A Patient with a Brain Abscess Presenting as an Acute Stroke

A brain abscess is an enclosed focal infection within the brain that is either initiated by haematogenous seeding or spreads contiguously from oto-sinusitis, local trauma or neurosurgery. We describe the case of a 71-year-old man presenting with acute confusion and unilateral neurology in the absence of systemic signs of sepsis or associated laboratory biomarkers. While his initial clinical presentation mimicked an acute cerebrovascular event or brain tumour, he was subsequently diagnosed with a particularly large spherical temporal lobe brain abscess of 5 cm diameter on neuroimaging. This abscess was treated successfully with craniotomy, evacuation and a prolonged course of anti-microbials, enabling him to return to his pre-morbid level of functioning. His prolonged course of anti-microbials was complicated by candidaemia and colonisation of an indwelling central venous catheter that was treated successfully with anti-fungals. LEARNING POINTS: A high index of suspicion for brain abscess should be maintained when a ring-enhancing lesion is found on neuroimaging, even in the absence of signs of sepsis or associated laboratory biomarkers. Commensal yeasts may colonise indwelling lines in patients treated with long-term broad-spectrum antibiotics. Distracting concomitant diagnoses may delay recognition of the primary pathological process.