Sir,
Focal intracranial infections remain a major source of morbidity and are often life-threatening
conditions. Rapid recognition and early neurosurgical intervention combined with appropriate
antimicrobial treatment give the best chances of a favorable prognosis.[[1]] We describe a rare case of a subdural empyema (SDE) and adjacent cerebral abscess
from Achromobacter species in a young patient with hematologic malignancy.
A 39-year-old Caucasian female with multiple myeloma, was admitted in the emergencies
with fever, headache, vomiting, gait disturbance, and seizures for 4 days. Neurological
examination revealed a left hemiparesis, nuchal rigidity, and positive Babinski sign.
Pre- and post-contrast computed tomography and magnetic resonance imaging brain scans
were suggestive of right frontal SDE and adjacent early capsule formation brain abscess
with perifocal edema [[Figure 1]]a, [[Figure 1]]b, [[Figure 1]]c, [[Figure 1]]d.
Figure 1: (a) Brain computed tomography scan without contrast, and (b) T1 - weighted postcontrast
image reveals a hyperdense to cerebrospinal fluid right frontal subdural collection
with clear capsule formation, and an adjacent intraparenchymal lesion of low signal
with considerable edema. (c) Fluid-attenuated inversion recovery postcontrast sequence
demonstrates a densely enhancing extraaxial lesion and a well-defined ring enhancing
brain lesion. (d) On diffusion-weighted image, the core of the subdural and brain
lesion has typically markedly hyperintense signal (restricted diffusion)
The patient underwent right frontal craniectomy and complete removal of SDE and cerebral
abscess [[Figure 2]]. Achromobacter xylosoxidans colonies were identified from blood samples and intracranial
pus cultured on MacConkey agar. The patient received a combination of Piperacillin–
Tazobactam and trimethoprim/sulfamethoxazole (TMP/SMX) intravenously for 6 weeks and
she gradually recovered. She was also given oral TMP/SMX for a further 2 months, and
at the time of writing this study, she is still well 1½ years after completion of
therapy [[Figure 3]].
Figure 2: Purulent material into the subdural space after opening of the dura mater and the
subdural empyema capsule
Figure 3: Postcontrast computed tomography scan 3 weeks after surgical procedure reveals the
intracranial infections decreased
Achromobacter species is often isolated from aqueous environments but is rarely recognized
as a human pathogen. However, it can cause serious infections in immunosuppressed
patients. Achromobacter infections in patients with cancer, and especially in those
who have underlying hematologic malignancies, usually are seen as uncomplicated hematogenous
infections and are seldom accompanied by a secondary suppurative focus of infection.[[2]],[[3]] Isolation of Achromobacter xylosoxidans from intracranial space was an unusual
finding and to the best of our knowledge is the first case that Achromobacter xylosoxidans
implicated for an intracranial abscess formation in an adult patient who had not undergone
any prior neurosurgical procedure.
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understand that their names and initials will not be published and due efforts will
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