Abscess within a Glioblastoma —
Masaharu Kiyoharu
Case Report—
ICHIKAWA,
IMATAKA,
Multiforme
Atsushi and
Yukio
SHIMIZU,
MASUDA, Yasushi Fumio SUZUKI*
Manabu
SATO,
HARA,
Hiroyuki
KITANO
Department of Neurosurgery, Shimizu Hospital, Kyoto; *Department of Neurosurgery, Shiga University of Medical Science, Otsu
Abstract A rare
case of abscess
within
female
who developed
right
imaging
demonstrated
veloped
ring enhancement.
later
re-expanded.
Key words:
hemorrhage The
abscess,
Staphylococcus
a glioblastoma hemiparesis
mass
was
intratumoral
mimicked
hemorrhagic
infarction.
showed
removed,
one to be an abscess,
examination
glioblastoma
multiforme,
abscess,
December present
Report
9, 1991;
address:
occurred
in a 46-year-old
and magnetic However, collapsed revealed
resonance
the lesions by drainage
de but
glioblastoma.
multicentric
glioma,
aureus
A 46-year-old female presented with transient dysesthesia of her left upper extremity on August 7, 1989. On admission, she had no neurological deficit. Computed tomographic (CT) scans revealed low-den sity areas in both the right frontotemporal area and left frontal lobe resembling multiple infarction (Fig. IA). T2-weighted magnetic resonance (MR) images also demonstrated high-signal intensity in both areas (Fig. 1C). The lesions were ill-defined on T, weighted images (Fig. 1B). Cerebral angiograms showed no stenotic lesion or abnormal vessels. She received antiplatelet therapy. After discharge, she was asymptomatic until her right upper extremity became unresponsive on Received
which
and histological
Abscess formation within a brain tumor is uncom mon, usually occurring within a pituitary tumor after direct extension. We report a case of metastatic abscess in a glioblastoma presenting with an unusual clinical course.
Author's
presentation tomography
Introduction
Case
an unusual Computed
which
Aspiration
with
and seizure.
Accepted
M. Ichikawa,
M.D.,
April
September 22, 1989. Deterioration of the unrespon siveness and subsequent seizure developed 7 days later. On the 2nd admission, neurological examina tion showed that she was alert with right hemiparesis and mild aphasia. No infectious sign, such as fever, leukocytosis, or increased C-reactive protein (CRP) level, was found. CT scans demonstrated a high-den sity area of hematoma associated with widespread edema in the left frontal lobe (Fig. 2A). T2-weighted MR images clearly demonstrated the hemorrhagic lesion (Fig. 2C). Subsequent CT scans revealed a small hyperdense lesion in the right frontal lobe on the 10th hospital day (Fig. 2B). Both lesions were suspected to be hemorrhagic infarction or intratu moral hemorrhage. Symptoms of increased intra cranial pressure were mild, so she received conser vative treatment. On the 11th hospital day, high fever began to develop and her consciousness became cloudy. Severe leukocytosis (white blood cell count, 18,700/ ,ul) with increased CRP level developed. Systemic ex amination revealed thrombophlebitis in her right femur and suspected sepsis. Phlebitis improved with antibiotic therapy and the fever subsided gradually,
3, 1992
Department
of Anatomy,
Shiga
University
of Medical
Science,
Otsu,
Japan.
Fig.
2
A: Precontrast
CT scan
demonstrating
a left
of
hematoma
penetrating Precontrast mission, area
with
revealing
an
Fig. 1
A: Precontrast CT scans on August 7, 1989, showing low-density areas in the left frontal lobe and right frontotemporal region. B, C: T, and T2-weighted MR images on August 11, 1989. T,-weighted images revealed low-inten sity areas in bilateral frontal lobes. The le sions were ill-defined (B). T2-weighted images demonstrated these lesions with edema as high intensity areas (C).
but the CRP level remained high. CT scans demonstrated a gradual change in both hematomas to ring-enhanced cystic masses suggesting abscess for mation (Fig. 3A). Aspiration of the left cystic mass on the 33rd hospital day revealed abscess. Pus culture identified Staphylococcus aureus and an tibiotics were administered systemically. CT scans demonstrated gradual diminution of the abscess
C:
left
lesion
appeared already
edema.
space. the 2nd
additional
T2-weighted
the 2nd admission, as
area edema, B: ad
hyperdense
in right
frontotem
lesions looked like hemor or intratumoral hemor
after
widespread
widespread
by edema
poral region. Both rhagic infarction
admission,
high-density
into the subdural CT scan 10 days after
surrounded
rhage.
on the 2nd
frontal
a
MR
images
showing low-intensity
Lesion
3 days
hematoma area
on the opposite
as a high-intensity
area
with
of and side
edema
present.
after drainage (Fig. 3B) and the hematological ex amination showed a return to normal values. Both right hemiparesis and aphasia improved. Serial CT scans, however, showed that the left frontal cystic mass had re-expanded irregularly and aggravated the midline shift (Fig. 3C). Her consciousness level, right hemiparesis, and aphasia deteriorated pro gressively despite the negative CRP, normal hemo gram, and afebrile state. On March 1, 1990, the mass was subtotally re moved. The mass included a few abnormal vessels, was partially hard and well-circumscribed like a granuloma,
but infiltration
obscured
the border
with
Fig. 3
Serial postcontrast CT scans on October 31, 1989 (A), November 15 (B), and February 19, 1990 (C). In the left frontal lobe (upper), a simple ring-enhanced lesion (A), once collapsed by drainage (B), changed to an irregularly enhanced large mass (C). The lesion on the opposite side (lower) became more apparent and gradually increased in size.
the brain. Histological examination of the tumor specimen revealed glioblastoma (Fig. 4). Subsequent radiation therapy did not continue the postoperative improvement and her condition worsened. She died on October 27, 1990. Autopsy was not permitted. Discussion We first diagnosed this case as brain abscess the aspirated pus from the cystic lesion
based on and the
presence of Staphylococcus aureus. The multiplicity of the lesions was also compatible with the diagnosis. The hidden glioma, however, was detected by the continuous enlargement in lesion size after drainage and increased irregularity of the cyst wall, despite the undetectable CRP, normal white blood cell count, and absence of fever. There are few reported cases of abscess within a brain tumor, most within pituitary tumors.",") Obrador and Blazquez1l) reported an abscess within a craniopharyngioma and reviewed five previous in tratumoral abscesses in the pituitary region. Three
cases had developed within pituitary adenoma and three within craniopharyngioma. In four patients, the signs and symptoms of meningeal irritation were first. Three patients showed clear evidence of sinus in fection, suggesting that such an abscess may develop due to direct extension of adjacent sinus infections. There are few reported cases of abscess within an intra-axial tumor such as glioma.1o,13) Noguerado et al. 10) reported an abscess within a glioblastoma multiforme. Long-term steroid therapy and the im munosuppressive effect of glioblastoma had prob ably participated in the etiology of the abscess. Rodriguez et al.") also reported an abscess within a brain metastasis from an embryonal carcinoma with testicular seminoma, but did not comment on the cause of the abscess. In both cases, the causative pathogen was Salmonella enteritidis metastasized via the blood. Abscess formation is frequently associated with cerebrovascular disease such as intracerebral hematoma and cerebral infarction.3,6-8) Disruption of blood-brain barrier by ischemia or edema and, in hemorrhagic infarction or intracerebral hematoma,
Fig. 4
upper:
Photomicrograph
showing with
abundant
increased
liferation.
mitosis
cellularity Some
Pseudopalisading x 200. lower:
giant
of
tumor
and and
specimen,
pleomorphism, endothelial
cells
was abortive. Photomicrograph
are
pro present.
HE stain, of the ap
parent capsule, showing mild infiltration flammatory cells in the connective tissue. stain,
of in HE
x 100.
the hematoma acting as a culture medium are impor tant in the development of metastatic abscess.''') An analogous mechanism was suspected in our case. In addition to the steroid therapy against the brain edema, the glioblastoma which has no blood-brain barrier and the nutritious hematoma within the tumor may have induced the metastatic abscess by sepsis following phlebitis. Two lesions were present in this case, and both demonstrated ring enhancement on postcontrast CT scans. The lesion in the left frontal lobe first ap peared like an abscess, then as a glioblastoma which was finally confirmed by histological examination. Both glioblastoma and metastatic tumor sometimes mimic a brain abscess on CT scans, confusing the clinical diagnosis. Hirschberg and Bosness) suggested that CRP is an indicator for differential diagnosis of brain abscess from malignant glioma in patients with a ring-enhanced cystic lesion on CT scans. CRP
levels, which may increase in glioma, were extremely elevated in seven of nine abscesses, although within the normal range in the other two. No confirmation was possible for the lesion on the opposite side, because autopsy was refused. How ever, this also increased in size gradually after the 2nd admission, so may have been a glioma. In cases of multiple cerebral lesions like ours, the most com mon causes of multiple ring-enhanced areas are met astatic tumors or multiple abscesses. Glioblastoma can induce multiple cerebral lesions, and multicen tric glioma is not so rare. Batzdorf and Malamud2) reported an incidence of about 2.4% and other reports vary from 1 to 10%. Barnard and Geddes') made a histological study of large hemispheric sec tions of a series of 241 gliomas, finding the incidence of multicentric gliomas was 7.5%, similar to the in cidence of multiple abscess of about 4%.14) However, multicentric glioma is often overlooked as a cause of multiple intracranial lesions. Moreover, differential diagnosis from metastatic tumor or multiple abscesses is occasionally difficult based only on CT. 12)Chadduck et al. 4)emphasized that the multicen tric gliomas are a cause of multiple cerebral masses, requiring prompt biopsy. In this case, the initial appearance was infarctions followed by hemorrhagic infarctions, but multiple le sions developed and an abscess occurred within the intratumoral hematoma, all confusing the early diagnosis. CT and MR diagnostic imaging methods are improving, but troublesome cases still occur. A combination of imaging information with general condition, laboratory data and, in some cases, biop sy is needed. References 1) 2)
Barnard RO, Geddes JF: The incidence of multifocal cerebral gliomas. Cancer 60: 1519-1531, 1987 Batzdorf U, Malamud N: The problem of multicen tric gliomas. J Neurosurg 20: 122-136, 1963
3) Biller J, Baker WH, Quinn JP, Shea JF: Intracranial hematoma with subsequent brain abscess after carotid endoarterectomy. Surg Neurol 23: 605-608, 1985 4)
5)
6)
Chadduck WM, Roycroft D, Brown MW: Multicen tric glioma as a cause of multiple cerebral lesions. Neurosurgery 13: 170-175, 1983 Hirschberg H, Bosnes V: C-reactive protein levels in the differential diagnosis of brain abscess. J Neurosurg 67: 358-360, 1987 Ichimi K, Ishiguri H, Kida Y, Kinomoto T: Brain abscess following cerebral infarction. No Shinkei Geka 17: 381-385, 1989 (in Japanese)
7) Kurihara
H, Mitsui T, Kohno N: Brain abscess
8)
9)
10)
11)
following intracerebral hematoma. No Shinkei Geka 17: 1037-1040, 1989 (in Japanese) Kurlan R, Criggs RC: Cyanotic congenital heart disease with suspected stroke. Should all patients receive antibiotics? Arch Neurol 40: 209-212, 1983 Nelson PB, Haverkos H, Martinez AJ, Robinson AG: Abscess formation within pituitary tumors. Neurosurgery 12: 331-333, 1983 Noguerado A, Cabanyes J, Vivancos J, Navarro E, Lonpez F, Isasia T, Martinez MC, Romero J, Lopez Brea M: Abscesses caused by Salmonella enteritidis within a glioblastoma multiforme. Case report. J Infect 15: 61-63, 1987 Obrador S, Blazquez MG: Pituitary abscess in a craniopharyngioma. Case report. J Neurosurg 36: 785-789, 1972
12) Rao KCVG, Leine H, Itani A, Sajor E, Robinson W: CT findings in multiple glioblastoma: Diagnostic pathologic correlation. CT 4: 187-192, 1980 13)
14)
Rodriguez RE, Valero V, Watanakunakorn C: Salmonella focal intracranial infections: Review of the world literature (1884-1984) and report of an unusual case. Rev Infect Dis 8: 31-41, 1986 Yang SY: Brain abscess: A review of 400 cases. J Neurosurg 55: 794-799, 1981
Address ment
reprint of
requests Neurosurgery,
Yamada-naka-yoshimi-cho, 615, Japan.
to:
M.
Sato,
Shimizu
M.D., Hospital,
Nishikyo-ku,
Depart 11-2 Kyoto
Masaharu Kiyoharu
Case Report—
ICHIKAWA,
IMATAKA,
Multiforme
Atsushi and
Yukio
SHIMIZU,
MASUDA, Yasushi Fumio SUZUKI*
Manabu
SATO,
HARA,
Hiroyuki
KITANO
Department of Neurosurgery, Shimizu Hospital, Kyoto; *Department of Neurosurgery, Shiga University of Medical Science, Otsu
Abstract A rare
case of abscess
within
female
who developed
right
imaging
demonstrated
veloped
ring enhancement.
later
re-expanded.
Key words:
hemorrhage The
abscess,
Staphylococcus
a glioblastoma hemiparesis
mass
was
intratumoral
mimicked
hemorrhagic
infarction.
showed
removed,
one to be an abscess,
examination
glioblastoma
multiforme,
abscess,
December present
Report
9, 1991;
address:
occurred
in a 46-year-old
and magnetic However, collapsed revealed
resonance
the lesions by drainage
de but
glioblastoma.
multicentric
glioma,
aureus
A 46-year-old female presented with transient dysesthesia of her left upper extremity on August 7, 1989. On admission, she had no neurological deficit. Computed tomographic (CT) scans revealed low-den sity areas in both the right frontotemporal area and left frontal lobe resembling multiple infarction (Fig. IA). T2-weighted magnetic resonance (MR) images also demonstrated high-signal intensity in both areas (Fig. 1C). The lesions were ill-defined on T, weighted images (Fig. 1B). Cerebral angiograms showed no stenotic lesion or abnormal vessels. She received antiplatelet therapy. After discharge, she was asymptomatic until her right upper extremity became unresponsive on Received
which
and histological
Abscess formation within a brain tumor is uncom mon, usually occurring within a pituitary tumor after direct extension. We report a case of metastatic abscess in a glioblastoma presenting with an unusual clinical course.
Author's
presentation tomography
Introduction
Case
an unusual Computed
which
Aspiration
with
and seizure.
Accepted
M. Ichikawa,
M.D.,
April
September 22, 1989. Deterioration of the unrespon siveness and subsequent seizure developed 7 days later. On the 2nd admission, neurological examina tion showed that she was alert with right hemiparesis and mild aphasia. No infectious sign, such as fever, leukocytosis, or increased C-reactive protein (CRP) level, was found. CT scans demonstrated a high-den sity area of hematoma associated with widespread edema in the left frontal lobe (Fig. 2A). T2-weighted MR images clearly demonstrated the hemorrhagic lesion (Fig. 2C). Subsequent CT scans revealed a small hyperdense lesion in the right frontal lobe on the 10th hospital day (Fig. 2B). Both lesions were suspected to be hemorrhagic infarction or intratu moral hemorrhage. Symptoms of increased intra cranial pressure were mild, so she received conser vative treatment. On the 11th hospital day, high fever began to develop and her consciousness became cloudy. Severe leukocytosis (white blood cell count, 18,700/ ,ul) with increased CRP level developed. Systemic ex amination revealed thrombophlebitis in her right femur and suspected sepsis. Phlebitis improved with antibiotic therapy and the fever subsided gradually,
3, 1992
Department
of Anatomy,
Shiga
University
of Medical
Science,
Otsu,
Japan.
Fig.
2
A: Precontrast
CT scan
demonstrating
a left
of
hematoma
penetrating Precontrast mission, area
with
revealing
an
Fig. 1
A: Precontrast CT scans on August 7, 1989, showing low-density areas in the left frontal lobe and right frontotemporal region. B, C: T, and T2-weighted MR images on August 11, 1989. T,-weighted images revealed low-inten sity areas in bilateral frontal lobes. The le sions were ill-defined (B). T2-weighted images demonstrated these lesions with edema as high intensity areas (C).
but the CRP level remained high. CT scans demonstrated a gradual change in both hematomas to ring-enhanced cystic masses suggesting abscess for mation (Fig. 3A). Aspiration of the left cystic mass on the 33rd hospital day revealed abscess. Pus culture identified Staphylococcus aureus and an tibiotics were administered systemically. CT scans demonstrated gradual diminution of the abscess
C:
left
lesion
appeared already
edema.
space. the 2nd
additional
T2-weighted
the 2nd admission, as
area edema, B: ad
hyperdense
in right
frontotem
lesions looked like hemor or intratumoral hemor
after
widespread
widespread
by edema
poral region. Both rhagic infarction
admission,
high-density
into the subdural CT scan 10 days after
surrounded
rhage.
on the 2nd
frontal
a
MR
images
showing low-intensity
Lesion
3 days
hematoma area
on the opposite
as a high-intensity
area
with
of and side
edema
present.
after drainage (Fig. 3B) and the hematological ex amination showed a return to normal values. Both right hemiparesis and aphasia improved. Serial CT scans, however, showed that the left frontal cystic mass had re-expanded irregularly and aggravated the midline shift (Fig. 3C). Her consciousness level, right hemiparesis, and aphasia deteriorated pro gressively despite the negative CRP, normal hemo gram, and afebrile state. On March 1, 1990, the mass was subtotally re moved. The mass included a few abnormal vessels, was partially hard and well-circumscribed like a granuloma,
but infiltration
obscured
the border
with
Fig. 3
Serial postcontrast CT scans on October 31, 1989 (A), November 15 (B), and February 19, 1990 (C). In the left frontal lobe (upper), a simple ring-enhanced lesion (A), once collapsed by drainage (B), changed to an irregularly enhanced large mass (C). The lesion on the opposite side (lower) became more apparent and gradually increased in size.
the brain. Histological examination of the tumor specimen revealed glioblastoma (Fig. 4). Subsequent radiation therapy did not continue the postoperative improvement and her condition worsened. She died on October 27, 1990. Autopsy was not permitted. Discussion We first diagnosed this case as brain abscess the aspirated pus from the cystic lesion
based on and the
presence of Staphylococcus aureus. The multiplicity of the lesions was also compatible with the diagnosis. The hidden glioma, however, was detected by the continuous enlargement in lesion size after drainage and increased irregularity of the cyst wall, despite the undetectable CRP, normal white blood cell count, and absence of fever. There are few reported cases of abscess within a brain tumor, most within pituitary tumors.",") Obrador and Blazquez1l) reported an abscess within a craniopharyngioma and reviewed five previous in tratumoral abscesses in the pituitary region. Three
cases had developed within pituitary adenoma and three within craniopharyngioma. In four patients, the signs and symptoms of meningeal irritation were first. Three patients showed clear evidence of sinus in fection, suggesting that such an abscess may develop due to direct extension of adjacent sinus infections. There are few reported cases of abscess within an intra-axial tumor such as glioma.1o,13) Noguerado et al. 10) reported an abscess within a glioblastoma multiforme. Long-term steroid therapy and the im munosuppressive effect of glioblastoma had prob ably participated in the etiology of the abscess. Rodriguez et al.") also reported an abscess within a brain metastasis from an embryonal carcinoma with testicular seminoma, but did not comment on the cause of the abscess. In both cases, the causative pathogen was Salmonella enteritidis metastasized via the blood. Abscess formation is frequently associated with cerebrovascular disease such as intracerebral hematoma and cerebral infarction.3,6-8) Disruption of blood-brain barrier by ischemia or edema and, in hemorrhagic infarction or intracerebral hematoma,
Fig. 4
upper:
Photomicrograph
showing with
abundant
increased
liferation.
mitosis
cellularity Some
Pseudopalisading x 200. lower:
giant
of
tumor
and and
specimen,
pleomorphism, endothelial
cells
was abortive. Photomicrograph
are
pro present.
HE stain, of the ap
parent capsule, showing mild infiltration flammatory cells in the connective tissue. stain,
of in HE
x 100.
the hematoma acting as a culture medium are impor tant in the development of metastatic abscess.''') An analogous mechanism was suspected in our case. In addition to the steroid therapy against the brain edema, the glioblastoma which has no blood-brain barrier and the nutritious hematoma within the tumor may have induced the metastatic abscess by sepsis following phlebitis. Two lesions were present in this case, and both demonstrated ring enhancement on postcontrast CT scans. The lesion in the left frontal lobe first ap peared like an abscess, then as a glioblastoma which was finally confirmed by histological examination. Both glioblastoma and metastatic tumor sometimes mimic a brain abscess on CT scans, confusing the clinical diagnosis. Hirschberg and Bosness) suggested that CRP is an indicator for differential diagnosis of brain abscess from malignant glioma in patients with a ring-enhanced cystic lesion on CT scans. CRP
levels, which may increase in glioma, were extremely elevated in seven of nine abscesses, although within the normal range in the other two. No confirmation was possible for the lesion on the opposite side, because autopsy was refused. How ever, this also increased in size gradually after the 2nd admission, so may have been a glioma. In cases of multiple cerebral lesions like ours, the most com mon causes of multiple ring-enhanced areas are met astatic tumors or multiple abscesses. Glioblastoma can induce multiple cerebral lesions, and multicen tric glioma is not so rare. Batzdorf and Malamud2) reported an incidence of about 2.4% and other reports vary from 1 to 10%. Barnard and Geddes') made a histological study of large hemispheric sec tions of a series of 241 gliomas, finding the incidence of multicentric gliomas was 7.5%, similar to the in cidence of multiple abscess of about 4%.14) However, multicentric glioma is often overlooked as a cause of multiple intracranial lesions. Moreover, differential diagnosis from metastatic tumor or multiple abscesses is occasionally difficult based only on CT. 12)Chadduck et al. 4)emphasized that the multicen tric gliomas are a cause of multiple cerebral masses, requiring prompt biopsy. In this case, the initial appearance was infarctions followed by hemorrhagic infarctions, but multiple le sions developed and an abscess occurred within the intratumoral hematoma, all confusing the early diagnosis. CT and MR diagnostic imaging methods are improving, but troublesome cases still occur. A combination of imaging information with general condition, laboratory data and, in some cases, biop sy is needed. References 1) 2)
Barnard RO, Geddes JF: The incidence of multifocal cerebral gliomas. Cancer 60: 1519-1531, 1987 Batzdorf U, Malamud N: The problem of multicen tric gliomas. J Neurosurg 20: 122-136, 1963
3) Biller J, Baker WH, Quinn JP, Shea JF: Intracranial hematoma with subsequent brain abscess after carotid endoarterectomy. Surg Neurol 23: 605-608, 1985 4)
5)
6)
Chadduck WM, Roycroft D, Brown MW: Multicen tric glioma as a cause of multiple cerebral lesions. Neurosurgery 13: 170-175, 1983 Hirschberg H, Bosnes V: C-reactive protein levels in the differential diagnosis of brain abscess. J Neurosurg 67: 358-360, 1987 Ichimi K, Ishiguri H, Kida Y, Kinomoto T: Brain abscess following cerebral infarction. No Shinkei Geka 17: 381-385, 1989 (in Japanese)
7) Kurihara
H, Mitsui T, Kohno N: Brain abscess
8)
9)
10)
11)
following intracerebral hematoma. No Shinkei Geka 17: 1037-1040, 1989 (in Japanese) Kurlan R, Criggs RC: Cyanotic congenital heart disease with suspected stroke. Should all patients receive antibiotics? Arch Neurol 40: 209-212, 1983 Nelson PB, Haverkos H, Martinez AJ, Robinson AG: Abscess formation within pituitary tumors. Neurosurgery 12: 331-333, 1983 Noguerado A, Cabanyes J, Vivancos J, Navarro E, Lonpez F, Isasia T, Martinez MC, Romero J, Lopez Brea M: Abscesses caused by Salmonella enteritidis within a glioblastoma multiforme. Case report. J Infect 15: 61-63, 1987 Obrador S, Blazquez MG: Pituitary abscess in a craniopharyngioma. Case report. J Neurosurg 36: 785-789, 1972
12) Rao KCVG, Leine H, Itani A, Sajor E, Robinson W: CT findings in multiple glioblastoma: Diagnostic pathologic correlation. CT 4: 187-192, 1980 13)
14)
Rodriguez RE, Valero V, Watanakunakorn C: Salmonella focal intracranial infections: Review of the world literature (1884-1984) and report of an unusual case. Rev Infect Dis 8: 31-41, 1986 Yang SY: Brain abscess: A review of 400 cases. J Neurosurg 55: 794-799, 1981
Address ment
reprint of
requests Neurosurgery,
Yamada-naka-yoshimi-cho, 615, Japan.
to:
M.
Sato,
Shimizu
M.D., Hospital,
Nishikyo-ku,
Depart 11-2 Kyoto
