Internal Medicine: Open Access
Open Access

Multiple Brain Abscesses Caused by Streptococcus intermedius: Prognostic Index of Mortality

Spyridon-Gerasimos M^*, Katsikas T and Drimis S ^*Correspondence: Spyridon-Gerasimos M, Department of Internal Medicine, 3rd Clinic of Internal Medicine, Tzaneio General Hospital of Piraeus, Greece, Tel: +306932985643, Email:

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Introduction

Brain abscess, whether single or multiple, represents a serious diagnostic and curative problem. Computer Tomography (CT) and Magnetic Resonance Imaging (MRI) are the essential studies for diagnosis as well as monitoring of the disease, which also seems to have a prognostic value for its evolution.

Purpose

To present a patient clinical case with multiple brain abscesses, presented with progressively worsening gait instability, which started a week before admission, fever and acute declination of level of consciousness.

Case Report

83 year-old male patient with history of prostatectomy 8 years ago due to prostate cancer, STEMI that occurred 15 years ago and arterial hypertension brought at the ER by his family members due to progressively worsening gait instability, which started a week before admission, fever and acute declination of level of consciousness, that according to his daughter started 12 hours ago. From the clinical examination the patient presented with a left hemiparesis of upper and lower extremity with reduced light touch sensitivity and a positive left Babinski sign. His GCS was 13/15. No other possible cause or source of fever was able to be identified through the remaining clinical examination of the patient (Table 1).

Table 1: Diagnostic tests and clinical course.

CT enhanced (Figure 1, right images) with iv contrast study showed multiple oedematous areas bilaterally, with increased peripheral density (ring-enhanced lesions) and mild perilesional edema, while their morphology features in additional testing with Gadoliniumenhanced MRI (Figure 1, left images, T1-weighted) raised the suspicion for multiple brain abscesses in both brain hemispheres, mostly in the right one.

Figure 1: MRI scan (left) and CT scan (right) images.

The patient was initiated on empirical antimicrobial therapy with ceftriaxone, vancomycin and metronidazole in full dosing regimes [1-3]. Neurosurgical consultation for stereotactic biopsy of the lesions was asked, which was successful and the result of the pus culture showed growth of Streptococcus intermedius (Streptococcus milleri group).

A full clinical laboratory and imaging investigation was initiated in order to track the primary focus of the infectious process, which presented with brain dissemination as the cause of this patient’s admission, but it was not possible to identify one (20%-30% of brain abscess cases are cryptogenic) (Table 2) [4-6].

Table 2: Diagnostic tests and results.

Discussion

A brain abscess is a focal, intracerebral infection that starts as an isolated area of encephalitis and evolves into a collection of pus surrounded by a well-vascularized capsule [4,7]. A method of classification of abscesses is based on the source of origin and the “primary gate” of infiltration of the infection and are categorized in:

• Spreading of the infection from nearby structures (per continuitatem)–the most common cause.

• Hematogenic dissemination.

• Penetrating trauma.

• Cranial Surgery.

• Meningitis spreading to brain parenchyma.

• Cryptogenic abscess [4,6,8,9]

The clinical presentation of brain abscess is not typical and depends on the size and location of the abscess as well as the virulent potency of the microorganism and it can vary from latent to fulminant [3,6,8].The most common symptoms are headache, altered mental status, fever and focal neurological symptomatology [1]. A retrospective analysis of clinical cases with brain abscess shows Streptococcus spp. as the most common microbial cause, whereas Staphylococcus sp. was the most common microbial cause after neurosurgical procedure [10-12].

The diagnosis is based on brain CT and MRI imaging studies, which are essential for monitoring the clinical course of the disease and its response to treatment, but also represent an indirect index for determination of prognosis and mortality by using an imagingbased score of severity of the disease [13-20] (it is considered more trustworthy index than GCS) including the following parameters (Table 3).

Table 3: Analysis of clinical cases with brain abscess.

Conclusion

According to the classification mentioned above this patient’s score was>10 points (in specific 12 points–>5+3+2+1+1).The patient has been hospitalized for a prolonged interval and has been receiving his antimicrobial regime. Despite the successful management of complications such as respiratory failure and seizures the patient eventually deceased without any improvement of the infectious process.

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