Case Presentation: A 54 year old male developed acute encephalopathy and unilateral paralysis. He had a history of lung adenocarcinoma for which in1998 he underwent open resection of both lung tumor and brain metastases followed by adjuvant chemo radiation. He subsequently
developed radiation esophagitis and esophageal strictures. He underwent 20 separate Esophagastroduodenoscopies (EGDs) for
esophageal dilation, stenting, and stent removal in the ten months prior to this illness, the most recent just 2 weeks prior to his
hospitalization.
In the ED he had fever, tachycardia, and tachypnea. He was confused and lethargic with 2/5 strength in his left upper and lower
extremities. Reflexes were normal and he had no meningeal signs. He had a peripheral leukocytosis, and CSF analysis showed low
glucose with WBCs of 6,800 cells/μL that were predominantly neutrophils. As there was no other clear focus of infection, he was treated
for presumptive bacterial meningitis with dexamethasone, vancomycin, ceftriaxone, and ampicillin. Brain MRI showed over seven ring-enhancing lesions with surrounding vasogenic edema suggestive of brain abscesses.These were found bilaterally, but the largest were in
the right cerebral hemisphere. One of these was close to right lateral ventricular wall and was without ependymal enhancement. We
presume the high CSF WBC count was due to rupture of this abscess into the ventricle.
Within 18 hours of the initiation of antibiotic therapy, the patient returned to his baseline cognitive function and had marked
improvement in his left sided weakness. Ultimately, cultures of blood and CSF did not grow any microbes and no malignant cells were
identified on his CSF cytological analysis.

Discussion: Endoscopy is known to cause transient bacteremia , but resultant bacterial abscesses are rare. The highest rates of bacteremia are from
esophageal dilation, variceal sclerotherapy, and instrumentation of obstructed bile ducts. The American Society of Gastrointestinal
Endoscopy suggests antibiotic coverage prior to upper endoscopy for patients with certain cardiac conditions and for those with likely
enterococcal gut infections. We present a case of multiple brain abscesses apparently due to transient bacteremia following
esophageal instrumentation in a patient who had no indications for pre-procedural antibiotic prophylaxis. In this case multiple brain abscesses developed after repeated esophageal instrumentation. The patient had none of the risk factors for brain abscess, which include immunosuppression, penetrating head trauma, recent neurosurgery, parameningeal or distant foci of infection, or congenital heart disease.

Conclusions: We conclude that the brain abscesses occurred from transient bacteremia caused by recurrent endoscopic procedures. Luckily, this patient had an excellent outcome. However, we question whether he may have benefitted from pre-procedure prophylactic antibiotics which may have prevented the abscesses all together. We wonder whether the indications for bacterial prophylaxis should be broadened to include patients with repeated instrumentation of the GI tract over a short time period.