The Silent Swallow
Clinical Vignette
A 78-year-old man with Parkinson's disease, hypertension, and gastroesophageal reflux disease, residing in a skilled nursing facility, is brought in by nursing staff for 10 days of progressive confusion and new left-sided weakness. He has baseline bradykinesia, rigidity, and postural instability, and was transitioned to pureed food with thickened liquids 8 months ago due to worsening oropharyngeal dysphagia. Six weeks prior, he was briefly hospitalized and treated with amoxicillin-clavulanate for a right lower lobe infiltrate attributed to aspiration pneumonia. His current medications include levodopa-carbidopa and pantoprazole.
On examination, temperature is 38.6°C, heart rate 98/min, and blood pressure 142/88 mmHg. He is confused and disoriented to place and time, with a baseline MMSE of 26 now scoring 16 on reassessment. Neurologic examination reveals a new left facial droop, left arm pronator drift, and mild dysarthria superimposed on his Parkinsonian hypophonia. Neck is supple. Funduscopic examination shows no papilledema.
Laboratory studies show WBC 14,200 cells/mcL with 82% neutrophils, CRP 68 mg/L, and ESR 72 mm/hr. Blood cultures are drawn. CT brain with contrast reveals a 3.2-cm ring-enhancing lesion in the right parietal lobe with surrounding vasogenic edema and 4 mm of midline shift. MRI with diffusion-weighted imaging confirms marked restricted diffusion within the lesion, as shown below. Chest CT obtained to evaluate the prior lung process reveals a 3.5-cm cavitary lesion in the posterior right lower lobe with an air-fluid level consistent with lung abscess. HIV antigen-antibody test is negative. Serum Cryptococcal antigen and Toxoplasma IgG are negative.
Diffusion-weighted MRI (DWI): restricted diffusion within a right parietal ring-enhancing lesion.
Question 1
Which infectious etiology best explains this ring-enhancing lesion?
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Question 2
Which empiric antibiotic regimen is most appropriate while awaiting culture results from surgical aspiration?
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Question 3
Neurosurgery is consulted. Which management approach is most appropriate for this abscess?
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References
Brouwer MC, Tunkel AR, McKhann GM 2nd, van de Beek D. Brain abscess. N Engl J Med. 2014;371(5):447-456.
Sonneville R, Ruimy R, Benzonana N, et al. An update on bacterial brain abscess in immunocompetent patients. Clin Microbiol Infect. 2017;23(9):614-620.