Images in Neurology
August 2008

Multiple Punctate Intracerebral Hemorrhages in Acute Leukemia With Escherichia coli Sepsis

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Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008

Arch Neurol. 2008;65(8):1128-1129. doi:10.1001/archneur.65.8.1128

A 56-year-old man was admitted to the hospital with a 2-week history of general myalgia, fever, and cough. A complete blood cell count on admission showed the following: white blood cell count, 1720/μL (to convert to value × 109/L, multiply by 106); hemoglobin level, 6.7 g/dL (to convert to grams per liter, multiply by 10.0); and platelet count, 24 × 103/μL (to convert to value × 109/L, multiply by .001). Acute leukemia was suspected, and a bone marrow examination revealed acute erythroid leukemia (acute myeloid leukemia M6 subtype). Ten days after initiating treatment with cytarabine hydrochloride and idarubicin hydrochloride, he developed a fever (temperature, 39.3°C). Blood smear results showed gram-negative rods, and Fournier gangrene was identified as a septic focus. Vancomycin, meropenem, and metronidazole treatment was initiated, and this treatment was changed to cefepime and metronidazole after the pathogen was identified as Escherichia coli. Five days later, the patient's neurologic status continued to deteriorate and the patient did not show any response to noxious stimuli. Gradient-echo magnetic resonance imaging showed multiple punctate hemorrhages in the cerebral hemisphere (Figure), including more confluent hematomas in the frontal and parietal lobes. They were isointense or slightly hyperintense on T1-weighted imaging, which was compatible with an acute to subacute hemorrhage. Regardless of the 3-week-long appropriate antibiotic drug treatment, the patient remained in a state of akinetic mutism.

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