Case 37 - Subacute BE with ventriculitis and sceptic emboli
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This was an inpatient who presented
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with new-onset seizures and fever.
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The patient was being treated for subacute bacterial
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endocarditis and was an IV drug abuser and had
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leaflets of the mitral valve that were showing, uh,
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areas where there was indeed little embolic foci.
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And, um, the patient was being evaluated for
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that septic emboli.
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This is the diffusion-weighted imaging.
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On the diffusion-weighted imaging,
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we see that there are foci of high signal intensity
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in the posterior fossa, including the posterior
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medial cerebellum, including within the fourth
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ventricle, and then proceeding more superiorly.
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We come into this very curious finding on
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diffusion-weighted imaging, where there's
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bright signal intensity in the occipital horns
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of the lateral ventricles.
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As we continue further superiorly, we
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find a lesion in the caudate nucleus.
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We see punctate areas in the peri-insular
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region, posteriorly, as well as in the medial
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frontal lobe on the left side, and then
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scattered in the medial frontal lobes of the
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right and left hemispheres, as well as in the
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region of the premotor cortex and the superior
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longitudinal fissure on the right side.
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So, bilateral involvement, as well as involvement
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of the posterior circulation, which again all
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feeds into potentially a cardiac source that is
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an embolic source that's flipping emboli into
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right and left carotid circulation,
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as well as the posterior circulation.
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That makes sense.
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What doesn't make sense is what's
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going on here in the ventricles.
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This is bright signal intensity on the DWI.
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When we look at the ADC map, we see it's
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actually dark signal intensity material.
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Now, this could potentially represent blood products,
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but in the scenario of a patient who has septic emboli,
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this is more likely to be purulent material
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in the ventricles, leading to a ventriculitis.
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So indeed, this patient had fever and seizures,
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secondary to septic emboli, embolic phenomenon
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that were infectious, that were associated with
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meningitis, as well as ventriculitis, with pus
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layering in the occipital horns
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of the lateral ventricles.
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If we look at the FLAIR scan again, we see that
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it's filled not with the normal low signal intensity
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CSF in the occipital horns, but that there is this
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brighter signal intensity material representing
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the purulent material in the patient's ventricles.
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So, another patient—fever, seizure. In this case,
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not abscesses per se, but septic emboli
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from the heart, secondary to the subacute
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bacterial endocarditis from IV drug abuse.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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