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Case 222

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A 57 year-old male patient, with serous rhinorrhea, nasal congestion , dry cough and sneezing for 30 days developed nasal discharge, purulent expectoration, sensation of pressure in the frontal region, severe headache and fever, with no meningeal signs upon physical examination. He was diagnosed with frontal sinusitis and treated with levofloxacin , without conducting additional workup. On the 9th day of antibiotic therapy , had no response to the established treatment and evolved with episodes of seizures. A computed tomography ( CT) and magnetic resonance imaging (MRI ) of the brain were requested.

Considering the clinical history and images, which is the most likely diagnosis?

a) Bacterial meningitis

25%

b) Frontal sinus osteoma

25%

c) Brain abscess

25%

d) Thrombosis of venous sinuses

25%
   

Image analysis

Image 1: Computed tomography of the skull, axial view, brain-window. Frontal bone plate presents a continuity defect, indicating a possible bone fracture secondary to the expansion of the infectious process (arrows). Take notice of a hypodense area suggesting cerebral edema (circle).

 

Image 2: Magnetic Resonance Imaging of the skull, axial view, weighed in T2, at the level of the thalamus. There is a possible site of frontal sinusitis to the left (veiling of the frontal sinus- arrow) that protrudes into the left frontal lobe as one hyperintense, encapsulated area, suggestive of brain abscess (red circle). There is also a hypointense area that generates a slight deviation of the midline structures around the probable abscess, suggesting cerebral edema (yellow circle).

 

Image 3: Magnetic Resonance Imaging of the skull, axial view, diffusion weighed, at supraventricular level. In the image , we see a hyperdense region of high protein content, shown by the diffusion technique (circle). Allied to other incidences and clinical information, this finding suggests an intracranial infectious / inflammatory process. 

Highlights

- The clinical presentation of brain abscess is varied and may be asymptomatic or manifest as headache, fever , focal neurological deficits and signs of intracranial hypertension;

- In immunocompetent patients, 35-50 % of brain abscesses are caused by streptococci , especially S. pneumoniae ;

- CT with contrast is a fast, affordable and cost-effective to detect the size , number and location of brain abscesses;

- MRI is the best method for performing differential diagnosis of ring shaped brain lesions seen in CT, with DW MRI being the most sensitive technique;

- Treatment consists of broad-spectrum antibiotic therapy, that should be indicted as soon as there is clinical suspicion, and may require surgical drainage of the abscess. 

References

- Rocha A. J., Vendolin L., Mendonça R. A. Encéfalo - Colégio Brasileiro de Radiologia e Diagnóstico por Imagem. 5a ed.  Rio de Janeiro: Elsevier, 2012.

- Yousem D. M., Zimmerman R. D., Grossman R. I. Requisitos em Neurorradiologia. 3a ed. Rio de Janeiro: Elsevier, 2011.

- Braunwald F., Kasper H. Longo J. Harrison Medicina Interna. 17.ed.  Rio de Janeiro: Mc Graw Hill, 2008.

- Mathisen GE, Johnson JP. Brain abscess. ClinInfectDis. 1997; 25:763–779.

- Matthijs C. B., Allan R. T., Guy M. M. II, Diederik B. Brain Abscess. N engl j med 371;5 nejm.org july 31, 2014.

Authors

Cairo Adriane Mendes Junior, 6th year medical student at UFMG.

E-mail: cairoamjr[at]gmail.com

 

Ícaro Emmanuel Cruz e Melo, graduated doctor from Univerdidade Federal de Juiz de Fora

E-mail: icaroecmelo[at]yahoo.com.br

 

Raíssa Lemos Ferreira da Silva, 6th year medical student at UFMG

E-mail: lemosferreira.raissa[at]gmail.com

Supervisor

André Noronha Arvellos, Professor of the Image Department of Faculdade de Medicina da Universidade Federal de Juiz de Fora (UFJF)

E-mail: aarvellos[at]hotmail.com 

Reviewers

Daniela Braga, Bárbara Queiroz, Raíra Cezar, Fabio M. Satake, André Guimarães, Débora Faria and Professor Viviane Parisotto.

Translated by

Rafael Fusaro Aguiar Oliveira, 5th year medical student at UFMG.

E-mail: rafusaro[at]hotmail.com 

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