Nervous system abscess: a rare complication of diverticulitis

A 37-year-old previously healthy man presented with dyspnoea, anorexia, malaise and high grade fever. Computed tomographic (CT) images of the chest, abdomen and pelvis demonstrated sigmoid diverticula with significant perisigmoidal inflammation and a concomitant liver abscess. The liver abscess was successfully drained by a percutaneous approach and antibiotics were initiated. The patient subsequently developed weakness of the right lower limb, with marked loss of power in the knee and ankle, and sensory loss in the left leg. CT of the brain (Fig. 1, panel A) showed multiple ring-enhancing lesions in the right fronto-parietal region and the right caudate and the left parietal region. Also seen on magnetic resonance imaging of the spine (Fig. 1, panel B) was a rim-enhancing partially septated lesion at the level of the thoracic spine (T 9-10) measuring 2.8 cm craniocaudaly and 0.8 cm anteroposteriorly. Investigation to detect immunocompromise did not reveal any deficiency. Blood cultures and cultures from the liver abscess grew colonies of Streptococcus intermedius. Due to nonremitting sepsis, the patient required a Hartmann’s procedure to obtain source control. After percutaneous drainage of the liver abscess and a prolonged course of antibiotics, including Vancomycin, Metronidazole, Imipenem and Clindamycin, which were continued on and off for 6 weeks, and subsequently Meropenem, there was resolution of abdominal sepsis. There was gradual full recovery of neurological function and resolution of the abscess. Pathology from the specimen showed multiple sigmoid diverticula with perforation and inflammation in the surrounding adipose tissue. After a period of 4 months, the patient successfully underwent an uneventful Hartmann’s reversal.