Magnetic resonance imaging abnormalities with septic encephalopathy

Abstract

A 48 year old woman, status post renal transplantation six years earlier, died after a two week illness characterised by fever, recurrent seizures, and coma. Widespread abnormalities were seen on neuroimaging. A diagnosis of septic encephalopathy was established on postmortem. We describe the magnetic resonance imaging findings of bilateral basal ganglia, thalamic, cerebellar, brainstem, and cerebral abnormalities in this patient, which correlate with the pathophysiology of septic encephalopathy. E ncephalopathy in association with sepsis without evidence of hepatic or renal dysfunction, hypoxaemia, or other identifiable aetiology is referred to as septic encephalopathy (SE) and is often a diagnosis of exclusion. 1A neuroimaging pattern with neuropathology that corresponds with the pathophysiology associated with SE is described. CASE REPORTA 48 year old woman with hypertension and polycystic kidney disease, status post renal transplant six years earlier, was in good health until one week before admission, when she developed symptoms of urinary tract infection. A subsequent urine culture was positive for Escherichia coli. She was treated with ciprofloxacin; however, symptoms of haematuria, and nausea and vomiting developed, and she was admitted to hospital.The patient was afebrile and her heart rate was 108/min, blood pressure 180/100 mm Hg, and respiratory rate 19/min. She was alert, oriented, and cooperative. The lungs were clear on auscultation, with no appreciable heart murmur. There was right lower quadrant tenderness. The rest of the physical examination was unremarkable. On hospital day 2, her temperature was 38.3˚C (101˚F). She had a grand mal seizure of three to five minutes duration with an apnoeic spell of 30-40 seconds. Phenytoin (1 g) was administered intravenously. A computed tomography (CT) scan of the head was negative. Later that day she had a second seizure, and she was intubated and transferred to the intensive care unit. Medications on admission included prednisone, mycophenolate, diltiazem, aciclovir, and hydrochlorothiazide. She was given levofloxacin 500 mg intravenously followed by one dose of 250 mg orally. Cefotaxime and ganciclovir were added on hospital day 4.On neurologic examination on day 2 the patient was lethargic with a non-focal examination. On day 3 she only opened her eyes to voice and pain, and on day 4 she was unresponsive even to deep pain. The extremities were flaccid and pupils were non-reactive. On day 3 she had another seizure followed by two further seizures on day 4. Cerebrospinal fluid analysis on day 3 was unremarkable other than for protein (195 mg/dl). Repeat spinal fluid analysis on day 8 showed 235 white blood cells/mm 3 , 80% granulocytes, and protein 240 mg/dl. Routine culture of the spinal fluid was negative. Polymerase chain reaction (PCR) for cytomegalovirus, herpes simplex virus, and Lyme's disease, and cryptococcal antigen and serological tests for Bartonella were all negative. A renal ultrasound and CT scan of the abdomen were normal. Blood and urine cu...

Sepsis-Associated Encephalopathy as a Differential Diagnosis With Motor Deficit Plus Altered Mental Status

“…The tachycardia and leucocytosis observed on day 2 confirmed the sepsis diagnosis, which was compatible with reports in the literature of SAE preceding sepsis signs. 2 The concomitant recovery from neurologic deficits and improvement of leucocytes, C-reactive protein, and arterial lactate was observed after antimicrobial therapy.…”

“…1 In some cases, SAE may precede other manifestations of sepsis. 2 We report a case of a 37-year-old pregnant woman who developed septic encephalopathy for whom the initial symptom was confusion that evolved with motor deficit and subsequently to coma.…”

In Vivo Imaging of Septic Encephalopathy

“…Recently, brain atrophy within the regions including amygdala, hippocampus, basal ganglia, brainstem, thalamic, and cerebellar neurons was also shown in Ref. [103,104]. Hence, complicated symptoms, if they represent irreversible morphological alteration, have been found with fMRI.…”

Spotlight on the July 5 Issue

“…Despite a negative tissue PCR, we did not perform a mycoplasma serology in our case. 3 Furthermore, we recently saw a 26-year-old woman who presented with somnolence and confusion with bilateral basal ganglia lesions on magnetic resonance fluid-attenuated inversion recovery (MR-FLAIR) consistent with striatal encephalitis with an elevated serum immunoglobulin G mycoplasma titer of 2.42 (n ϭ Ͻ0.09). She had a history of spleen removal after trauma.…”

“…As in the patients described by Newsome et al, MR-FLAIR change was the dominant MR feature in the patients cited above. 2,3 Mycoplasma pneumonia should be considered in the differential diagnosis of bilateral basal ganglia lesions of all immunocompetent and immunocompromised patients.…”