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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 66-69

Unusual presentation of brain tumor with intratumoral abscess formation


1 Department of Neurosurgery, NMCH, Nellore, A.P., India
2 Department of Neurology, NMCH, Nellore, A.P., India
3 Department of Maxillo-facial Surgery, NMCH, Nellore, A.P., India

Date of Web Publication28-Aug-2013

Correspondence Address:
Suryapratap Singh
Department of Traumatology and Neurosurgery, NMCH, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.117138

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  Abstract 

Abcess within a brain tumor is very rare and is usually seen in a pituitary tumor. We present a patient with glioblatoma that was found to contain abcess at operation. A 50-year-old man presented with a rare case of glioblastoma associated with intra-tumoral abscess formation manifesting as seizures, headache and vomiting after fever, cough, and chest infection. Computed tomography and magnetic resonance imaging demonstrated a ring-enhanced lesion mimicking malignant glioma. Craniotomy and tumor removal were performed. Abscess formation within the intra-axial tumor was found intra-operatively. Histological examination revealed glioblastoma with abscess and the etiological agent was anaerobic gram-negative bacilli. The post-operative recovery of the patient was satisfactory. Abcess in a gliobastoma is uncommon. The suspected route of microbial migration and colonization in this tumor was probably bacteremia from chronic lung infection. Careful evaluation and appropriate treatment would lead to a good outcome.

Keywords: Bacteremia, brain abscess, brain tumor, glioblastoma, intratumoral abscess


How to cite this article:
Singh S, Singh S, Mohammad A, Hussain J. Unusual presentation of brain tumor with intratumoral abscess formation. Arch Int Surg 2013;3:66-9

How to cite this URL:
Singh S, Singh S, Mohammad A, Hussain J. Unusual presentation of brain tumor with intratumoral abscess formation. Arch Int Surg [serial online] 2013 [cited 2019 Jun 25];3:66-9. Available from: http://www.archintsurg.org/text.asp?2013/3/1/66/117138


  Introduction Top


Abscess formation within a brain tumor is rare, usually occurring within a pituitary tumor after direct extension from infected paranasal sinuses. [1] Intra-parenchymal posterior fossa tumor and suprasellar tumor with abscesses are rare. Intra-sellar or parasellar tumors are among the common tumors developing abscess formation inside the tumor, as the result of direct extension of the microbial flora from the contiguous infected sinuses or from anatomical "danger area of the face," which drains into the cavernous sinus. [2],[3],[4] Glioma with abscess formation is extremely uncommon, and very few cases have been described. [2],[5],[6],[7]

Various diagnostic approach and treatment have been described in the literature, but accurate guidelines for the diagnosis and treatment of gliomas complicated by intra-tumoral abscesses have thus not been determined.

We present a case of abscess formation within a glioblastoma and discuss the diagnostic approach and treatment.


  Case Report Top


A 50-year-old man came with a complaint of loss of consciousness for 1 min at home. There was no associated head ache or dizziness. Urgent computed tomography (CT) carried out, but CT scan was normal and no abnormal density noted. About 3 weeks later, he complained of fever, cough dyspnoea and chest pain. Following clinical and radiological examination of the chest pneumonia was diagnosed. He was treated for pneumonia with appropriate antibiotics. After successful treatment, he was discharged from the hospital and later he developed seizures, headache associated with vomiting. There was no history of trauma to the head. Neurological examination was unremarkable, including absence of neck stiffness. CT revealed an irregularly shaped low density area in the right fronto-parietal lobe. Magnetic resonance (MR) imaging showed a hypointense area on T1 weighted imaging and a hyperintense area on T2-weighted imaging in the right fronto-parietal lobe. The wall of the abnormal area was hypointense on T2-weighted imaging, with ring-enhancement by gadolinium on T1-weighted imaging. However, diffusion-weighted MR imaging (DWMRI) showed no strong hyperintense lesion in this area [Figure 1] and [Figure 2]. Leukocytosis (white blood cell count 17,300 cu/mm) were found. Pre-operatively, these findings were considered consistent with malignant glioma which was considered as the clinical diagnosis.
Figure 1: Intra-operative image showing excised part of tumor

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Figure 2: Intra-operative image showing abscess with pus and cavity of tumor

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Craniotomy and removal of the fronto-parietal mass were performed [Figure 3] and [Figure 4]. Histological examination of frozen sections revealed atypical astrocyte proliferation and huge areas of necrosis with neutrophilic infiltration. Therefore, we punctured the center of the mass and aspirated red-grayish material, and culture of this purulent material grew anaerobic gram-negative bacilli.
Figure 3: T2 weighted magnetic resonance imaging image showing hyperdense lesion at fronto-parietal region right side of brain

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Figure 4: T1 weighted magnetic resonance imaging showing hypodense lesion with ring-enhancement

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The histological diagnosis was glioblastoma with abscess formation [Figure 5]. Post-operative magnetic resonance imaging (MRI) scan shows complete removal of the tumor. Broad spectrum antibiotic therapy was administered for 21 days following surgery. Post-operatively, the patient was given local irradiation with 66 Gy at the tumor bed and synchronous temozolomide administration (120 mg/day for 42 days). At present patient is doing well in follow-up.
Figure 5: Histopathological slide image showing diffusely invasive proliferation of atypical astrocytes and infi ltration of neutrophils in tumor specimen

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  Discussion Top


Only few cases of an abscess associated with a brain tumor were found in the literature. About 60% were intra-sellar or parasellar tumors. [8] In our case, the location was at parietal lobe.

The differential diagnosis of a brain lesion that shows a ring-like enhancement pattern on CT and MRI may be difficult and typically includes necrotic tumor and pyogenic brain abscess. Combined hydrogen protons magnetic resonance spectroscopy (1H-MRS) and DWI were used to establish the pre-operative diagnosis of brain abscess and glioblastoma. [9] This information facilitates surgical planning during abscesses aspiration, whereas necrotic brain tumors should have diagnostic tissue biopsied from cavity walls. Although not definitive for brain abscess, restricted water diffusion is an important MR imaging sign and is useful in neurosurgical treatment strategies for ring-enhancing lesions. [10]

The pathogenesis of glioma associated with abscess formation is thought to be related to multiple factors, such as destruction of the blood-brain barrier (BBB), intra-tumoral necrosis, and tumor bleeding with hematoma. [8],[11] Disruption of the BBB due to direct tumor invasion aids the invasion of microbes. Intra-tumoral necrosis and hematoma acting as a culture medium are also important in the development of abscess. Glioblastoma, which involves failure of the BBB due to direct tumor invasion, and the nutritious conditions caused by necrosis and hematoma within the tumor, may induce metastatic abscess by bacteremia. [3],[6],[7]

Moreover, the BBB and immune system are important in resisting bacterial infection to the brain. Immunocompromised patients are at risk for the development of brain abscess. Long-term steroid treatment and the immunosuppressive effects of glioblastoma probably facilitate infection, resulting in the abscess. The major challenge is the detection of glioma associated with abscess formation prior to surgery. Pre-operative suspicion of brain tumor with abscess could be supported by neuroimaging studies (CT, MR imaging), which would reveal sudden increase in size and atypical perifocal edema. [5],[12]

In our patient, diffusion-weighted MR imaging demonstrated no homogeneous hyperintensity within a ring-enhanced lesion. This is probably because the hematoma might have mixed with purulent material because of the reddish color of aspirated material intra-operatively and hyperintensity on fluid-attenuated inversion recovery imaging. However, CT revealed sudden development of an irregularly shaped low density area in the right fronto-parietal lobe after initial CT. Brain tumor with abscess might be suspected based on these findings. Nevertheless, the majority of abscesses within a glioma have been accidental findings during surgery as found in our patient. [6],[11]

In the case of gliomas, adjuvant therapy such as chemo-radiotherapy is often needed. [13]

However, chemotherapy is usually not administered for glioma associated with abscess formation, since such treatment compromises patient immunity and increases the risk of infection recurrence. [14],[15] On the other hand, radiotherapy is beneficial under these conditions due to the antibacterial and anti-inflammatory effects in general. Most cases of abscess within a glioblastoma show poor prognosis despite partial resection and conventional radiotherapy. In the present case, since complete total removal of the glioblastoma was achieved, the patient first received antibacterial therapy for 21 days following surgery, followed by chemo-radiotherapy. At present patient is fine in follow-up.

In conclusion we presented a patient who had an abcess in a glioblastoma. Although the abcess was discovered at operation, complete resection of the tumor and evacuation of the abcess was carried out. This together with appropriate chemoradiotherapy resulted in a good outcome of treatment. Therefore, aggressive resection is associated with favorable prognosis even in cases of abscess formation within a glioblastoma.

 
  References Top

1.Nelson PB, Haverkos H, Martinez AJ, Robinson AG. Abscess formation within pituitary tumors. Neurosurgery 1983;12:331-3.  Back to cited text no. 1
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2.Bansal S, Vasishta RK, Pathak A, Jindal VN, Khosla VK, Banerjee AK. Cerebral abscess with astrocytoma. Neurol India 2001;49:91-3.  Back to cited text no. 2
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3.Mohindra S, Gupta R, Mohindra S, Gupta SK, Radotra BD. Posterior-fossa intra-tumoural abscess: A report of three patients and literature review. Br J Neurosurg 2004;18:556-60.  Back to cited text no. 3
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4.Zorub DS, Martinez AJ, Nelson PB, Lam MT. Invasive pituitary adenoma with abscess formation: Case report. Neurosurgery 1979;5:718-22.  Back to cited text no. 4
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5.Kalita O, Kala M, Svebisova H, Ehrmann J, Hlobilkova A, Trojanec R, et al. Glioblastoma multiforme with an abscess: Case report and literature review. J Neurooncol 2008;88:221-5.  Back to cited text no. 5
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6.Noguerado A, Cabanyes J, Vivancos J, Navarro E, Lopez F, Isasia T, et al. Abscess caused by Salmonella enteritidis within a glioblastoma multiforme. J Infect 1987;15:61-3.  Back to cited text no. 6
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7.Tsai TH, Hwang YF, Hwang SL, Hung CH, Chu CW, Lua BK, et al. Low-grade astrocytoma associated with abscess formation: Case report and literature review. Kaohsiung J Med Sci 2008;24:262-9.  Back to cited text no. 7
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8.Nassar SI, Haddad FS, Hanbali FS, Kanaan NV. Abscess superimposed on brain tumor: Two case reports and review of the literature. Surg Neurol 1997;47:484-8.  Back to cited text no. 8
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9.Nakaiso M, Uno M, Harada M, Kageji T, Takimoto O, Nagahiro S. Brain abscess and glioblastoma identified by combined proton magnetic resonance spectroscopy and diffusion-weighted magnetic resonance imaging - Two case reports. Neurol Med Chir (Tokyo) 2002;42:346-8.  Back to cited text no. 9
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10.Leuthardt EC, Wippold FJ 2 nd , Oswood MC, Rich KM. Diffusion-weighted MR imaging in the preoperative assessment of brain abscesses. Surg Neurol 2002;58:395-402.  Back to cited text no. 10
    
11.Ichikawa M, Shimizu Y, Sato M, Imataka K, Masuda A, Hara Y, et al. Abscess within a glioblastoma multiforme - Case report. Neurol Med Chir (Tokyo) 1992;32:829-33.  Back to cited text no. 11
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12.Shankar A, Chacko G, Chacko AG. Intratumoral abscess: An unusual complication of ventriculoperitoneal shunt infection. Childs Nerv Syst 2004;20:204-6.  Back to cited text no. 12
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13.Tannock IF. Treatment of cancer with radiation and drugs. J Clin Oncol 1996;14:3156-74.  Back to cited text no. 13
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14.Sharma S, Raja A, Shivananda PG. Isolation of Salmonella typhi from brain tumor - A case report. Indian J Med Sci 1986;40:233-5.  Back to cited text no. 14
    
15.Stupp R, Hegi ME, Gilbert MR, Chakravarti A. Chemoradiotherapy in malignant glioma: Standard of care and future directions. J Clin Oncol 2007;25:4127-36.  Back to cited text no. 15
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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