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Título

Rhombencephalitis secondary to brain abscess as a differential diagnosis in subacute tetraparesis in a immunocompromised patient

RESUMO

Case presentation: R.M, 48 years old, male, with a previous history of untreated HIV infection. Started vomiting, diarrhea, abdominal pain, headache and hiccups in March/2022. After 2 weeks, initiates progressive tetraparesis, starting with the lower limbs and ascending to the upper limbs, preventing ambulation, associated with urinary incontinence, dysphagia, paresthesias that predominated in the lower limbs and unintentional weight loss (8 kg in 2 months). During the initial evaluation, tetraparesis was demonstrated associated with hyperreflexia. The evaluation of the cranial nerves showed a deficit to lift the palate bilaterally, as well as the inability to protrude the tongue.
Brain CT was normal, as well as CSF test. Systemic investigation also was negative. Two days after the initial evaluation, the patient had an episode of fever, respiratory failure, and was intubated and started on cefepime. Three days later, the patient started to experience significant clinical improvement in the tetraparesis, as well as in the lower cranial nerves. Brain MRI was performed after clinical stabilization, demonstrating a nodular lesion on T1-weighted gadolinium enhancement in the medulla, with T2 hyperintensity in the medulla up to C5 level in spinal cord. Due to clinical improvement, the hypothesis of brain abscess is considered, and antibiotic therapy is maintained for 6 weeks. A new brain MRI was performed 3 weeks later, demonstrating a significant reduction in the lesion as well as the associated edema. After 6 weeks, the patient was discharged from the hospital with resolution of symptoms.
Discussion: Brain abscess does not usually occur in the brainstem region, and the involvement in this location is associated with significant morbidity and mortality. The most likely etiology of a bacterial brain abscess in immunocompromised patients is Listeria monocytogenes, and the response to beta-lactam makes this the main hypothesis for our case. Nocardia spp is also an important agent, but its clinical course occurs in a more insidious way.
Final comments: The immunocompromised patient can be affected by several serious insults, often without the typical manifestations, as we demonstrate a patient with absence of fever and headache in the initial condition. Thus, brain abscess should always be a differential diagnosis in the context of tetraparesis associated with signs of upper motor neurons, especially in immunocompromised patients

Palavras Chave

Brain abscess, HIV