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| LETTER TO EDITOR |
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| Year : 2014 | Volume
: 62
| Issue : 2 | Page : 196-198 |
Abscess within a meningioma: Pathogenesis and rare case report
Shyam Sundar Krishnan1, Manas Panigrahi2, Satvik G. Pattanagare2, Ravi D. Varma3, Satish I. Rao3
1 Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh; Department of Neurosurgery, Voluntary Health Services, Taramani, Chennai, Tamil Nadu, India
2 Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India
3 Department of Neuroradiology, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh, India
| Date of Submission | 23-Jan-2014 |
| Date of Decision | 24-Jan-2014 |
| Date of Acceptance | 06-Apr-2014 |
| Date of Web Publication | 14-May-2014 |
Correspondence Address:
Manas Panigrahi
Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh
India
Shyam Sundar Krishnan
Department of Neurosurgery, Krishna Institute of Medical Sciences, Secunderabad, Andhra Pradesh; Department of Neurosurgery, Voluntary Health Services, Taramani, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.132398
How to cite this article:
Krishnan SS, Panigrahi M, Pattanagare SG, Varma RD, Rao SI. Abscess within a meningioma: Pathogenesis and rare case report. Neurol India 2014;62:196-8 |
Sir,
A 55-year-old lady presented with status epilepticus and features of raised intracranial pressure. She had a distinct history of urosepsis following a double-J (DJ) stent for auretric calculi just 2 weeks prior to the presentation. She was duly investigated and magnetic resonance imaging brain showed a contrast-enhancing extra-axial lesion with mass effect near the motor cortex and severe edema [Figure 1]. Preoperative diagnosis was dural based lesion probable metastasis. She underwent a standard frontoparietal craniotomy and excision of the lesion. The lesion was of dural origin with intratumoral abscess. The Gram stain revealed Gram-negative rods, which on culture proved to be Escheresia coli. [Figure 2]. The lesion itself was a psamomatous meningioma with no atypia. Patient was duly treated with appropriate antibiotic as per sensitivity and was discharged. | Figure 1: Magnetic resonance imaging showing left posterior frontal lesion which on T1-weighted images show a dural based isointense lesion (a), T2-weighted images shows a mixed intensity predominantly hyperintense (b) and on T1 contrast shows irregular peripheral contrast enhancement (c)
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 | Figure 2: Histopathology showing typical meningioma with inflammatory cell layer around the necrotic center (empty portion) (a), and under magnification (b). Gram stain of abscess within lesion shows Gram-negative bacilli (c)
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About 25 cases have been reported of tumor with abscess so far and only six have been reported with meningiomas [Table 1]. [1],[2],[3],[4],[5],[6] Intratumoral abscess in brain tumors is rare. Perisellar tumors like pituitary and craniopharyngiomas are the most common sites due to proximity to the paranasal sinuses. [7] Reasons that make intracranial tumors susceptible to abscesses cannot be extrapolated to meningiomas as well. Meningiomas are the most common site of intratumoral metastasis. [8],[9] We postulate that these very reasons and others make them susceptible to abscess formation: (1) Meningioma vascularity: (a) Predominant meningeal blood supply and being outside the blood brain barrier, (b) increased vasculature, making them act as sieves filtering out the pathogens in bacteremia, (c) the flow pattern: Main supplying artery entering the meningioma does not branch until it reaches the center where it bifurcates into arterioles and capillaries; hence, the entire branching to the periphery originates at the center giving adequate time for the pathogen to lodge and get entrapped, and (d) in case of parasagittal and falcine locations mainly due to the compression/occlusion of the draining veins hence stagnates the blood in the meningioma giving further chance for harboring the pathogen; (2) absence of the blood brain barrier; (3) absence of immune response; (4) rich nutritive environment, rich in lipids and glycogen with its indolent growth rate.
The source of infection varies, the most common causes being genitourinary, dental, respiratory infections and contiguous spread. Our patient had a definite genitourinary intervention following DJ stent placement. The following bacteremia might have induced an indolent meningioma to become a nidus for an abscess formation and the organism was also E. coli which is commonly found to infect ureteric stents. [10],[11] Abscess within the meningioma can result the asymptomatic incidental meningioma to become symptomatic. Meningiomas with abscess should be the differential diagnosis in extra-axial dural based lesions with cerebral edema in the presence of a source of infection. Patients with incidental asymptomatic meningiomas presenting with infection anywhere in the body should be treated aggressively with antibiotics to prevent abscess formation within the tumor.
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[Figure 1], [Figure 2]
[Table 1]
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