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Multimodal Diagnostic Approach to Brain Abscess

机译：脑脓肿的多模式诊断方法

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A tertiary hospital based study comprising of a case series of 25 patients was carried out to evaluate various diagnostic modalities and arrive at a sensitive algorithm for diagnosis of brain abscess. Diagnostic efficacy of MRI scan, MR spectroscopy, PCR for tuberculosis & histological evaluation was assessed against a gold standard of Microbial diagnosis. The study group included 16 cases of pyogenic, 4 tubercular, 4 fungal and one actinomycotic abscess. Additionally, microvessel density and thickness of abscess wall was assessed by histo-morphometry. MRI was diagnostic in 92 % of the cases. MR spectroscopy revealed, lactate, lipids and amino acid metabolites all cases. Acetate and succinate indicated anaerobic etiology. Histological demonstration of microbes was possible in 6/16 cases of pyogenic abscesses, 3/4 cases of tubercular abscesses, in all 4/4 cases of fungal abscess and the 1/1 case had actinomycosis. M. tuberculosis was detected by PCR in all 4 cases of tubercular abscess. Morphometric analysis of the abscess wall showed prominent zone of inflammation in tubercular abscesses, which was significantly wider than in pyogenic abscesses (t=3.987, p= <0.001). This correlated well with the zone of enhancement inT1.weighted images in MR scans. Extent of microvessel proliferation in both groups was the same. Early diagnosis and accurate localization of brain abscess is possible by a combination of MRI & MR spectroscopy. Rapid diagnosis of tuberculous brain abscess can be achieved by PCR allowing initiation of therapy in the immediate postoperative period preventing fulminant infection. Introduction In the past two decades, technologic advancements have facilitated the diagnosis and management of brain abscess. Multiple diagnostic modalities are now available. Early diagnosis of brain abscess and accurate localization by CT and MRI has resulted in significant reduction in mortality. Added to this are the improvements in isolation techniques that have made rapid identification of causative organisms possible, hence increasing cure rates and reducing morbidity significantly.In the current study we have attempted to assess the efficacy of diagnostic modalities including MRI scan, MR spectroscopy, demonstration of microbial pathogen in pus smears & histological specimen, and PCR for Mycobacterium tuberculosis in the diagnosis of brain abscess. Further morphometric analysis of the abscess wall in terms of the thickness of capsule, inflammatory reaction and microvessel density assessment was done to define variations, if any, between the pyogenic, tubercular and fungal infections and relate them to the MRI appearance. Materials And Methods A prospective tertiary hospital based study, conducted in a case series with brain abscesses undergoing surgical therapy was done. Cases, which could be categorized on etiological basis by microbial diagnosis, were included. The study group (n=25) comprised of 16 pyogenic (12 aerobic, 4 anaerobic), 4 tubercular, 4 fungal (2 aspergillus and 2 candida) and 1 actinomycotic abscesses. Microbial examination: Pus was collected at operation in thioglycollate medium with B-lactamase (Whatman,USA ), in sterile screw capped bottles and transported immediately for culture to the laboratory along with the smears prepared simultaneously. Grams, Ziehl Neelson (ZN) and Gomori's Methenamine Silver (GMS) stained smears were examined for various organisms. The pus was inoculated without delay in 5% sheep blood agar incubated aerobically and anaerobically; 5% sheep blood agar with .01% neomycin; incubated anaerobically; in chocolate agar incubated in 10% CO2; McConkey medium and Lowenstein Jenson medium and Sabouraud's dextrose agar. Clinical Assessment: included age, sex, presenting symptoms, signs, general condition and predisposing factors. Radiological assessment included MR Imaging: MR spectroscopy: Ex-vivo MRS studies involved freezing one portion of exudates with in 5 min of surgical excision.0.4g of froze
机译：进行了一项基于三级医院的研究，该研究由25位患者组成的病例系列进行了评估，以评估各种诊断方式并得出诊断脑脓肿的敏感算法。根据微生物诊断的金标准，评估了MRI扫描，MR光谱，PCR对结核病和组织学评估的诊断功效。研究组包括化脓性16例，结核4例，真菌4例，放线菌性脓肿1例。另外，通过组织形态测定法评估脓肿壁的微血管密度和厚度。 MRI对92％的病例具有诊断意义。 MR光谱显示，所有情况下乳酸，脂质和氨基酸代谢产物。醋酸盐和琥珀酸盐表明厌氧病因。在化脓性脓肿中有6/16例，结核性脓肿中有3/4例，在所有真菌性脓肿中有4/4例，有1/1例有放线菌病，可能进行微生物的组织学证实。通过PCR检测到4例结核性脓肿中的结核分枝杆菌。脓肿壁的形态计量学分析显示，结核性脓肿中有明显的炎症区域，比化脓性脓肿中的炎症区域明显更宽（t = 3.987，p = <0.001）。这与MR扫描中T1加权图像的增强区域很好地相关。两组的微血管增殖程度相同。 MRI和MR光谱相结合，可以对脑脓肿进行早期诊断和准确定位。通过PCR可以快速诊断结核性脑脓肿，允许在术后立即开始治疗以预防暴发性感染。简介在过去的二十年中，技术进步促进了脑脓肿的诊断和管理。现在有多种诊断方式。脑脓肿的早期诊断和CT和MRI的准确定位已导致死亡率的显着降低。此外，隔离技术的改进使对致病生物的快速鉴定成为可能，从而提高了治愈率并大大降低了发病率。在本研究中，我们试图评估包括MRI扫描，MR光谱学，演示在内的诊断方法的有效性。脓液涂片和组织学标本中微生物病原体的检测及结核分枝杆菌PCR在脑脓肿诊断中的意义。根据囊的厚度，炎症反应和微血管密度评估对脓肿壁进行了进一步的形态分析，以定义化脓性，结核性和真菌性感染之间的变异（如有），并将其与MRI表现相关。材料和方法基于前瞻性三级医院的研究，该研究针对一系列脑脓肿正在接受手术治疗的病例进行。病例可以通过病原学根据微生物诊断进行分类。研究组（n = 25）包括16个化脓性（12个好氧，4个厌氧），4个结核，4个真菌（2个曲霉菌和2个念珠菌）和1个放线菌性脓肿。微生物检查：手术时，将脓液收集在带有B-内酰胺酶的硫代乙醇酸盐培养基中（Whatman，美国），放在无菌的旋盖瓶中，并与同时制备的涂片一起立即运送到实验室进行培养。检查了革兰氏菌，Ziehl Neelson（ZN）和Gomori的甲胺银（GMS）染色涂片中的各种生物。将脓液立即接种在需氧和厌氧培养的5％羊血琼脂中; 5％羊血琼脂与0.01％新霉素;厌氧培养在10％CO2中孵育的巧克力琼脂中; McConkey培养基和Lowenstein Jenson培养基以及Sabouraud的葡萄糖琼脂。临床评估：包括年龄，性别，症状，体征，一般状况和诱发因素。放射学评估包括MR成像：MR光谱：离体MRS研究包括在手术切除后5分钟内冻结一部分渗出液。0.4g冻结

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