CASE 11786 Published on 12.05.2014

Brain abscess in a drug abuser with history of cocaine sniffing

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Muhammad Asim Rana, Ahmed F. Mady, Abdulrehman Alharthy, Omar E. Ramadan, Waleed T. Hashim, Sameh A. Ashmawi, Mohammed A. Alodat, Mahmoud H. AlKurdi, Mohammed M. Gharba, Ahmed Ragab, Mazen A. Hallak

King Saud Medical City,
Riyadh, Saudi Arabia
Email:drasimrana@yahoo.com

Patient

37 years, male

Categories

Area of Interest Head and neck ; Imaging Technique CT

Procedure Imaging sequences ; Special Focus Abscess ;

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Clinical History

An adult male patient with history of sniffing cocaine, presented with 14-day history of progressive fever and confusion. Examination revealed a highly febrile drowsy patient with swollen left eye, external ophthalmoplegia and weakness of right arm. Echocardiography was normal. Blood cultures showed no bacterial growth.

Imaging Findings

CT Brain plain and with contrast done on presentation showed collection in left frontal lobe with few air locules and marked perilesional oedema with mass effect causing midline shift along with effacement of left lateral ventricle.
Subdural collection was also noted on right side representing subdural empyema; however, no significant enhancement was seen post contrast.

CT Paranasal sinuses showed opacification involving left frontal as well as left ethmoidal air cells and left maxillary sinus suggestive of sinusitis. Erosions in the roof of the left extra-orbital frontal and sphenoidal sinus indicate intracranial extension.

In post-craniotomy follow-up plain and contrast enhanced CT brain showed left fronto-parietal bone plate missing with subgaleal haematoma and surgical emphysema. There was large outwards bulging of parenchyma and pulling of midline associated with diffuse oedema with effaced ipsilateral ventricle as well as cortical sulci. However, no defined abscess was noted.

Discussion

Brain abscess is a focal collection within the brain parenchyma, which can arise as a complication of a variety of infections, trauma, or surgery.
Bacteria can invade brain directly or through blood [1, 2].
Direct spread is from adjacent sites like teeth or mastoid sinuses and results in a localized single focus of abscess while haematogenous spread usually results in multiple foci [3, 4].
Usual causes of haematogenous spread include chronic lung supperative conditions like cystic fibrosis and broncheactasis, skin, pelvic, intra-abdominal infections and infective endocarditis [5]. Different procedures like endoscopy [6] and neurosurgery have also been associated with development of brain abscess [7].
Locations of brain abscess in decreasing order of frequency are frontotemporal, frontoparietal, parietal, cerebellar and occipital lobes [8].
A wide variety of bacteria can cause brain abscess depending on the site of infection, age and immune status of the patient. These include aerobic bacteria like Streptococci and Staphylococci, pneumococci are associated with emphysema (also seen in our case in Fig. 1c). While anaerobes include anaerobic streptococci, bacteroides like B. fragilis [9, 10], immunocompromised hosts may have a broader range of opportunistic organisms and fungi [11].
Patients may present with fever, headache, and decreased sensorium or focal neurological symptoms. Examination may show neck stiffness, papilloedema or cranial nerve palsies.
Diagnosis can be established by brain imaging. Contrast enhanced CT brain is a useful modality as it is readily available, although the sensitivity is lower than at MRI.
Early cerebritis appears as non-enhancing irregular area of low density (see frontal lesion in this case in Fig. 2 c). An older lesion becomes surrounded with an enhancing ring because of breakdown of blood brain barrier and development of an inflammatory capsule.
MRI with gadolinium causes more prominent enhancement of lesions than CT and is more sensitive for early cerebritis. Diffusion-weighted MR images differentiate between abscess and neoplasms [12, 13].
Lumbar puncture usually is contraindicated in cases of focal neurological signs but when performed shows high proteins and PMN cells.
Cultures should be performed from the specimens as well as histopathology to establish definitive diagnosis.
Successful management of a brain abscess usually requires a combination of antibiotics and surgical drainage. The antibiotic regimen is dependent on Gram stain, if available, and the likely source of abscess. Antibiotics should be given for four to eight weeks. Glucocorticoids are used when substantial mass effect can be demonstrated on imaging and the mental status is significantly depressed. [14, 15]
Mortality ranges from zero to 30 percent. Of neurologic sequelae seizures are the most common and occur in 30 to 60 percent of patients [16].

Differential Diagnosis List

Brain abscess in a drug abuser with history of cocain sniffing.

Epidural and subdural empyema

Septic dural sinus thrombosis

Mycotic cerebral aneurysms

Septic cerebral emboli with associated infarction

Acute focal necrotizing encephalitis

Metastatic or primary brain tumours

Pyogenic meningitis

Final Diagnosis

Brain abscess in a drug abuser with history of cocain sniffing.

References

[1] Chun CH, Johnson JD, Hofstetter M, Raff MJ (1986) Brain abscess. A study of 45 consecutive cases. Medicine (Baltimore) 65(6):415. (PMID: 3784900)

[2] Bakshi R, Wright PD, Kinkel PR, Bates VE, Mechtler LL, Kamran S, Pullicino PM, Sirotkin I, Kinkel WR (1999) Cranial magnetic resonance imaging findings in bacterial endocarditis: the neuroimaging spectrum of septic brain embolization demonstrated in twelve patients. J Neuroimaging 9(2):78 (PMID: 10208104)

[3] Gallagher RM, Gross CW, Phillips CD (1998) Suppurative intracranial complications of sinusitis. Laryngoscope 108(11 Pt 1):1635. (PMID: 9818818)

[4] Kangsanarak J, Fooanant S, Ruckphaopunt K, Navacharoen N, Teotrakul S (1993) Extracranial and intracranial complications of suppurative otitis media. Report of 102 cases. J Laryngol Otol 107(11):999. (PMID: 8288994)

[5] Patel KS, Marks PV (1989) Multiple brain abscesses secondary to bronchiectasis. A case of 34 discrete abscesses in one brain. Clin Neurol Neurosurg 91(3):265. (PMID: 2548794)

[6] Schlaeffer F, Riesenberg K, Mikolich D, Sikuler E, Niv Y (1996) Serious bacterial infections after endoscopic procedures. Arch Intern Med 156(5):572. (PMID: 8604964)

[7] Staecker H, Nadol JB Jr, Ojeman R, McKenna MJ (1999) Delayed intracranial abscess after acoustic neuroma surgery: a report of two cases. Am J Otol 20(3):369. (PMID: 10337980)

[8] Nielsen H, Gyldensted C, Harmsen A (1982) Cerebral abscess. Aetiology and pathogenesis, symptoms, diagnosis and treatment. A review of 200 cases from 1935-1976. Acta Neurol Scand 65(6):609. (PMID: 7113666)

[9] Lakshmi V, Rao RR, Dinakar I (1993) Bacteriology of brain abscess--observations on 50 cases. J Med Microbiol 38(3):187. (PMID: 7681113)

[10] Brook I (1992) Aerobic and anaerobic bacteriology of intracranial abscesses. Pediatr Neurol 8(3):210. (PMID: 1622518)

[11] Guppy KH, Thomas C, Thomas K, Anderson D (1998) Cerebral fungal infections in the immunocompromised host: a literature review and a new pathogen--Chaetomium atrobrunneum: case report. Neurosurgery 43(6):1463. (PMID: 9848862)

[12] Britt RH, Enzmann DR (1983) Clinical stages of human brain abscesses on serial CT scans after contrast infusion. Computerized tomographic, neuropathological, and clinical correlations. J Neurosurg 59(6):972. (PMID: 6631519)

[13] Leuthardt EC, Wippold FJ 2nd, Oswood MC, Rich KM (2002) Diffusion-weighted MR imaging in the preoperative assessment of brain abscesses. Surg Neurol 58(6):395. (PMID: 12517619)

[14] Mathisen GE, Johnson JP (1997) Brain abscess. Clin Infect Dis 25(4):763. (PMID: 9356788)

[15] Cavuşoglu H, Kaya RA, Türkmenoglu ON, Colak I, Aydin Y (2008) Brain abscess: analysis of results in a series of 51 patients with a combined surgical and medical approach during an 11-year period. Neurosurg Focus 24(6):E9. (PMID: 18518754)

[16] Brouwer MC, Coutinho JM, van de Beek D (2014) Clinical characteristics and outcome of brain abscess: Systematic review and meta-analysis. Neurology 82(9):806-13. (PMID: 24477107)

Case information

URL:	https://www.eurorad.org/case/11786
DOI:	10.1594/EURORAD/CASE.11786
ISSN:	1563-4086

Figure 1

Brain Abscess Pre-operative Plain CT

CT Brain without contrast showing opacification of left maxillary sinus

CT Brain without contrast showing left frontal lobe hypodense lesion with some extradural collection.

CT Brain Plain with well defined left lobe collection with air pockets. Usually seen in cases of pneumoccocal cerebral abcess.

CT Brain Plain shows the extension of lesion to cortex and left parieto-occipital area.

Figure 2

Contrast enhanced CT Brain Cerebral Abscess

CECT Brain with opaque sinuses

CECT Brain extent of lesion with mass effect

Left frontal lobe collection seen with compression of left lateral ventricle. Post contrast enhancement is not seen in left frontal lobe because of element of cerebritis (abcess was recent).

Mass effect with mid-line shift

Figure 3

Post-operative Plain CT Brain

Post-craniotomy follow-up CT with subgalial haematoma and pneumocephalus.

Brain protrusion from bone defect with pneumocephaly.

Post-operative changes

Bone defect with extension of brain into the defect, some local oedema.

Figure 4

Follow-up contrast enhanced CT brain (post-operative)

Bone defect secondary to craniotomy with subgalial haematoma.

Left fronto-parietal bone plate missing with subgaleal haematoma and surgical emphysema. There is large outwards bulging of parenchyma and pulling of midline associated with diffuse oedema and effacement of lateral ventricle.