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Images in Neurology |

Multiple Punctate Intracerebral Hemorrhages in Acute Leukemia With Escherichia coli Sepsis

Sang-Bae Ko, MD; Hee-Joon Bae, MD, PhD; Seong-Ho Park, MD, PhD
Arch Neurol. 2008;65(8):1128-1129. doi:10.1001/archneur.65.8.1128.
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A 56-year-old man was admitted to the hospital with a 2-week history of general myalgia, fever, and cough. A complete blood cell count on admission showed the following: white blood cell count, 1720/μL (to convert to value × 109/L, multiply by 106); hemoglobin level, 6.7 g/dL (to convert to grams per liter, multiply by 10.0); and platelet count, 24 × 103/μL (to convert to value × 109/L, multiply by .001). Acute leukemia was suspected, and a bone marrow examination revealed acute erythroid leukemia (acute myeloid leukemia M6 subtype). Ten days after initiating treatment with cytarabine hydrochloride and idarubicin hydrochloride, he developed a fever (temperature, 39.3°C). Blood smear results showed gram-negative rods, and Fournier gangrene was identified as a septic focus. Vancomycin, meropenem, and metronidazole treatment was initiated, and this treatment was changed to cefepime and metronidazole after the pathogen was identified as Escherichia coli. Five days later, the patient's neurologic status continued to deteriorate and the patient did not show any response to noxious stimuli. Gradient-echo magnetic resonance imaging showed multiple punctate hemorrhages in the cerebral hemisphere (Figure), including more confluent hematomas in the frontal and parietal lobes. They were isointense or slightly hyperintense on T1-weighted imaging, which was compatible with an acute to subacute hemorrhage. Regardless of the 3-week-long appropriate antibiotic drug treatment, the patient remained in a state of akinetic mutism.

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Figure.

Serial magnetic resonance images of the patient. A through C, A miliary pattern of multiple hemorrhages was noted in the whole cerebral hemisphere on gradient-echo imaging. D, A fluid-attenuated inversion recovery image shows vasogenic edemas in the left temporal hematomas. E, Hematomas were seen as isointense or hyperintense on T1-weighted images, compatible with an acute or early subacute stage. F through H, Follow-up gradient-echo images at 3-week intervals show that the number and size of miliary hemorrhages decreased.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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