title: Beware of Rim-Enhancing Lesions: A Rare Case of Multiple Scedosporium apiospermum and Vancomycin-Resistant Enterococcus faecium Intra-Cranial Abscesses.
abstract: BACKGROUND
  The aim of this submission is to demonstrate the need for broad antimicrobial therapy, including empiric anti-fungal therapy, if rim-enhancing lesions are noted on cerebral imaging.
  
  
  METHODS
  A retrospective microbiological and radiologic review of the management of a rare case of multiple Scedosporium apiospermum and vancomycin-resistant Enterococcus faecium intra-cranial abscesses in an immunocompromised patient was performed. A manual chart review assessing clinical and epidemiologic characteristics was completed including procedures and operative notes, use of invasive devices, biochemical and haematological blood test results, antimicrobial agents received, and documentation of a travel history.
  
  
  RESULTS
  Antimicrobial therapy combined with source control, typically surgical drainage, is considered the gold standard management of an intra-cranial abscess. Fungal abscesses produce rim-enhancing lesions, and where this radiographic feature is identified, evidence suggests that anti-fungal agents should be added. Antimicrobial therapy with linezolid and voriconazole failed, and the patient died. There was extensive disease progression evident on serial imaging despite therapy. A definitive surgical drainage procedure could not be performed.
  
  
  CONCLUSIONS
  Interval imaging assisted with the management of this challenging case. A low index of clinical suspicion for fungal intra-cerebral abscesses is necessary when treating immunosuppressed patients.
authors.affiliation: 1 Department of Clinical Microbiology, Beaumont Hospital , Dublin, Ireland .
authors.forename: Ciara
authors.initials: C
authors.lastname: O'Connor
authors.affiliation: 2 Department of Neuroradiology, Beaumont Hospital , Dublin, Ireland .
authors.forename: Fidelma
authors.initials: F
authors.lastname: Fitzpatrick
authors.affiliation: 3 Department of Clinical Microbiology, Royal College of Surgeons in Ireland , Dublin, Ireland .
authors.forename: Seamus
authors.initials: S
authors.lastname: Looby
authors.affiliation: 1 Department of Clinical Microbiology, Beaumont Hospital , Dublin, Ireland .
authors.forename: Karina
authors.initials: K
authors.lastname: O'Connell
mesh_terms: D001922:Brain Abscess / Q000000981:diagnostic imaging / Q000188:drug therapy*; D020314:Central Nervous System Fungal Infections / Q000000981:diagnostic imaging / Q000188:drug therapy*; D024901:Drug Resistance, Multiple, Bacterial; D026141:Drug Resistance, Multiple, Fungal; D016984:Enterococcus faecium; D016908:Gram-Positive Bacterial Infections / Q000000981:diagnostic imaging / Q000188:drug therapy*; D006801:Humans; D008279:Magnetic Resonance Imaging; D012189:Retrospective Studies; D021681:Scedosporium; D014640:Vancomycin / Q000627:therapeutic use*
chemical_list: D014640:Vancomycin