Brain Abscess after Transanal Hemorrhoidal Dearterialization: A Case Report
A 51-year-old man was seen at our outpatient clinic. He complained of soiling and a feeling of prolapse after defecation, which resolved spontaneously. His medical record consisted only of an ear operation a long time ago, he was otherwise healthy and used no medication. Proctoscopy showed internal hemorrhoids, and three rubber band ligations were placed at the left lateral, right anterior and right posterior positions. However, symptoms persisted at 2-month follow-up and a THD procedure under spinal anesthesia was carried out. Six end branches of the superior rectal artery were detected and ligated. The day care procedure was uneventful. He was seen postoperatively at 7 and 10 days on an outpatient basis. An analgesic was prescribed in order to relieve postoperative pain.\nTwo weeks later the patient was admitted to the Neurology Department with a headache, bradyphrenia, flattened behavior and a left hemiplegia. Laboratory tests showed a leukocyte count of 20.6 × 109/l, a C-reactive protein of 126 mg/l and an erythrocyte sedimentation rate of 82 mm/h. A contrast CT scan of the cerebrum showed a right temporoparieto-occipital abscess (fig. ), with edema and compression of the surrounding tissue and lateral ventricles. One day later, MRI was performed which also showed an abscess with leakage in the right lateral ventricle (fig. ). Treatment with dexamethasone and intravenous antibiotics (penicillin two million units 6 times daily, metronidazole 500 mg 3 times daily for 2 weeks and ceftriaxone 2 g twice daily for 3 days) was started. Despite prolongation of antibiotic treatment, 4 days later there was progression of the bradyphrenia and the left hemiplegia. A CT scan showed reduction of the size of the abscess, but progression of ventricle size and the right frontal edema (fig. ). There was no indication for a drain at that time. Antibiotic treatment with penicillin was continued. Because of progression of symptoms, 3 weeks later a ventriculoscopy was performed and the abscess was drained. Culture of the punctuate showed a S. milleri, which was sensitive to penicillin (MIC < 0.1 mg/l). Cultures of blood and liquor taken at the time of ventriculoscopy remained negative. There were no perianal complaints and/or abscess formation all the time. Antibiotics were continued for 2 months. Because of developing hydrocephalus 3 days after ventriculoscopy, first an external ventricle drain and later a ventriculoperitoneal drain was placed. Hereafter the hemiplegia and cognitive disorders improved. Three months later he was discharged to a rehabilitation clinic where he stayed 2 weeks. During the rehabilitation period cognitive disorders, balance and walking function improved. Six months after discharge from the rehabilitation clinic he was back to work for 32 h a week.