Multiple Streptococcus sanguinis brain abscesses misdiagnosed as cerebral manifestation of tuberculosis

A 68-year-old man with a known history of pulmonary tuberculosis (TB) was admitted to our hospital following sudden onset of left hemiplegia. Cranial magnetic resonance imaging (MRI) showed multiple hyperintense lesions on T2-weighted images with surrounding vasogenic edema (Figure 1A) and ring-enhancement following administration of an intravenous contrast agent (Figure 1B-C). MR spectroscopy revealed lipid and lactate peaks with low levels of n-acetyl aspartate, consistent with the inflammatory process. There were no abnormal findings, except the TB-induced left lung damage on thoracic computed tomography (Figure 2); infective endocarditis was not evident on transesophageal echocardiography. The patient was preliminarily diagnosed with TB abscess due to a history of pulmonary TB and was administered anti-tubercular treatment. As the cranial lesions progressed under TB treatment, surgical drainage was performed, and pus culture from the abscess showed Streptococcus sanguinis.

FIGURE 1:
(A) Axial T2-weighted images showing hyperintense lesion (arrow) with surrounding edema (asterisk) of right frontal lobe. (B-C) Axial post contrast T1-weighted images showing ring-enhancing lesions (arrows) of bilateral parietal and frontal lobes, and right thalamus.

FIGURE 2:
Thorax computed tomography showing unilateral tuberculous lung destruction (arrow).

S. sanguinis is a facultative anaerobic commensal bacterium found in the oral cavity. Central nervous system infectiondue to S. sanguinis has rarely been reported in the literature. Facilitating conditions included infective endocarditis, pulmonary arteriovenous fistulas, and history of craniotomy in previously reported cases^1-3; however, neither foci of infection nor facilitating causes were found in the present case.

To our knowledge, this is the most severe case of brain abscess caused by S. sanguinis. Moreover, the diagnostic challenge posed by the patient’s history of pulmonary TB is noteworthy. Awareness of this pathogen as a rare cause of brain abscess will help clinicians determine the accurate diagnosis.

ACKNOWLEDGMENTS

Not applicable.

REFERENCES

• ¹
  Kassis H, Marnejon T, Gemmel D, Cutrona A, Gottimukkula R. Streptococcus sanguinis brain abscess as complication of subclinical endocarditis: emphasizing the importance of prompt diagnosis. South Med J. 2010;103(6):559-62.
• ²
  Chang CY, Chai CSY, Ong ELC.Streptococcus sanguisbrain abscess as an initial manifestation of pulmonary arteriovenous malformation. Clin Case Rep. 2020;8(12):2685-8.
• ³
  Dhawan B, Lyngdoh V, Mehta VS, Chaudhry R. Brain abscess due to Streptococcus sanguis. Neurol India. 2003;51(1):131-2.

• Financial Support: No funding was received for this study.

Publication Dates

• Publication in this collection
  16 Dec 2022
• Date of issue
  2022

History

• Received
  08 Aug 2022
• Accepted
  11 Oct 2022