Cerebritis mimicking cerebral venous sinus thrombosis in MRSA infective endocarditis

초록

Background & Significance: CNS complications of infective endocarditis (IE) could be associated with high mortality and serious sequelae. The septic emboli from IE vegetation can cause stroke, mycotic aneurysm, cerebritis, and abscess. Here, we report the rare case of IE with cerebritis mimicking CVST with hemorrhagic conversion. Case: A 55-year-old man visited emergency room for high fever, drowsiness, and general weakness. He had the history of diabetes mellitus with polyneuropathy. Ten days before visit, he suffered a burn on his left foot while using a warm compress to relieve neuropathic pain and he had stopped the medication for 7 days. On examination, he had drowsiness, pale skin, dehydration, several skin lesion in bilateral upper and lower extremities, like Janeway’s nodule and burn lesions in left foot. The laboratory finding indicated that elevated HbA1c, MRSA in blood culture, vegetation in TEE and increased ketone body, suggesting MRSA infective endocarditis with septic condition. Initial brain images including CT and MR scans showed high signal intensities in bilateral thalamus on diffusion weighted image (DWI) and T2-weighted/FLAIR images and with hemorrhagic transformation on gradient echo images (GRE). Our initial differential diagnosis included cerebral venous sinus thrombosis (CVST) with hemorrhagic transformation, CNS infection, Wernicke’s encephalopathy, osmotic myelinolysis, Japanese encephalitis, and Wilson disease. The empirical therapy, piperacillin/tazobactam was changed to vancomycin and ampicillin/sulbactam for coverage dry gangrene in left foot. T