Presentation
Fall. On warfarin for AF.
Patient Data
Non contrast CT of the brain demonstrates large hemorrhagic contusions.
CT scan with contrast 3 weeks later, when the patient was febrile and deteriorating clinically demonstrates the contusions to be peripherally enhancing.
The previously demonstrated contusion demonstrate peripheral enhancement and central diffusion restriction. They are surrounded by substantial vasogenic edema.
In the presence of ample blood product, diffusion needs to be taken with extreme caution, however in the setting of febrile deterioration superimposed infection is suspected.
This patient went on to have a craniotomy and evacuation of the collections.
Histology
Microscopic Description:
Sections of RIGHT BRAIN HEMATOMA show degenerating red blood cells and focal collections of degenerating polymorphonuclear leukocytes.
Sections of RIGHT BRAIN CAPSULE show necrotic brain parenchyma with adjacent deposition of fibrin. There are extensive inflammatory infiltrates, which are poorly preserved. There is new blood vessel formation. Special stains were done; no organisms were seen on Gram, Grocott, Ziehl Neelsen and modified Ziehl Neelsen stains.
However, some structures consistent with bacilli were evident on the Giemsa stain.
Final Diagnosis: The findings are consistent with early abscess formation and hemorrhage.
Case Discussion
This elderly patient on warfarin for AF fell and developed bilateral frontal hemorrhagic contusions. During his convalescence, he became uroseptic and subsequently meningitic.
Histology confirmed secondary infection, with the development of cerebral abscesses. He had a protracted and stormy clinical course but eventually recovered.
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