Sepsis-Associated Encephalopathy with Multiple Microbleeds in Cerebral White Matter

A 66-year-old man with prolonged fever and diarrhea progressed into a coma and was brought to our hospital. He had eaten raw venison 3 days prior to the onset of his symptoms. The temperature was 39.5°C, respiratory rate was 30 breaths per minute, pulse was 130 beats per minute, and blood pressure was 70/50 mm Hg. On neurologic examination, the Glasgow Coma Scale (GCS) score was 11 (E4V2M5). There were no meningeal signs. A computed tomography scan of the whole body demonstrated air fluid levels within the small and large intestines. Blood and stool cultures taken at the time of admission yielded positive results for Lactobacillus spp. and anaerobes. Although his general conditions were stabilized in a moment, he remained in comatose status despite the absence of sedatives. On day 15, his GCS score was 3 (E1V1M1). Brain magnetic resonance imaging (MRI) showed a symmetric, enhanced fluid-attenuated inversion recovery (FLAIR) signal in the white matter (Figure, A). Susceptibility-weighted imaging (SWI) revealed multiple microbleeds in the white matter (Figure, B). Electroencephalography showed a diffuse nonspecific background theta wave without any epileptic discharge. His cerebrospinal fluid showed normal cell counts and glucose level, a protein level of 206 mg/dL, and an elevated immunoglobulin G index (0.75; normal range <0.73) and interleukin 6 level (13.8 pg/mL; normal <4 pg/mL). We made a diagnosis of sepsis-associated encephalopathy. MRI showed a reduction in the enhancement on FLAIR in the white matter and brain atrophy on day 60 (Figure, C). The multiple microbleeds in the white matter persisted with no changes on SWI. Although the findings on MRI improved gradually, the GCS score was 7 (E4V1M2), without significant neurological recovery.