Brain Abscesses Associated with Asymptomatic Pulmonary Arteriovenous Fistulas

Abstract

Brain abscess commonly occurs secondary to an adjacent infection (mostly in the middle ear or paranasal sinuses) or due to hematogenous spread from a distant infection or trauma. Pulmonary arteriovenous fistulas (AVFs) are abnormal direct communications between the pulmonary artery and vein. We present two cases of brain abscess associated with asymptomatic pulmonary AVF. A 65-year-old woman was admitted with a headache and cognitive impairment that aggravated 10 days prior. An magnetic resonance (MR) imaging revealed a brain abscess with severe edema in the right frontal lobe. We performed a craniotomy and abscess removal. Bacteriological culture proved negative. Her chest computed tomography (CT) showed multiple AVFs. Therapeutic embolization of multiple pulmonary AVFs was performed and antibiotics were administered for 8 weeks. A 45-year-old woman presented with a 7-day history of progressive left hemiparesis. She had no remarkable past medical history or family history. On admission, blood examination showed a white blood cell count of 6290 cells/uL and a high sensitive C-reactive protein of 2.62 mg/L. CT and MR imaging with MR spectroscopy revealed an enhancing lesion involving the right motor and sensory cortex with marked perilesional edema that suggested a brain abscess. A chest CT revealed a pulmonary AVF in the right upper lung. The pulmonary AVF was obliterated with embolization. There needs to consider pulmonary AVF as an etiology of cerebral abscess when routine investigations fail to detect a source.

Brain abscess associated with Mycoplasma faucium – The initial presentation of pulmonary arteriovenous malformation

“…The association between PAVMs and infections has been well reported in the literature. Cerebral infections are the most significant and well described in case reports and patient cohorts [6] , [7] , [8] , [9] . In 2016, Nam et al presented two very similar cases to ours in which the patients, each with an unremarkable past medical history, were admitted to the hospital for brain abscesses and were then found to have pulmonary AVMs on CT imaging [7] .…”

“…Cerebral infections are the most significant and well described in case reports and patient cohorts [6] , [7] , [8] , [9] . In 2016, Nam et al presented two very similar cases to ours in which the patients, each with an unremarkable past medical history, were admitted to the hospital for brain abscesses and were then found to have pulmonary AVMs on CT imaging [7] . In 2011, Mathis et al reviewed 26 patients from 5 French medical centers with a concomitant diagnosis of HHT and cerebral abscess [10] .…”

Precision diagnosis and therapy of a case of brain abscesses associated with asymptomatic pulmonary arteriovenous fistulas

“…CPZ, Cefoperazone; CTRX, Ceftriaxone; LEV, Levofloxacin; MEPM, Meropenem rare vascular disease that has abnormal communication between the pulmonary artery and vein, leading to a shunt from right to left [11]. Clinical manifestations mainly include cyanosis, exertional dyspnea, and clubbing fingers, while 56% of patients are also asymptomatic [6]. It is an important cause of recurrent brain abscess which is rare and easy to neglect in the clinic.…”

“…Streptococcus intermedius (S. intermedius) is a known pathogen that can cause brain abscesses [2]. Pathogens can spread directly to the brain from contiguous sinus infection, head trauma or neurosurgical procedures [3], or through a right-to-left shunt disease, such as patent foramen ovale [4], cyanotic cardiac disease [5] or pulmonary arteriovenous fistulas (PAVFs) [6]. PAVFs have abnormal direct communications between pulmonary artery and vein which called fistula [7].…”

Silent Persistent Left Superior Vena Cava Right-to-Left Shunt as a Unique Cause of Recurrent Brain Abscesses

“…Transient bacteremia with oral flora occurs with routine oral hygiene such as tooth-brushing and flossing. In the setting of a right-to-left shunt, oral bacteria bypass the pulmonary circulation, which would usually eliminate them [ 3 , 4 ]. In bypassing the lungs, these bacteria can enter the arterial circulation and embolize to the brain [ 5 ].…”