Infective endocarditis complicated by cerebral abscess and mycotic intracranial aneurysm: A case report

Infective endocarditis (IE), is an infection of the endocardial surfaces of the heart, which primarily affects the valve leaflets, the mural endocardium, chordae tendinae and prosthetic valves among others. IE has various complications among which neurological complications include stroke, infected intracranial aneurysms, intracranial abscesses, meningitis, encephalopathy and seizures which could prove fatal if not treated on time. We report a case of a 17 year old girl, who was a known case of bacterial endocarditis that presented with sudden onset deterioration of mental status, fever and dizziness. On CT scan imaging of the brain, the patient showed features of intracranial abscess and mycotic aneurysm. Since early detection, diagnosis and timely management is crucial for the prognosis of the patient, we should always opt for timely imaging in patients of infective endocarditis with neurological symptoms.     

Aortic root abscess from Enterococcus faecalis infective endocarditis: Case report and brief review of the literature

Infective endocarditis is a life-threatening disease that is associated with a significant risk of morbidity and mortality. One of the most serious complications of infective endocarditis is perivalvular and aortic root abscess formation. Due to the high propensity for rupture and continued spread within the aorta and surrounding organs, surgical management is recommended and can improve long-term survival. Imaging plays a critical role in diagnosis of infective endocarditis and its sequalae. Initial workup includes transthoracic and/or transesophageal echocardiography, as part of the modified Duke criteria for diagnosing infective endocarditis. If paravalvular abscesses are suspected, CTA chest can characterize invasion and spread of the abscess. Here, we present a 55-year-old male with recurrent infective endocarditis with an aortic root abscess. The abscess was first identified through transesophageal echocardiography and subsequently confirmed using CTA chest. Surgically, the patient required pulmonic and aortic valve replacement along with aortic root reconstruction.     

29例小儿感染性心内膜炎的临床分析

目的;分析小儿感染性心内膜炎（IE）当前的临床特征。方法;前瞻性研究了我市近10年来收治的29例感染性心内膜炎的患儿。结果;感染性心内膜炎在小儿中发病率较高,占住院病儿的0.23%,男女比例为2：1。10例患儿年龄小于2岁,19例年龄大于2岁,绝大多数为青少年。两组患儿在病原学和预后方面表现出显著差异。先天性心脏病是22例患儿的易患因素。金黄色葡萄球菌（13例）和草绿色链球菌（6例）是最常见的病原菌。有9例为继发感染,其中6例病变存在于修复后的瓣膜上。结论：在小儿中,尽管感染性心内膜炎治疗 方面已经取得很大的进展,但它仍为一种严重的疾病,其病死率高达24例。年龄小于2岁、致病菌为金葡菌、经历瓣膜手术是预示不良预后的主要因素。     

Cardiac computed tomography in the contemporary evaluation of infective endocarditis

Increasing data have accumulated on the role of Cardiac Computed Tomography (CCT) in infective endocarditis (IE) with high accuracy for large vegetations, perivalvular complications and for exclusion of coronary artery disease to avoid invasive angiography. CCT can further help to clarify the etiology of infective prosthetic valve dysfunction (e.g. malposition, abscess, leak, vegetation or mass). Structural interventions have increased the relevance of CCT in valvular heart disease and have amplified its use. CCT may be ideally integrated into a multimodality approach that incorporates a central role of transesophageal echocardiography (TEE) with 18-FDG PET and/or cardiac magnetic resonance in individually selected cases, guided by the Heart Team. The coronavirus-19 (COVID-19) pandemic has resulted in renewed attention to CCT as a safe alternative or adjunct to TEE in selected patients. This review article provides a comprehensive, contemporary review on CCT in IE to include scan optimization, characteristics of common IE findings on CCT, published data on the diagnostic accuracy of CCT, multimodality imaging comparison, limitations and future technical advancements.     

临床表现不典型感染性心内膜炎的超声诊断价值

目的:评价超声心动图对临床表现不典型的感染性心内膜炎(IE)的诊断价值。方法:对由超声心动图检查发现的26例IE患者特征进行分析总结。结果:①明确器质性心脏病基础17例(占65%),包括先天性心脏病8例,风湿性心脏病9例;②无明确心脏基础病变者9例,包括4例静脉药瘾者。全部病例均追踪随访,其中16例外科手术证实。结论:超声能为临床提供不典型IE患者的基础心脏病因、诊断、鉴别诊断、指导治疗和判断预后等具有重要价值的信息。     

Sudden infant death due to Lactococcal infective endocarditis

Infective endocarditis (IE) of infants is rare, most of which occur associated with congenital heart disease or its cardiac surgery. We experienced a case of sudden death of a four-month-old male infant without congenital heart disease. It was elucidated by postmortem examination that the dead had suffered severe IE, which led him to death. In the microbiological genetic analysis using histological section, the pathogen causing inflammation in the present case was identified as Lactococcus lactis subspecies, although Staphylococci have been reported to be common and important one. Previously reported infectious diseases by Lactococcus lactis subspecies were all adult cases and this is the first report of an infantile death due to Lactococcal IE according to our knowledge. Any fatal disease may be included in sudden death cases targeted for forensic autopsy, even if it is rare. It is expected for forensic pathologists that they note such case and share each experience among themselves and other medical fields to develop a strategy for prevention.     

Differentiation of infective from neoplastic brain lesions by dynamic contrast-enhanced MRI

INTRODUCTION: It is not always possible to differentiate infective from neoplastic brain lesions with conventional MR imaging. In this study, we assessed the utility of various perfusion indices in the differentiation of infective from neoplastic brain lesions. METHODS: A total of 103 patients with infective brain lesions (group I, n=26) and neoplastic brain lesions (high-grade glioma, HGG, group II, n=52; low-grade glioma, LGG, group III, n=25) underwent dynamic contrast-enhanced MR imaging. The perfusion indices, including relative cerebral blood volume (rCBV), relative cerebral blood flow (rCBF), transfer coefficient (k(trans)) and leakage (v(e)), were calculated and their degree of correlation with immunohistologically obtained microvessel density (MVD) and vascular endothelial growth factor (VEGF) determined. The rCBV was corrected for the leakage effect. Discriminant analysis for rCBV, rCBF, k(trans) and v(e) was performed to predict the group membership of each case and post hoc analysis was performed to look for group differences. RESULTS: The rCBV, rCBF, k(trans), v(e), MVD and VEGF were significantly different (P<0.001) between the three groups. Discriminant analysis showed that rCBV predicted 73.1% of the infective lesions, 84.6% of the HGG and 72.0% of the LGG. The rCBF classified 86.5% of the HGG, 80.0% of the LGG and 65.4% of the infective lesions. The k(trans) discriminated 98.1% of the HGG, 76.0% of the LGG and 88.5% of the infective lesions correctly. The v(e) classified 98.1% of the HGG, 76.0% of the LGG and 84.6% the infective lesions. The rCBV was correlated significantly with MVD and VEGF, while the correlation between k(trans) and MVD was not significant. CONCLUSION: Physiological perfusion indices such as k(trans) and v(e) appear to be useful in differentiating infective from neoplastic brain lesions. Adding these indices to the current imaging protocol is likely to improve tissue characterization of these focal brain mass lesions.     

Unusual femoral artery mycotic aneurysm complicated by infective spondylitis

We present a patient who experienced an aortic aneurysm and a left femoral artery mycotic aneurysm, which resulted from L4-infective spondylitis via the iliopsoas compartment. This rare complication could be underdiagnosed in the absence of a more extended field of imaging view such as is provided by computed tomography.     

Brain magnetic resonance findings in infective endocarditis with neurological complications

Purpose  Diagnosing infective endocarditis and its complications can be difficult because of the nonspecific symptoms. We reviewed findings of intracranial abnormalities on magnetic resonance imaging (MRI) in 14 patients with neurological complications and herein discuss the overall intracranial MRI findings. Materials and methods  We retrospectively reviewed patients with infective endocarditis from August 2004 to August 2006. Brain MRI, the causative bacteria, and abnormal neurological symptoms were reviewed for 14 patients with neurological complications. Results  Of the 14 patients, 13 showed intracranial abnormalities on MRI. Embolization was seen in 10 patients, hemorrhage in 3, abscess formation in 3, and encephalitis in 2. Hyperintense lesions with a central hypointense area on T2-weighted and/or T2*-weighted imaging (Bull’s-eye-like lesion) were seen in four patients. A combination of these intracranial abnormalities was observed in 6 patients. Conclusion  The MRI findings associated with infective endocarditis are wide-ranging: embolization, hemorrhage, meningitis, cerebritis, abscess, the bull’s-eye-like lesion. Clinicians should consider the possibility of infective endocarditis in patients with unknown fever and neurological abnormality. Brain MRI should be promptly performed for those patients, and T2*-weighted imaging is recommended for an early diagnosis of infective endocarditis.     

Brain abscess with hemorrhage

Summary A very rare case of brain abscess with hemorrhage in the basal ganglia is reported. We discuss the difficulties in the differential diagnosis and the mechanism of hemorrhage.     

Mammary tuberculosis: percutaneous treatment of a mammary tuberculous abscess

It is currently very rare to find mammary involvement in cases of tuberculosis, in either primary or secondary form. Diagnosis is classically clinical and microbiological, and the basic techniques used in imaging diagnosis are mammography and ultrasound. Computed tomography may define the involvement of the thoracic wall in those cases which present as mammary masses adhering to deep levels, and is also able to evaluate accompanying pulmonary disease, if it is present. Traditionally, treatment has consisted of quadrantectomy and specific antibiotic therapy. We present a case of tuberculous mammary abscess secondary to pulmonary disease, which was treated by percutaneous drainage controlled by CT and specific antibiotic therapy. We revise the diagnosis, differential diagnosis and treatment of mammary tuberculosis. Received: 27 July 1998; Revision received: 2 February 1999; Accepted: 20 April 1999     

Mycotic pulmonary artery aneurysm as a late complication of infective endocarditis after pacemaker implantation

A 49-year-old-woman who had had a pacemaker implanted 15 years earlier became acutely ill with a continuous high fever and general fatigue. A pulmonary artery aneurysm had been rapidly developing and had arrived at the acute phase within 2 weeks. After removal of the pacemaker and with antibiotic therapy the aneurysm gradually decreased in size and has been without rupture for 3 years. Conservative treatment seemed to be sufficient for the management of a mycotic aneurysm in this case.     

Intraventricular mass lesions of the brain

Intraventricular tumours represent a diverse group of lesions, some of them infrequent, with a wide variety of radiological features. Determination of their precise aetiology or origin can be difficult. Nevertheless, considering patient's age, location within the ventricles, and some specific radiological features, the radiologist should be able to narrow down the differential diagnosis. This paper reviews the characteristic radiological appearances of the diverse intraventricular lesions emphasising its differential diagnosis. Received: 6 July 1999; Revised: 5 August 1999; Accepted: 9 August 1999     

Primary intraventricular brain abscess

We report a primary intraventricular brain abscess in a 13-year-old boy. We discuss possible explanations for this rare occurrence.     

Technetium-99m hexamethylpropylene amine oxime leucocyte scintigraphy in the differential diagnosis of cerebral abscesses

The diagnosis of brain abscess is often difficult, as the clinical symptoms are not specific. Computed tomography (CT) and magnetic resonance imaging (MRI) are highly sensitive, but different cerebral lesions, especially neoplasms, can have the same ring-like contrast enhancement. Brain abscess is a severe illness requiring rapid diagnosis to choose the most appropriate therapy. Technetium-99m hexamethylpropylene amine oxime (HMPAO)-labelled leucocyte scintigraphy is commonly used to detect an inflammatory process. The aim of this study was to present the results obtained with leucocyte scintigraphy in 65 patients with intracranial mass lesions and clinical findings compatible to or suggestive of brain abscess. The final diagnosis, based on surgery, clinical findings and stereotatic puncture, was brain abscess in 17 patients, primary brain neoplasm in 22, brain metastasis in 16, lymphoma in 2, cysticercosis in 2, hematoma in 2 and cerebral infarction in 4. ^99mTc-HMPAO leucocyte scintigraphy was positive in all abscess cases. The scan was negative in the rest of the patients examined, with the exception of one lesion, which was finally diagnosed as a tumour (1 false-positive). All patients who did not have false-negative scans were treated with steroids. The sensitivity, specificity and diagnostic accuracy of leucocyte scintigraphy was 100%, 97.8% and 98.4%, respectively. In conclusion, in our experience, leucocyte scintigraphy is a valuable aid in the differential diagnosis between abscess and neoplasm. Received 25 April and in revised form 12 August 1999     

Hemorrhagic prepatellar bursitis

 Simple prepatellar bursitis is easily diagnosed both clinically and by MRI. MRI shows the typical T1 and T2 lengthening of fluid within the bursa. However, because of complex MRI appearance of hemorrhage, chronic hemorrhagic bursitis and the size of the prepatellar mass the clinical and MRI appearance can be very different.     

Diagnostic performance of cardiac computed tomography versus transesophageal echocardiography in infective endocarditis: A contemporary comparative meta-analysis

ObjectiveTo compare the diagnostic accuracy of transesophageal echocardiography (TEE) and cardiac computed tomography (CCT) in diagnosing infective endocarditis (IE).BackgroundTEE is a mainstay imaging modality for IE, while the use of CCT is becoming increasingly prevalent. Data directly comparing the diagnostic performance of these two imaging modalities for IE are limited.MethodsWe conducted a systematic review and meta-analysis of published literature in Embase, PubMed and Cochrane databases through October 1, 2020 for studies comparing diagnostic performance of CCT and TEE for the diagnosis of IE in the same patient populations. A meta-analysis of diagnostic accuracy was performed using the bivariate model based on studies that used surgical pathology as a reference standard for defining endocarditis. From a total of 10 studies included in the meta-analysis, a total of 872 patients were evaluated.ResultsThe pooled sensitivities and specificities of TEE for detecting vegetations were 96% and 83% respectively, whereas for CCT, they were 85% and 84%, respectively. In the prosthetic valve sub-group, the pooled sensitivities and specificities of TEE for detecting vegetations were 89% and 74% respectively, whereas for CCT, they were 78% and 94%, with CCT being more specific than TEE (p < 0.05). The pooled sensitivities and specificities of TEE for detecting periannular complications were 70% and 96% respectively, whereas for CCT, they were 88% and 93%, respectively. CCT showed a trend (p = 0.06) towards higher sensitivity than TEE for detection of periannular complications. The pooled sensitivities and specificities of TEE for detecting leaflet perforation were 79% and 93% respectively, whereas for CCT, they were 48% and 93% respectively, with TEE being more sensitive (p < 0.05). The two modalities also showed comparable diagnostic performance for detecting fistulae, paravalvular leaks and prosthetic valve dehiscence.ConclusionIn a contemporary comparative meta-analysis, TEE and CCT demonstrated both good diagnostic accuracy for detecting valvular involvement and complications of IE. TEE performed better for detecting leaflet defects, whereas CCT performed better in cases of prosthetic valve involvement, and showed a trend towards improved detection of periannular complications. Appropriate, complementary use of both TEE and CCT in a multimodality imaging approach in clinical practice may achieve the highest diagnostic performance.     

包膜期脑脓肿的MRI表现与病理分析

目的：分析包膜期脑脓肿的MRI表现，方法：经手术或临床抗炎治疗证实的包膜期脑脓肿18例，男14例，女4例，年龄，8－65岁，所有病例均行平扫及增强MRI检查，结果：所有病例脓肿壁上均有一光滑的低信号“暗带”，增强扫描见脓肿壁呈厚度均匀的不环形强化，强化环周围可见云絮状强化区。9例手术患者包膜上的“暗带”对应于病理上脓肿壁第3带的胶原包膜及丰富的巨噬细胞。5例经内科治愈的病灶其低信号“暗带”随访消失。结论：包膜期脑脓肿的MRI表现有一定的特征，其中“暗带”最具特征。     

Sequential scintigraphic strategy for the differentiation of brain tumours

Both thallium-201 and iodine-123 α-methyltyrosine (¹²³I-IMT) have been shown to be useful in the diagnostic evaluation of brain tumours. The aim of this study was to investigate the respective contributions of ²⁰¹Tl and ¹²³I-IMT single-photon emission tomography (SPET) in the non-invasive evaluation of intracerebral tumours. We analysed 65 patients with the following brain tumours: 8 non-neoplastic lesions, 4 meningiomas, 12 low-grade gliomas, 28 high-grade gliomas, 11 metastases and 2 high-grade lymphomas. ²⁰¹Tl SPET and ¹²³I-IMT SPET were performed [start of ²⁰¹Tl SPET: 15 min p.i. (early) and 180 min p.i. (delayed); start of ¹²³I-IMT SPET: 15 min p.i.]. The intensity of uptake was quantified as the ratio between tracer accumulation in the tumour and in the contralateral hemisphere. None of the non-neoplastic lesions or low-grade gliomas expressed marked ²⁰¹Tl uptake. All malignant tumours except one small metastasis and all meningiomas except one small, cystic and degenerated lesion showed significant ²⁰¹Tl accumulation [Tl(15’)>2.0]; ¹²³I-IMT uptake was either absent or intermediate in non-malignant lesions except in two low-grade gliomas; the highest levels were observed in high-grade gliomas followed by metastases and lymphomas (mean IMT: 2.7 vs 2.1 vs 1.8), with metastases showing a high variability in ¹²³I-IMT uptake (range: 0.8–3.6). Using ²⁰¹Tl to distinguish non-neoplastic lesions from malignant tumours and meningiomas, 63 of 65 patients were characterised correctly. In the latter group, high-grade gliomas were correctly identified in 27 of 28 cases by their amino acid uptake. It is concluded that the combination of ²⁰¹Tl and ¹²³I-IMT surpasses the accuracy of each single test in the differentiation of space-occupying lesions of the brain. Based on these preliminary results, a sequential strategy is proposed involving an initial ²⁰¹Tl SPET study and an additional ¹²³I-IMT SPET study in the event of positive ²⁰¹Tl uptake. Received 1 October 1999 and in revised form 8 January 2000