LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES
Figure 1: Neuroimaging showing an initial left cerebellar (A) intraparenchymal hemorrhage on CT scan. A subsequent MRI
T2 weighted image revealed multiple lesions at day 3 post-admission (B). A CT scan following drain placement showed new
hemorrhagic lesions (C).
antibiotic change to cloxacillin. The patient improved neurologically
showing septic arteritis. In the present report, we describe a
over 36 hours and his platelet count normalized. Acute neurological
patient who developed S. aureus endocarditis with a bicuspid
deterioration developed on day three following admission, with an
aortic valve and multiple neuropathological findings
unresponsive right pupil, papilloedema, bilateral cranial nerve VI
accompanied by intense macrophage infiltration.
palsies, bilateral positive Babinski reflexes and decerebrate posturing on
the right. CT scan revealed a large left hemisphere hemorrhage and
CASE REPORT
obliteration of basal cisterns.
The patient was taken to the operating room for emergent craniotomy
and drainage. Post-op day one the patient demonstrated remarkable
neurological improvement. A magnetic resonance angiogram did not
exhibit any vascular structural abnormalities but a MRI showed multiple
hemorrhages (Figure 1B). Postoperatively on day two, after continued
improvement the patient acutely deteriorated with a rapid drop in blood
pressure and was unresponsive neurologically. A head CT showed a
repeat hemorrhage into areas previously drained (Figure 1C). The
patient was pronounced brain-dead, based on clinical findings and
absent blood flow on perfusion scan.
A 35-year-old man was transferred to a tertiary care hospital because
of confusion, headache and thrombocytopenia. He presented with a five-
day history of fever, headache, and myalgias. Two days prior to
admission, visual changes and worsening headache prompted a visit to
the local walk-in clinic, a diagnosis of “strep throat” was made and
amoxicillin was prescribed. After 24 hours and a negative throat swab,
the antibiotic was discontinued. The following evening the patient
presented to the nearest emergency department with ‘delusional’
behavior, staggering gait, fever and headache.
On arrival at the initial hospital, a history revealed migraine
headaches, asthma, and a congenital aortic valve abnormality with
stenosis. Physical examination was remarkable for a heart rate of 100,
PATHOLOGICAL FINDINGS
o
temperature of 39.3 C, a ‘peri-oral lesion’, and a grade II/VI systolic
ejection murmur at the right upper sternal border. The patient’s
neurologic exam was noted to be normal. Laboratory results revealed a
white blood cell count of 7.0, hemoglobin of 143 g/dl, and platelet count
of 29,000. Blood cultures were drawn and a lumbar puncture was done
at that time, showing the following results: RBC 2130, WBC 350 (90%
neutrophils, 10% monocytes), protein 0.75 mg/dl and glucose of 3.1
mg/dl. A cranial CT revealed six discrete intracranial hemorrhages
involving both the cerebrum and cerebellum (Figure 1A). The patient
was transfused with 6 units of platelets, received intravenous antibiotics:
gentamicin, vancomycin and penicillin and was transferred immediately
to our hospital under the Neurology service.
Examination on arrival revealed facial and palatine petechiae, neck
ecchymosis, a grade II/VI systolic ejection murmur at the aortic region
radiating to carotids and precordium, splinter hemorrhages and Janeway
lesions. On neurologic examination the patient was oriented to person
and place but had slurred speech, left homonymous hemianopsia, right
cranial nerve VI palsy, left facial weakness, a left Babinski reflex, left
sided motor weakness and neglect.
Autopsy was limited to the brain and heart, revealing a
congenitally abnormal heart with bicuspid aortic valve and
vegetations, accompanied by gram-positive cocci. Erosion into
the myocardium had occurred, with necrosis and purulent
material, resulting in a ring abscess, exhibiting gram-positive
cocci. Multiple myocardial infarcts of varying age were present.
Neuropathological autopsy showed an edematous brain
weighing 1500 grams. Subarachnoid blood was present,
accompanied by obvious hemorrhages in the left occipital and
left cerebellar hemispheres and herniation of the cerebellar
tonsils. Histological staining revealed microscopic areas of
septic arteritis and necrotic infarction (Figure 2A) and multiple
micro-abscesses (Figure 2B) throughout the cerebral
hemispheres involving the cerebral cortex and white matter.
Intense microglial activation and monocyte infiltration (Figure
2
B), together with a few neutrophils, were observed throughout
the neuropil but was most striking in the vicinity of hemorrhages.
Secondary midbrain tegmental (Duret) hemorrhages were also
present together with hemispheric hemorrhages. Several mycotic
aneurysms were identified (Figure 2C), and at least two
A transthoracic echocardiogram showed an echobright area near the
aortic valve, moderate aortic insufficiency and mitral valve thickening.
Blood cultures showed coagulase positive Gram positive cocci,
eventually shown to be S. aureus at 20 hours, thus prompting an
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