Asymptomatic Brain Abscess with Intracerebral Hemorrhage

  
NCJ_cover.jpgBy Eun Ju Yoon, Sang Woo Ha, Hyun Goo Kang

First Online: 20 February 2019

Dear Editor,
A 44-year-old man with hypertension and diabetes presented with an acute headache and left hemiparesis. He reported recent inadequate control of blood pressure and diabetes. At the time of admission, his blood pressure was 240/130 mmHg, but fever and myalgia were absent. Immediate computed tomography (CT) revealed a right frontotemporal lobe intracerebral hemorrhage (ICH), and some areas of ICH appeared to be associated with other lesions (Fig. 1). Immediate surgery was performed because of rapidly deteriorating consciousness. After insertion of a catheter to the nearest ICH site, white purulent discharge was observed and irrigation was performed. Blood tests revealed unremarkable findings, with the exception of a slightly increased C-reactive protein level (0.12 mg/L). Staphylococcus saprophyticus was detected on culture, and vancomycin was given for 21 days. Postoperative CT confirmed that the fluid level disappeared and problems caused by the mass as a space-occupying lesion had nearly resolved (Fig. 2). The patient became more alert, and the left hemiparesis gradually improved.

Brain abscess typically presents with various neurological symptoms and is associated with high mortality [1]. It sometimes occurs in association with ICH, but may occur due to hematogenous spread from distal foci [2]. In a case of brain abscess, prompt diagnosis, timely surgical treatment, and antibiotic therapy are important for improving prognosis. In this patient, a brain abscess developed with ICH. It was thought that the abscess was caused by hematogenous spread from an unknown site and that uncontrolled diabetes contributed to abscess generation or exacerbation. Moreover, it is possible that the abscess was overlooked on initial brain imaging because of hemorrhage into the abscess cavity. Treatment for the abscess might have been delayed, but fortunately, the fluid level in the abscess cavity raised the suspicion of an abscess. This case demonstrates that an abscess can be overlooked when ICH invades the abscess cavity, although an abscess should be suspected in the presence of a fluid level and differences in density of the brain parenchyma around the ICH.

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