A 34-year-old woman with known intravenous drug use presented with fever, somnolence, dysarthria, ataxia, and a generalized papulopustular rash. Cerebrospinal fluid and blood cultures were positive for methicillin-resistant Staphylococcus aureus. Cardiac ultrasonography showed mitral valve vegetations consistent with infective endocarditis. The patient rapidly became comatose and required mechanical ventilation. Brain magnetic resonance imaging showed numerous bilateral embolic lesions in the infratentorial and supratentorial compartments on fluid-attenuated inversion recovery sequences (Figure 1A and B, arrowheads), of which many contained microbleeds (gradient echo sequences, Figure 1C and D, arrowheads). A larger hemorrhagic lesion with space-occupying effect was seen in the left parietal lobe and was possibly due to the rupture of a mycotic aneurysm. The patient was not medically stable enough to undergo a cerebral angiogram to prove our suspicion. Despite aggressive neurointensive care and maximal osmotherapy, our patient's brain edema progressed and resulted in uncal herniation and midbrain compression. The family withdrew care according to the patient's wishes. An autopsy confirmed multiple acute and subacute infarcts, with microabscesses and hemorrhage in the bilateral hemispheres, brainstem, and cerebellum. Localized meningitis, as well as meningeal vessels containing infectious brain emboli, was seen on microscopy (Figure 2).
Tisdell J, Smith TW, Muehlschlegel S. Multiple Septic Brain Emboli in Infectious Endocarditis. Arch Neurol. 2012;69(9):1206–1207. doi:10.1001/archneurol.2011.3563
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