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Clinically mild encephalitis/encephalopathy with a reversible splenial lesion caused by methicillin-sensitive Staphylococcus aureus bacteremia with toxic shock syndrome: a case report.

Kosami K, Kenzaka T, Sagara Y, Minami K, Matsumura M - BMC Infect. Dis. (2016)

Bottom Line: The lesion in the SCC completely disappeared on MRI 7 days after disease onset.We diagnosed this case as MERS caused by S. aureus bacteremia with TSS.This is the first report of such a case, and we suggest that when a TSS patient presents with neurological symptoms, the possibility of MERS should be considered.

View Article: PubMed Central - PubMed

Affiliation: Division of General Internal Medicine, Jichi Medical University Hospital, Shimotsuke, Japan.

ABSTRACT

Background: Clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a mild encephalopathy caused by various pathological processes, but encephalopathy due to bacteria is rare.

Case presentation: We report the case of a 45-year-old Japanese woman who on receiving chemotherapy for advanced breast cancer developed an altered mental status and dysarthria soon after fever from infection of a subcutaneous implantable port. Staphylococcus aureus was detected in her blood cultures. Magnetic resonance imaging (MRI) revealed an ovoid lesion in the central portion of the splenium of the corpus callosum (SCC). Although hypotension was not observed, we diagnosed probable toxic shock syndrome (TSS) based on fever (temperature: >38.9 °C), altered mental status, erythema, desquamation, thrombocytopenia, liver dysfunction, and creatine phosphokinase elevation. We administered antimicrobial therapy and her neurological symptoms improved gradually. The lesion in the SCC completely disappeared on MRI 7 days after disease onset.

Conclusions: We diagnosed this case as MERS caused by S. aureus bacteremia with TSS. This is the first report of such a case, and we suggest that when a TSS patient presents with neurological symptoms, the possibility of MERS should be considered.

No MeSH data available.


Related in: MedlinePlus

Head magnetic resonance imaging on admission day 2. a Diffusion-weighted imaging (DWI), b Apparent diffusion coefficient (ADC). Head magnetic resonance imaging revealed an ovoid lesion in the central portion of the splenium of the corpus callosum. The lesion appears as reduced diffusion on DWI and has a low ADC value (red circles)
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Fig1: Head magnetic resonance imaging on admission day 2. a Diffusion-weighted imaging (DWI), b Apparent diffusion coefficient (ADC). Head magnetic resonance imaging revealed an ovoid lesion in the central portion of the splenium of the corpus callosum. The lesion appears as reduced diffusion on DWI and has a low ADC value (red circles)

Mentions: At the onset of neurological symptoms, her vital signs were as follows: blood pressure, 109/63 mmHg; pulse, 96 bpm; respiratory rate, 26 bpm; and temperature, 39.5 °C. The Glasgow Coma Scale score for consciousness was 13 (eye opening, 4; verbal response, 4; and best motor response, 5). No obvious paralysis was noted, although evaluation of neurological symptoms was difficult because of disorders of consciousness. Conjunctival hyperemia was noted. Except for the subclavian lesion at the site of the implantable port, no abnormalities of the skin, lung, heart, and abdomen were noted. The subclavian lesion was red and swollen. Laboratory test results were as follows: white blood cell count 400/mm3; hemoglobin, 9.9 g/dl; platelet, 6.2 × 104/mm3; blood urea nitrogen, 15 mg/dl; creatinine, 0.69 mg/dl; aspartate aminotransferase, 48 U/l; alanine aminotransferase, 26 U/l; lactate dehydrogenase, 353 U/l; creatine phosphokinase, 1859 U/l; serum sodium, 130 mEq/l; serum potassium, 3.3 mEq/l; and C-reactive protein, 13.5 mg/dl (Table 1). Head magnetic resonance imaging (MRI) revealed an ovoid high-intensity lesion in the central portion of the SCC on diffusion-weighted imaging (DWI, Fig. 1). Based on the MRI findings, septic embolus or cerebral infarction was considered because the neurological symptoms occurred suddenly following fever due to catheter-related bloodstream infection. On the same day, gram-positive cocci were detected in blood cultures. Therefore, on hospital day 2, piperacillin/tazobactam therapy was switched to cefepime and vancomycin. On hospital day 4, methicillin-sensitive S. aureus (MSSA) was detected in blood cultures. Nafcillin and oxacillin, the first treatment of choice for MSSA-related diseases of the central nervous system, are not available in Japan. Therefore, cefepime was administered at 2 g every 8 h.Table 1


Clinically mild encephalitis/encephalopathy with a reversible splenial lesion caused by methicillin-sensitive Staphylococcus aureus bacteremia with toxic shock syndrome: a case report.

Kosami K, Kenzaka T, Sagara Y, Minami K, Matsumura M - BMC Infect. Dis. (2016)

Head magnetic resonance imaging on admission day 2. a Diffusion-weighted imaging (DWI), b Apparent diffusion coefficient (ADC). Head magnetic resonance imaging revealed an ovoid lesion in the central portion of the splenium of the corpus callosum. The lesion appears as reduced diffusion on DWI and has a low ADC value (red circles)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4836078&req=5

Fig1: Head magnetic resonance imaging on admission day 2. a Diffusion-weighted imaging (DWI), b Apparent diffusion coefficient (ADC). Head magnetic resonance imaging revealed an ovoid lesion in the central portion of the splenium of the corpus callosum. The lesion appears as reduced diffusion on DWI and has a low ADC value (red circles)
Mentions: At the onset of neurological symptoms, her vital signs were as follows: blood pressure, 109/63 mmHg; pulse, 96 bpm; respiratory rate, 26 bpm; and temperature, 39.5 °C. The Glasgow Coma Scale score for consciousness was 13 (eye opening, 4; verbal response, 4; and best motor response, 5). No obvious paralysis was noted, although evaluation of neurological symptoms was difficult because of disorders of consciousness. Conjunctival hyperemia was noted. Except for the subclavian lesion at the site of the implantable port, no abnormalities of the skin, lung, heart, and abdomen were noted. The subclavian lesion was red and swollen. Laboratory test results were as follows: white blood cell count 400/mm3; hemoglobin, 9.9 g/dl; platelet, 6.2 × 104/mm3; blood urea nitrogen, 15 mg/dl; creatinine, 0.69 mg/dl; aspartate aminotransferase, 48 U/l; alanine aminotransferase, 26 U/l; lactate dehydrogenase, 353 U/l; creatine phosphokinase, 1859 U/l; serum sodium, 130 mEq/l; serum potassium, 3.3 mEq/l; and C-reactive protein, 13.5 mg/dl (Table 1). Head magnetic resonance imaging (MRI) revealed an ovoid high-intensity lesion in the central portion of the SCC on diffusion-weighted imaging (DWI, Fig. 1). Based on the MRI findings, septic embolus or cerebral infarction was considered because the neurological symptoms occurred suddenly following fever due to catheter-related bloodstream infection. On the same day, gram-positive cocci were detected in blood cultures. Therefore, on hospital day 2, piperacillin/tazobactam therapy was switched to cefepime and vancomycin. On hospital day 4, methicillin-sensitive S. aureus (MSSA) was detected in blood cultures. Nafcillin and oxacillin, the first treatment of choice for MSSA-related diseases of the central nervous system, are not available in Japan. Therefore, cefepime was administered at 2 g every 8 h.Table 1

Bottom Line: The lesion in the SCC completely disappeared on MRI 7 days after disease onset.We diagnosed this case as MERS caused by S. aureus bacteremia with TSS.This is the first report of such a case, and we suggest that when a TSS patient presents with neurological symptoms, the possibility of MERS should be considered.

View Article: PubMed Central - PubMed

Affiliation: Division of General Internal Medicine, Jichi Medical University Hospital, Shimotsuke, Japan.

ABSTRACT

Background: Clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a mild encephalopathy caused by various pathological processes, but encephalopathy due to bacteria is rare.

Case presentation: We report the case of a 45-year-old Japanese woman who on receiving chemotherapy for advanced breast cancer developed an altered mental status and dysarthria soon after fever from infection of a subcutaneous implantable port. Staphylococcus aureus was detected in her blood cultures. Magnetic resonance imaging (MRI) revealed an ovoid lesion in the central portion of the splenium of the corpus callosum (SCC). Although hypotension was not observed, we diagnosed probable toxic shock syndrome (TSS) based on fever (temperature: >38.9 °C), altered mental status, erythema, desquamation, thrombocytopenia, liver dysfunction, and creatine phosphokinase elevation. We administered antimicrobial therapy and her neurological symptoms improved gradually. The lesion in the SCC completely disappeared on MRI 7 days after disease onset.

Conclusions: We diagnosed this case as MERS caused by S. aureus bacteremia with TSS. This is the first report of such a case, and we suggest that when a TSS patient presents with neurological symptoms, the possibility of MERS should be considered.

No MeSH data available.


Related in: MedlinePlus