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| style="background: #F5F5F5; padding: 5px;" |[[Palpitation|Palpitations]], [[sweating]], [[dizziness]], low serum, [[glucose]]
| style="background: #F5F5F5; padding: 5px;" |[[Palpitation|Palpitations]], [[sweating]], [[dizziness]], low serum, [[glucose]]
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===Differentiating brain abscess in [[immunocompromised]] host===
Brain abscess is common among [[Immunocompromised|immunocompromised patients]] who are at high risk for other [[fungal]], [[bacterial]], and [[viral infections]]. It should be differentiated from the following diseases:
{| class="wikitable"
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Disease
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Differentiating signs and symptoms
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Differentiating tests
|-
|[[Lymphoma|CNS lymphoma]]<ref name="pmid20212226">{{cite journal |vauthors=Gerstner ER, Batchelor TT |title=Primary central nervous system lymphoma |journal=Arch. Neurol. |volume=67 |issue=3 |pages=291–7 |year=2010 |pmid=20212226 |doi=10.1001/archneurol.2010.3 |url=}}</ref>
|
* Patient is [[immunocompetent]]
* Focal symptoms indicative of a mass [[lesion]]
* [[Seizure]]
|
*Single solitary ring enhancing [[lesion]] on [[CT]] or [[MRI]]
|-
|[[Disseminated tuberculosis]]<ref name="pmid21740673">{{cite journal |vauthors=von Reyn CF, Kimambo S, Mtei L, Arbeit RD, Maro I, Bakari M, Matee M, Lahey T, Adams LV, Black W, Mackenzie T, Lyimo J, Tvaroha S, Waddell R, Kreiswirth B, Horsburgh CR, Pallangyo K |title=Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality |journal=Int. J. Tuberc. Lung Dis. |volume=15 |issue=8 |pages=1087–92 |year=2011 |pmid=21740673 |doi=10.5588/ijtld.10.0517 |url=}}</ref>
|
* Prior history of residence in an [[Endemic (epidemiology)|endemic]] area
* Chronic [[cough]], [[weight loss]], [[hemoptysis]]
|
* [[PCR]] of [[CSF]] for [[tuberculosis]]
* Mycobacterial culture of [[CSF]]
* [[Brain]] biopsy for [[acid-fast bacilli]] staining
* Culture and acid stain positive for [[acid-fast bacilli]]
* CXR shows [[Cavitation|cavitations]]
|-
|[[Aspergillosis]]<ref name="pmid10194462">{{cite journal |vauthors=Latgé JP |title=Aspergillus fumigatus and aspergillosis |journal=Clin. Microbiol. Rev. |volume=12 |issue=2 |pages=310–50 |year=1999 |pmid=10194462 |pmc=88920 |doi= |url=}}</ref>
|
* [[Pulmonary]] [[lesions]] in addition to [[CNS]] [[lesions]]
* Symptoms may include [[cough]], [[chest pain]], and [[hemoptysis]]
|
*[[CSF]] fungal culture, [[galactomannan]]
|-
|[[Cryptococcosis]]
|
*Symptoms include [[cough]], [[chest pain]], and [[hemoptysis]]
|
*[[Cryptococcal infection|Cryptococcal]] [[antigen]] from [[CSF]] and [[serum]]
*[[CSF]] fungal culture
|-
|[[Chagas disease]]<ref name="pmid20399979">{{cite journal |vauthors=Rassi A, Rassi A, Marin-Neto JA |title=Chagas disease |journal=Lancet |volume=375 |issue=9723 |pages=1388–402 |year=2010 |pmid=20399979 |doi=10.1016/S0140-6736(10)60061-X |url=}}</ref>
|
*History of residence in Central or  South America
*Acute infection is rarely symptomatic
*[[Encephalitis]] or focal [[brain]] [[lesions]]
*[[Myocarditis]]
*[[Chronic]] [[infections]] in [[immunocompromised]] patients develop into [[encephalitis]] with [[necrotic]] [[brain]] lesions causing a [[mass effect]]
|
*[[Trypanosoma cruzi]] in [[blood]], [[Tissue (biology)|tissue]], or [[CSF]], [[PCR]] of [[Tissue (biology)|tissue]] or [[body fluids]], and [[Serological testing|serologic tests]]
|-
|[[Cytomegalovirus infection|CMV infection]]<ref name="pmid11215290">{{cite journal |vauthors=Emery VC |title=Investigation of CMV disease in immunocompromised patients |journal=J. Clin. Pathol. |volume=54 |issue=2 |pages=84–8 |year=2001 |pmid=11215290 |pmc=1731357 |doi= |url=}}</ref>
|
*Most common [[CNS]] [[opportunistic infection]] in [[AIDS]] patients
*Presents with [[encephalitis]], [[retinitis]], progressive [[myelitis]], or [[polyradiculitis]]
*In [[disseminated disease]], it involves both the [[liver]] and kidneys
|
*[[Brain]] [[CT]]/[[MRI]]/[[biopsy]]: location of [[lesions]] is usually near the [[brain stem]] or periventricular areas
*[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic
*[[Brain biopsy]] with + [[staining]] for [[CMV]] or evidence of owl's eyes is also diagnostic, but it is rarely performed because of the location of [[brain]] lesions
|-
|[[HSV|HSV infection]]<ref name="pmid1919640">{{cite journal |vauthors=Bustamante CI, Wade JC |title=Herpes simplex virus infection in the immunocompromised cancer patient |journal=J. Clin. Oncol. |volume=9 |issue=10 |pages=1903–15 |year=1991 |pmid=1919640 |doi=10.1200/JCO.1991.9.10.1903 |url=}}</ref>
|
*[[Seizures]], [[headache]], [[confusion]] and/or [[urinary retention]] can be seen in [[disseminated disease]], which usually affects only the [[immunocompromised]] or acute [[infections]]
*In [[pregnant]] women, it may be associated with concurrent [[genital]]/[[oral]] [[lesions]]; can be spread to the [[neonate]] during acute infection in the mother, or via [[viral shedding]] in the [[birth canal]]
*[[Neonatal]] [[Herpes simplex virus|HSV]] can range from localized [[Skin and soft-tissue infections|skin infections]] to [[encephalitis]], [[pneumonitis]], and [[disseminated disease]]
|
*[[Brain]] [[CT]]/[[MRI]]/[[biopsy]]: location of [[lesions]] is usually the [[medial]] [[temporal lobe]] or the [[Orbital cavity|orbital]] surface of the [[frontal lobe]].
*[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic
|-
|[[Chickenpox|Varicella Zoster infection]]<ref name="pmid15864101">{{cite journal |vauthors=Hambleton S |title=Chickenpox |journal=Curr. Opin. Infect. Dis. |volume=18 |issue=3 |pages=235–40 |year=2005 |pmid=15864101 |doi= |url=}}</ref>
|
*Multifocal involvement has subacute course, usually only in [[immunosuppressed]], with [[headache]], [[fever]], focal deficits, and [[seizures]].
*Unifocal involvement is more typically seen in [[immunocompetent]] hosts, occurring after [[contralateral]] [[cranial nerve]] [[herpes zoster]], with [[Altered mental status|mental status changes]], [[TIA|TIAs]], and [[stroke]]
*[[Disseminated disease|Disseminated]] [[varicella zoster virus]] can occur in adults during primary [[infection]], presenting with [[pneumonitis]] and/or [[hepatitis]]
*Disease is a [[Vasculitis|vasculopathy]] with [[hemorrhage]] and [[stroke]]
|
*[[PCR]] of [[CSF]] with detectable [[virus]] is diagnostic
|-
|[[Brain abscess]]<ref name="pmid24174804">{{cite journal |vauthors=Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR |title=Brain abscess: Current management |journal=J Neurosci Rural Pract |volume=4 |issue=Suppl 1 |pages=S67–81 |year=2013 |pmid=24174804 |pmc=3808066 |doi=10.4103/0976-3147.116472 |url=}}</ref><ref name="pmid25360205">{{cite journal |vauthors=Patel K, Clifford DB |title=Bacterial brain abscess |journal=Neurohospitalist |volume=4 |issue=4 |pages=196–204 |year=2014 |pmid=25360205 |pmc=4212419 |doi=10.1177/1941874414540684 |url=}}</ref>
|
*Associated with [[sinusitis]] (abutting the sinuses) or with [[bacteremia]]
*Signs and symptoms includes [[fever]] and [[necrotizing]] [[brain]] [[lesions]] with [[mass effect]]
|
*[[CSF]] culture or culture of [[brain abscess]]
|-
|[[Progressive multifocal leukoencephalopathy]]<ref name="pmid20298966">{{cite journal |vauthors=Tan CS, Koralnik IJ |title=Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis |journal=Lancet Neurol |volume=9 |issue=4 |pages=425–37 |year=2010 |pmid=20298966 |pmc=2880524 |doi=10.1016/S1474-4422(10)70040-5 |url=}}</ref>
|
*Symptoms are often more insidious in onset and progress over months. Symptoms include progressive [[weakness]], poor [[coordination]], with gradual slowing of [[mental]] function. Only seen in the [[immunosuppressed]]. Rarely associated with [[fever]] or other systemic symptoms


|
*[[Polymerase chain reaction|PCR]] of [[CSF]] for [[JC virus]]
*[[Biopsy]] reveals [[white matter]] [[lesions]] and not well-circumscribed [[lesions]].
|}
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Disease]]
 
[[Category:Neurology]]
[[Category:Infectious disease]]
[[Category:Neurosurgery]]


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Revision as of 16:06, 14 August 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

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Overview

Brain abscess must be differentiated from metastatic tumors, necrotic tumors, and lymphomas.[1][2]

Differential Diagnosis

Brain abscess must be differentiated from:

Metastatic Tumor

  • The big differential is that the abscess is often located in watershed regions, and tumors often enhance diffusely with contrast.

Necrotic Tumor

  • Diagnosis of brain abscesses and necrotic tumors is often impossible without conventional MR imaging.[1]
    • Several studies demonstrate the utility of Diffusion-weighted imaging (DWI) to differentiate between necrotic or cystic lesions and brain abscesses.[3]
    • DWI has a sensitivity and specificity of over 90% for distinguishing abscess (low ADC) from necrotic tumors (high ADC).

Lymphoma

  • Some studies suggest that indium scans can help differentiate abscess from CA, and thallium SPECT scans can distinguish CNS toxoplasmosis from lymphoma.[2]

Despite these differences, the true diagnosis is sometimes not made until biopsy.



Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumour[4][5] ✔ Cancer cells[6] MRI ✔ ✔ ✔ ✔ ✔ ✔ Cachexia, gradual progression of symptoms
Delirium tremens ✔ Clinical diagnosis ✔ ✔ ✔ ✔ ✔ ✔ Alcohol intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus,
Subarachnoid hemorrhage[7] ✔ Xanthochromia[8] CT scan without contrast[9][10] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke ✔ Normal CT scan without contrast ✔ ✔ ✔ ✔ ✔ TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[11][12] ✔ ↑ Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[13]

✔ ✔ ✔ ✔ ✔ ✔ Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis ✔ Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment ✔ ✔ ✔ ✔ ✔ ✔ ✔ Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis ✔ Clinical assesment ✔ ✔ ✔ ✔ ✔ History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal ✔ ✔ ✔ History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess ✔ ↑ leukocytes >100,000/ul, ↓ glucose and ↑ protien, ↑ red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

✔ ✔ ✔ ✔ ✔ ✔ ✔ History of drug abuse, endocarditis, ↓ immune status High grade fever, fatigue,nausea, vomiting
Drug toxicity ✔ ✔ Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion ✔ ✔ ✔ ✔ ✔ Tremors, blindness, difficulty swallowing
Electrolyte disturbance ↓ or ↑ Depends on the cause ✔ ✔ Confusion, seizures
Febrile convulsion Not performed in first simple febrile seizures Clinical diagnosis and EEG ✔ ✔ ✔ ✔ Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema ✔ Clinical assesment and MRI ✔ ✔ ✔ ✔ ✔ ✔ History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ↓ or ↑ Serum blood glucose

HbA1c

✔ ✔ ✔ History of diabetes Palpitations, sweating, dizziness, low serum, glucose

Differentiating brain abscess in immunocompromised host

Brain abscess is common among immunocompromised patients who are at high risk for other fungal, bacterial, and viral infections. It should be differentiated from the following diseases:

Disease Differentiating signs and symptoms Differentiating tests
CNS lymphoma[14]
Disseminated tuberculosis[15]
Aspergillosis[16]
Cryptococcosis
Chagas disease[17]
CMV infection[18]
HSV infection[19]
Varicella Zoster infection[20]
Brain abscess[21][22]
Progressive multifocal leukoencephalopathy[23]
  • Symptoms are often more insidious in onset and progress over months. Symptoms include progressive weakness, poor coordination, with gradual slowing of mental function. Only seen in the immunosuppressed. Rarely associated with fever or other systemic symptoms

References

  1. ↑ 1.0 1.1 Desprechins B, Stadnik T, Koerts G, Shabana W, Breucq C, Osteaux M (1999). "Use of diffusion-weighted MR imaging in differential diagnosis between intracerebral necrotic tumors and cerebral abscesses". AJNR Am J Neuroradiol. 20 (7): 1252–7. PMID 10472982.
  2. ↑ 2.0 2.1 Ruiz A, Ganz WI, Post MJ, Camp A, Landy H, Mallin W; et al. (1994). "Use of thallium-201 brain SPECT to differentiate cerebral lymphoma from toxoplasma encephalitis in AIDS patients". AJNR Am J Neuroradiol. 15 (10): 1885–94. PMID 7863938.
  3. ↑ Bavelloni A, Piazzi M, Raffini M, Faenza I, Blalock WL (2015). "Prohibitin 2: At a communications crossroads". IUBMB Life. 67 (4): 239–54. doi:10.1002/iub.1366. PMID 25904163.
  4. ↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  5. ↑
  6. ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  7. ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  8. ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  9. ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  10. ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  11. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  12. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  13. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  14. ↑ Gerstner ER, Batchelor TT (2010). "Primary central nervous system lymphoma". Arch. Neurol. 67 (3): 291–7. doi:10.1001/archneurol.2010.3. PMID 20212226.
  15. ↑ von Reyn CF, Kimambo S, Mtei L, Arbeit RD, Maro I, Bakari M, Matee M, Lahey T, Adams LV, Black W, Mackenzie T, Lyimo J, Tvaroha S, Waddell R, Kreiswirth B, Horsburgh CR, Pallangyo K (2011). "Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality". Int. J. Tuberc. Lung Dis. 15 (8): 1087–92. doi:10.5588/ijtld.10.0517. PMID 21740673.
  16. ↑ Latgé JP (1999). "Aspergillus fumigatus and aspergillosis". Clin. Microbiol. Rev. 12 (2): 310–50. PMC 88920. PMID 10194462.
  17. ↑ Rassi A, Rassi A, Marin-Neto JA (2010). "Chagas disease". Lancet. 375 (9723): 1388–402. doi:10.1016/S0140-6736(10)60061-X. PMID 20399979.
  18. ↑ Emery VC (2001). "Investigation of CMV disease in immunocompromised patients". J. Clin. Pathol. 54 (2): 84–8. PMC 1731357. PMID 11215290.
  19. ↑ Bustamante CI, Wade JC (1991). "Herpes simplex virus infection in the immunocompromised cancer patient". J. Clin. Oncol. 9 (10): 1903–15. doi:10.1200/JCO.1991.9.10.1903. PMID 1919640.
  20. ↑ Hambleton S (2005). "Chickenpox". Curr. Opin. Infect. Dis. 18 (3): 235–40. PMID 15864101.
  21. ↑ Alvis Miranda H, Castellar-Leones SM, Elzain MA, Moscote-Salazar LR (2013). "Brain abscess: Current management". J Neurosci Rural Pract. 4 (Suppl 1): S67–81. doi:10.4103/0976-3147.116472. PMC 3808066. PMID 24174804.
  22. ↑ Patel K, Clifford DB (2014). "Bacterial brain abscess". Neurohospitalist. 4 (4): 196–204. doi:10.1177/1941874414540684. PMC 4212419. PMID 25360205.
  23. ↑ Tan CS, Koralnik IJ (2010). "Progressive multifocal leukoencephalopathy and other disorders caused by JC virus: clinical features and pathogenesis". Lancet Neurol. 9 (4): 425–37. doi:10.1016/S1474-4422(10)70040-5. PMC 2880524. PMID 20298966.


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