Cerebral Abscess Due to Persistent Left Superior Vena Cava Draining Into the Left Atrium

A 47-year-old woman with a history of paroxysmal atrial fibrillation presented with seizure. She noted progressive fatigue in the preceding 6 months. The week before admission, she had worsening headaches and increased irritability. On the day of admission, she developed an episode of grand-mal seizure. MRI of the brain revealed a round lesion in the left frontal lobe measuring 11 cm by 15 mm with an extensive halo of T2 hyperintensity surrounding the lesion and minimal inherent T1 high signal along the border. The lesion was suspicious for an abscess. She was taken to the operating room for biopsy. Craniotomy and corticectomy revealed an abscess cavity with a large amount of purulent material. Culture of the purulent drainage grew Streptococcus intermedius. She was started on penicillin G and metronidazole.A transthoracic echocardiogram revealed normal right and left ventricular size and function (Movie I in the online-only Data Supplement). There was mild left atrial enlargement without evidence for significant valvular abnormalities. Doppler interrogation of the septum in the subcostal view revealed abnormal color flow in the inferoposterior part of the interatrial septum suspicious for a left-to-right shunt (Figure 1 and Movie II in the online-only Data Supplement). Chest x-ray to confirm placement of a peripherally inserted central catheter line showed the tip of the line overlying a left-sided superior vena cava (Figure 2).Figure 1. Transthoracic echocardiogram images in the subcostal view with Doppler interrogation of the septum …