The Unusual Relationship Between a Dense Homonymous Hemianopsia and Skin Sinus Tract Drainage

Abstract

This 50 year old African-American male bricklayer was admitted with a two week history of headache, neck pain and blurry vision. He also endorsed a history of 2 months of fever, night sweats and 40 pound weight loss. He had had a left thigh infection months before, with multiple draining sinus tracts, which had resolved. Examination established a dense left homonymous hemianopsia and left hemineglect. MRI demonstrated multiple ring-enhancing lesions in the right occipital lobe with restricted diffusion, vasogenic edema and mass effect. Perfusion studies confirmed decreased blood flow. Chest CT illustrated right upper lobe volume loss and scarring with scattered indeterminate nodules throughout the lungs. Intra-operative pathologic consultation confirmed the presence of dense abscess walls and proved to be a surprise as to causative agent, when “sulfur granules” were identified. Recognition of these structures and communication with the microbiology lab was instrumental in holding the anaerobic cultures longer than usual; long enough for these organisms to grow. Final identification of the organisms involved included both Actinomyces meyeri and Actinobacillus actinomycetemcomitans. This combination has only been reported once before in brain.