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Multiple Brain Abscesses ‑ Diagnostic Dilemma and Therapeutic Nightmare!

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Multiple Brain Abscesses ‑ Diagnostic Dilemma and Therapeutic Nightmare! Published online: 2019-09-26 Letters to the Editor Meningiomas are the commonest intracranial tumors to which systemic metastases occur.[2,3] In meningiomas, Multiple brain the meningothelial variety appears to be the commonest and to the best of our knowledge there are no reports of abscesses ‑ diagnostic metastasis to a psammomatous meningioma.[3] Tumor to tumor metastasis are differentiated from collision tumors dilemma and by Chamber’s[4] but if stricter criteria of Campbell et al., are used the phenomenon appears to be exceedingly therapeutic nightmare! rare with less than 100 cases in reported literature and [5] very few to intracranial tumors. Several theories have Sir, been proposed to explain the proclivity of metastasis to A 32‑year‑old housewife presented with high‑grade meningiomas these include rich vascularity, slow growth fever since 15 days, breathlessness, altered sensorium rate of meningiomas, hormonal factors and low metabolic and seizures since 1 day, oozing right breast abscess rate but the conclusive causes remain unknown. since 2 months. There was no focal neurological deficit. Laboratory investigations revealed anemia, leukocytosis; Although, metastasis from a breast carcinoma to HIV negative. Incision and drainage of the breast abscess a meningioma has been described in literature, this case was done. MRI brain showed multiple signal abnormalities illustrates metastasis to a psammomatous meningioma at in bilateral cerebellar hemispheres, pons, thalami, posterior the tuberculum sellae (both the pathology and location limbs of internal capsule and left frontal sub cortical white being rare). It stresses the need to maintain a high level matter [Figure 1] with peripheral ring enhancement post of suspicion for neurological symptoms in a diagnosed contrast. In view of the fever, seizures, breast abscess, case of breast carcinoma. the impression was multiple microabscesses in the brain. Pus culture of breast abscess was positive for klebsiella Ravi Dadlani, Nandita Ghosal1, Alangar Sathya Hegde species. She was treated with intravenous antibiotics Departments of Neurosurgery, 1Pathology, Sri Satya Sai Institute of as per the sensitivity pattern (piperacillin‑tazobactum), Higher Medical Sciences, Bangalore, India antiepileptics and supportive care for 4 weeks. She became afebrile after 2 weeks and was discharged after Address for correspondence: Dr. Ravi Dadlani, 4 weeks of treatment. However, after another 2 weeks Department of Neurosurgery, she was readmitted with high grade fever, dyspnoea and Sri Sathya Sai Institute of Higher Medical Sciences, maculopapular rash all over the body ‑ Steven Johnson’s EPIP area, Whitefield, Bangalore ‑ 560 066, India. E mail: [email protected] syndrome, secondary to phenytoin, hence it was changed over to levetiracetam. Her right breast abscess had healed References completely. Hemoglobin and platelet count dropped, with leukocytosis and deranged liver and renal functions. She 1. Lin JW, Su FW, Wang HC, Lee TC, Ho JT, Lin CH, et al. Breast developed hypotension, oliguria, and acute respiratory carcinoma metastasis to intracranial meningioma. J Clin Neurosci 2009;16:1636‑9. distress syndrome (ARDS). 2 DECHO did not show any 2. Lanotte M, Benech F, Panciani PP, Cassoni P, Ducati A. Systemic cancer vegetation. Blood culture s/o MRSA coagulase positive metastasis in a meningioma: Report of two cases and review of the staphylococcus aureus, procalcitonin level of 9.5; coagulation literature. Clin Neurol Neurosurg 2009;111:87‑93. 3. Takei H, Powell SZ. Tumor‑to‑tumor metastasis to the central nervous profile was suggestive of disseminated intravascular system. Neuropathol 2009;29:303‑8. coagulation. She was put on inj imipenem‑cilastatin (as per 4. Chambers PW, Davis RL, Blanding JD, Buck FS. Metastases to primary sensitivity), platelet and fresh frozen plasma transfusions, intracranial meningiomas and neurilemomas. Arch Pathol Lab Med hemodialysis and supportive care. 1980;104:350‑4. 5. Campbell LV Jr, Gilbert E, Chamberlain CR Jr, Watne AL. Metastases of cancer to cancer. Cancer 1968;22:635‑43. She was investigated for vasculitis, tuberculosis, macrophage activation syndrome[1] (MAS) and Access this article online toxoplasmosis, which were negative. Repeat MRI showed Quick Response Code: same ring enhancing lesions in left parietal, bilateral basal Website: ganglia, pons, bilateral cerebellar hemispheres but with www.ruralneuropractice.com hemorrhagic changes with perifocal edema. Magnetic resonance spectroscopy [Figure 2] was done, which was DOI: suggestive of multiple brain abscesses with perifocal 10.4103/0976‑3147.112780 edema and hemorrhagic changes. Stereotactic biopsy of the lesion was deferred due to the hemorrhagic changes in 234 Journal of Neurosciences in Rural Practice | April - June 2013 | Vol 4 | Issue 2 Letters to the Editor Figure 1: MRI brain showing multiple RELs in cerebellar hemispheres, Figure 2: MR spectroscopy showing a subcortical brain abscess with pons, thalami, posterior limbs of internal capsule and left frontal sub hemorrhagic changes; aminoacid, acetate and succinate peaks were cortical white matter observed the brain abscesses. CSF study was not done due to risk of choice of inappropriate antibiotics, ventriculitis due to herniation. Her condition deteriorated further and she was rupture, bilateral/multiple, large, deep or multiloculated kept on mechanical ventilation with inotropic support for abscesses, posterior fossa abscesses, poor sensorium, 12 days with the other supportive care. Despite all efforts, hydrocephalus, septic shock, HIV co‑infection.[1,3] she succumbed to death on day 52 of second admission. Our patient had bilateral, multiple brain abscesses in the posterior fossa, as well as supratentorial, a septic Brain abscess is a focal intracerebral infection, beginning focus ‑ untreated breast abscess, but no other risk factors. with a localized area of cerebritis and developing into MRI, diffusion‑weighted MRI, perfusion ‑ weighted MRI a collection of pus surrounded by a well defined capsule. also are sensitive methods for identifying cystic lesions Seeding of the brain presumably occurs via transit of and enhancement. Magnetic resonance spectroscopy infecting bacteria through the valveless emissary veins study determines the concentration of brain metabolites that drain regions of paranasal sinuses, middle ear, such as N‑acetyl aspartate, choline, creatine and lactate teeth, etc., and permit direct or retrograde flow into the in the brain tissue, this technique helps in differentiating venous drainage systems of the brain. Other causes are tumor from infective pathogens and abscesses.[5] penetrating injury, metastatic seeding of the brain from distant extracranial sources etc.[2] In immunocompetent To summarize, our patient had multiple brain abscesses individuals the most common pathogens are secondary to an untreated brain abscess and hematogenous streptococcus spp. (anaerobic, aerobic, and viridians‑40%), spread. Her refractoriness to treatment and progressive staphylococcus aureus, enterobacteriaceae, proteus, klebsiella deterioration led us to investigate her extensively. Though pneumonia and anaerobes. In immunocompromised we could not get a tissue diagnosis, MR spectroscopy, hosts, it is mostly caused by nocardia spp, aspergillus a useful tool, aided and supported our diagnosis. Despite spp, and candida spp.[1,3] The incidence of multiple brain the availability of new antibiotics, new powerful imaging abscesses in all intracranial abscesses is about 2 to 15% technologies and development of better neurosurgical and carry a mortality rate of 62 to 100%. Multiple brain techniques the therapeutic outcome of brain abscess has abscesses are often caused by hematogenous spread of not shown a statistical significant change. Often, diagnostic bacteria from a primary source and are frequently found challenge is stiffer than expected, and exact diagnosis may in the territory of middle cerebral artery. Likely sources not be forthcoming even after clinical evaluation and of primary infection include cyanotic heart disease, a battery of tests, and besides the diagnostic dilemma, endocarditis, suppurative lung diseases, skin/abdominal therapy can become a physician’s nightmare! and pelvic infections. They are common in patients with HIV infection, organ transplant recipients, intravenous Kavita Krishna, Elizabeth Sada, drug abuse, chemotherapy for lymphoma, diabetes, Anita Vikram, Ankur Gupta [4] congenital cardiac defects and prosthetic valves. Factors Department of Medicine, Bharati Vidyapeeth University Medical predictive of poor outcome include delay in diagnosis, College and Bharati Hospital, Pune, Maharashtra, India Journal of Neurosciences in Rural Practice | April - June 2013 | Vol 4 | Issue 2 235 Letters to the Editor Address for correspondence: shown disappointing results. As pointed out by the Dr. Kavita Krishna, author’s “Plants provide wealth of bioactive compounds, Bungalow No. 23, Sopan Baug Coop Housing Society, Pune, Maharashtra, India. which exert a substantial strategy for the treatment of E‑mail: [email protected] neurological disorders such as Alzheimer’s disease.”[1] References It would be worthwhile to include certain additional plants of Indian origin that have demonstrated to 1. Lu CH, Chang WN, Lin YC, Tsai NW, Liliang PC, Su TM, et al. Bacterial brain abscess: Microbiological features, epidemiological trends and possess beneficial properties for managing dementia/AD. therapeutic outcomes. QJM
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