PMC5359233_01
Initial and follow-up brain and spinal cord MRI and F-18 FDG PET/computed tomography (CT) scans of the patient. (A) Diffusion-weighted image (upper row) exhibiting small, round, high, and central low-signal-intensity lesions in the right frontal lobe and internal capsule. T2 fluid attenuation inversion recovery (FLAIR) image (middle row) showing multiple small high-signal-intensity lesions in both cerebral hemispheres. Enhanced T1-weighted image (lower row) demonstrating rim enhancement in both the frontal cortical and internal capsular lesions. (B) F-18 FDG PET/CT scan showing another high-uptake lesion in the patient's neck. (C) The cervical spinal T2 FLAIR image revealing high-signal-intensity lesions with surrounding edema at the C2-C6 level of the spinal cord, especially the left pyramidal tract. The cervical spinal enhanced T1-weighted image displaying heterogenous enhancement, at the same level. (D) The follow-up T2 FLAIR and enhanced T1-weighted images performed after biopsy showing that both frontal cortical and subcortical high-signal-intensity lesions have increased in size.
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F1
T1 images (Figure 1A). After consultation with oncologist, an F-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET)-CT scan, which was subsequently performed to determine the presence of any hidden malignancies revealed a hypermetabolic lesion in the cervical spinal cord (Figure 1B). A cervical MRI scan revealed high signal intensities along the C2-C6 level of the spinal cord with heterogeneous enhancement, including the left pyramidal tract (Figure 1C). A follow-up MRI scan taken just after the brain biopsy revealed additional increases in sizes and numbers of the multiple brain lesions (Figure 1D).
(A) Gomori methenamine silver stain (1,000x), (B) hematoxylin and eosin (H&E) stain (1,000x), and (C) Gram stain (x1,000) revealing Gram-positive bacilli. (D,E) The DNA sequencing results for the 65 kDa heat shock protein (Hsp65) gene of Propionibacterium acnes strain were entirely consistent with a P. acnes infection.
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F2
The microorganism was Gram-positive, had a positive Gomori methenamine silver test, a negative acid-fast bacteria test, and a negative Warthin-Starry test; these findings indicate that it was a Gram-positive microorganism, but its specific identification could not be determined (Figures 2A-C). The results of the DNA sequencing were entirely consistent with an infection with Propionibacterium acnes (Figures 2D,E).
Follow-up brain and cervical spine magnetic resonance imaging (MRI) scans taken 3 months after the maintenance of antibiotic treatment. (A) Diffusion-weighted imaging (upper row), T2 fluid attenuation inversion recovery (middle row), and enhanced T1-weighted axial images (lower row) showing marked decrease in size of multiple lesions and perilesional edema. (B) Cervical spine MRI (T1, T2, and enhanced T1) displaying the nearly disappeared of high-intensity lesions in the cervical spinal cord.
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F3
Follow-up brain and cervical spine MRI scans taken 3 months after the initiation of the antibiotic maintenance therapy showed nearly resolved lesions (Figure 3) concomitant with amelioration of her left hemiparesis (MRC grades of 4 or above).