World Journal of Colorectal Surgery

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1 World Journal of Colorectal Surgery Volume 6, Issue Article 2 Diverticulitis Resulting In Brain Abscess: A Case Report Sean J. Wallace MD David J. Deisher DO Thomas Daniel Harrison DO Lehigh Valley Health Network, Allentown, Pennsylvania, The United States Of America, sean.wallace@lvhn.org Lehigh Valley Health Network, Allentown, Pennsylvania, The United States Of America, david.deisher@lvhn.org Lehigh Valley Health Network, Allentown, Pennsylvania, The United States Of America, Tdaniel.Harrison@lvhn.org Copyright c 2017 The Berkeley Electronic Press. All rights reserved.

2 Diverticulitis Resulting In Brain Abscess: A Case Report Sean J. Wallace MD, David J. Deisher DO, and Thomas Daniel Harrison DO Abstract Background: Diverticular disease is common in the western hemisphere with approximately half of the United States population aged 50 and over being affected. The spectrum of diverticulitis ranges from uncomplicated microperforation to large-scale macroperforation resulting in feculent peritonitis. Treatment modalities are governed base on Hinchey classification. Extra-abdominal manifestations of diverticulitis, such as brain abscesses, remain exceedingly rare with only five previously reported cases in the literature. The bacteria involved in this phenomenon are commonly flora of the Streptococcus milleri group and of the Enterococcus faecium species, both of which were isolated in this patient. Case Report: In this report, we describe a case of a 64-year-old female with diverticulitis resulting in brain abscess formation, present the clinical and radiologic features, and discuss the treatment options. Conclusions: Brain abscess secondary to diverticulitis are seldom reported in the literature, it is our hope that reporting these unusual instances will raise awareness of disease manifestations and allow for earlier diagnosis and treatment. KEYWORDS: Diverticulitis, Diverticular Disease, Brain Abscess

3 Wallace et al.: Diverticulitis Resulting In Brain Abscess: A Case Report 1 Introduction: Diverticular disease collectively refers to diverticulosis and diverticulitis, which differ based on the presence of an inflammatory process. Diverticula can be described as true or false, depending on which layers of bowel wall have been compromised. The vast majority are false diverticula in which the mucosa and muscularis mucosa have penetrated through the colonic wall. The most supported etiology of diverticulosis results from lack of dietary fiber causing smaller stool volumes and higher colonic intraluminal pressures. Persistent higher pressures at locations of weakness in the large intestine between teniae coli results in the formation of diverticula. The sigmoid colon is particularly susceptible to developing diverticular disease 1. Diverticulosis is very common in western countries, especially in the United States of America. Approximately half of the US population aged 50 years or older is estimated to be affected. Although a common disease, in most instances diverticula are asymptomatic. Diverticulitis occurs when diverticula become inflamed, which can lead to perforation of bowel. The spectrum of diverticulitis ranges from uncomplicated microperforation to large macroperforation, abscess formation, and peritonitis 1. Diagnosis and treatment options for acute diverticulitis depend on Hinchey classification. This classification system outlines the stage of severity of disease, ranging from simple phlegmon up to generalized fecal peritonitis. Treatment algorithms have been proposed based on this staging system. Overall occurrence of formation of brain abscess of any etiology is low, with an incidence of per 100,000 persons per year 2. Formation of brain abscesses are most commonly seen in immunocompromised patients, those with recent head trauma or neurosurgical interventions, or direct spread from parameningeal infections 3. Extra-abdominal manifestations of diverticulitis, such as brain abscesses, remain exceedingly rare with only five previously reported cases in the literature 4,5,6,7,8. In this case report, we describe an instance of diverticulitis resulting in brain abscess formation, present the clinical and radiologic features, and discuss the treatment options. Case Report: A 64-year-old female was admitted to the Neurology Critical Care Service at a level 1 trauma and tertiary care center. She presented as a transfer from an outside Produced by The Berkeley Electronic Press, 2016

4 2 World Journal of Colorectal Surgery Vol. 6, Iss. 5 [2016], Art. 2 facility with diagnoses of intraventricular hemorrhage, subarachnoid hemorrhage, fever, and leukocytosis of unclear etiology. On arrival, she had previously been intubated and sedated at the transferring hospital for altered mental status. Her transfer records indicated that she reported several days of headache, confusion, nausea, vomiting, diarrhea, and intermittent fevers. Her past medical and surgical histories were significant for hypertension, hyperlipidemia, gastroesophageal reflux disease, major depressive disorder, appendectomy, hysterectomy, bilateral salpingo-oophorectomy, cholecystectomy, and a previous ankle surgery. On admission, she was noted to be hemodynamically stable, but febrile to 101 o F. She was ventilator-dependent and had a Glasgow Coma Scale 3TP. Her abdomen was described as obese and mildly distended with well-healed surgical scars. Pertinent admission laboratory studies included a hemoglobin 9.4, platelet count 330, WBC 18.7, creatinine 1.21, and INR 1.2. Imaging from the outside facility included a CT head with evidence of intraventricular hemorrhage and associated hydrocephalus. A non-contrast CT abdomen & pelvis showed a soft tissue mass within the presacral region, as well as a soft tissue prominence within the mid-todistal sigmoid colon suspicious for a colonic lesion MRI/MRA brain performed revealed a right frontal periventricular intra-axial abscess with surrounding edema and mass effect dissecting into the adjacent ventricular systems with associated meningitis and ventriculitis (Figure 1). Repeat CT chest, abdomen, and pelvis with contrast showed a presacral fluid collection with peripheral enhancement and internal gas compatible with an abscess, as well as sigmoid diverticulosis with abnormal mural thickening (Figure 2). Bilateral externalized ventricular drains were placed by Neurosurgery with immediate return of thick purulent drainage. Gram stain and culture went on to grow pansensitive Streptococcus intermedius. Antibiotics were managed by Infectious Disease with initial broad spectrum coverage, but then narrowed to Ceftriaxone and Metronidazole.

5 Wallace et al.: Diverticulitis Resulting In Brain Abscess: A Case Report 3 Figure 1. A representative image of the MRI/MRA brain illustrating right frontal periventricular intra-axial abscess with surrounding edema and mass effect dissecting into the adjacent ventricular systems with associated meningitis and ventriculitis. Figure 2. A representative image of the CT abdomen and pelvis illustrating a presacral fluid collection with peripheral enhancement and internal gas compatible with an abscess. Also notable is sigmoid diverticulosis with abnormal mural thickening. Produced by The Berkeley Electronic Press, 2016

6 4 World Journal of Colorectal Surgery Vol. 6, Iss. 5 [2016], Art. 2 The patient was evaluated by the General Surgery Service. Percutaneous drainage could not be achieved secondary to the location of the presacral abscess. A second opinion was obtained by the Colon & Rectal Surgery Service, who performed a flexible sigmoidoscopy that showed evidence of extensive diverticular disease without gross colonic mass. Secondary to the abscess not being amenable to percutaneous drainage and suspicion of this as the source of seeding for brain abscess, the patient was taken for operative drainage. Exploratory laparotomy and Hartmann procedure were performed. Intraoperative cultures were obtained, which were positive for Enterococcus faecium. Final pathology revealed perforated diverticula and pericolonic abscess without evidence of dysplasia or malignancy. The patient had a prolonged ICU hospitalization, eventually developing ventilator-dependent respiratory failure requiring tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. She also developed deep venous thromboses, treated with systemic anticoagulation and inferior vena cava filter placement. Prior to discharge and once cultures were negative, a ventriculoperitoneal shunt was placed by Neurosurgery for persistent hydrocephalus. On hospital day forty, the patient had been successfully weaned from the ventilator and was transferred to an acute care rehabilitation center for continued care. Approximately one month after hospital discharge, she was released from acute care rehabilitation. During her rehabilitation, she was decannulated from her tracheostomy, her PEG was removed, and she had eventual return to baseline functionality. She was seen as an outpatient the subsequent months following hospital discharge and was progressing well with a functional colostomy. Oneyear following her Hartmann procedure, colostomy reversal was discussed and plans initiated to commence reversal. Discussion: Up to 25% of patients with diverticulitis develop complicated disease 9. These complications routinely include strictures, abscesses, and obstructions. Most commonly, the pelvis and liver are the sites of extra-colonic abscess formation. Rarely, complicated diverticulitis has been shown to cause pathology of the central nervous system. Brain abscess formation is exceedingly rare with approximately 900 3,900 new cases each year 2. Most cases involve immunosuppressed patients with recent surgery or trauma 10. However, in

7 Wallace et al.: Diverticulitis Resulting In Brain Abscess: A Case Report 5 otherwise healthy patients, brain abscesses can develop as complications of other infections. A literature review of the relationship between diverticulitis and brain abscess reveals five documented cases of diverticulitis leading to abscess formation in the brain 4,5,6,7,8. The bacteria involved in this phenomenon are commonly flora of the Streptococcus milleri group (SMG) and of the Enterococcus faecium species, both of which were isolated in this patient. When a virulent organism, such as Streptococcus intermedius is involved, there is a higher chance of extra-abdominal and hematogenous spread of disease. S. intermedius has been implicated in central nervous system abscesses described in the literature 12. When a patient has evidence of extra-abdominal diverticular disease, prompt direct source control is needed for resolution. Often, this includes surgical therapy, such as colonic resection, along with antibiotic therapy. Nervous systems lesions can be treated in several different ways, ranging from antibiotic therapy alone, percutaneous and/or ventricular drainage, up through aggressive debridements. For complete resolution and return to baseline, the underlying source must be identified and treated as well 3. With brain abscess resulting from diverticulitis seldom reported in the literature, it is our hope that reporting our experience will raise awareness and allow for earlier diagnosis and treatment. Conflicts of Interest: The authors declare that there are no conflicts of interest regarding publication of this case report. References: 1. F. Brunicard, D. Andersen, T. Billiar, D. Dunn, J. Hunter, J. Matthews, R. Pollock. Schwartz's Principles of Surgery, 10th Edition. New York: McGraw-Hill Medical, M. Brouwer, J. Coutinho, D. van de Beek. Clinical Characteristics and Outcome of Brain Abscess: systematic review and meta-analysis. Neurology 82: ; DOI: /WNL [Online January 29th, 2014]. Produced by The Berkeley Electronic Press, 2016

8 6 World Journal of Colorectal Surgery Vol. 6, Iss. 5 [2016], Art M. Brouwer, A. Tunkel, G. McKhann, D. van de Beek. Brain Abscess. New England Journal of Medicine 371: ; DOI: /NEJMra [Online July 31st, 2014]. 4. V. Kamath, N. Mishra, V. Gunabushanam, B. Friedman, D. Held. Nervous system abscess: a rare complication of diverticulitis. Colorectal Disease 13: ; DOI: /j [Online August 5th, 2011]. 5. M. Valero, D. Pares, M. Pera, L. Grande. Brain abscess as a rare complication of acute sigmoid diverticulitis. Techniques in Coloproctology 12: 73-78; DOI: //s [Accepted December 18th, 2007]. 6. J. Loyal, T. Connolly, R. Bergamaschi. Sigmoid Diverticulitis with Brain Abscess. Colorectal Disease 17: ; DOI: /codi [Online November 18th, 2014]. 7. H. Helfritzsch, S. Seifert, O. Solch, W. Pfister, J. Scheele. Brain abscess in retroperitoneal perforated colonic diverticulitis. Chirurg 2001; 12: A. Dixon, J. Holmes, A. Waters. Intracranial abscess complicating diverticulitis with CT scan mimicking primary glioma. Postgraduate Medical Journal 1989; August 65(766): A. Weizman, G. Nguyen. Diverticular disease: Epidemiology and Management. Canadian Journal of Gastroenterology 2011 July 25(7): J Helweg-Larsen, A Astradsson, H Richhall, J Erdal, A Laursen, J Brennum. Pyogenic Brain abscess, a 15 year survey. BMC Infectious Diseases 12: 332; DOI: / [Online November 30th, 2012]. 11. A. Mishra, P. Fournier. The role of Streptococcus intermedius in brain abscess. European journal of Clinical Microbiology Infectious Disease 32: ; DOI: /s [Online November 28th, 2012]. 12. R. Lampen, G. Bearman. Epidural abscess caused by Streptococcus milleri in a pregnant woman. BMC Infectious Diseases 5: 100; DOI: / [Online November 3rd, 2005].