Presentation
Left-sided weakness.
Patient Data
Right frontoparietal, left thalamic, and left temporal multiple subcortical space occupying lesions. They elicit a high signal on FLAIR and T2 WI with hypointense margins. They show diffusion restriction with marginal post contrast enhancement. The largest lesions are seen on the right frontoparietal region. The lesions are surrounded by vasogenic edema and exert a positive mass effect in the form of effacement of the overlying cortical sulci. MRS revealed markedly elevated lipid/lactate peak. No significant elevation of the Choline peak.
Radiological findings were impressive of pyogenic cerebral abscesses.
Laboratory workup showed elevated ESR and CRP levels.
The patient was treated with empirical antibiotics, however, his condition deteriorated.
The patient had a CT scan of the chest and an MRI of the abdomen and pelvis, in order to detect the possible source of infection.
CT scan of the chest was normal.
MRI of the abdomen and pelvis revealed a large hepatic abscess.
MRI of the abdomen showed right hepatic lobe segment VII large cystic lesion showing thick wall with characteristic diffusion restriction with adjacent perihepatic smudging and mild reactive pleural effusion, in keeping with large hepatic abscess.
Similiar smaller lesions were seen at segments VIII, III, and IV.
The patient's neurological manifestations deteriorated rapidly. The patient developed slurred speech, urine incontinence, and decreased consciousness level. He had another follow-up MRI of the brain to assess the brain abscesses.
Progression regrading the size and the surrounding vasogenic edema of the right frontoparietal lesions.
However, some of the lesions (such as the thalamic and left temporal lesions) had regressed in size.
The patient had surgical excision of the frontoparietal abscesses. E-Coli as the causative organisms.
Case Discussion
Cerebral abscesses usually have typical radiological patterns even in the absence of clinical infection manifestations such as fever. Diffusion restriction and marginal contrast enhancement are highly specific for the diagnosis of cerebral abscesses. Also, MRS is characteristic with marked elevation of the lipid/lactate peaks. Detailed cross-sectional body imaging usually detects the source of infection, as in our case, an MRI of the abdomen revealed a large hepatic abscess which was treated by aspiration after the treatment of the cerebral abscesses.