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CC BY-NC-ND 4.0 · Asian J Neurosurg 2025; 20(02): 291-300
DOI: 10.1055/s-0045-1802623
Original Article

Brain Abscess Mimicking Brain Tumors: A Systematic Review of Individual Patient's Data

Anis Choucha
1   Department of Neurosurgery, Aix Marseille University, APM, UH Timone, Marseille, France
2   Laboratory of Biomechanics and Application, UMRT24, Gustave Eiffel University, Aix Marseille University, Marseille, France
,
Matteo De Simone
3   Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana,” University of Salerno, Via S. Allende, Baronissi, Italy
,
Nathan Beucler
4   Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon Cedex 9, France
,
Solenne Hulot
5   IHU Méditerranée Infection, Marseille, France
6   Aix-Marseille Université, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France
,
Jean-Christophe Lagier
5   IHU Méditerranée Infection, Marseille, France
6   Aix-Marseille Université, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France
,
Henry Dufour
1   Department of Neurosurgery, Aix Marseille University, APM, UH Timone, Marseille, France
› Author Affiliations
Funding None
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Abstract

Objectives Brain abscess is a worrisome condition with a 1-year mortality rate of 21% and a 32% rate of new-onset epilepsy. Brain magnetic resonance imaging (MRI) is strongly recommended as a screening modality with contrast-enhanced T1-weighted images, diffusion-weighted imaging (DWI), and attenuated diffusion coefficient. However, there is a 10% rate of false negative, which could potentially impact management and prognosis. Our systematic review aims at identifying risk factors for false negative.

Materials and Methods A database search of our institutions plus a systematic literature review was conducted using MEDLINE/PubMed, including studies of brain abscesses misdiagnosed as brain tumors. Data on patient demographics, clinical presentations, imaging findings, pathogens, treatments, and outcomes were extracted and analyzed. We present a case of a 59-year-old male with HIV, who developed a brain abscess misdiagnosed as a tumor. Initial symptoms included left-side weakness and weight loss. Imaging showed a ring-enhancing lesion in the right thalamus. The abscess was caused by T. gondii, and the patient was treated with sulfadiazine, pyrimethamine, ceftriaxone, and metronidazole, achieving a GOS-E score of 8 at 1 year.

Results The review included 14 studies, with 1 additional illustrative case, encompassing a total of 15 cases. Patients ranged from 39 to 77 years, with a mean age of 59 years. Comorbidities included human immunodeficiency virus (HIV), glioblastoma, breast cancer, arthritis, gastric cancer, and nephrotic syndrome. Common symptoms were hemiparesis, generalized seizures, headache, and confusion. Imaging often revealed ring-enhancing lesions with restricted diffusion on DWI. Lesions were located in various brain regions. Pathogens identified included 40% Nocardia species, Toxoplasma gondii, Mycobacterium tuberculosis, Aggregatibacter aphrophilus, Rickettsia typhi, Arcanobacterium haemolyticum, Aspergillus terreus, and Providencia rettgeri. Treatments involved antibiotics and, in some cases, surgical intervention. Outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E) at 1 year indicated good recovery in most cases.

Conclusion Despite the high sensitivity and specificity of brain MRI in diagnosing brain abscesses, the standard protocol used for the past two decades still results in a 10% false-negative rate. Such inaccuracies can significantly impact the patient's management, potentially delaying antibiotic therapy and impacting the surgical planning, hence affecting the outcome. Immunocompromised patients are particularly vulnerable to misdiagnoses of brain abscesses as brain tumors. To improve diagnostic accuracy, new imaging techniques and computational tools are currently under investigation.

Keywords

brain abscess - systematic review - case reports - mimicking - toxoplasmosis - nocardia - tumor - MRI

Authors' Contributions

The study was conceptualized by A.C. and M.D.S., with methodology developed by N.B. and H.D. Formal analysis and investigation were conducted by A.C. and M.D.S., while the original draft was prepared collaboratively by A.C., M.D.S., N.B., and S.H. J.-C.L. and H.D. contributed to the review and editing of the manuscript. Resources were provided by A.C. and M.D.S., and supervision was carried out by J.-C.L. and H.D.


Ethical Approval

All principles in the Declaration of Helsinki were followed, and the Italian laws on privacy (Art. 20–21, DL 196/2003) as published in the Official Journal, volume 190, August 14, 2004, which explicitly waives the need for ethical approval for the use of anonymous data, were respected.




Publication History

Article published online:
06 February 2025

© 2025. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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