168

Pyogenic Brain Abscess Cavitated

By STANLEY JACKSON From the Central Middlesex

Introduction

Only terminally in phthisis has secondary infection of lung cavities any significance. At any earlier stage in the disease cavcrn- oscopic examinat ion (Coryllos and Ornstein, I938 ) has shown that cavities yield only a pure culture of tubercle bacilli. Terminal ly a mixed flora does collect, but normally does not penetrate into the cavity wall (Pagel, 1948). The usual occurrence is then broncho- genie aspiration of tubercle bacilli plus the mixed flora causing a caseous consolidation of basal areas. An exception seems to be the rare cases of pyogenic brain abscess compli- cating pu lmonary tuberculosis with cavita- tion. The question arises whether the source of the metastatic organism is really the tuberculous cavity, or bronchiectatic lesions associated with chronic fibrotic tuberculosis.

In the following case it can be shown that the origin was the wall of the tuberculous cavity.

A. S., male, aged 22. H i s t o r y . - In ~944 the patient was invalided

August 1951

as a Complication of Phthisis

and WALTER PAGEL Hospital, London, N.W.10

out of the services for 'osteo-arthritis' of the left hip. In July 1947 routine x-ray showed extensive bilateral pulmonary tuberculosis. The patient was hospitalized soon afterwards and before death took place in January 1949 was clinically a case of chronic pulmonary tuber- culosis with cavity formation. There was also an enlarged liver and spleen and a tuberculous arthritis of the left hip. One week before death convulsions occurred and the plantar response w a s e x t e n s o r .

Posl-mortem. - Brain (fig. l): Convolutions flattened, membranes hy.peraemic. Localized purulent exudate at varmus sites over the brain surface. After lmrdening, dissection showed four main abscess cavities in the right hemisphere: two in the right frontal lobe each about 2 • I • I cm., One in the right temporal lobe 2 X I • I cm., and a larger one situated in the right occipital lobe 3 • 2 • 2 cm.

Lungs (fig. 2): Bilateral pleural adhesions of considerable extent. Right upper lobe largely replaced by several inter-communicating cavi- ties, largest 9 • 3 • 3 cm. lined by fibro- caseous material 5 mm. thick; ossified lymph node 5 • 5 ram. present near the hilum of the right upper lobe. Apex of left lower lobe con- tained one cavity 4 • 2 • 2 cm. with fibro- caseous lining and other smaller cavities below

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Fro. 1. - Brain showing abscess cavities in frontal and FIe,. 2 . - Lung showing extensive cavitation with scattered occipital lobes-, nodules of caseat ion.

August 1951 T U B E R C L E 169

FIG. 3" - Lung: Cavity wall. Haematoxylin and eosin stain. Necrotizing caseous wall, giant cells and polyrnorphonuclear infihration in the wall and in the overlying cxudate. X ~oo.

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F i c . 4-- Section of hmg: Cavity exudate. Gram stain to show numerous Gram-positlve cocci present. X 54 o.

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FxG. 5.-Section of lung: Cavity exudate with scanty acid fast bacilli present. Ziehl Neelsen. x 600.

the larger one. Remainder of this lobe and left lobe were emphysematous and contained a few scattered nodules of caseation up to 2 cm. in diameter. Brbnchitis with purulent material in the bronchi was present, but no evidence of bronchiectasis.

H i s t o l o g y . - Lung: Various cavities were examined showing in addit ion to ttle necrotizing caseous wall and giant cells of the Langhans type, a tltick layer ofpolymorphs . I n tile former, scant)' but definite acid-fast bacilli were found; in tile latter, numerous Gram-posit ive cocci, and also some Gram-negat ive bacilli (figs. 3, 4, and 5)- In some of tile cavities, tile caseous wall predominated, but there were still areas in which the latter was covered by polymorphs.

Brain: No evidence of tuberculous structures in the cavities, tile picture being one of pure pyogenic abscess formation with haemorrhages in the wall. Tire sections as well as a s m e a r o f pus from the cavities showed Gram-posit ive cocci, as did material from the cerebral surface.

Liver and kidney showed extensive amyloid deposits.

C o m m e n t

Schors te in (19o9)i wr i t ing on ce rebra l abscess c o m p l i c a t i n g p u l m o n a r y tuberculosis , r epor t ed no t a single case in p o s t - m o r t e m s a t B r o m p t o n Hosp i t a l b c t w c c n 1894 to 19o4, t h o u g h he d id no t agree wi th Gowcr s tha t t hey ' n e v e r o c c u r wi th t rue t ube rc u lous

170 T U B E R C L E August 1951

cavities'. He suggested that the occlusions of hmg vessels around a tuberculous focus followed by fibrosis prevented.dislodgment of emboli. Evans (z931), in his review of cerebral abscess, noted its rarity in pulmonary tuberculosis in comparison with bronchiec- tasis from other causes. He considered it less uncommon, however, where bronchiectasis occurred as a result of, or associated with, tuberculosis than with tuberculosis alone.

It would appear therefore that whilst pyogenic brain metastasis is unusual in phthisis, it is excessively rare when bron- chiectasis is not present in addition. In point of fact we were unable to find any such case having adequate description recorded in literature.

We would suggest a probable explanation as follows: mixed infection of even large tuberculous cavities, although usually assumed to be present, in actual fact is un- common - with the exception of the terminal phases of the disease. Where such infection

does occur, however, and the case here described is a good example, then the inci- dence of metastases to the brain is likely to be comparable with that in other pulmonary- sepsis.

Summary and Conclusions

The rarity of cerebral abscess as a complica- tion of cavitated pulmonary tuberculosis is commented on. Such a case is described and an explanation for the unusual association is suggested.

We should like to thank Mrs B. Burnett for the photographs and ~lr L. G. Spain for technical assistance.

References Coryllos and Ornstein (1938) ffournal of Thoracic Surger).,

~,qll~ I0 , Evans, W. (1931) Lancet, I, 1231 , 1289--1292. Pagel, W., in: Kayne, Pagel and O'Shaughnessy's l'ul-

monary Tuberculosis t918, ?nd edition, Oxford U.P., p. I~.

Schorstein (x9o9) Lancet, H, 843-85.o.

' S o l v o t e b e n ' - a W a t e r - s o l u b l e T h i o s e m i c a r b a z o n e

Report of a Case of Tuberculous Infection of the Extrapleurai Space, Treated by Local Injections

By HILARY ROCHE Montana, Switzerland

In this case a favourable result was obtained with the local use of 'Solvoteben ' (Bayer) in a severe tuberculous infection of the extra- pleural space following an "extrapleural pneumonolysis.

The response was particularly gratifying, as, when the local treatment with Solvoteben was begun, the tubercle bacilli grown from the pus were resistant both to PAS and to Streptomycin.

A man aged 24 (patient of Dr N. Lloyd Rusby) was admitted to Montana Hall on October 26, 1949. He left on Septeinber 22, 195o. The main features of his case on admission were:

Right upper lobe; Extensively infiltrated and cavitated.

Left upper lobe: Infiltrated, with smaller areas of cavitation.

Sputum: Positive for tubercle bacilli. B.S.R.: 24 (Westergren). Afcbrile.

Collapse treatment was carried out as follows:

(x) Nov. 29, I949: R.A.P. induced. (o) Dec. 3, I949: Internal pneumonolysis

(partly extrapleural) complete. During the l a s tweek of January 195o , the right lower lobe was allowed to re-expand, and the pneumothorax was stabilized on the right side from February with refills once a week and later at intervals of nine to eleven days.

(3) Jan. 6, i95o: L.A.P. induced. Collapse contra-selective.

(4) Jan. 21, I95O: Operation for left