Case contributed by Sylvia Okwemba
Diagnosis almost certain


Confusion and fever.

Patient Data

Age: 55 years
Gender: Male

Predominantly left frontal lobe areas of T2/FLAIR signal abnormality with extension along the body of the corpus callosum and into the right frontal lobe. The lesions demonstrate central restricted diffusion (increased DWI signal and reduction in ADC values compared to the white matter) and peripheral ring enhancement (involving the corpus callosum and within the right frontal white matter). No SWI signal abnormality is demonstrated.

Case Discussion

The differential diagnosis for ring enhancing lesions in the context of confusion and fever includes cerebral abscess, tuberculoma and neurocysticercosis.

The patient presented with confusion on a background of multi-organ septicemia involving the lungs, liver, spleen, prostate and left ankle joint. Blood cultures and ultrasound- guided left ankle joint aspirate were obtained and sent for microbiological C&S testing. Both specimens were positive for Burkholderia pseudomallei. Identifiable risk factors in this case included recent travel to an endemic area and diabetes mellitus.

The key imaging findings associated with CNS involvement in this case include the spread of infection along white matter tracts and microabscesses as reported by Hsu et al. In this case this is highlighted by spread of infection across the corpus callosum.

Subsequent serial imaging demonstrated radiological improvement with areas of persistent enhancement and SWI signal abnormality.

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