Case Report

A girl with abscess cerebri, etiological

diagnosis: cyanotic heart disease, anatomical
diagnosis: tetralogy of fallot, functional
diagnosis: NYHA II, undernourished

Yanuar Nus Pitriandani

Supervisor:
dr. Mustarsid Sp..A (K)
dr. Sri Lilijanti W, Sp.A(K)
dr. Fadhilah Tia Nur, SpA (K) M.kes
Dr. Bagus Artiko Sp.A M.kes
 Introduction

Brain abscess is a frequent and serious complication of

Tetralogy of Fallot (TF)

Patient with TF particularly with highest hematocrit

(Hct) level have significant risks of the occurrence of
brain abscess

Goodunderstandingofthenaturalhistoryand
complicationsofthisdiseaseisveryimportant
for themanagementofpatients
2
 Patient Identity

Name S

Sex Female

Age 13 years old

32 kg
Body Weight/Height
144 cm

Medical record 01328933

Date of admission February 7th 2016

3
 Parent Identity
FATHER MOTHER

Name: Mr. S Name: Mrs. Y

Age : 38 y.o Age : 35 y.o

Education : Junior HS Education : Junior HS

Job : Labour Job : Housewife

Ras/religion : Java/Moslem Ras/religion : Java/Moslem

4
Chief complaint:

Right sided
weakness

5
History of Present
Illness

Baby 1 year old Childhood

Shortness Bluish Instinctive

of breath coloration ly squat
and rapid of the skin when she
breathing especially was
during nails and playing
feeding lips with her
friends
Her parents never took her to see a
doctor

6
 History of Present
Illness
Two weeks
Right sided
Easily got tired before weakness
after exercise admission
followed with headache
breathing No numbness
difficulty Headache No vision
Bluish No fever changes or
discoloration of language
the skin
No seizure problem
especially No changes in Slight difficulty
fingers and lips mental state in swallowing
Patient was No weakness No changes in
taken to RSDM or paralysis mental state
ECG & on one side of No seizure
Echocardiograp
y heart the body No fever
No vomiting No vomiting
defect
propanolol
4 years No language Three days
was given problem or
before
discharged before
vision
admission
her parents
changes
admission
never checked
her condition 7
History of Present
Illness
1 day before admission

Right sided weakness got worse could not lift a spoon

or glass

taken to RSDM
At emergency room;
Right sided weakness, headache
No fever, no vomiting, no vision changes, no mental state
changes
8
 Patient was
hospitalized with heart
Histor disease
No history of
y of hypertension
past No history of head
injury
illness No history of chronic
sinus or middle ear
infection
9
Familial No heart disease
history No hypertension

10
History
of Mother during pregnancy didnt feel sick,
routinely control and always consume
labour vitamin from midwife
Birth weight 2600 gram
and breathlessness (-), cyanotic (-)
No abnormality of labour and
pregnan pregnancy

cy
Breastfeeding until 1 year old,
Nutriti without formula milk
Eat three meals a day: meat, fish,
onal vegetables, eggs, fruits always
History finished her meal
Good in quantity and quality

11
 The development is
Growth and concordance with
developmen
tal history her age
Poor weight gain

Concordance with
health ministery
Immunizatio
n
department
programe

12
Pedigree

13
Nutritional Status
BW/A = 32/64 100% = 69,6%; BB/U = P3
underweight
BH/A = 144/157 x 100% = 91,7%; P3 < BH/A <
P10
stunted
BW/BH = 32/37 x 100% = 86,5%; P3 < BB/TB <
P10
undernourish

14
Conclusion : undernourished, underweight,
Physical
Examination
General appearance: cyanotic, fully alert,
undernourished
Heart rate: 100 beats/min, regularly,
adequate filling
Respiratory rate: 20 times/min, regularly
Temperature : 37.00 C
Blood pressure :90/60 mmHg
O2 saturation: 80-85% in four extremities
15
 General status
Head : Normocephal
Eye : anemic conjunctiva (-/-),
Icteric Sclera (-/-), pupils
equal, round, 2mm/2mm in size,
reactive to light
Nose : secret (-/-)
Ear : secret (-/-)
Mouth : cyanotic (+), mouth attracted
towards left side
Throat : hyperemic pharynx or tonsils (-),
uvula deviation to the left
Neck : JVP <5+2cmH2O
Thorax : retraction (-) 16
 General status
Cardiac :
I : ictus cordis not visible
P: ictus cordis palpable in ICS IV LMCS
P: up right heart border in ICS II LPSD, up left in ICS
II LPSS, right bottom in ICS IV LPSD, the apex in ISC
IV LMCS.
A: normally I-II heart sound, reguler, systolic
murmur grade II/III punctum maximum in ICS
II LPSS

17
 General status
Lung
I: wall movements were simetric on both
side
P: tactile fremitus was equal
P: sonor / sonor
A: vesicular sound (+/+), no additional
sounds

Abdominal
I: abdominal wall in line with chest wall,
A: peristaltic sound were normal
P: tympanic 18
 General status
Extremities :
warm, artery dorsalis pedis well palpable,
capillary refill time < 2 s
Cyanotic (+), edema (-), clubbing fingers (+)

19
 Neurological examination
Cranial nerve examination revealed paralysis
of N.VII, N.IX, N.X, NXI, N.XII

Muscle strength obtained a value of 3 on the

right arm and the value of 4 on the right leg

Pathological reflexes were negative

Physiological reflexes were within normal

limit

Sensory testing within normal limit

Meningeal signs were negative

20
Laboratory

Hb 22,1 g/dL, RBC 7.15x106/L, hematocrit

64%, WBC 8.6x103/L, platelet 165x103/L,
MCV 90.1/um, MCH 30.9 pg, MCHC 34,4 g/dl,
RDW 12.3%, MPV 9 fl, PDW 17%. eosinophils
0.10%, basophil 1,10%, netrophil 82.4%,
limphosit 11.8%, monosit 4.60%, random
blood glucose 103mg/dl, sodium 138 mmol/L,
kalium 4.2 mmol/L, calcium 1.18 mmol/L.

21
Electrocardiogram

sinus rhythm, heart beat107X/min, right axis deviation, right

ventricle hypertrophy

22
 Thorax x ray

Slight right ventricle hypertrophy,

23
 MSCT without
contrast

Brain abscess DD ischemic DD

mass
24
 List of problems
Easily got tired after
13 years old girl
exercise followed
Right sided weakness
with breathing
Headache
difficulty
No numbness, no Bluish discoloration of
vision changes or
the skin especially
language problem,
fingers and lips
no changes in mental Babyshortness of
state, no seizure, no
breath and rapid
fever, no vomiting
breathing during
Slight difficulty in
feeding
swallowing 1 year oldbluish
coloration of the
skin
25
 List of problems

Patient was hospitalized systolic murmur grade II/III
with heart disease punctum maximum in
ICS II LPSS
No history of
Clubbing fingers in four
hypertension extremities
No history of head injury Cranial nerve examination
No history of chronic revealed paralysis of
sinus or middle ear N.VII, N.IX, N.X, NXI,
infection N.XII
Poor weight gain Muscle strength obtained a
O2 saturation: 80-85% value of 3 on the right
in four extremities arm and the value of 4 on
Cyanotic of the lips and the right leg
Pathological and
fingers
physiological reflexes
Mouth attracted towards
were within normal limit
left side Sensory testing within
Uvula deviation to the normal limit
left Polycythemia 26
 List of problems

ECG: right axis

deviation, right
ventricle hypertrophy
Thorax x ray: Slight
right ventricle
hypertrophy
MSCT without
contrast: Brain
abscess DD ischemic
DD mass

27
Differential
diagnosis
1. Hemiparesis dextra due to dd:
-abscess cerebri ec cyanotic heart
disease
-acute ischemic stroke ec cyanotic heart
disease
-mass
2. Etiological diagnosis : suspected for
cyanotic heart disease, anatomical
diagnosis : suspected tetralogy of fallot
dd pulmonal stenosis, functional
diagnosis : NYHA II
28
 Working diagnosis
1. Suspected brain abscess

2. Etiological diagnosis : suspected for

cyanotic heart disease, anatomical
diagnosis : suspected tetralogy of fallot
dd pulmonal stenosis, functional
diagnosis : NYHA II

3. Undernourished, underweight, stunted

29
 Therapy
1. Admitted to cardiology ward joint responsibility
with neurology department
2. Nasal O2 2 lpm
3. Cardiac diet IV 1700 kkal/day
4. Ceftriaxone (50mg/kg/12 hr)- 1 gram/12 hr iv
5. Metronidazole loading dose 15mg/kg- 450 mg
7,5 mg/kg/8 hr- 225mg/8 hr
6. Manitol (0,5 gr/kg/8 hr)- 75 ml/8 jam
7. Propanolol (0,02mg/kg/kali)- 2x5 mg
8. knee chest position when sianotic spell

30
 Plan

1. Echocardiography
2. Catheterization
3. Head MRI with contrast
4. Consult to neurosurgery department after
MRI is performed

31
PATIENT
MONITORING

32
DATE February 8th , 2016
Right sided weakness, headache
S Fluid balance was +73 ml/day, diuresis was 1.11 ml/body
weight/hour
Moderate sickness, fully alert, undernourished
Anemic Conjuntiva (+/+)
BP: 100/70 mmHg, HR:102x/ RR: 20x/ t: 36.8oC, O2 saturation
80%-85%
Mouth attracted towards left side
Uvula deviation to the left
systolic murmur grade II/III punctum maximum in ICS II LPSS
Clubbing fingers in four extremities
O Cranial nerve examination revealed paralysis of N.VII, N.IX, N.X,
NXI, N.XII
Muscle strength obtained a value of 3 on the right arm and the
value of 4 on the right leg
Pathological reflexes were negative and physiological reflexes
were within normal limit
Sensory testing within normal limit
Meningeal signs were negative

1.Suspected brain abscess 33

2.Etiological diagnosis : suspected for cyanotic heart disease,
DATE February 8th 2016

1. Admitted to cardiology ward joint responsibility

with neurology department
2. Nasal O2 2 lpm
3. Cardiac diet IV 1700 kcal/day
4. Ceftriaxone (50mg/kg/12 hr)- 1 gram/12 h iv
Tx 5. Metronidazole loading dose 15mg/kg- 450 mg
7,5 mg/kg/8 h- 225mg/8 hr
6. Manitol (0,5 gr/kg/8 h)- 75 ml/8 h
7. Propanolol (0,02mg/kg/dose)- 2x5 mg
8. knee chest position when sianotic spell

1. Echocardiography (February 9, 2016)

2. Catheterization
3. Head MRI with contrast
P
4. Consult to neurosurgery department after MRI
is performed 34
DATE February 9th , 2016
Right sided weakness, headache
S Fluid balance was +53 ml/day, diuresis was 1.01ml/body
weight/hour
Moderate sickness, fully alert, undernourished
Anemic Conjuntiva (+/+)
BP: 90/60 mmHg, HR: 101x/ RR: 20x/ t: 36.7oC O2 saturation
80-85%
Mouth attracted towards left side
Uvula deviation to the left
systolic murmur grade II/III punctum maximum in ICS II LPSS
Clubbing fingers in four extremities
O Cranial nerve examination revealed paralysis of N.VII, N.IX, N.X,
NXI, N.XII
Muscle strength obtained a value of 3 on the right arm and the
value of 4 on the right leg
Pathological reflexes were negative and physiological reflexes
were within normal limit
Sensory testing within normal limit
Meningeal signs were negative

1.Suspected brain abscess

2.Etiological diagnosis : cyanotic heart disease,35 anatomical
A diagnosis : tetralogy of fallot, functional diagnosis : NYHA II
 Echocardiography

VSD SADC diameter1,7 cm L to R shunt, severe

PS 70,78 mmHg, Overriding aorta>50%, RVH,
EF: 63%, LA/Ao: 0,85, left Arkus Aorta , no
Coartasio aorta .TOF.

36
DATE February 9th 2016

1. Nasal O2 2 lpm
2. Cardiac diet IV 1700 kcal/day
3. Ceftriaxone (50mg/kg/12 hr)- 1 gram/12 h iv
4. Metronidazole loading dose 15mg/kg- 450 mg
7,5 mg/kg/8 h- 225mg/8 hr
Tx
5. Manitol (0,5 gr/kg/8 h)- 75 ml/8 h
6. Propanolol (0,02mg/kg/dose)- 2x5 mg
7. knee chest position when sianotic spell
8. Passive general exercise

1. Catheterization
2. Head MRI with contrast (February 15th 2016)
P
3. Consult to neurosurgery department after MRI
is performed 37
DATE February 15th , 2016
Right sided weakness, headache
S Fluid balance was +73 ml/day, diuresis was 1.2ml/body
weight/hour
Moderate sickness, fully alert, undernourished
Anemic Conjuntiva (+/+)
BP: 90/60 mmHg, HR: 100x/ RR: 20x/ t: 36.8oC O2 saturation
80-85%
Mouth attracted towards left side
Uvula deviation to the left
systolic murmur grade II/III punctum maximum in ICS II LPSS
Clubbing fingers in four extremities
O Cranial nerve examination revealed paralysis of N.VII, N.IX, N.X,
NXI, N.XII
Muscle strength obtained a value of 3 on the right arm and the
value of 4 on the right leg
Pathological reflexes were negative and physiological reflexes
were within normal limit
Sensory testing within normal limit
Meningeal signs were negative

1.Brain abscess parietal lobe

2.Etiological diagnosis : cyanotic heart disease,38 anatomical
A diagnosis : tetralogy of fallot, functional diagnosis : NYHA II
DATE February 9th 2016

1. Nasal O2 2 lpm
2. Cardiac diet IV 1700 kcal/day
3. Ceftriaxone (50mg/kg/12 hr)- 1 gram/12 h iv
4. Metronidazole loading dose 15mg/kg- 450 mg
7,5 mg/kg/8 h- 225mg/8 hr
Tx
5. Manitol (0,5 gr/kg/8 h)- 75 ml/8 h
6. Propanolol (0,02mg/kg/dose)- 2x5 mg
7. knee chest position when sianotic spell
8. Passive general exercise

1. Catheterization
2. Head MRI with contrast (February 15th 2016)
P
3. Consult to neurosurgery department after MRI
is performed 39
 MRI with contrast

Abscess cerebri parietal lobe

40
Case Analysis

41
 Cyanotic heart
disease Hyper
polysitemi viscosit
a y of the
blood

Hypo
perfusio
n
Chronic
hypoxemia

Prone to
seeding by
micro
organism

42
Tetralogy of fallot

43
Tetralogy of fallot
Bluish coloration of lips
and fingers

Baby: shortness of
Clinical manifestation In this
breath andpatient
rapid
Bluish coloration of the breathing during
skin feeding

shortness of breath and

Poor weight gain
rapid breathing during
feeding
easily got tired after
exercise
Poor weight gain
Instinctively squat when
easily got tired after she was playing with
exercise her friends

squatting
44
 Bluish coloration of

Tetralogy of fallot
lips and fingers

systolic murmur
Physical examination In this
grade patient
II/III punctum
maximum in ICS II
A bluish coloration LPSS
of the skin
Clubbing fingers in
Systolic ejection four extremities
murmur along left
sternal border Blood saturation 80-
85%
Clubbing fingers

45
Tetralogy of fallot
Electrocardiography In this patient

RVH

Prominent P waves RVH

Right atrial Right axis deviation

enlargement

Right axis deviation

46
Tetralogy of fallot
Echocardiography In this patient

VSD
VSD

Overriding aorta
Overriding aorta
PS
PS
RVH
RVH

47
Tetralogy of fallot
Chest x ray In this patient

Right ventricle
Slight right ventricle
hypertrophy hypertrophy
Boot shape heart

Decrease
pulmonary vascular
marking

48
Abscess cerebri
Clinical manifestation This Patient

Headache

Hemiparesis

GCS 15

Paralysis of N. VII,
IX, X, XI, XII

49
Abscess cerebri
hemiparesis
Physical examination In this patient
Hemiparesis
Neurological deficit
GCS 15
Altered level of
conciousness Paralysis of N. VII,
IX, X, XI, XII
Papiledema

Cranial nerve
paresis

50
Abscess cerebri
ring of iso- or hyperdense
Head MRI with contrast In this patient
tissue

central low attenuation

(fluid/pus)

surrounding low density

(vasogenic oedema)

ventriculitis may be
present, seen as
enhancement of the
ependyma

obstructive hydrocephalus
will commonly be seen
when intraventricular
spread has occurred 51
Abscess cerebri
ring of iso- or hyperdense
Head MSCT without contrast In this patient
tissue

central low attenuation

(fluid/pus)

surrounding low density

(vasogenic oedema)

ventriculitis may be
present, seen as
enhancement of the
ependyma

obstructive hydrocephalus
will commonly be seen
when intraventricular
spread has occurred 52
Thank You

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