) revealed hypointensity. Brain abscess was sus-pected according to the DWI findings (Figure 3). Mag-netic resonance spectroscopy (MRS) showed decreasedN-acetylaspartate (NAA, 2.0 ppm) and creatinine (Cr,3.0 ppm), elevated choline (Cho, 3.2 ppm), and pro-minent lipid peak (1.3 ppm) at the lesion (Figure 4),which led to a diagnosis of glioblastoma or metastaticbrain tumor.

The patient received surgery under the impressionof a brain tumor with necrotic cystic change. Cranio-tomy and removal of the temporal mass were per-formed. During the operation, yellow-grayish material

flowed out from the center of the tumor. Pathology of the tumor revealed World Health OrganizationGrade II astrocytoma (Figure 5) and culture revealedoxacillin-sensitive Staphylococcus aureus. Due to theaccidental finding of brain abscess, antibiotic therapywith oxacillin and cefepime were given. After treat-ment, the patient was discharged without any speechdisorder.

DISCUSSION

We present a rare case of low-grade astrocytoma as-sociated with abscess formation. This patient receivedsurgery under the impression of a brain tumor withnecrotic cystic change. During operation, a brain ab-scess within the tumor was found accidentally. Thepathology of the tumor demonstrated low-grade as-trocytoma and the culture of the abscess revealedoxacillin-sensitive S. aureus. The definite diagnosis ofthis patient was low-grade astrocytoma with abscessformation.

We reviewed previous literature related to braintumors with abscess. Intracranial neoplasms contain-ing abscesses were first described by Asenjo in 1950[6]. There are few reported cases of abscesses withinbrain tumors; most are within pituitary tumors[7–10]. Intrasellar or parasellar tumors are among themost common neoplasms that develop such a com-plication, as the result of direct extension of microbial

Figure 1. (A) Noncontrast computed tomography demonstrates left temporal hypodense lesion with perilesional edema. (B) Contrast-enhanced computed tomography demonstrates mild hyperdense soft tissue components with mild enhancement in the left temporal lobe.

A B

Kaohsiung J Med Sci May 2008 • Vol 24 • No 5264

T.H. Tsai, Y.F. Hwang, S.L. Hwang, et al

flora from the sinuses [6]. Hatiboglu et al reported a pituitary abscess with adenoma [10]. Pituitary ab-scess secondary to an adenoma is rare. Only 19 caseshave been reported. Craniopharyngioma with ab-scesses were first described by Riser in 1956 [6]. Fewcases of abscess within a craniopharyngioma havebeen reported [9,11,12].

There are few reported cases of abscess within anintra-axial tumor such as glioblastoma multiforme[9], astrocytoma [6,13], ependymoma [6,14], and me-dulloblastoma [6]. Mohindra and Gupta reviewedtwo cases of glioblastoma with abscess [6]. Nogueradoet al reported an abscess within a glioblastoma multi-forme first and Ichikawai et al presented a rare case ofabscess within a glioblastoma as well [9]. Bansal et alreported a child with a right parieto-occipital astro-cytoma [13]. Two cases of brain abscess with astrocy-toma were reported. At present, our case is the third

case of low-grade astrocytoma with abscess. There arefew reported cases of abscess within an extra-axialtumor, most within meningioma [14–20]. Shimomuraet al were the first to report a case of meningiomawith abscess formation [15]. Five cases of meningiomawith abscess have been reported to date [14–20]. Afew cases of abscess with brain metastasis have beenreported [13,21,22].

We reviewed the literature on cases of low-gradeastrocytoma with abscess. Two such cases have beenreported (Table 1). Bansal et al described a child witha right parieto-occipital astrocytoma. Histopathologicexamination showed a tumor composed of astrocyticcells. This abscess was seen in tumor areas. The puswas teeming with Gram-negative bacilli and showedheavy growth of Pseudomonas aeruginosa [13]. Mohindraand Gupta presented a case of a midline posterior fossatumor with abscess [6]. Histopathology revealed many

A

C

B

Figure 2. Magnetic resonance imaging demonstrates a mass lesionin the left temporal lobe with: (A) hyperintensity on T2-weightedimages; (B) hypointensity on T1-weighted images. (C) Afteradministration of contrast medium, the lesion shows a thickenedenhanced wall.



inflammatory cells interspersed in a low-grade tumorwith glial differentiation, suggestive of a low-gradeastrocytoma containing an abscess [6]. We also presenta rare case of low-grade astrocytoma associated withabscess formation. The pathology of the tumor revealedWHO Grade II astrocytoma, and the culture of theabscess was positive for oxacillin-sensitive S. aureus.

The pathogenesis of brain tumors with abscessesis thought to be related to multiple reasons, such asdestruction of the blood–brain barrier, fenestration ofvessels, tumor bleeding with hematoma, and hormonalimbalance [7,9,15]. First, disruption of the blood-brain

barrier and fenestration of vessels by brain tumorsare important in the development of abscess. Second,tumor bleeding with hematoma acting as a culturemedium is important in the development of an abscessas well. Glioblastoma, which has no blood–brain bar-rier, and the nutritious hematoma within the tumor,may induce metastatic abscess by sepsis [9]. Menin-gioma may also cause fenestration of vessels and destruction of the blood–brain barrier such as a metas-tatic brain tumor and glioblastoma [15]. Third, chron-ic hormonal overstimulation is the pathogenesis ofpituitary adenoma with Toxoplasma gondii infection [7].

The immune system and the blood–brain barrierplay important roles in resisting bacterial infection.Immunocompromised patients are at risk for brainabscess. Brain abscess can be attributed primarily toimmunodeficiency and secondarily to various im-munosuppressive agents that are used in aggressivecancer treatment and organ transplantation [4,5]. De-struction of the blood–brain barrier by a brain tumoris also a factor in the development of brain abscess.Analyzing the pathogenesis of the brain abscess withtumor, our patient had hepatitis B virus-related cir-rhosis (Child-Pugh Class A). The immune system ofthe patient was compromised and the blood–brainbarrier may have been destroyed by the tumor. Brainabscess associated with tumor may occur in immu-nocompromised patients with destruction of theblood–brain barrier by the tumor.

Brain abscess may be caused by aerobic, anaerobic,Gram-positive and Gram-negative bacteria. What is thecommon pathogen of abscesses with tumors? We sum-marize the previous pathogens of cerebral abscess

20,000

16,000

12,000

8,000

4,000

0

−4,000

−6,2504.29 3.69 3.08 2.47 1.86 1.25 0.630.39

ppm

Figure 4. Magnetic resonance spectroscopy reveals decreased N-acetylaspartate and creatine, elevated choline, and prominentlipid peak at the lesion.

A B

Figure 3. (A) Diffusion-weighted imaging shows hyperintensity; (B) apparent diffusion coefficient reveals hypointensity.



with brain tumor and emphasize abscesses with intra-axial brain tumors in Table 2. The data indicate that S. aureus was the most common organism in intra-axial tumors. The findings of our case are consistentwith these results. This indicates that homogeneousspread is the pathogenesis of abscesses with intra-axialtumors.

Brain abscesses and tumors are usually diagnosedon the basis of findings from CT and MRI, togetherwith clinical presentation [23]. However, early diag-nosis of brain abscess and brain tumor remains chal-lenging. It is more difficult to diagnose brain abscessesassociated with tumors. DWI and ADC have recentlyshown promise in differentiating ring-enhancing le-sions such as a brain abscess and malignant neoplasm[23,24]. MRS has also been widely applied in differ-entiating ring-enhancing lesions such as brain abscessand malignant neoplasm [23,24]. Combined protonMRS and diffusion-weighted MRI were used toestablish the preoperative diagnosis of brain abscessand tumor [23].

Previously reported experience with DWI, hyper-intensity within the central portion of a ring-enhancingmass on DWI and a low ADC suggest cerebral abscess[24]. In our case, DWI demonstrated hyperintensityand ADC revealed hypointensity. According to DWI,brain abscess over the left temporal lobe was highlysuspected. On MRS, the presence of lactate cytosolicamino acids with/without succinate, acetate, alanineand glycine can be regarded as a marker for abscess,and lactate and choline for nonabscess cases [23]. Inour patient, MRS revealed decreased NAA and Cr,elevated Cho, and prominent lipid peak at the lesion,which were initially thought to be compatible with theusual findings for metastatic brain tumor or glioblas-toma. Owing to the finding of DWI and MRS, we couldnot differentiate brain tumor and abscess or coexistingtumor with abscess preoperatively.

In summary, we presented a rare case of astrocy-toma associated with abscess formation. We discussedthe common brain tumors that are associated with ab-scess, pathogens that coexist with brain tumors, and

A

C

B

Figure 5. Polymorphonuclear cells and low-grade astrocytomadetected under the microscope indicates the coexistence of brainabscess and low-grade astrocytoma (hematoxylin & eosin, 100×).



the pathogeneses of coexisting brain abscesses and tu-mors. It is very important to understand how to diag-nose brain abscess and tumor, or brain abscess withtumor, preoperatively, based on clinical presentationand findings from CT, MRI, DWI or MRS.

REFERENCES

1. Walker DG, Kaye AH. Low grade astrocytomas: con-troversies in management. J Clin Neurosci 2000;7:475–80.

2. Walker DG, Kaye AH. Low grade glial neoplasms. J Clin Neurosci 2003;10:1–13.

3. Loiseau H, Dartigues JF, Cohadon F. Low-grade astro-cytomas: prognostic factors and elements of manage-ment. Surg Neurol 1995;44:224–7.

4. Karampekios S, Hesselink J. Cerebral infections. EurRadiol 2005;15:485–93.

5. Yoshikawa TT, Goodman SJ. Brain abscess. West J Med1974;121:207–19.

6. Mohindra S, Gupta R. Posterior-fossa intra-tumouralabscess: a report of three patients and literature review.Br J Neurosurg 2004;18:556–60.

7. Zhang X, Li Q, Hu P, et al. Two case reports of pituitaryadenoma associated with Toxoplasma gondii infection. J Clin Pathol 2002;55:965–6.

8. Jadhav RN, Dahiwadkar HV, Palande DA. Abscess formation in invasive pituitary adenoma: case report.Neurosurgery 1998;43:616–9.

9. Ichikawai M, Shimizu Y, Manabu Sato M, et al. Abscesswithin a glioblastoma multiforme. Neurol Med Chir(Tokyo) 1992;32:829–33.

10. Hatiboglu MA, Iplikcioglu AC, Ozcan D. Abscess forma-tion within invasive pituitary adenoma. J Clin Neurosci2006;13:774–7.

11. Shanley DJ, Holmes SM. Salmonella typhi abscess in acraniopharyngioma: CT and MRI. AJNR Am J Neuroradiol1994;36:35–6.

Table 2. Pathogen of brain abscesses with intra-axialtumors

Pathology Pathogen

Glioblastoma Staphylococcus aureus [5]

Ependymoma Enterobacter aerogenes [22]

Astrocytoma Pseudomonas aeruginosa [15]Staphylococcus aureus (this case)

Brain metastasis Propionibacterium acnes [17](lung carcinoma)

Brain metastasis Staphylococcus species [17](unknown origin)

Tab

le 1

.Ast

rocy

tom

a w

ith

absc

ess

Aut

hor

Age

(yr)

/se

xSy

mpt

oms

& s

igns

Syst

emic

dis

ease

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atio

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de

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sis

Ban

sal e

t al

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ocal

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zure

Non

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ight

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ieto

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ow-g

rad

e P

seud

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as

Die

d[1

3]oc

cipi

tal l

obe

astr

ocyt

oma

aeru

gino

sa

Moh

ind

ra &

35/

MD

iffu

se h

ead

ache

, pro

ject

ile

Non

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idlin

e po

ster

ior

Low

-gra

de

Non

eFu

lly

Gup

ta [1

2]vo

mit

ing,

dim

inut

ion

of

foss

aas

troc

ytom

ain

dep

end

ent

visi

on, d

runk

en g

ait,

dif

ficu

lty

in s

wal

low

ing

and

nas

al in

tona

tion

to

voi

ce

Thi

s ca

se52

/M

Ano

mic

aph

asia

Liv

er c

irrh

osis

Lef

t tem

pora

l lob

eW

HO

Gra

de

IISt

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12. Obrador S, Blazquez MG. Pituitary abscess in a cranio-pharyngioma. Case report. J Neurosurg 1972;36:785–9.

13. Bansal S, Vasishta RK, Pathak A, et al. Cerebral abscesswith astrocytoma. Neurol India 2001;49:91–3.

14. Nassar SI, Haddad FS, Hanbali FS. Abscess superim-posed on brain tumor: two case reports and review ofthe literature. Surg Neurol 1997;47:484–8.

15. Shimomura T, Hori S, Kasai N, et al. Meningioma asso-ciated with intratumoral abscess formation. Neurol MedChir (Tokyo) 1994;34:440–3.

16. Yeates KE, Halliday W, Miyasaki J, et al. A case of cir-cling seizures and an intratumoral abscess. Clin NeurolNeurosurg 2003;105:128–31.

17. Eisenberg MB, Lopez R, Stanek AE. Abscess forma-tion within a parasagittal meningioma. Case report. J Neurosurg 1998;88:895–7.

18. Young JP, Young PH. Meningioma associated with abscess formation—a case report. Surg Neurol 2005;63:584–5.

19. Onopchenko EV, Grigorian IA. Meningioma with aperitumoral abscess. Zh Vopr Neirokhir Im N N Burdenko1999;1:28–30.

20. Lind CR, Muthiah K, Bok AP. Peritumoral Citrobacterkoseri abscess associated with parasagittal meningioma.Neurosurgery 2005;57:E814.

21. Kovacic S, Bunc G, Krajnc I. Abscess formation withincerebellar metastatic carcinoma—report of two casesand review of the literature. Wien Klin Wochenschr 2004;116:60–3.

22. Ng WP, Lozano A. Abscess within a brain metastasis.Can J Neurol Sci 1996;23:300–2.

23. Lai PH, Ho JT, Chen WL, et al. Brain abscess andnecrotic brain tumor: discrimination with proton MRspectroscopy and diffusion-weighted imaging. AJNRAm J Neuroradiol 2002;23:1369–77.

24. Leuthardt EC, Wippold FJ, Oswood MC, et al. Diffusion-weighted MR imaging in the preoperative assessmentof brain abscesses. Surg Neurol 2002;58:395–402.


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low grade astrocytoma associated with abscess f : c … · 2016. 12. 12. · low-grade astrocytoma...

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