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

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