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o Meningitis
o Viral encephalitis
o Subdural empyema
o Neurocysticercosis
Inflammatory processes
o Multiple sclerosis
o Neuromyelitis optica
o Differentiating factors:
o Patients usually have previous events (numbness, tingling, weakness, visual loss, etc.) that
can be elicited by a thorough history
o No fever
Malignancy
o Glioma
o Lymphoma
o Differentiating factors:
o Negative cultures
Intraparenchymal hematoma
o Differentiating factors:
o Negative cultures
Contusion
o Differentiating factors:
o Negative cultures
o History of trauma
Ischemia
o Subacute ischemia can have contrast enhancement, but not in the same pattern. Restricted
diffusion may or may not be present.
Radiation necrosis
o Differentiating factors:
o Negative cultures
o History of radiation
Frontal lobe: poor attention, decline in cognitive abilities, hemiparesis, and seizures.
Temporal lobe: aphasia, visual field deficits, hemiparesis or sensory deficits, particularly in
the face.
Parietal lobe: findings can be subtle, but can include neglect and apraxia.
o Focal findings can help localize the lesion, but focal findings may not be present in all
cases.
Fundoscopic examination
Otoscopic examination: fluid levels; appearance of tympanic membrane can help diagnose
otitis media.
General examination
1. What laboratory studies (if any) should be ordered to help establish the
diagnosis? How should the results be interpreted?
Complete blood count (CBC): elevated white count.
Lumbar puncture: Prior to performing the procedure, perform imaging to ensure that
vasogenic edema has not caused significant mass effect, and risk of herniation is low.
Positive in 10-30% of cases. Cerebrospinal fluid (CSF) can be normal if abscess is
localized. Intracranial pressure is usually 20 to 300 millimeters mercury (mmHg). White cell
count is usually elevated in brain abscess. Cell count ranges from 0 to 100,000 cells per
microliter. Differential can help determine if the cause is more likely to be from bacterial or
fungal sources. If glucose is low, indicative of infectious process but is generally normal.
Human immunodeficiency virus (HIV): CD4 (cluster of differentiation 4) count in known HIV-
positive individuals.
Any material obtained from a neurosurgical procedure should be sent to the laboratory for
pathological evaluation and cultures (aerobic, anaerobic, mycobacterial, fungal).
2. What imaging studies (if any) should be ordered to help establish the
diagnosis? How should the results be interpreted?
Brain imaging is essential to the work-up of a patient with a suspected brain abscess.
Computed tomography (CT) and/or MRI with contrast should be performed. MRI is
preferred.
o MRI
o T1 weighted images with contrast also show enhancement of capsule. May show a
characteristic "ring-enhancing lesion". Hypointensity is present in the necrotic core. Figure
1 is a typical "ring enhancing lesion" in a HIV-positive patient with toxoplasmosis. Figure 2 is
an irregularly shaped capsule with enhancement in an immunosuppressed patient
with Listeria abscess.
o T2 and fluid-attenuated inversion recovery (FLAIR) images show hyperintense vasogenic
edema with hypointense capsule. Figure 3 shows FLAIR imaging in the HIV-positive patient
with toxoplasmosis.
o Diffusion weighted images (DWI) and apparent diffusion coefficient (ADC) images are
compared to help differentiate abscess from malignancy. Abscess usually has restricted
diffusion (brightness on DWI with correlating dark area on ADC). Figure 4 shows a central
area of restricted diffusion in the patient with Listeria abscess.
Chest X-ray: evaluation of pulmonary causes.
Figure 1.
T1 with contrast in a patient with toxoplasmosis
Figure 2.
T1 with contrast. Atypical appearance of abscess in immunocompromised patient. Listeria was
determined to be cause of abscess after contaminated cantelope ingestion.
Figure 3.
T2 FLAIR image in a HIV positive patient with toxoplasmosis
Figure 4.
Central area of restricted diffusion on DWI (left) and ADC (right) images. Immunocompromised
patient with multiple listeria abscesses.
F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.
N/A
Abscess aspiration can help to determine pathogen and to reduce the size of the abscess.
With modern stereotactic neurosurgical techniques, brain abscesses measuring at least 1
centimeter (cm) in diameter are amenable to stereotactic aspiration.
If there is brain shift, with risk of brain herniation, neurosurgical intervention is indicated
regardless of abscess size.
In patients with multiple abscesses, the largest abscess should be aspirated for diagnostic
purposes.
Total resection has a limited role these days but if is considered when abscess is superficial
and not located in eloquent brain tissue and when there is suspicion of fungal or
tuberculous infection or of branching bacteria (Actinomyces or Nocardia).
If edema is present causing hydrocephalus, shunting may be necessary.
If edema is severe and causing significant mass effect, mannitol or hypertonic saline can be
considered.
A. Immediate management.
Antibiotics should be initiated as soon as possible. If mass effect is present, consider
corticosteroids. It is unusual to require an emergent neurosurgical procedure for abscess,
but a consultation should be considered if the patient has severe mass effect, is comatose,
stuporous or has a capsule larger than 2 cm.
If phenytoin is used, levels should be drawn daily until a clear therapeutic steady state is
achieved. Liver profiles should be checked at the onset of therapy, and approximately
weekly while the patient is admitted. If liver panels are not elevated in subsequent lab
draws, then infrequent intermittent checks should be performed.
D. Long-term management.
The length of intravenous antibiotic course is dependent upon the organism(s) found, but is
typically 6 to 8 weeks. This is often followed by oral antimicrobial therapy for 2 to 3 months if
an appropriate agent is available although the efficacy of this approach has not been
established. It is important to continue antibiotic therapy until resolution of the abscess by
neuroimaging. Of note, prolonged therapy with metronidazole can lead to peripheral
neuropathy.
Other consultations may be necessary, such as with oncology in a patient with cancer, or
cardiology in a patient with endocarditis. In patients with immunocompromised states,
careful coordination with consultants is required to ensure that medications are managed
appropriately.
The combination of surgical aspiration or removal of all abscesses larger than 2.5 cm in
diameter, a 6-week or longer course of intravenous antibiotic therapy, and neuroimaging
follow-up until resolution provides the best chances for cure.
Patients with intracranial abscess should be monitored closely for progression of disease.
Abscess rupture is an uncommon complication, but should be on the differential if a patient
worsens. Ventriculitis and diffuse spread of bacteria are associated with worse outcomes.
A. Renal Insufficiency.
Dose reduction of antibiotics may be necessary.
Renally cleared antiepileptics (levetiracetam, topiramate, etc.) may require dose reduction.
B. Liver Insufficiency.
Drug levels of antiepileptics metabolized by the liver (phenytoin, valproate) should be
monitored. Liver function tests to ensure the values remain stable should be performed.
F. Malignancy
In patients with malignancy, a discussion should occur with the treating oncologist to
determine an appropriate treatment plan. Frequently, chemotherapeutics and radiation
treatments will be suspended during the treatment for brain abscess. A conversation with
the patient and the family regarding the consequences of deferment of treatment should
occur. In some cases, goals of care should be clearly established due to the consequences
of holding cancer treatment and neurological sequelae that can occur after abscess
treatment is complete.
V. Transitions of Care
Fever despite tailored antibiotics to the source of the infection should be further evaluated
with chest x-ray, blood cultures, urinalysis, and testing for Clostridium difficile if diarrhea is
present. Broadening the antibiotic regimen may be necessary if it is believed that the fever
originated from the abscess and is possibly improperly covered by the current antibiotic
regimen.
Infectious disease: within 4-6 weeks after discharge and thereafter until discontinuation of
antibiotics.
2. What tests should be conducted prior to discharge to enable best clinic first
visit.
None
3. What tests should be ordered as an outpatient prior to, or on the day of, the
clinic visit.
CT or MRI with contrast to ensure resolution of abscess.
E. Placement Considerations.
Frequently, patients with brain abscess will require rehabilitation. Most patients require
acute or sub-acute rehabilitation. Rehabilitation specialties (physical, occupational and
speech therapy) should be consulted early during the hospitalization. A physical medicine
and rehabilitation physician can help to determine when the patient is stable for transfer to
these facilities based upon progress with therapy. This consultation should occur a few days
prior to the anticipated discharge.
A peripherally inserted central catheter (PICC) line should be placed in all patients requiring
an outpatient course of intravenous antibiotics.
Gastrointestinal (GI) prophylaxis with a proton pump inhibitor if steroids are used. Blood
sugar monitoring and an insulin sliding scale can also be considered with steroid use.
If HIV-positive and low CD4, immune reconstitution with combined antiretroviral therapy is
recommended.