2025 American Academy of Neurology Abstract Website

Objective:

To describe a case of diffuse brain abscesses and highlight the importance of considering esophageal perforation as a predisposing factor.

Background:

Brain abscesses can arise from direct extension or hematogenous spread from various sources, including dental infections and sinusitis. Esophageal perforation, although rare, can lead to brain abscess formation through bacteremia following mediastinal infection. This case involves a spontaneous esophageal perforation and its suspected contribution to multiple brain abscesses.

Design/Methods:

N/A

Results:

A previously healthy 31-year-old man presented with chest tightness and a foreign body sensation in the throat. CT angiography revealed distal esophageal thickening and mediastinal findings consistent with abscess formation. The patient was diagnosed with esophagitis and initially discharged home on pantoprazole.

One week later, he returned with altered mentation, fever, and worsening leukocytosis. Brain MRI revealed over 50 lesions suggestive of brain abscesses. Despite unrevealing biopsies of both the brain and mediastinal abscesses—likely due to prior antibiotic administration—Karius testing identified Streptococcus intermedius, a known abscess-forming bacterium.

The suspected mechanism involved a microperforation in the esophagus, allowing S. intermedius entry into the bloodstream, leading to a mediastinal abscess and subsequent hematogenous spread to the brain. The patient was treated with ceftriaxone and metronidazole, as well as steroids for cerebral edema that also ultimately required external ventricular drains.

Conclusions:

This case highlights the need to consider esophageal perforation in the differential diagnosis of brain abscesses, particularly when common causes are excluded. Early recognition and treatment can reduce delays in diagnosis and improve outcomes.