A 79-year-old male was admitted to stroke ward following two episodes of mild headaches, slurred speech and left arm weakness over the past 3 days. On both occasions, the symptoms resolved within an hour. On admission to the ward he suffered 2 focal seizures. He denies any fever.
He has the background of benign oesophageal stricture which was recently dilated, and melanoma on his neck which was resected 5 years ago.
Neurological examination was unremarkable. WBC- normal, CRP- slightly high. LP was also normal.
The MRI brain revealed 4 ring-enhancing lesions bilaterally. DWI showed restricted diffusion.
After discussion with neuroradiologists and neurosurgeons, antibiotics started for brain abscesses. Despite this, he gradually developed progressive left arm weakness. After another discussion, it was thought that his lesions were metastases. Biopsy/aspiration could not be performed due to limited resources. We stopped antibiotics and started dexamethasone. His left arm weakness subsequently improved. However, MRI scan repeated after 2 weeks showed increase in size of lesions. Thus, antibiotics restarted, and the subsequent scans showed improvement.
Discussion Brain abscess is a rare but serious complication following oesophageal dilation. A cystic lesion that markedly restricts centrally on DWI should be considered an abscess until proven otherwise.
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