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Case Report Jae-Hun Jung

Cardiovascular Division
Department of Internal Medicine
Kangnam Sacred Heart Hospital
Brain Abscess in an Adult With Atrial Hallym University Medical Center
948-1 Daerim-1-dong,
Septal Defect Yeongdeungpo-gu Seoul,
Republic of Korea, 150 950
unny@hallym.ac.kr
Chong Won Sung, MD; Jae-Hun Jung, MD; Sang-Hak Lee, MD; Seonghoon Choi, MD;
Jung Rae Cho, MD; Namho Lee, MD; Chang-Hyun Kim, MD
Cardiovascular Division, Department of Internal Medicine (Jung, Sung, Choi, Cho, Lee),
Seoul, Republic of Korea; Department of Neurosurgery (Kim), Kangnam Sacred Heart Hospital,
Hallym University Medical Center, Seoul, Republic of Korea

Brain abscess is a serious complication of congenital heart disease in children and adolescents. This association
is rarely observed in adults. This article describes the case of a 41-year-old man who presented with altered
mental status. Brain MRI showed a brain abscess at the left frontal lobe. The patient was successfully
treated with surgical removal and appropriate antibiotics. Echocardiographic examination showed atrial
septal defect (ASD) with bidirectional shunt. Transcatheter closure of ASD was carried out 6 months after
neurosurgical treatment. We discuss the association of brain abscess and ASD.

Introduction Because of the stuporous mental status, the neurosurgeon

Brain abscess is generally regarded as a rare disease and
is a serious complication of congenital heart disease in
children and adolescents. It usually occurs in children
and adolescents with high incidence at ages 4 through
7 years.1 This association is rarely observed in adults. We
report the case of a 41-year-old man presenting with a
brain abscess associated with an asymptomatic atrial septal
defect (ASD).
Case Report
In July 2005, a 41-year-old man was referred to our hospital
for management of a cystic mass lesion in the left frontal
lobe. He was unmarried and lived alone. He had been well
until 4 days earlier. Past history was uneventful. His level
of consciousness was stuporous. His blood pressure was
110/80 mm Hg. His temperature was 36.4 C, with a pulse
of 72 beats per minute, and a respiratory rate of 23 breaths
per minute. Chest radiographs showed no active lesions.
Computed tomographic (CT) scanning of the head
showed a large, low-attenuationmass lesion in the left frontal
lobe (Figure 1A). Magnetic resonance imaging (MRI) of the
brain disclosed a cystic mass, measuring 5.5 cm in diame-
ter. A T2-weighted image showed the mass with high signal
intensity that was surrounded by an area of high signal
intensity, a finding consistent with edema (Figure 1B). On
the gadolinium-enhanced T1-weighted image, the mass had
heterogenous low signal intensity and was surrounded by a
ring of enhancement (Figure 1C). There was subfalcial her-
niation in the frontal lobe due to mass effect. There was no
evidence of otitis media, paranasal sinusitis, or mastoiditis.
decided to perform an emergency surgery. The patient
underwent osteoplastic craniotomy with removal of abscess
capsule.
Blood culture study failed to detect bacteremia because
of systemic intravenous administration of antibiotics, which
had been administered to the patient at the former hospital
before he was transferred to our hospital. Pathologic
specimen revealed acute and chronic inflammation with
fibrosis. There was no evidence of tumor. Cultures of the pus
for aerobic and anaerobic bacteria were negative. Antibiotic
therapy was administered intravenously to the patient for 8
weeks. Because of the presumed hematogenous source,
we recommended an echocardiogram. Echocardiogram
showed increased right atrium and a large atrial septal
defect (2.06 cm) with mild pulmonary hypertension (Figure
1D). The Qp/Qs was 3.2. There were no vegetations. On
echocardiogram with intravenousagitated saline injection, a
right-to-left shunt was detected. This finding supported the
diagnosis of a paradoxical brain abscess. Transcatheter
closure of ASD was carried out 6 months after neurosurgical
treatment. When last seen in October 2008, he was healthy
and he is being followed as an outpatient.
Discussion
Brain abscess is generally regarded as a rare disease, and
may develop in 4 clinical settings: (1) by direct spread from
a contiguous cranial site of infection, such as paranasal
sinusitis, otitis media, mastoiditis, or dental infection; (2) as
a result of hematogenous spread from a remote site of
infection; (3) following head trauma or a neurosurgical

Received: October 27, 2008 Clin. Cardiol. 33, 4, E51 E53 (2010) E51
Accepted: October 31, 2008 Published online in Wiley InterScience. (www.interscience.wiley.com)
DOI:10.1002/clc.20552 2010 Wiley Periodicals, Inc.
 Case Reports continued

(A) (B)

RA

LA

(C) (D)

Figure 1. Brain CT, MRI, and echocardiogram findings. CT showing low-attenuation mass lesion in the left frontal lobe (A), and MRI showing mass with high
signal intensity with edema, T2-weighted image (B), and mass with heterogenous low signal intensity with a ring of enhancement, gadolinium-enhanced
T1-weighted image (C), and echocardiogram showing ASD with right atrium enlargement (D).

procedure; (4) cryptogenic. Brain abscess is a serious of the great vessels and a peak in the age distribution
complication in patients with congenital heart malformation. can be seen in childhood.2 However, association of brain
The great majority of cases are limited to cyanotic congenital abscess and congenital heart disease rarely occurs in
heart disease such as tetralogy of Fallot and transposition adults.3 5

E52 Clin. Cardiol. 33, 4, E51 E53 (2010)

J.-H. Jung et al: Brain Abscess in an Adult With ASD
Published online in Wiley InterScience. (www.interscience.wiley.com)
DOI:10.1002/clc.20552 2010 Wiley Periodicals, Inc.
 The right-to-left shunt is well-known to be associated
with systemic desaturation, paradoxical embolization, and
brain abscess. This right-to-left shunt would allow septic
microemboli to pass through the pulmonary circulation
and avoid the normal pulmonary capillary filter, thereby
affording direct access to cerebral circulation. Similar
phenomenon can occur with pulmonary arteriovenous
malformations.
Optimal therapy of brain abscesses involves a combi-
nation of high-dose parenteral antibiotics and neurosur-
gical drainage. Aspiration and drainage of the abscess
under stereotaxic guidance are beneficial for both diag-
nosis and therapy. Complete excision of a bacterial
abscess via craniotomy or craniectomyis generally reserved
for multiloculated abscesses or those in which stereo-
taxic aspiration is unsuccessful. In our patient, emer-
gent surgery was mandatory because of stuporous metal
status.
Published online in Wiley InterScience. (www.interscience.wiley.com)
Our patient was presented with brain abscess and ASD
with right-to-left shunt. Although being an adult patient, an
acyanotic congenital heart disease should be considered as
the hematogenous source.
References
1. Kagawa M, Takeshita M, Yato S, Kitamura K. Brain abscess in
congenital cyanotic heart disease. J Neurosurg. 1983;58:913917.
2. Fischbein CA, Rosenthal A, Fischer EG, Nadas AS, Welch K. Risk
factors of brain abscess in patients with congenital heart disease.
Am J Cardiol. 1974;34:97102.
3. Roder R, Erbel R, Henkel B, Meyer J, Sch urmann K, Hopf HC.
Brain abscess in a bidirectional atrial septal defect in adulthood.
Z Kardiol. 1985;74:555559.
4. Guy JM, Cerisier A, Lamaud M, Dacosta A, Bouvet L, Verneyre H.
Cerebral abscess disclosing congenital heart disease. Ann Cardiol
Angeiol. 1992;41:387389.
5. Kawamata T, Takeshita M, Ishizuka N, Hori T. Patent foramen ovale
as a possible risk factor for cryptogenic brain abscess: report of two
cases. Neurosurgery. 2001;49:204206.
Clin. Cardiol. 33, 4, E51 E53 (2010) E53
J.-H. Jung et al: Brain Abscess in an Adult With ASD
DOI:10.1002/clc.20552 2010 Wiley Periodicals, Inc.