Medullary abscess: a rare clinical entity
EANS Academy. Muranovs P. 09/25/19; 275878; EP02119
Dr. Pavels Muranovs
Dr. Pavels Muranovs

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Background: Brain abscesses represent areas of localized infection of the brain parenchyma. Those which are isolated to the brainstem are rare and usually fatal. Streptococcus intermedius is a common causative organism of brain abscesses, however, is associated with significant morbidity.
Clinical presentation: A 68-year-old gentleman presented to his local hospital following a fall. He complained of generalized weakness associated with headache and flu-like symptoms. He was recently treated for a dental abscess and underwent tooth extraction. On examination he had left hemiparesis (MRC grade 2/5) and horizontal nystagmus to the left. His blood tests showed raised infection markers - WCC (18.2), Neutrophils (15.3) and CRP (46). MRI Brain with contrast showed 3.6 cm rim enhancing lesion within the medulla with restricted diffusion. Further work-up did not show any other sources of infection and patient was diagnosed with medullary abscess secondary to dental infection.
Management: The patient underwent emergency posterior fossa craniectomy and drainage of brainstem abscess. Complete aspiration of pus was limited by bradycardia (brainstem reflex). Following discussion with microbiology team, he was started on a course of antibiotics consisting of 6 weeks of Metronidazole and 3 months of Ceftriaxone. Intra-operative pus samples taken for microbiology grew Streptococcus Intermedius. Post-op he required intensive care management and a tracheostomy. Regular interval MRI scans of the Brain with contrast showed improvement of the abscess with complete resolution at 3 months. He completed a 3-month course of intravenous antibiotics with normalised infection markers.
Conclusion: This case highlights the significant morbidity associated with medullary abscess in an immunocompetent patient. Prompt diagnosis, with immediate surgical intervention, maximal therapy with antibiotics and extensive rehabilitation is vital to ensure good neurological outcome.
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