60 year-old with diabetes and renal disease presents with progressive aphasia



 
CT noncontrast                                                                       



CT postcontrast


    
FLAIR


                                                                                    
T1 noncontrast (Gad not given due to renal disease)


   
GRE



DWI




ADC



MR spectroscopy single voxel:  control right brain                                                                    Left temporal lesion





Findings:

Multiple ring-enhancing partially hemorrhagic mass lesions with restricted diffusion and high lactate (1.3 PPM)


DDX:

Metastases
Abscess
Subacute embolic infarcts


Diagnosis:

Left temporal biopsy revealed  gram positive cocci in clusters consistent with abscess.  Culture grew Strep milleri.


Discussion:

Restricted diffusion and elevated lactate with low NAA and choline favor brain abscess over metastases

Submitted by Kathleen Tozer, MD, UW Neuroradiology Fellow

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