A Tile Layer's Nightmare

Abstract

A 62-year-old male tile layer with a history of aortic valve repair, autoimmune hemolytic anemia, and chronic obstructive pulmonary disease presented to the emergency department complaining of a 1-month history of right-hand weakness and numbness, weight loss, and a productive cough. Magnetic resonance imaging (MRI) of the brain showed multiple peripherally enhancing hemorrhagic masses within both cerebral hemispheres that were highly suggestive of metastatic disease. A computerized-tomography chest scan showed enlarged hilar lymph nodes and a bilateral upper lobe infiltrate suggestive of an infectious process; however, a neoplastic process could not be entirely ruled out. Bacterial and fungal cultures of the blood and cerebrospinal fluid were negative. The following day, the patient's mental status abruptly declined, and he developed respiratory distress, requiring ventilator support. Broad-spectrum antibiotics were administered, and he was then transferred to another hospital to undergo further evaluation and possible wholebrain radiation. A follow-up MRI of the brain showed worsening hemorrhagic masses. The patient was taken off life support and died later the same day. An autopsy was performed that confirmed the presence of multiple bilateral hemorrhagic masses within the brain. No additional masses were noted in any other organs examined. Histologically, the brain parenchyma, meninges, and vasculature contained numerous organisms as depicted in Fig. 1