Rahiminejad M, Hasegawa H, Papadopoulos M, MacKinnon A. Actinomycotic brain abscess. BJR Case Rep 2016; 2: 20150370.
CASE REPORT
Actinomycotic brain abscess
1 MARYAM RAHIMINEJAD, MRCS, 1HARUTOMO HASEGAWA, MRCS, 1MARIOS PAPADOPOULOS, FRCS (SN) and 2 ANDREW MACKINNON, FRCR 1 Department of Neurosurgery, Atkinson Morley Wing, St George’s Hospital, London, UK 2 Department of Neuroradiology, Atkinson Morley Wing, St George’s Hospital, London, UK Address correspondence to: Dr Maryam Rahiminejad E-mail: Maryam.rahn@gmail.com
ABSTRACT Actinomycosis is caused by Gram-positive filamentous anaerobic organisms of genus Actinomyces, which are commensals of mucosal membranes of the oropharyngeal cavity, and gastrointestinal and genitourinary tracts. Central nervous system involvement is rare and may present as cerebral abscess, meningitis, meningoencephalitis, subdural empyema or epidural abscess. The radiological appearances of actinomycotic brain abscesses are not well recognized. Here, we present the characteristic imaging features of an actinomycotic brain abscess.
CLINICAL PRESENTATION such as glioblastoma multiforme. Pyogenic abscess walls are
A 50-year-old male presented with a 2-day history of pro- usually smooth and well defined with a disproportionate gressive difficulties with his speech. He reported no other amount of oedema. Homogeneous restricted diffusion in a relevant symptoms. His past medical history included smooth-walled enhancing lesion is suggestive of a pyogenic ischaemic heart disease and cardiac stents. He smoked abscess, whereas restricted diffusion related to a high-grade 20 cigarettes per day. There was no history of immunosup- tumour is often heterogeneous.1 Infections that may appear pression. Neurological examination revealed an alert similar to brain tumours on imaging include Actinomyces, patient with mild expressive dysphasia and right-sided Nocardia, tuberculous granuloma, neurocysticercosis facial weakness. The remainder of the physical examina- and eumycetoma. tion was normal. He was apyrexial and the pulse rate, blood pressure and oxygen saturations were normal. Blood TREATMENT tests, including full blood count, urea and electrolytes, and The patient underwent stereotactic aspiration of the lesion liver function tests were normal. The C-reactive protein and 16 ml of pus was aspirated. Cultures grew Actinomyces level was 29.6 mg l 1 (normal range 0–10 mg l 1). meyeri and Fusobacterium nucleatum. The treatment of actinomycotic brain abscess includes surgical aspiration IMAGING FINDINGS and a substantive course of antibiotics.2 Our patient was MRI demonstrated a large, peripherally enhancing thick- treated with metronidazole and clindamycin following sur- walled lesion in the left temporal lobe. The lesion com- gical aspiration. The abscess recurred after a month and prised a larger cavity posteriorly and grape-like clustering required re-aspiration, but subsequently responded to fur- anteriorly (Figure 1, arrow). The wall was T2 hypointense ther antibiotic treatment. We were unable to identify the and T1 hyperintense (arrowhead) (Figure 1). The contents source of infection in our patient, although periodontal of the lesion showed restricted diffusion. disease, which is associated with smoking,3 may have played a role. The principal differential diagnosis of a peripherally enhanc- ing lesion in the brain is between a necrotic or cystic tumour DISCUSSION and an abscess. Radiological diagnosis of the lesion is impor- There is a paucity of literature with focus on the radiolog- tant because it may influence the initial surgical strategy. ical appearances of actinomycotic brain abscesses.4,5 Tumours typically present insidiously, whereas a cerebral Imaging descriptions in case reports often do not contain abscess may present rapidly with clinical features of infec- much detail on characteristic radiological features.6–8 tion. The history and clinical examination may not, however, Actinomycotic brain abscesses have been described as be suggestive, especially in abscesses caused by atypical irregular, thick and nodular,5 or thin4,6 peripherally organisms. Radiologically, an irregular peripheral enhance- enhancing lesions4–9 with a hypointense core and a rim ment pattern can be seen with high-grade intrinsic tumours that is hyperintense on T1 non-contrast imaging4,5 and
Figure 1. There is a large, peripherally enhancing thick-walled lesion in the left temporal lobe. The lesion comprises a larger cavity posteriorly and grape-like clustering anteriorly (arrow). The wall is T2 hypointense and T1 hyperintense (arrowhead). The contents of the lesion show restricted diffusion, which is consistent with an abscess. The diagnosis is suggested by the grape-like cluster pattern with a T2 hypointense wall, which is a characteristic feature of an actinomycotic abscess. DWI, diffusion-weighted imaging.
hypointense on T2 images.5 Restricted diffusion of the core is an actinomycotic brain abscess (A. meyeri). MRI showed the often seen4,5,7 but is not the rule.9 The periphery may not T2 hypointense grape-like clustering pattern in the right parie- restrict the diffusion.4,5 In our patient, the diagnosis was sug- tal lobe (Figure 2). gested by the grape-like cluster pattern with a T2 hypointense wall, which is a characteristic feature of an actinomycotic Actinomycosis is caused by Gram-positive filamentous anaer- abscess, which, to our knowledge, has not been reported in the obic organisms of genus Actinomyces, which are commensals literature. This imaging appearance was also well demonstrated of mucosal membranes of the oropharyngeal cavity, and the in another patient treated in our department, a 60-year-old gastrointestinal and genitourinary tracts.2,10 Actinomyces isra- male with no relevant medical history who presented to our elii is most commonly isolated in clinical infections. A. department with confusion and falls, and was found to have meyeri is less common but has a propensity to cause dissem- inated disease.2,11 Infection begins with a breach of the Figure 2. Axial T2 and diffusion-weighted MRI in a 60-year-old mucosa and is associated with poor dental hygiene, trauma male with an actinomycotic brain abscess in the right and intrauterine devices. Infection is often polymicrobial and parietal lobe with surrounding oedema. There is grape-like can be associated with Fusobacterium (as in this case)12 or clustering with a T2 hypointense thick wall. The contents show other commensal organisms.2 Brain abscesses represent restricted diffusion. approximately two-thirds of central nervous system infec- tions, the rest being meningitis, encephalitis, subdural empy- ema and epidural abscess.10 The organisms grow in clusters of tangled filaments and may exhibit an outer zone of gran- ulation around the central purulent fluid, which contains tiny yellow clumps (“sulfur granules”) formed by a matrix of bacteria, calcium phosphate and host tissue.13 The granula- tion zone is usually very thick and consists of a highly cellu- lar fibrous tissue containing collagen fibres, fibroblasts, capillaries and inflammatory cells, mainly lymphocytes and monocytes.14 We postulate that these pathological features may lead to the grape-like clustering pattern, although it is interesting that this imaging feature has not been reported in Nocardia and fungal infections that share similar morpholog- ical and pathological features.15
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Case report: Actinomycotic brain abscess BJR|case reports
LEARNING POINTS CONSENT
1. Actinomycotic brain abscess is a rare but potentially We were unable to obtain signed informed consent from our life-threatening infection. patient as the patient is deceased and attempts to contact the 2. Actinomycotic brain abscesses appear on MRI as next of kin were unsuccessful. Exhaustive attempts have been peripherally enhancing lesions that may exhibit a made to contact the family and the paper has been suffi- hyperintense rim on T1 non-contrast imaging and a ciently anonymized not to cause harm to the patient or grape-like cluster pattern with a T2 hypointense wall. his family.
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