Abstract 31 year old man with a PMH of seizures was admitted to the hospital after a motor vehicle accident. He reported sudden onset blurred vision that caused the accident. He did not sustain any injuries from the crash and his vision loss had resolved on arrival. He had normal vitals. He was on Keppra 1000 mg BID and Lacosamide 200 mg BID at home. His last seizure was 6 months ago when he missed his medications but was otherwise well controlled. A brain MRI 6 months ago was within normal limits. He smoked cannabis daily. Physical exam did not reveal any neurological deficits or other abnormalities. Labs were remarkable for leukocytosis 12.4 K/cubic mm, Cr and electrolytes were within normal limits. CT head showed new loss of gray white matter differentiation in the right posterior parietal/occipital region concerning for acute infarct. A follow up brain MRI showed abnormal signal in the right parietal lobe concerning for intracranial abscess. CT chest showed a cavitary lesion within the superior segment of the right lower lobe as well as subcarinal lymphadenopathy. He underwent craniotomy with drainage of the intracerebral lesion found to contain purulent material. He underwent bronchoscopy with bronchoalveolar lavage in the right lower lobe. Endobronchial ultrasound guided transbronchial needle aspiration of the station 7 lymph node showed acute inflammation and no evidence of malignancy. BAL cultures were negative. Intracerebral fluid cultures grew streptococcus anginosus. Blood cultures were negative. HIV screen non reactive. Antibodies for cysticercosis, toxoplasma and cryptococcus were negative. Transthoracic echocardiogram showed a normal ejection fraction of 57%, bubble study revealed a right to left intracardiac shunt. No vegetations were seen. He was initially treated with broad spectrum antibiotics Vancomycin, Cefepime and Metronidazole. He completed 6 weeks of antibiotic therapy with IV ceftriaxone once susceptibilities were available. Follow up MRI brain and CT chest showed near complete resolution of both abscesses. Our case describes a rare presentation of simultaneous lung and brain abscesses from an oral commensal in an immunocompetent patient. The spread in this case was likely aspiration and then hematogenous spread to the brain aided by his right to left intracardiac shunt (likely patent foramen ovale). Most lung abscesses resolve with antibiotics in contrast to brain abscesses that frequently need drainage. This abstract is funded by: None
Wajid et al. (Fri,) studied this question.