Cerebral abscess

Case contributed by Dr Dinesh Palipana

Presentation

This patient initially presented to an emergency department with coryzal symptoms; dysuria; lower back pain described as muscular; and right testicular pain. Several hours after arrival in emergency department, he developed sudden onset weakness and paraesthesias of the right arm. Apart from a history of lymphoma, his history is unremarkable.

Patient Data

Age: 47 years
Gender: Male
CT

Initial non-contrast CT taken shortly after presentation

Unremarkable CT scan of the head.

MRI

An MRI taken approximately 24 hours after presentation

Two intra-axial lesions are seen in the left cerebral hemisphere. The first is within the left frontal lobe. The second is within the posterior left frontal lobe extending into the parietal lobe.

Both lesions demonstrate heterogeneous internal signal intensity. They have surrounding vasogenic oedema. 

The MRI features are consistent with intracerebral abscesses.

 

CT

A contrast CT scan taken approximately 38 hours after presentation

Surgical clips and a left frontal burr hole with associated pneumocephalus is visible within the left anterior frontal lobe.

Two foci of intraaxial haemorrhage in the left frontal and left frontoparietal lobes are noted. Associated mass effect with midline shift which has increased compared to the MRI approximately 14 hours before. No underlying enhancing lesion is demonstrated.

A peripheral wedge-shaped hypodensity in the inferior left frontal lobe demonstrated restricted diffusion on MRI. This likely represents a focus of infarct.

Case Discussion

This patient's initial presentation was not suggestive of neurological pathology. Testicular pathology was excluded by ultrasound.

The subsequent sudden-onset mild subjective right-sided weakness and paraesthesia prompted a non-contrast CT. This was unremarkable.

Ongoing deterioration caused a right-sided neuromotor deficit with 0/5 power. GCS was still 15. This lead to a MRI that demonstrated findings suggestive of a cerebral abscess. The suspicion was heightened by Staphylococcus aureus positive blood cultures.

With further deterioration in GCS, urgent neurosurgical intervention with drainage of the cerebral abscess was performed. A small amount of blood-stained was fluid aspirated.

The pathology report from the left frontal lesion noted interstitial haemorrhage and acute inflammation with scant Staphylococcus aureus growth. The fluid sample also grew a scant amount of the same species.

A swab from a wound found on the left lateral malleolus grew Staphyloccus aureus. This was thought to be the source of infection.

The final contrast CT demonstrates anatomic correlation to eventual significant neurological deterioration.   

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Case information

rID: 44649
Case created: 30th Apr 2016
Last edited: 6th May 2016
Inclusion in quiz mode: Included

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