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Pyogenic Brain Abscess Caused by S. viridans Following Esophagectomy FREE TO VIEW

Erica Bang, MD; Louis Voigt, MD; Stephen Pastores, MD; Sunil Kamat, MD; Nabil Rizk, MD; Sherard Lacaille, MD; Neil Halpern, MD
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MSKCC, New York, NY

Chest. 2013;144(4_MeetingAbstracts):338A. doi:10.1378/chest.1702701
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SESSION TITLE: Critical Care Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Serious postoperative complications including anastomotic leaks, pulmonary infections, and cardiac dysrhythmias occur in 20-40% of patients following esophagectomy for esophageal cancer. However, neurological complications such as pyogenic brain abscesses are rare. We report a case of a pyogenic brain abscess following esophagectomy for cancer.

CASE PRESENTATION: A 55-year-old male was admitted to an outside hospital with headaches and mental status changes two months after an Ivor-Lewis esophagectomy for cancer. Physical exam revealed a disoriented man with aphasia and left-sided weakness. Laboratory tests were unremarkable except for an elevated WBC count of 17.5. Brain MRI demonstrated a 2.5 x 2.5-cm ring-enhancing lesion in the right frontal lobe with cerebral edema. The patient was treated with IV steroids and anti-epileptics for presumed brain metastasis. He was then transferred to our hospital for further care. Within 12 hours, his clinical status worsened as he became non-verbal with flexor posturing and non-reactive pupils. Repeat MRI revealed a 3.3-cm right frontal lobe pyogenic abscess with surrounding edema (Figure 1). Vancomycin and Piperacillin/Tazobactam were initiated and craniotomy was performed with drainage of 15 mL of pus; culture of this fluid grew Streptococcus viridans. Postoperatively, he was transferred to our ICU and treated for septic shock. Further imaging revealed pulmonary infiltrates and hemoperitoneum. By ICU day 5, his mental status improved and he was transferred to the ward and subsequently discharged from the hospital. Blood cultures were negative throughout his hospital stay. Two months later, his cognitive and motor functions returned to baseline and imaging demonstrated resolution of the brain abscess.

DISCUSSION: Pyogenic brain abscesses are rare occurrences following esophagectomy. Streptococcus viridans colonizes the oropharynx and esophagus and has been reported to cause bacteremic sepsis after esophageal dilatation for benign strictures, but not following esophagectomy. We ascribe the development of pyogenic brain abscess in our patient to hematogenous seeding from a colonized oropharynx or entry of bacteria into the brain via the Batson’s paravertebral plexus. Surgical drainage of the pyogenic brain abscess and antimicrobial therapy are the mainstays of treatment.

CONCLUSIONS: Critical care practitioners need to be aware of pyogenic brain abscess as a rare and life-threatening complication of esophagectomy.

Reference #1: Thapar, V.K, Rajashekharam, S., Bapat, R.D., Kantharia, C.V. Brain abscess following esophageal dilatation. Diseases of the Esophagus 2003; 16: 145-147

Reference #2: Raymond D. Complications of esophagectomy. Surg Clin N Am 2012;92:1299-1313.

Reference #3: Fares J, Al-Khatatneh S, Baddoura W. Fatal E. coli brain abscesses following dilatation of a strictured colonic interposition in a patient with an esophageal metallic stent. Am J Gastroenterol 2001;96 (9); S195.

DISCLOSURE: The following authors have nothing to disclose: Erica Bang, Louis Voigt, Stephen Pastores, Sunil Kamat, Nabil Rizk, Sherard Lacaille, Neil Halpern

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