Infected lobar haemorrhage

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: 45 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 suggestive of acute haemorrhage. They have surrounding vasogenic oedema. Although diffusion signal is heterogeneous, care must be taken to not over-interpret this in the presence of blood product. No convincing features of dural venous sinus thrombosis. A small area of non-haemorrhagic infarction is also noted inferiorly. 

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 consistent with lobar haemorrhages. In the setting of systemic symptoms and  Staphylococcus aureus positive blood cultures the possibility of superimposed infection or haemorrhagic cerebritis where considered. 

With further deterioration in GCS, urgent neurosurgical intervention with drainage of the cerebral collection 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.   

It remains unclear what precipitated these lobar haemorrhages and how they relate to sepsis. Possibilities include:

  1. CT-occult cerebritis that progressed to haemorrhage
  2. cerebral vein thrombosis (not visualised)
  3. mycotic aneurysms from sepsis
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Case information

rID: 44649
Published: 5th May 2016
Last edited: 4th May 2018
Inclusion in quiz mode: Included

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