A 47‐year‐old man with hypertension and depression presented with 2 weeks of right‐sided photophobia and retro‐orbital pain described as constant with increasing intensity over the last 4 days. Several days prior, the patient had transient left‐sided weakness of his upper and lower extremities lasting for 30 minutes. He did not have any signs or symptoms consistent with meningitis. Vital signs were normal, and the physical exam was unremarkable including a normal neurological assessment. The ESR was 14 mm/h, C‐reactive protein was 9.5 mg/L, and the white blood cell count was 8.32 K/μL. An HIV test was negative. Although the patient refused a lumbar puncture, numerous negative blood cultures, a normal TEE, and an absence of Duke's minor criteria argued against a diagnosis of endocarditis. An MRI of the brain showed 2 ring‐enhancing lesions in the right temporal lobe. The patient was treated with a prolonged course of intravenous vancomycin and then discharged. A repeat MR1 1 month later showed almost complete resolution of both abscesses. Subsequent history indicated that he undergone a craniotomy for right temporal lobe MRSA abscess 9 months prior.
Community‐acquired MRSA (CA‐MRSA) is an emerging threat that the internist must consider in all patients presenting with an infectious etiology. There have been 5 other reported cases of MRSA brain abscesses. Three of these cases involved patients with comorbid conditions, such as hepatitis, IV drug use. and recurrent sinusitis. The 2 remaining cases were in healthy individuals with no previous risk factors. Although hospital‐acquired MRSA has well‐known risk faclors, well‐documented risk factors for CA‐MRSA infections are less widely know. These include poor hygiene, skin abrasions, and reuse of disposable razors. Our patient most likely developed his initial brain abscess after lancing a furuncle on his face several weeks prior to The initial presentation. To our knowledge, this is the first reported case of a reoccurrence of a CA‐MRSA brain abscess, as well as The first reported case associated with furunculosis in which endocarditis has been ruled out This case raises the issue of empiric treatment for brain abscesses as some sources recommend the empiric jse of vancomycin. However, the penetration of vancomycin into the CSF is dependent on inflammation of the blood‐brain barrier Other studies demonstrated better outcomes using linezolid, owing to superior CNS penetration particularly in the absence of meningeal inflammation, as can be found with brain abscesses. If our patient was initially treated with linezolid, the outcome of this clinical scenario may not have led to the reoccurrence of the CA‐MRSA abscess.
In selecting appropriate antimicrobial therapy for CNS infections, the internist should consider the degree of meningeal inflammation and the regional prevalence of MRSA.
A. Smith, none; G. Owen, none.