Samara Efthymia, Siasios Ioannis, Katsiardanis Konstantinos, Liaptsi Eirini, Tsoleka Kalliopi, Deretzi Georgia
Department of Neurology, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece.
Department of Neurosurgery, Papageorgiou Hospital of Thessaloniki, Periferiaki Odos N. Efkarpia, Thessaloniki, Central Macedonia, Greece.
Surg Neurol Int. 2021 Mar 17;12:97. doi: 10.25259/SNI_886_2020. eCollection 2021.
Immunosuppression is a significant parameter in the pathogenesis of brain abscesses (BA) and it could be the result of severe infections such as acquired immunodeficiency syndrome or drug-induced, by several medications used for systemic autoimmune diseases. Leflunomide is a pyrimidine synthesis inhibitor that affects the proliferation of lymphocytes and is used as a disease-modifying antirheumatic drug. Mild infections, particularly those of the respiratory tract and herpes zoster, are one of its most common adverse effects. However, atypical and severe infections have also been reported under treatment with leflunomide.
A 70-year old female was referred to our hospital with headache, aphasia, and right-sided hemiparesis and a lesion of the left parietal lobe initially interpreted as a malignancy. Her medical history revealed a 12-year old history of rheumatoid arthritis under current treatment with leflunomide. A cerebral magnetic resonance imaging (MRI) revealed typical findings for a BA. She subsequently underwent a left craniotomy, which confirmed the MRI-based diagnosis. The abscess was evacuated and cultures were obtained intraoperatively. In the postoperative examination, the patient showed no neurological deficit.
The differential diagnostic considerations in immunocompromised patients with neurologic deficits should include focal central nervous system infections such as a BA, even in the absence of fever or immunosuppressant-induced leukopenia. It also demonstrates the importance of early neurosurgical intervention for the prevention of sequelae. To the best of our knowledge, this is the second-to-date reported case of a BA under immunomodulatory therapy with leflunomide.
免疫抑制是脑脓肿（BA）发病机制中的一个重要参数，它可能是严重感染的结果，如获得性免疫缺陷综合征，或由用于治疗全身性自身免疫性疾病的多种药物引起的药物性免疫抑制。来氟米特是一种嘧啶合成抑制剂，可影响淋巴细胞的增殖，用作改善病情的抗风湿药物。轻度感染，尤其是呼吸道感染和带状疱疹，是其最常见的不良反应之一。然而，也有报道在使用来氟米特治疗期间出现非典型和严重感染。
一名70岁女性因头痛、失语和右侧偏瘫被转诊至我院，左顶叶有一个病变，最初被诊断为恶性肿瘤。她的病史显示有12年类风湿关节炎病史，目前正在接受来氟米特治疗。脑部磁共振成像（MRI）显示为BA的典型表现。随后她接受了左开颅手术，术中证实了基于MRI的诊断。脓肿被引流，术中进行了培养。术后检查显示患者无神经功能缺损。
免疫功能低下且有神经功能缺损的患者的鉴别诊断应包括局灶性中枢神经系统感染，如BA，即使没有发热或免疫抑制剂引起的白细胞减少。这也证明了早期神经外科干预对预防后遗症的重要性。据我们所知，这是第二例报道的在接受来氟米特免疫调节治疗期间发生BA的病例。
