Journal of the Royal Society of Medicine Volume 85 October 1992
641
Cerebral abscess due to Clostzidium septicum
A G Marangou BM MD' R A Joske MD FRCP' A 0 Kaard FRACR2 W Thomas FRCAS 'University Department of Medicine and Departments of 2Radiology and 3Neurosurgery, Sir Charles Gairdner Hospital, Verdun Street, Nedlands, Western Australia 6009 Keywords: cerebral abscess; clostridium
Infection with Clostridium septicum is rare and usually associated with haematological malignancies or solid tumours"3.
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Cerebral Clostridium septicum is very uncommon, with only two previously reported cases"5. We report a case of Clostridium septicum cerebral abscess in a patient with colonic adenocarcinoma, presenting with hemiplegia and with unusual radiological findings. Case report An 85-year-old man presented with a 2-day history of headache and pyrexia, culminating in confusion aInd leftsided weakness. On examination, he was febrile (380C) and drowsy, but responsive to commnands. Pulse 80/min, blood pressure 140/80 mmHg. There was no neck stiffness. Fundi were normal. He had a- flaccid -hemiparesis on the left side, with associated hyperreflexia.The white blood cell-count was 16.3x 10/1 (94% neutrephils, 3% lymphocytes, 2% monocytes). Computerized tomography showed a large gas filled cavity in the-right frontal and parietal areas and frontal subdural space (Figure 1) and a caecal mass consistent with a neoplasm
Figure 1. Computerized -tomography (CT) scan from head (noncontrast) There is a large complex gas-filled mass in the right frontoparietal region in addition to frontal subdural gas There is no breach of the skull vault or abnormality of the sinuses. The large amount of gas and relatively little soft tissue component is not typical of a pyogenic abscess
(Figure 2). One blood culture grew Clostridium septicum. Despite aspiration of the necrotic brain tissue and therapy with benzylpenicillin -and metronidazole, his condition deteriorated and he died 16 -days after -admission. At autopsy significant findings were in the colon, liver and brain. There were multiple tumour nodules in the caecum and pericaecal fat. Microscopy revealed moderately differentiated adenocarcinoma, invading all'layers of the colonic wall and extending to the pericolic fat. In the liver, there were multiple necrotic areas, but no metastases evident. Central nervous system findings consisted of a 4 cm cystic lesion filled with necrotic tissue in the right fronto-parietal region. Microscopy showed multiple- foci of liquefication necrosis with purulent exudate. Swabs obtained from tumour necrotic areas in the liver andbrain showedmixed bacterial growth only. Discussion Clostridium septicum infection is uncommon and cerebral infection particularly rare. It appears to have a fulminant course"13 and is usually associated with malignancy1'. Our patient presented with hemiparesis and had a localized cerebral abscess with culture proven Clostridia septicum septicaemia. Pathological examinationrevealed caecal adenocarcinoma, a fronto-parietal and multiple hepatic absc. There have been only two previous reports of Clostridium septicum infection of the brain associated with colonic adenocarcinoma"2. In one report4 cerebral infection occurred 11 years after colectomy for colonic adenocarcinoma. There was evidence of metastatic adenocarcinoma in the liver alone. In the other report5, the patient presented with cerebral infection and colonic adenocarcinoma was diagnosed at autopsy. Both patients were managed with antibiotics alone and died within 24 h of admission. In contrast our patient presented with cerebral infection and the diagnosis of underlying colonic neoplasm was made. radiologically, antemortem. Moreover he underwent neurosurg-ical intervention with aspiration of necrotic brain tissue. Antibiotic therapy consisted of benzylpenicillin and metronidazole. He
soft tissue mass in Figure 2. CTithrough lower abdomen& There aso relatien to the caecum with small pockets ofgas. The finding is nonspecific but is consistent with neoplasm or abscess with necrotic tissue
survived for 16 days following admission. It is likely that the combined approach helped prolong survival. The pathogenesis of cerebral Clostridia infection in patients with bowel neoplasm remains unclear. Presumably the neoplasm permits growth and multiplication of the bacteria with subsequent seedling to the central nervous system. In conclusion, cerebral Clostridium septicum infection is rare. Neurosurgical aspiration together with antibiotic therapy may help prolong survival. References 1 Alpern RJ, Dowell VR Jr. Clostridium septicum infections and malignancy. JAMA 1969;209:385-8 2 Lehman TJA, Quinn JJ, Siegel SE, et aL Clostridium septicum infection in childhood leukaemia. Cancer 1977;40:950-3 3 Koransky JR, Stargel MD, Dowell VR Jr. Clostridium septicum bacteremia, its clinical significance. Am J Med 1979;66:63-6 4 Roeltgen D, Shugar G, Towfighi J. Cerebritis due to Clostridium septicum. Neurology 1980;30:1314-16 5 Gorse GJ, Slater LM, Sobol E, et aL CNS infection and bacteremia due to Clostridium septicum. Arch Neurol 1984;41:882-4
(Accepted 20 August 1991)
0141-0768/92 100641-01/$02.00/0 © 1992 The Royal Society of Medicine
641
Cerebral abscess due to Clostzidium septicum
A G Marangou BM MD' R A Joske MD FRCP' A 0 Kaard FRACR2 W Thomas FRCAS 'University Department of Medicine and Departments of 2Radiology and 3Neurosurgery, Sir Charles Gairdner Hospital, Verdun Street, Nedlands, Western Australia 6009 Keywords: cerebral abscess; clostridium
Infection with Clostridium septicum is rare and usually associated with haematological malignancies or solid tumours"3.
z
NNCtreL1Y wt a % s~~~~~~~-N yb
Cerebral Clostridium septicum is very uncommon, with only two previously reported cases"5. We report a case of Clostridium septicum cerebral abscess in a patient with colonic adenocarcinoma, presenting with hemiplegia and with unusual radiological findings. Case report An 85-year-old man presented with a 2-day history of headache and pyrexia, culminating in confusion aInd leftsided weakness. On examination, he was febrile (380C) and drowsy, but responsive to commnands. Pulse 80/min, blood pressure 140/80 mmHg. There was no neck stiffness. Fundi were normal. He had a- flaccid -hemiparesis on the left side, with associated hyperreflexia.The white blood cell-count was 16.3x 10/1 (94% neutrephils, 3% lymphocytes, 2% monocytes). Computerized tomography showed a large gas filled cavity in the-right frontal and parietal areas and frontal subdural space (Figure 1) and a caecal mass consistent with a neoplasm
Figure 1. Computerized -tomography (CT) scan from head (noncontrast) There is a large complex gas-filled mass in the right frontoparietal region in addition to frontal subdural gas There is no breach of the skull vault or abnormality of the sinuses. The large amount of gas and relatively little soft tissue component is not typical of a pyogenic abscess
(Figure 2). One blood culture grew Clostridium septicum. Despite aspiration of the necrotic brain tissue and therapy with benzylpenicillin -and metronidazole, his condition deteriorated and he died 16 -days after -admission. At autopsy significant findings were in the colon, liver and brain. There were multiple tumour nodules in the caecum and pericaecal fat. Microscopy revealed moderately differentiated adenocarcinoma, invading all'layers of the colonic wall and extending to the pericolic fat. In the liver, there were multiple necrotic areas, but no metastases evident. Central nervous system findings consisted of a 4 cm cystic lesion filled with necrotic tissue in the right fronto-parietal region. Microscopy showed multiple- foci of liquefication necrosis with purulent exudate. Swabs obtained from tumour necrotic areas in the liver andbrain showedmixed bacterial growth only. Discussion Clostridium septicum infection is uncommon and cerebral infection particularly rare. It appears to have a fulminant course"13 and is usually associated with malignancy1'. Our patient presented with hemiparesis and had a localized cerebral abscess with culture proven Clostridia septicum septicaemia. Pathological examinationrevealed caecal adenocarcinoma, a fronto-parietal and multiple hepatic absc. There have been only two previous reports of Clostridium septicum infection of the brain associated with colonic adenocarcinoma"2. In one report4 cerebral infection occurred 11 years after colectomy for colonic adenocarcinoma. There was evidence of metastatic adenocarcinoma in the liver alone. In the other report5, the patient presented with cerebral infection and colonic adenocarcinoma was diagnosed at autopsy. Both patients were managed with antibiotics alone and died within 24 h of admission. In contrast our patient presented with cerebral infection and the diagnosis of underlying colonic neoplasm was made. radiologically, antemortem. Moreover he underwent neurosurg-ical intervention with aspiration of necrotic brain tissue. Antibiotic therapy consisted of benzylpenicillin and metronidazole. He
soft tissue mass in Figure 2. CTithrough lower abdomen& There aso relatien to the caecum with small pockets ofgas. The finding is nonspecific but is consistent with neoplasm or abscess with necrotic tissue
survived for 16 days following admission. It is likely that the combined approach helped prolong survival. The pathogenesis of cerebral Clostridia infection in patients with bowel neoplasm remains unclear. Presumably the neoplasm permits growth and multiplication of the bacteria with subsequent seedling to the central nervous system. In conclusion, cerebral Clostridium septicum infection is rare. Neurosurgical aspiration together with antibiotic therapy may help prolong survival. References 1 Alpern RJ, Dowell VR Jr. Clostridium septicum infections and malignancy. JAMA 1969;209:385-8 2 Lehman TJA, Quinn JJ, Siegel SE, et aL Clostridium septicum infection in childhood leukaemia. Cancer 1977;40:950-3 3 Koransky JR, Stargel MD, Dowell VR Jr. Clostridium septicum bacteremia, its clinical significance. Am J Med 1979;66:63-6 4 Roeltgen D, Shugar G, Towfighi J. Cerebritis due to Clostridium septicum. Neurology 1980;30:1314-16 5 Gorse GJ, Slater LM, Sobol E, et aL CNS infection and bacteremia due to Clostridium septicum. Arch Neurol 1984;41:882-4
(Accepted 20 August 1991)
0141-0768/92 100641-01/$02.00/0 © 1992 The Royal Society of Medicine
