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Images in Neurology |

Multiple Brain Abscesses Associated With Tongue Piercing

Moshe Yoel Herskovitz, MD; Dorit Goldsher, MD; Renato Finkelstein, MD; Yaron Bar-Lavi, MD; Marius Constantinescu, MD; Gregory Telman, MD
Arch Neurol. 2009;66(10):1292. doi:10.1001/archneurol.2009.204.
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A previously healthy 22-year-old man was referred to our institution by another hospital because of high fever, drowsiness, and multiple ring-enhancing lesions on brain computed tomography (CT). Medical history was unremarkable, except for a tongue piercing the patient had gotten 2 weeks earlier. On hospital admission, global aphasia and right hemiplegia were found. His temperature was 39°C, and his white blood cell count showed leukocytosis with a left shift. The patient was given empirical antibiotic treatment. Magnetic resonance imaging of the brain revealed 13 ring enhancement lesions with surrounding edema, with focal bleeding in some of them (Figure). Results of an extensive clinical and laboratory workup, including abdominal CT, transesophageal echocardiography, immunoelectrophoresis, complement levels, antinuclear antibody test, human immunodeficiency virus test, and sweat test for cystic fibrosis, were negative, while chest CT showed local bronchiectases on the left lower lobe. Biopsy aspiration from one of the brain lesions revealed Streptococcus intermedius. The patient received treatment with penicillin according to bacterial sensitivity. Because of convulsions, treatment with phenytoin was initiated, with a further switch to valproic acid. Administration of mannitol and dexamethasone was started on admission, stopped, and restarted because of clinical deterioration and enlargement of both the lesions and the surrounding edema on subsequent magnetic resonance imaging. Chloramphenicol was added to the antibiotic regimen. Under this treatment, there was clinical and radiological improvement. Five weeks after admission, the patient was referred to a rehabilitation center. Unfortunately, 3 weeks later, the patient developed fulminate hepatic failure probably due to catheter-related bacteremia and severe septic shock attributable to Klebsiella pneumoniae. Despite all the efforts, the patient died some days later of multiorgan failure.

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Magnetic resonance (MR) images of patient. A, Sagittal T2-weighted MR imaging demonstrates round lesions with a typical hypointense rim and hyperintense vasogenic edema. B, Axial T1-weighted MR imaging with gadolinium demonstrates thick rim enhancement of the lesions. C, Diffusion-weighted imaging shows high-intensity signal within these lesions, typical for abscesses.

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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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