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Meningioma-associated abscess: an unusual case report and review of the literature

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Central nervous system (CNS) infection and neoplasm occur most often independently. Their concomitant presentation has been noted across different CNS tumours but is considered a rare entity. The phenomenon is mostly seen in relation to direct seeding of infection via frontal air sinuses. Here, we present an unusual case of an occipital meningioma associated with intraparenchymal paratumoural abscess formation. It is also the second documented to culture methicillin-susceptible Staphylococcus aureus. We then review and surmise the relevant literature of meningioma-associated abscess. We discuss the clinical presentations, aetiology, suspected pathogenesis, management and outcomes reported.
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1
Journal of Surgical Case Reports, 2022;1, 1–6
https://doi.org/10.1093/jscr/rjab582
Case Series
CASE SERIES
Meningioma-associated abscess: an unusual case
report and review of the literature
Sami Rashed1,*, Anna Vassiliou2, Rosalie Ogborne1and Gráinne McKenna1
1Neurosurgical Department, Royal London Hospital, London, UK and 2Barts and the London School of
Medicine, London, UK
*Correspondence address. Neurosurgical Department, Royal London Hospital, Whitechapel Road, London, UK. E-mail: s.rashed@nhs.net
Abstract
Central nervous system (CNS) infection and neoplasm occur most often independently. Their concomitant presentation has
been noted across different CNS tumours but is considered a rare entity. The phenomenon is mostly seen in relation to
direct seeding of infection via frontal air sinuses. Here, we present an unusual case of an occipital meningioma associated
with intraparenchymal paratumoural abscess formation. It is also the second documented to culture methicillin-susceptible
Staphylococcus aureus. We then review and surmise the relevant literature of meningioma-associated abscess. We discuss the
clinical presentations, aetiology, suspected pathogenesis, management and outcomes reported.
INTRODUCTION
Central nervous system (CNS) infection and neoplasm occur
most often independently, but their concomitant presentation
has also been reported across the literature. A variety of
neoplasms have been linked with tumoural abscess for-
mation including glioblastoma, high-grade and low-grade
astrocytoma, ependymoma and metastatic lesions. However,
a majority of these lesions described intrasellar or parasel-
lar tumours where infection has spread directly from the
prenasal cavity, and on the whole, it is considered a rare
entity [1]. This case report presents the clinical course and
management of a meningioma with related intraparenchy-
mal paratumoral abscesses. We then discuss this in the
context of the wider literature as the second case to isolate
methicillin sensitive staphylococcus aureus (MSSA) within a
meningioma.
Received: October 27, 2021. Revised: November 19, 2021. Accepted: November 29, 2021
Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2022.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),
which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
CASE REPORT
A 52-year-old female presented with headache and visual distur-
bance. She had no significant past medical history. On examina-
tion, a left homonomous inferior quadrantopia was noted. CT
and then MRI imaging revealed a solitary 3-cm right parieto-
occipital extra-axial lesion with associated dural tail and sur-
rounding oedema (Fig. 1). Her headaches improved with a short
course of steroids and the neuro-oncology MDT recommenda-
tion was for surgical excision of the suspected meningioma.
Two weeks later, whilst awaiting surgery, she attended the
Emergency Department with a fever of 38.6C and mildly raised
inflammatory markers (WCC 10.4, Neut 8.4). Urine dip and CXR
were unremarkable. The source of the infection was not iso-
lated and the emergency medicine physicians discharged her
with a course of empirical oral antibiotics. The neurosurgical
team were not made aware of this attendance. Twelve days
2S. Rashed et al.
Figure 1 : Axial view of a T1 weighted MRI post-gadolinium enhancement
demonstrating the appearance of a 3-cm right parieto-occipital extra-axial mass
with bony involvement and adjacent small nodule. Most in keeping with a
meningioma.
Figure 2 : T1 weighted MRI postgadolinium enhancement in both sagittal (A)and
coronal (B) views. There are two new rim-enhancing cystic lesions. A superior
lesion of 31.4 mm as measured on the coronal reconstructed images and is
abutting the adjacent dura of the right parietal lobe and is sited superior and
lateral to the right occipital lesion. Another lesion sited inferior to the known
right occipital lesion is the larger of the two lesions and has a septation within it.
This measures approximately 34.4 mm on the coronal reconstructed images. On
the sagittal images, it can be seen that the anterosuperior enhancing border of
this lesion has a thicker and more ill-defined age. There is an adjacent vasogenic
oedema.
later, she underwent a planned neuronavigation-planning MRI
scan as an outpatient. This was arranged one week prior to
the scheduled surgery, in line with our departmental protocol.
The MRI was reviewed and two new rim-enhancing collections
superior and inferior to the tumour were noted, associated with
extensive perilesional oedema (Fig. 2A and B). The patient was
then immediately contacted via telephone and reported new
worsening of headaches and new right sided weakness. She
was admitted to hospital directly for assessment and emergency
treatment. Her inflammatory markers on admission had risen
to a WCC of 19.5, Neut 16.6, but CRP was <1. She was started on
an emergency steroid treatment and subsequently underwent
craniotomy, total resection of the meningioma and drainage of
the intraparenchymal paratumoural abscesses. Intra-operatively
the brain was swollen; pus collections were encountered in
abscess cavities superior and inferior to the solid tumour, which
had a necrotic core.
The operation was successful with a post-operative MRI
within 48 h demonstrating complete resection of the tumour and
resolution of the cystic lesions, but persisting intraparenchymal
oedema (Fig. 3). The patient had an uncomplicated two-day
stay in a neurosurgery high dependency unit postoperatively
Figure 3 : T1 weighted axial MRI postgadolinium enhancement within 48 h post-
operatively. Small amount of enhancement within the surgical bed remains. Good
resection margins with vasogenic oedema. This may represent a small residual.
The rim-enhancing cystic lesions appear to have resolved.
Figure 4 : T1 weighted axial MRI post-gadolinium enhancement 8 weeks post-
discharge. Right occipital postsurgical appearances are again demonstrated with
reduction in the extent of vasogenic oedema. The enhancing rim that waspresent
previously has retracted, with only focal curvilinear enhancement now evident
in the right occipital lobe. These appearances are likely postsurgical/treatment
related, and there is no convincing residual or recurrent disease.
before being stepped down to the general neurosurgery ward.
She was reviewed by the microbiology team and worked up
for the source of infection. Blood cultures, urine cultures, CXR
and transthoracic echocardiography were all negative for a
source of infection. Intra-operative pus cultures isolated MSSA.
The histopathology of the tumour was Meningioma WHO
Grade 1 with large areas of necrosis and secondary abscess
formation. She was discharged feeling well 5 days later after
a satisfactory biochemical and clinical response. She was given
a weaning course of steroids and a 6-week course of intravenous
ceftriaxone via a PICC line as an outpatient as per microbiology
advice. Ophthalmology assessment 3 months after discharge
confirmed a left inferior quadrantonopia and preserved visual
acuity. Repeat MRI and clinic review 8 weeks later showed no
radiological residual tumour or oedema (Fig. 4), and the patient’s
limb function recovered completely but had ongoing visual
symptoms.
Meningioma-associated abscess 3
Tab le 1 . Summary of meningioma-associated abscesses reported in the literature included out own case
Case Patient Clinical features Organism Meningioma
location
Relationship
of abscess to
meningioma
Histological
finding
Grade WHO
(2016)
Source of
infection
Favourable
outcome
Shimomura et al.
1994 [2]
64/F Drowsiness and
fever
Bacteroides oralis Right frontal Intratumoral Transitional
meningioma
110days
postgynaecologic
surgery
+
Nassar et al. 1997
[3]
78/F Left hemiparesis Escherichia coli Right occipital Intratumoral ‘Benign
meningioma’
1 Urinary tract
infection
+
Eisenberg et al.
1998 [4]
78/F Focal seizure Proteus mirabilis Left frontal Intratumoral Transitional
meningioma
1 Urinary tract
infection
Onopchenko et
al. 1999 [5]
63/F N/A Staphylococcus
aureus
Left convexity Peritumoral N/A N/A Recent
nephrectomy for
abscessed
pyelonephritis
and drainage of
gluteal abscess
+
Yea te s et al. 2003
[6]
38/F Seizures, fever,
chills and night
sweats
Bacteroides fragilis Left frontal Intratumoral Meningothelial
meningioma
1 3 weeks
postvaginal
hysterectomy
+
Lind et al. 2005 [7] 78/F Confusion and
personality
change
Citrobacter koseri Right frontal Peritumoral N/A N/A Unknown +
Youn g et al. 2005
[8]
38/M Headache and
fever
Group B
streptococcus,
Peptostreptococcus
Right temporal Intra and
peritumoral
Meningothelial
meningioma
1 Dental work +
Lo et al. 2014 [9] 70/F Left hemiparesis E. coli Right parietal and
left frontal
Intratumoral Transitional/fibrous
meningioma
16days
postureteroscopy
and lithotripsy
+
Krishnan et al.
2014 [10]
55/F Status epilepticus E. coli Left frontal
convexity
Intratumoral Psammomatous
meningioma
1 Recent urinary
stent insertion
+
Moliere et al.
2015 [11]
65/F Headache Norcardia novia Left occipital Intratumoral Meningothelial
meningioma
1 Unknown +
Rao Patibandla et
al. 2017 [12]
35/M Headache and
vomiting
Proteus Mirabilis Right lateral
ventricle
Intratumoral Transitional
type
N/A Urinary tract
infection
+
Sannareddy et al.
2018 [13]
56/M Headache and
vomiting
E. coli Left occipital Intratumoral Psammomatous
meningioma
I Unknown +
Sosa-Najera et al.
2018 [14]
42/F Left hemiparesis,
focal left seizures
and headache
N/A Right parietal Intratumoral Atypical
meningioma
II Unknown +
Continued
4S. Rashed et al.
Tab le 1 . Continued
Case Patient Clinical features Organism Meningioma
location
Relationship
of abscess to
meningioma
Histological
finding
Grade WHO
(2016)
Source of
infection
Favourable
outcome
Chandra et al.
2018 [15]
70/M Right hemimotor
and sensory
disturbance
Streptococcus
constellatus,
Fusobacterium,
Prevotella dentalis
and Parvimonas
micra
Left posterior
frontal/parietal
lobe
Intra- and
peritumoral
Meningothelial
meningioma
1 Unknown +
Ponce-Ayala et al.
2020 [16]
63/M Confusion,
aphasia and right
hemiparesis
N/A Left hemispheric Intratumoral Anaplastic
meningioma
III N/A
Fabbri et al. 2020
[17]
76/M Left sided hearing
loss
N/A - ‘sterile’ Right convexity Intratumoral Meningothelial I N/A +
Cristopher et al.
2020 [18]
75/F Focal seizures
developing to
status epilepticus
E. coli Known left frontal
and parietal
meningiomas
Intratumoral N/A I Urinary
tract
infection
+
Our Case 52/F Left Inferior
quadrantopia,
headache and
confusion
Staphylococcus
aureus (MSSA)
Right occipital Peritumoral N/A I Unknown +
WHO = World Health Organisation, M = Male, F = Female, N/A = Not Applicable.
Meningioma-associated abscess 5
DISCUSSION
Upon review of the literature with respect to meningiomas asso-
ciated with tumoral abscess specifically, we identified eighteen
cases including our own (Tab le 1 ). The most common presenting
symptom seen was headache, which was present in six cases
including our own [8,1114]. Hemiparesis and seizures were also
common and seen in four patients [3,4,6,9,14,16,18].
An infective source was identified in a total of ten cases.
Six patients had operative interventions, either gynaecological,
urological or dental, in the recent period prior to presentation
and cultured corresponding organisms [2,5,6,810]. The
remaining four cases had associated urinary tract infections
identified through urine cultures [3,4,12,18]. Despite inves-
tigation, eight remaining cases including our own had no
clear infective source. One of these cases described a ‘sterile’
abscess formation thought related to androgen treatment in the
context of prostate carcinoma [17]. The immunocompromised
nature of the patient, recent steroid treatment and presumed
urinary/dental infections were cited as potential sources/con-
tributing factors to the remaining cases without a clear cause
[7,11,1316].
The organisms cultured were also consistent with a majority
abdominopelvic origin. Of the fifteen cases with a confirmed
organism, ten were consistent with abdominopelvic microbiota
with E. coli being the most common organism seen in five cases
[3,9,13,18]. The clinical/biochemical inf lammatory response
seen to infection demonstrated a variable level of severity, from
asymptomatic to occult sepsis and also a varied temporal rela-
tionship between infection and tumour identification.
As given above, haematogenous spread has been postulated
as the most likely pathogenesis of abscess formation in
meningiomas. Especially as destruction to the blood brain barrier
through open epithelial junctions, gaps between epithelial cells
and capillary fenestrations have been demonstrated in menin-
giomas [9]. The rich vascular supply of tumours, their vascular
branching patterns, compression of nearby venous structures
resulting in stasis and the nutrient-rich environment have also
been cited as potentially contributory [10]. Intratumoral cultures
showing very similar sensitivities to those cultured peripherally
and our case being one of few describing a lesion remote from
the frontal sinuses also strengthens the case [18].
The most common location for abscess formation was
within the tumour alone, which was seen in fourteen cases.
A peritumoral abscess was seen in two cases and a further
two demonstrated the presence of both peritumoral and
intratumoral abscesses [5,7,8,15]. One case demonstrated
intratumoral abscess formation solely within one of two
meningiomas present raising the possibility of preferential
seeding of infections depending on vascular supply [18].
The immunocompetent nature and occult source of infec-
tion of our case make an interesting point of discussion with
the majority of cases occurring with a known infective source,
causative procedure or immunocompromised status. As with
our case and sixteen of the eighteen cases in the literature, a
favourable outcome was achieved. This was defined as complete
recovery in nine cases and persistent mild neurological deficit
in six cases. All cases required surgical intervention to achieve
this and most utilized prolonged antibiotic therapy. Those cases,
which mention antibiotic, produce a mean therapeutic duration
of 6.7 weeks (range 10 days–12 weeks). Most describe resolution
on follow-up imaging with one case requiring repeat surgical
intervention in the acute post-operative period due to imaging
findings.
In conclusion, we describe the presentation and successful
treatment of a rare meningioma and associated intraparenchy-
mal paratumoural abscesses. A phenomenon noted within
the literature with evidence suggesting its association to
haematogenous spread of classically abdominopelvic organ-
isms. Occult infection, as in our case, is also seen but despite
this patients usually have uncomplicated recoveries following
surgical intervention and a prolonged antibiotic course.
CONFLICT OF INTEREST STATEMENT
None declared.
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Introduction: Abscesses associated with tumors are a rare entity. Imaging to differentiate abscess from other entities is often non-diagnostic, and often the source of infection is unknown. We present an unusual case of peritumoral abscess infected with both gram-negative and gram-positive bacteria. Methods: A 70-year-old, previously healthy male presented with a 1-day history of right-sided facial weakness sparing the forehead, as well as concomitant right upper and lower extremity numbness. A homogenously enhancing mass with adjacent rim-enhancing lesion with diffusion restricting cavity seen on magnetic resonance imaging (MRI) raised the possibility of abscess. Results: Separate biopsy specimens of both the tumor and adjacent fluid collection during drainage of the collection confirmed World Health Organization (WHO) grade I meningioma and bacterial abscess containing Streptococcus constellatus, Fusobacterium species, Prevotella dentalis, and Parvimonas micra. The histologic diagnosis therefore confirmed the preoperative radiologic findings of two different but associated lesions. Investigations to determine a definitive source of infection were inconclusive, including urinalysis, blood cultures, respiratory cultures, endoscopy, and an orthopantomogram. Conclusions: Gram-negative and gram-positive bacteria can both be culprits in the formation of peritumoral abscess. Although the source of infection is unconfirmed, the presence of oropharyngeal flora in the abscess suggests a subclinical odontogenic infection with hematogenous spread to the tumor and adjacent brain.