Brain Abscess: Signs & Symptoms

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.