Brain Abscess: Signs & Symptoms

by John Fisher, MD

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    00:01 So, let's talk about the clinical features of brain abscess.

    00:06 It can be an indolent sneaky infection or fulminant symptoms and signs depending upon the size and location of the abscess and what it's pushing on or what it’s destroying.

    00:19 Another determining factor is the virulence of the infecting organism.

    00:25 Most of the patients will present with headache.

    00:28 It can be on one side of the brain and it usually is on the same side of where the brain abscess is.

    00:37 And so, it can be a generalized headache or hemi-cranial.

    00:42 There are really no distinguishing factors, and so that often results in a delay in diagnosis.

    00:52 But if a patient has sort of an indolent course and then becomes suddenly very ill, that suggests that the brain abscess has ruptured into the ventricles and is causing now meningitis.

    01:11 So, various pathogens produce brain abscess.

    01:18 We started earlier talking about Nocardia.

    01:22 And I should point out at this point that about 10% of the patients who develop a Nocardio lung abscess also have a brain abscess.

    01:35 This is a very abscessogenic organism.

    01:38 So, if you diagnose lung abscess due to Nocardia, the incidence of brain abscess is so high that those patients should have imaging of their brain, symptomatic or not.

    01:54 The zygomycetes, they are angioinvasive.

    01:59 These are the bread molds.

    02:01 And angioinvasive means that they invade blood vessels and they then can occlude those blood vessels and disseminate.

    02:12 And most of the time, it's in and around the paranasal sinuses.

    02:18 And most of the time it’s associated with diabetic ketoacidosis.

    02:22 The absolute worst case of this I've ever seen is a man that was treated at an outside hospital for some kind of infection on the skin, a cellulitis.

    02:34 He was given antibacterial antibiotics.

    02:38 And during the course of that hospitalization, his glucose was out of control and he developed diabetic ketoacidosis in the other hospital.

    02:48 He then began to complain of nasal congestion and trouble with his vision.

    02:56 And they then transported him to the Medical College of Georgia, where I work, and at the time he arrived he was absolutely sightless in both eyes.

    03:10 He had no light perception in either eye.

    03:14 His face was swollen and you could almost demarcate where the infection was.

    03:21 He had essentially caused an infarction of his face.

    03:26 This organism had invaded all of the blood vessels in and around his sinuses and face.

    03:32 And it had spread already to his brain, and so emergency surgery was done because you have to cut this infection out.

    03:42 Remember, if the blood vessels are occluded, then how are antifungals even going to get there.

    03:48 So, you’ve got to cut this entire infection out.

    03:52 And the neurosurgeons and ENT physicians, when they cut, they kept finding fuzzy mold beneath the skin and deep into the sinuses.

    04:04 And the patient literally had his face taken off by the surgeons.

    04:13 And he was about to be fitted with a mannequin like mast to place over his face, but unfortunately he died of a bacterial meningitis because of the proximity of all this surgery to his brain.

    04:28 But I'll never forget that patient.

    04:30 And the main reason I want you never to forget it, anything – in a diabetic with ketoacidosis, anything suspicious about the sinuses, those patients need an emergency workup by ENT for invasive mucormycosis.

    04:51 And then, we’ve already talked about the association of near-drowning with Scedosporium.

    04:59 Toxoplasma encephalitis in brain abscess will present usually with confusion.

    05:05 We’re usually talking about an HIV patient and the patient may have extrapyramidal findings because the basal ganglia are frequently involved in abscesses due to Toxo.

    05:19 In a patient with aspergillosis, this, like mucor and like the bread molds, is angioinvasive.

    05:28 And the main patients at risk for this infection are patients with neutropenia.

    05:35 Indeed, the most common fungal infection in a patient with leukemia and neutropenia is aspergillosis.

    05:43 And a patient may actually present as if they've had a stroke, and so stroke in a leukemic victim should be considered to possibly be Aspergillus until proven otherwise.

    About the Lecture

    The lecture Brain Abscess: Signs & Symptoms by John Fisher, MD is from the course CNS Infection—Infectious Diseases. It contains the following chapters:

    • Signs/Symptoms – Clinical Features
    • Various Pathogens

    Included Quiz Questions

    1. Aspergillosis
    2. Toxoplasmosis
    3. Mucormycosis
    4. Abscess due to Nocardia species
    5. Abscess due to Scedosporium apiospermum
    1. 10%
    2. Less than 1%
    3. 30%
    4. 5%
    5. 65%
    1. ...the age of the patient
    2. ...the size of the abscess
    3. ...the location of the abscess
    4. ...the structures being compressed by the abscess
    5. ...the virulence of the infecting organism
    1. A patient with a long history of poorly controlled diabetes
    2. A patient who suffered a near drowning episode
    3. A patient who has chronic sinus infections but is otherwise quite healthy
    4. A patient with leukemia and stroke-like symptoms
    5. A patient who is HIV positive and presents with extrapyramidal symptoms
    1. Toxoplasma gondii
    2. Aspergillus
    3. Scedosporium apiospermum
    4. Zygomycetes
    5. Nocardia

    Author of lecture Brain Abscess: Signs & Symptoms

     John Fisher, MD

    John Fisher, MD

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