1. A 34-year-old woman with sudden onset of confusion
Teaching NeuroImages
Neurology
Resident and Fellow Section
© 2016 American Academy of Neurology
Melmed K et al

2. Vignette
34-year-old female underwent chemotherapy for newly diagnosed acute lymphocytic leukemia
Subsequently developed sepsis with Bacillus Cereus.
A week later with sudden onset of confusion
Found to have multiple lesions on magnetic resonance imaging
Work-up for possible embolic etiology of these lesions with transthoracic echocardiogram and transcranial doppler
Treated with broad-spectrum antibiotics and hyperosmolar therapy
She developed worsening cerebral edema and hydrocephalus
An external ventricular drain was placed, however she developed uncal herniation followed by central herniation from elevated intracranial pressure
Died the following day after palliative extubation
© 2016 American Academy of Neurology
Melmed K et al

3. IMAGING Melmed K et al © 2016 American Academy of Neurology Fig 1.
A. Multiple lesions on magnetic resonance imaging (Fluid Attenuation Inversion recovery (FLAIR))
B. Transcranial doppler with increased velocities and elevated pulsatility indices for bilateral middle cerebral, anterior cerebral and basilar arteries, suggestive of severe vasospasm
C. CT angiogram with evidence of bilateral middle cerebral, anterior cerebral and basilar arteries, suggestive of severe vasospasm
D. Gross pathology with multiple bilateral well-defined hemorrhagic-necrotic lesions measuring 1-2 cm in diameter
E. Micropathology with organisms morphologically consistent with Bacillus bacteria
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© 2016 American Academy of Neurology
Melmed K et al

4. Intracranial imaging, monitoring and gross and microscopic pathology of Bacillus Cereus abscess and vasospasm
Bacillus cereus causes a rapidly progressive, hemorrhagic meningoencephalitis with high mortality among patients with neutropenia.1
TCD can be a valuable bedside test to detect arterial alterations in patients with bacterial meningitis.2
A poor prognosis is associated with delayed diagnosis, immunocompromised patients, and the presence of multiple abscesses.    
References
Vodopivec, I. et al. A Cluster of CNS Infections Due to B. cereus in the Setting of Acute Myeloid Leukemia: Neuropathology in 5 Patients. J Neuropathol Exp Neurol 74,
2. Klein, M. et al. Arterial cerebrovascular complications in 94 adults with acute bacterial meningitis. Crit Care 15, R281
© 2016 American Academy of Neurology
Melmed K et al