Multiple Brain Abscesses Due to Odontogenic Infection
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Multiple Brain Abscesses Due to Odontogenic Infection Nicolas Alejandro Gemelli1*, Luis Alejandro Boccalatte2 and Nicolas Marcelo Ciarrocchi1 © 2020 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society
A 71-year-old female patient, with history of biological mitral valve replacement due to severe insufficiency, pulmonary hypertension type II, and atrial fibrillation treated with acenocumarol, presented to the emergency department with a 24-hour history of altered mental status, asthenia, adynamia, and dyspnea. Relatives did not account for nausea, vomiting, seizures, or headaches. At physical examination, she was febrile (38.7 °C), saturating 85%, with pulmonary crackles. She was confused, disoriented in time and space with inattention, showing difficulty following commands. The language was unaltered, no signs of focal deficit were found, and cranial nerves were preserved. Kernig and Brudzinski signs were negative. The rest of the neurological examination was unremarkable. Endooral exploration revealed poor condition of dental pieces with signs of periodontal disease and multiple tooth plaques. Admission laboratory test results are shown in Table 1. Endotracheal intubation was performed, requiring vasopressors after the administration of sedative drugs. Blood cultures were taken, and empirical antibiotic treatment with vancomycin 1000 mg every 12 h (with previous load dose) and piperacillin 4000 mg–tazobactam 500 mg every 6 h was initiated. Chest computed tomography (CT) revealed bilateral lung consolidation. The patient was transferred to the intensive care unit showing a clear improvement of her respiratory function after 48 h of treatment. After removal of sedative drugs, the patient persisted disoriented and inattentive, so brain and maxillofacial CT scan without intravenous contrast was obtained (Fig. 1a, b), showing a hypodense fluid collection with gas bubbles in teeth 16 and 17 together *Correspondence: [email protected] 1 Adult Intensive Care Department, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH Buenos Aires, Argentina Full list of author information is available at the end of the article
with multiple brain lesions. Magnetic resonance imaging (MRI) of the brain showed 38 supra- and infratentorial nodular bilateral high-signal lesions in T2 sequence with central restriction in diffusion-weighted imaging with perilesional edema (Fig. 2a–c). Blood cultures revealed the presence of Aggregatibacter aphrophilus (HACEK group), and antibiotics were rotated to ceftriaxone 2 grams every 12 h. HIV test was negative. Findings in one transthoracic and two separate transesophageal echocardiograms did not reveal vegetations, right–left shunts, or other signs linked to endocarditis. Lumbar puncture and cerebrospinal fluid analysis and culture were negative for meningeal infection with negative Indian ink and negative protein chain reaction tests for Toxoplasma and Mycobacteria. New chest CT demonstrated the presence o
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