Brain abscesses complicating acute pneumococcal meningitis during etanercept therapy

Abstract

Brain abscess formation as a sequelae of community-acquired pneumococcal meningitis is extremely rare, accounting for less than 1% of all meningitis complications. Although metastatic seeding from a distal peripheral septic focus has been observed, this phenomenon most commonly occurs in the context of ear, nose and throat infections, post-cranial neurosurgical procedures, traumatic open cranial injury, or immunosuppression. We present the case of a man, 61 years old, on etanercept therapy for ankylosing spondylitis who developed multiple brain abscesses as a complication of pneumococcal meningitis. We believe that the predisposition to this extremely rare complication of a particularly aggressive pneumococcal meningitis was most likely due to the underlying immunosuppression resulting from etanercept therapy. As far as we know, this case is the first report linking multiple brain abscess formation in a patient with community-acquired pneumococcal meningitis with etanercept therapy.

Figure 1.

Computed tomography of the head without contrast done on day 2 of admission showing a focal hyper-dense image in the right frontal lobe parenchyma, consistent with intracerebral hemorrhage (see arrow) with surrounding edema.

Figure 2

T2-weighted contrast-enhanced magnetic resonance imaging study showing increased signal intensity in the right frontal lobe and in the anterior periventricular areas consistent with cerebritis and ventriculitis (see arrows). Minimal mass effect is also noted.

Figure 3

Contrast-enhanced computed tomography of the head done 14 days after admission showing 3 ring-enhancing lesions (see arrows) in the frontal lobe with low-density edema surrounding them.

Figure 4

Contrast-enhanced computed tomography of the head done after 6 weeks of antibiotic treatment. The ring-enhancing lesions evident on figure 3 have practically disappeared and now are seen as small focal areas of enhancement (see arrow). Associated low-density edema has also decreased.