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Pyogenic Brain Abscesses in a Patient With Digital Clubbing

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 34-year-old man presented with headache, double vision, and seizures for 1 month and altered consciousness for 1 week. He had had 2 episodes of seizures that were characterized by tonic head and eye deviation to the left, followed by a brief period of tonic-clonic activity of all 4 limbs and postictal confusion for 10 to 15 minutes. He denied a history of fever, head trauma, limb weakness, or vomiting. He was a vegetarian, nonsmoker, and nondrinker. He denied a history of drug addiction.

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C. Pulmonary arteriovenous shunt

A pyogenic brain abscess can occur because of purulent spread from infections in the middle ear, meninges, paranasal sinuses, mastoids, lungs (in cases of empyema, bronchiactesis, and pulmonary abscess), heart (in cases of infective endocarditis or cyanotic congenital heart diseases), gastrointestinal tract, or mouth (in cases of dental infection). A brain abscess can also occur after head trauma and neurosurgical procedures.1 Among the pulmonary causes, digital clubbing and pyogenic brain abscess can be seen in empyema thoracis, lung abscess, bronchiactesis, interstitial lung disease, and pulmonary arteriovenous shunts.2 Symptoms of pulmonary arteriovenous shunt depend on the size of the shunt. A patient with a pulmonary arteriovenous shunt may remain asymptomatic, whereas patients with empyema thoracis and lung abscess present with acute fever, chest pain, cough, and dyspnea on exertion or at rest.3

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Article Information

Corresponding Author: Vimal Kumar Paliwal, DM, Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India (dr_vimalkpaliwal@rediffmail.com).

Published Online: October 7, 2019. doi:10.1001/jamaneurol.2019.3327

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
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2.
Sarkar  M, Mahesh  DM, Madabhavi  I.  Digital clubbing.  Lung India. 2012;29(4):354-362. doi:10.4103/0970-2113.102824PubMedGoogle ScholarCrossref
3.
Dines  DE, Arms  RA, Bernatz  PE, Gomes  MR.  Pulmonary arteriovenous fistulas.  Mayo Clin Proc. 1974;49(7):460-465.PubMedGoogle Scholar
4.
Ahn  S, Han  J, Kim  HK, Kim  TS.  Pulmonary arteriovenous fistula: clinical and histologic spectrum of four cases.  J Pathol Transl Med. 2016;50(5):390-393. doi:10.4132/jptm.2016.04.18PubMedGoogle ScholarCrossref
5.
White  RI  Jr, Lynch-Nyhan  A, Terry  P,  et al.  Pulmonary arteriovenous malformations: techniques and long-term outcome of embolotherapy.  Radiology. 1988;169(3):663-669. doi:10.1148/radiology.169.3.3186989PubMedGoogle ScholarCrossref
6.
Kagawa  M, Takeshita  M, Yato  S, Kitamura  K.  Brain abscess in congenital cyanotic heart disease.  J Neurosurg. 1983;58(6):913-917. doi:10.3171/jns.1983.58.6.0913PubMedGoogle ScholarCrossref
7.
Khurshid  I, Downie  GH.  Pulmonary arteriovenous malformation.  Postgrad Med J. 2002;78(918):191-197. doi:10.1136/pmj.78.918.191PubMedGoogle ScholarCrossref
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