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| LETTER TO EDITOR |
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| Year : 2012 | Volume
: 60
| Issue : 2 | Page : 240-242 |
Sterile hemorrhagic brain abscess in infective endocarditis
Rishi Wadhwa, Jai Deep Thakur, Anil Nanda, Bharat Guthikonda
Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, USA
| Date of Submission | 02-May-2012 |
| Date of Decision | 27-Feb-2012 |
| Date of Acceptance | 28-Mar-2012 |
| Date of Web Publication | 19-May-2012 |
Correspondence Address:
Bharat Guthikonda
Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.96425
How to cite this article:
Wadhwa R, Thakur JD, Nanda A, Guthikonda B. Sterile hemorrhagic brain abscess in infective endocarditis. Neurol India 2012;60:240-2 |
Sir,
Overt hemorrhage into the cerebral abscess associated with infective endocarditis (IE) is a rare entity, of which only one case has been reported. [1] We report a rare case of a macro-hemorrhagic brain abscess (HBA), which became symptomatic within three months of heart valve replacement surgery and required emergent surgical evacuation.
A 49-year-old male presented with a two-day history of lethargy and aphasia. Three months prior the patient underwent aortic valve replacement, mitral valve replacement and tricuspid valve annuloplasty for a triple native valve IE. Preoperatively, his blood cultures were positive for Staphylococcus aureus and enterococci which were treated by IV antibiotics. Of note, two months before his cardiac surgery, head computed tomography (CT) scan was unremarkable. The post-surgical course was complicated by acute interstitial nephritis. Within three months of cardiac surgery, patient was discharged with no neurologic deficits. Two weeks later patient was admitted under neurosurgical service having a two-day history of progressive lethargy and aphasia. On examination, patient was awake with bilateral equal normal reactive pupils and global aphasia. He was able to move all extremities spontaneously but was unable to follow simple commands. Non-contrast CT revealed a large left temporoparietoccipital circumscribed cystic lesion with overt hemorrhage, both within and outside the cystic wall, significant mass effect and midline shift [Figure 1]a and b. His international normalized ratio was found to be 3.79 at admission. Patient was taken to the operative room for resection of the lesion. A left temporal craniotomy was performed, and the hemorrhagic mass was identified. The lesion was a dark shiny, rubbery mass that was surrounded by a large lesional hemorrhage, both of which were resected [Figure 1]c. Histopathology revealed blood clots with focal acute inflammation and necrosis consistent with a diagnosis suggestive of abscess with hemorrhage [Figure 2]a and b. Gram stain, Acid-Fast Bacilli, Grocott's-methenamine-silver stain, Periodic acid-Schiff stains as well as other routine cultures were negative (sterile HBA). The patient showed significant resolution of his aphasia during the postoperative course and was subsequently discharged on broad-spectrum antibiotics. | Figure 1: (a, b) Axial CT head without contrast showing left-sided intra-cerebral well-circumscribed spherical brain abscess with associated hemorrhage both surrounding and within the cavity (c) Follow-up CT head without contrast showing evacuation of the hemorrhagic brain abscess
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 | Figure 2: (a) Low-power photomicrograph showing acutely inflamed brain with several large hemorrhages (H and E, original magnification × 100) (b) High-power photomicrograph showing numerous polymorphonuclear leukocytes and fibrin in area of abscess (H and E, original magnification × 600)
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To our knowledge hemorrhagic brain abscess in a patient with IE has only been reported once. [1] In general, hemorrhage in a cerebral abscess is a rare entity, and only few cases have been reported so far. [2],[3],[4],[5] Since hemorrhage in cystic tumors is a known entity, differentiating HBA from these lesions is important. Apart from the clinical history and examination, radiological and histopathological tools are invaluable in making the diagnosis. Magnetic resonance imaging (MRI), specifically diffusion-weighted imaging and MR-spectroscopy are valuable diagnostic tools having a high specificity. Since our patient recently had an episode of acute interstitial nephritis following a valve replacement surgery, CT without contrast was the only possible imaging modality. The imaging was remarkable for a spherical-circumscribed lesion displaying heterogeneous hyperdensities (inside and outside the wall) representing a likely hemorrhage within as well as scattered on the periphery of the abscess capsule. The pathophysiology for the development of HBA is not well understood. [5] During the formation of an abscess capsule, neo-vascularization occurs. These fragile blood vessels are prone to bleed when exposed to conditions such as raised intracranial pressure, increased intra-cystic pressure due to enlargement of the cavity and factors promoting an inefficient clotting mechanism of the surrounding vessels. In conclusion, although HBA is a rare entity in IE, it should be listed among the differentials in a patient with neurological symptoms. Preventive factors such as quick effective antibiotic therapy (to decrease the chances of embolization) and tight control over coagulation parameters may help in minimizing the chances of HBA.
| » References | |  |
| 1. | Inamasu J, Nakamura Y, Saito R, Kuroshima Y, Ichikizaki K. Hemorrhagic brain abscess in infective endocarditis. Emerg Radiol 2001;8:308-10. 
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| 2. | Corral I, Martín-Dávila P, Fortún J, Navas E, Centella T, Moya JL, et al. Trends in neurological complications of endocarditis. J Neurol 2007;254:1253-9.
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| 3. | Tunkel AR, Kaye D. Neurologic complications of infective endocarditis. Neurol Clin 1993;11:419-40.
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| 4. | Kocaeli H, Hakyemez B, Bekar A, Yilmazlar S, Abas F, Yilmaz E, et al. Unusual complications and presentations of intracranial abscess: Experience of a single institution. Surg Neurol 2008;69:383-91.
[PUBMED] [FULLTEXT] |
| 5. | Terakawa Y, Takami T, Yamagata T, Saito T, Nakanishi N. Magnetic resonance imaging of brain abscess with hemorrhage: implications for the mechanism of hemorrhage. Neurol Med Chir (Tokyo) 2007;47:516-8.
[PUBMED] [FULLTEXT] |
[Figure 1], [Figure 2]
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