We describe an 81-year-old man receiving azacitidine monotherapy for myelodysplastic syndrome who was improving from Listeria monocytogenes bacteremia after receiving antibiotic therapy during an earlier hospital admission. Shortly after discharge he developed new-onset seizure activity, with brain imaging on subsequent admissions demonstrating a posterior right frontal lobe mass. Specimen cultures after resection of the mass revealed this to be a cerebral abscess related to L. monocytogenes. Brain abscesses related to this organism are rare.L isteria monocytogenes is a ubiquitous, opportunistic pathogen that rarely causes illness in healthy individuals. Th e immunocompromised and those with underlying illness are at greater risk for serious and potentially fatal infection. Approximately 20% of all listeriosis patients succumb to infection despite early aggressive treatment, with particularly elevated case fatality rates in those with comorbid illnesses and in immunocompromised states (1-4). While L. monocytogenes is a well-known cause of meningitis and encephalitis, brain abscesses related to this organism are rare and reported to occur in only 10% of all Listeria central nervous system (CNS) infections (4). Here we present the case of an immunocompromised man who developed L. monocytogenes bacteremia and a subsequent single supratentorial brain abscess. CASE DESCRIPTIONAn 81-year-old man with myelodysplastic syndrome was being treated with azacitidine monotherapy. He also had a remote history of acute myelogenous leukemia in remission, medically controlled atrial fi brillation, basal cell skin carcinoma resection, and treated prostate cancer. For 1 week, the patient complained only of intermittent fevers, reaching a maximum temperature of 102.4°F, and mild fatigue. Four days after the onset of fevers, blood cultures were drawn and he was started on levofl oxacin and later on amoxicillin clavulanate once Gram-positive rods were isolated. Blood cultures grew L. monocytogenes, and the patient was hospitalized.He received intravenous piperacillin-tazobactam for 2 days. When sensitivity tests revealed susceptibility to ampicillin, penicillin G, and trimethoprim sulfamethoxazole, the treatment was changed to intravenous ampicillin, which continued for his remaining 2 days in the hospital. Repeat blood cultures were negative at the time of discharge and he was afebrile. Th e patient was discharged home on continuous intravenous penicillin infusion. During the hospital admission there were no specifi c neurologic complaints, headaches, or altered sensorium.Th e morning after discharge, the patient had generalized jerking movements and left facial droop that lasted approximately 10 minutes while he remained lucid. Two additional seizure-like episodes occurred during transport to the emergency department. Noncontrast head computed tomography (CT) demonstrated a mass in the right frontoparietal region. Treatment with lorazepam and dexamethasone was initiated. Subsequent contrast-enhanced magnetic resonance imaging (MRI) ...
Multiple recent randomized controlled trials have proven the benefit of mechanical thrombectomy using stent retrievers for emergent large vessel occlusion (ELVO).1–5 Techniques currently used for endovascular treatment of stroke employ either direct aspiration, stent retriever thrombectomy or a combination of both. When stent retrievers are used, temporary flow arrest with an extracranial balloon guide catheter or assisted local aspiration with a large bore intracranial suction catheter is recommended. This allows for more complete recanalization and prevents embolization to previously uninvolved territories. Recent advancements in large bore intracranial suction catheter technology have made it easier to utilize coaxial stent retriever thrombectomy assisted by local aspiration. At our high-volume comprehensive stroke center, we have found the second generation large bore intracranial Arc support catheter (ev3 Neurovascular, Irvine, CA) to be extremely effective when used in combination with the Solitaire stent retriever (ev3 Neurovascular, Irvine, CA). We have found the Arc support catheter to be much more navigable, less prone to kinking and easier to deliver into the M1 segment (without causing spasm) than the first generation local aspiration catheters. Additionally, the Arc support catheter is less costly than the currently available suction catheters. The Sol-Arc technique begins with placement of a stent retriever device across the embolic occlusion by deployment though a 021 or 027 microcatheter. This microcatheter is placed coaxially through the Arc support catheter which is positioned just proximal to the embolus. After waiting 5 minutes, the stent retriever is pulled inside the Arc support catheter which is simultaneously aspirated. Subsequently, the Arc support catheter is removed while aspirating the guiding sheath in the neck. This technique should allow for faster, safer and more successful stent retriever thrombectomy when used in conjunction with local aspiration.DisclosuresA. Onofrio: None. A. Miller: None. J. Hise: None. I. Thacker: None. J. Haithcock: None. D. Graybeal: None. K. Layton: None.
Editor's Note.-RadioGraphics continues to publish radiologic-pathologic case material selected from the American Institute for Radiologic Pathology (AIRP) "best case" presentations. The AIRP conducts a 4-week Radiologic Pathology Correlation Course, which is offered five times per year. On the penultimate day of the course, the best case presentation is held at the American Film Institute Silver Theater and Cultural Center in Silver Spring, Md. The AIRP faculty identifies the best cases, from each organ system, brought by the resident attendees. One or more of the best cases from each of the five courses are then solicited for publication in RadioGraphics. These cases emphasize the importance of radiologic-pathologic correlation in the imaging evaluation and diagnosis of diseases encountered at the institute and its predecessor, the Armed Forces Institute of Pathology (AFIP).
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