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A 52-year-old diabetic Indian man presented with a 2-week history of headache and fever. He had no evidence of meningism. There was mild polymorph leucocytosis and raised erythrocyte sedimentation rate of 113 mm/h. Other investigations, including tests for human immunodeficiency virus and immunoglobulins, yielded negative or normal results. Initial skull X-ray and brain computed tomography (CT) scan were normal. Three days later, he was found to have subcutaneous swelling over the left frontoparietal region of the scalp. Incision drainage revealed a subaponeurotic abscess in direct contact with the bone. Pseudomonas cepacia was grown from pus and treated with appropriate antibiotics. Fever and headache settled and he became asymptomatic after few days. Two weeks later, a discharging sinus with serosanguinous material from the scalp wound was noted. At this point, osteomyelitis of the cranial vault was clearly seen on plain skull X-ray (figure 1). A follow-up brain CT scan showed left-sided soft tissue swelling and multiple ring-enhancing frontal lobe abscesses (figure 2). Surprisingly, apart from the scalp discharge, he remained asymptomatic. P cepacia was again grown from the wound and treated with a combination of piperacillin and ceftazidime. Three weeks later, a repeat CT scan showed marked improvement of his intracerebral and scalp lesions. The antibiotics were continued for another 3 weeks. This case demonstrates that even a minor superficial suppurative lesion has the potential to become sinister in an immunocompromised subject, as it may rapidly extend to deeper tissues. Moreover, the diagnosis of these multiple and apparently silent cerebral abscesses would have been delayed if repeated radiological imaging had not been undertaken.
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