We report the case of a 35-year-old man with a 21-year history of intravenous heroin abuse who developed moderate global aphasia on the day of admission. Cerebral magnetic resonance imaging (MRI) was in line with an acute ischemic infarction in the left supplementary motor cortex (Figure
a-c). 4.5 h after symptom onset, systemic thrombolysis was no longer a therapeutic option. Laboratory parameters on admission were consistent with an acute bacterial infection with a C-reactive protein level of 23.0 mg/dl and leukocytosis of 21.3x103/μl. Detailed clinical examination revealed a Janeway lesion on the fingertip of his left hand (Figure
d), which was highly indicative of a septic-embolic focus as the cause also of the ischemic stroke. Transthoracic as well as transesophageal echocardiography provided no evidence for an endocarditis or cardiac right-to-left shunt and repeated aerobic and anaerobic blood cultures came out negative. Magnetic resonance angiography and doppler/duplex-sonography revealed no relevant stenoses of the cervical or cerebral arteries. Chest X-ray, however, showed a large fluid and air containing lesion in the right lower lobe (Figure
e) which was confirmed as a lung abscess by computed tomography (CT, Figure
f). There were no further lesions suspicious of septic emboli in the high-resolution CT-scan or other chest X-rays. Antibiotic treatment with piperacillin/tazobactam 3x4.5g/d was immediately initiated. Bronchoscopy confirmed a pulmonary abscess; culture of the aspired purulent liquid revealed no bacterial growth. Tuberculosis was considered unlikely due to the negative interferon-gamma release assay, negative Ziehl Neelsen stain and cultures of sputum, urine, and gastric juice. HIV serology was also negative. As a right-to-left shunt was excluded and echography gave no evidence of a tricuspid endocarditis, we considered the pulmonary abscess to be a consequence of the intravenous heroin abuse.
Figure 1 a) T2 weighted axial image displayed a hyperintense cortical signal alteration in two adjacent gyri of the left supplementary motor cortex (white arrow).b) This lesion was hyperintense in the axial diffusion weighted image (b = 1000 sec/mm2. Although (more ...)
As contrast transcranial Doppler sonography
] and echocardiography showed no right-to-left shunt an erosion of a pulmonary vein by the pulmonary abscess and consecutive transcardiac embolisation was thought to be the most probable cause of the ischemic stroke and the Janeway lesion. 72 h monitoring of blood pressure and ECG and a formal 24 h holter ECG gave no evidence of arterial hypertension or relevant cardiac arrhythmia; serum cholesterol, LDL and HDL were normal.
A control CT scan two days after admission revealed a round, well demarcated lesion at the location of the initial stroke (Figure
g). 11 days after admission the neurological status deteriorated and the patient developed a complete paralysis of his right arm and global aphasia. On the same day a CT scan revealed a large left frontal mass with ring-enhancement of contrast media typical for a cerebral abscess (Figure
h-i). The patient was immediately transferred to the neurosurgical department where the abscess was drained and rinsed. The antibiotic treatment was changed to metronidazol 3x500mg/d, vancomycin 2x1g/d, and ceftriaxone 2g/d. Cultures of the abscess content revealed Fusobacterium nucleatum which was sensitive to ampicillin/sulbactam and metronidazol. The drainage was removed after one week but as the size of the abscess cavity and oedema increased in a control CT scan a new drainage was placed another week later and the abscess rinsed daily. CT scan showed no further progression thus the drainage could be removed and the patient was transferred to a rehabilitation centre where antibiotic treatment with ampicillin/sulbactam 3x3g/d and metronidazole 2x500mg/d was continued for another six weeks. During rehabilitation the neurological status improved, the patient was able to walk and speak again and could be discharged after seven weeks with only a latent paresis of his right arm and a slight incomplete aphasia which were both barely noticeable on examination corresponding to a modified Rankin scale of 1.