A rare case of Achromobacter species subdural empyema and brain abscess in an adult patient with hematologic malignancy

Sir,

Focal intracranial infections remain a major source of morbidity and are often life-threatening conditions. Rapid recognition and early neurosurgical intervention combined with appropriate antimicrobial treatment give the best chances of a favorable prognosis.[[1]] We describe a rare case of a subdural empyema (SDE) and adjacent cerebral abscess from Achromobacter species in a young patient with hematologic malignancy.

A 39-year-old Caucasian female with multiple myeloma, was admitted in the emergencies with fever, headache, vomiting, gait disturbance, and seizures for 4 days. Neurological examination revealed a left hemiparesis, nuchal rigidity, and positive Babinski sign. Pre- and post-contrast computed tomography and magnetic resonance imaging brain scans were suggestive of right frontal SDE and adjacent early capsule formation brain abscess with perifocal edema [[Figure 1]]a, [[Figure 1]]b, [[Figure 1]]c, [[Figure 1]]d.

Figure 1: (a) Brain computed tomography scan without contrast, and (b) T1 - weighted postcontrast image reveals a hyperdense to cerebrospinal fluid right frontal subdural collection with clear capsule formation, and an adjacent intraparenchymal lesion of low signal with considerable edema. (c) Fluid-attenuated inversion recovery postcontrast sequence demonstrates a densely enhancing extraaxial lesion and a well-defined ring enhancing brain lesion. (d) On diffusion-weighted image, the core of the subdural and brain lesion has typically markedly hyperintense signal (restricted diffusion)

The patient underwent right frontal craniectomy and complete removal of SDE and cerebral abscess [[Figure 2]]. Achromobacter xylosoxidans colonies were identified from blood samples and intracranial pus cultured on MacConkey agar. The patient received a combination of Piperacillin– Tazobactam and trimethoprim/sulfamethoxazole (TMP/SMX) intravenously for 6 weeks and she gradually recovered. She was also given oral TMP/SMX for a further 2 months, and at the time of writing this study, she is still well 1½ years after completion of therapy [[Figure 3]].

Figure 2: Purulent material into the subdural space after opening of the dura mater and the subdural empyema capsule

Figure 3: Postcontrast computed tomography scan 3 weeks after surgical procedure reveals the intracranial infections decreased

Achromobacter species is often isolated from aqueous environments but is rarely recognized as a human pathogen. However, it can cause serious infections in immunosuppressed patients. Achromobacter infections in patients with cancer, and especially in those who have underlying hematologic malignancies, usually are seen as uncomplicated hematogenous infections and are seldom accompanied by a secondary suppurative focus of infection.[[2]],[[3]] Isolation of Achromobacter xylosoxidans from intracranial space was an unusual finding and to the best of our knowledge is the first case that Achromobacter xylosoxidans implicated for an intracranial abscess formation in an adult patient who had not undergone any prior neurosurgical procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflict of Interest

There are no conflicts of interest.

Financial support and sponsorship

Nil.

• References

• 1 Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRx 2005;2:324-32.
• 2 Shie SS, Huang CT, Leu HS. Characteristics of Achromobacter xylosoxidans bacteremia in Northern Taiwan. J Microbiol Immunol Infect 2005;38:277-82.
• 3 Aisenberg G, Rolston KV, Safdar A. Bacteremia caused by Achromobacter and Alcaligenes species in 46 patients with cancer (1989-2003). Cancer 2004;101:2134-40.

Publication History

Received: 29 December 2019

Accepted: 24 January 2020

Article published online:
16 August 2022