Novel Partial Anomalous Pulmonary Venous Connection Associated with Brain Abscess
A 47-year-old woman presented with worsening headache and neck pain over 4 days associated with nausea and vomiting. She denied subjective fevers or chills. She reported traveling to the Dominican Republic 1 month prior to presentation. She had no other medical history and was not on any medications. She denied any recent illnesses or dental procedures.\nHer temperature was 38.0℃, heart rate was 70 beats/min, respiratory rate was 18/min, and blood pressures were 140/72 mm Hg. The patient had no evident toxicity and was alert and oriented to person and time but not to place. An oral examination showed good dentition with no notable abscess, pain, or gingival disease. A cardiovascular examination revealed no abnormalities, including murmurs. There was no evidence of skin infections or lesions. She had mild expressive aphasia with clear, unpressured speech. Reception and comprehension were intact. Her cranial nerves and the results of motor and sensory examinations were normal. However, she did have a shuffling gait with loss of balance to the right and clonus at the right ankle.\nThe laboratory parameters of the patient at admission were remarkable for leukocytosis with a left shift (17.8×109 WBCs per liter and 90% neutrophils). The results of electrocardiogram and chest X-ray examinations were normal. Computed tomography (CT) of the brain without contrast agent demonstrated a left thalamic mass with a hypodense center and hyperdense periphery. A mass effect was noted on the left lateral and third ventricles. Well-aerated paranasal sinuses and mastoid cells were noted. Magnetic resonance imaging of the brain with and without contrast agent revealed a 2.4×2.2×1.9-cm lesion with mild surrounding hyperintense T2-weighted and fluid-attenuated-inversion-recovery (FLAIR) signals compatible with edema (). The enhanced rim demonstrated a hypointense T2-weighted signal. The internal contents of the lesion were hyperintense on T2-weighted and FLAIR signals with corresponding restricted diffusion. These imaging findings were highly suggestive of a brain abscess.\nStereotactically guided drainage was applied immediately to the patient. Five milliliters of foul-smelling, purulent fluid was aspirated. The patient was initially started on vancomycin, ceftriaxone, and metronidazole after cultures were obtained. Streptococcus mitis grew in these cultures, and so the antibiotic coverage was appropriately narrowed.\nThe patient subsequently underwent transthoracic echocardiography (TTE) and transesophageal echocardiography with agitated-saline contrast agent injected into the right arm; the results were unrevealing. A CT scan of the chest was performed with contrast agent on postoperative day 13 due to a transient episode of hypoxia, which revealed an incidental finding of an anomalous connection between the left brachiocephalic vein and the left superior pulmonary vein. No PAVMs were noted.\nDiagnostic cardiac catheterization via the left basilic vein confirmed the anomalous venous connection and the presence of a predominantly left-to-right shunt based on measurement of the oxygen saturation. TTE with agitated saline injected into the left arm this time demonstrated the passage of a large amount of bubbles into the left side of the heart. The patient recovered well after abscess drainage and was discharged to a rehabilitation facility with plans for close follow-up, and eventual percutaneous closure of the anomalous connection.