- Email: [email protected]
Multiple brain abscesses after professional tooth cleaning: Case report and literature review
Accepted Manuscript Title: Multiple brain abscess after professional tooth cleaning: case report and literature review Author: Massimo Viviano Serena Cocca PII: DOI: Reference:
S2468-7855(18)30108-3 https://doi.org/doi:10.1016/j.jormas.2018.04.016 JORMAS 183
To appear in: Received date: Accepted date:
6-5-2017 30-4-2018
Please cite this article as: Massimo VivianoSerena Cocca Multiple brain abscess after professional tooth cleaning: case report and literature review (2018), https://doi.org/10.1016/j.jormas.2018.04.016 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Multiple brain abscess after professional tooth cleaning: case report and literature review.
Massimo Viviano, Serena Cocca, M.D
ip t
University of Siena First Author: Massimo Viviano, MD
cr
ABSTRACT
Brain abscess (BA) is an encapsulated infection and can be the consequence of head and
us
cranio-maxillo-facial surgery or trauma, or may be secondary to cavernous thrombophlebitis, but is most frequently due to hematogenous septic dissemination from
an
an adjacent site of infection, such as the paranasal sinuses, middle ear or oral cavity. We report a rare and unfortunate case of multiple BA caused by dental procedures in a young man with undiagnosed patent foramen ovale (PFO).
M
Simple routine dental procedures, such as tooth brushing and professional oral hygiene, can predispose to life-threatening conditions.
d
This case report and literature review highlights that multiple BA after professional tooth cleaning is extremely rare, but cardiac defects (in first place PFO which is a
Ac ce pt e
potential source of paradoxical embolism) promote BA formation.
Key words: oral hygiene, brain abscess, patent foramen ovale, periodontitis, odontogenic, tooth brushing.
Page 1 of 13
2
TEXT
Introduction Brain abscess (BA) is a focal purulent encapsulated infection. It may involve different regions of the brain but mainly the frontal lobe, temporal lobe and cerebellar area [1]. It
ip t
can be a consequence of head and cranio-maxillo-facial surgery, or secondary to
cavernous thrombophlebitis, but is most often due to hematogenous septic
cr
dissemination from a primary focus at a distant site (i.e. bacterial endocarditis) [2]. It
may also arise by dissemination from an adjacent site of infection, such as the paranasal
us
sinuses, middle ear, teeth and gums. No underlying cause of infection is found in 1060% of patients with BA. Such abscesses are termed cryptogenic.
Predisposing conditions may be diabetes, organ transplant, steroid therapy, congenital
an
hypogammaglobulinemia, myelodysplasia and cyanotic congenital heart disease. In adults, BA due to paradoxical embolism is a rare complication of patent foramen ovale
M
(PFO) [3].
d
Case report
A healthy 28-year-old male patient was admitted to our hospital with fever (38.5°C),
Ac ce pt e
severe headache, nuchal pain and vomiting. Previous medical history included frequent sinusitis. Recent medical history was negative for head trauma, falls, flu, medications and drug abuse. The patient was given antipyretics to control fever. No other pathology was noted. Seven days previously the patient had undergone oral hygiene with scaling and root planing. He experienced generalized malaise after the treatment and five days later manifested fever and vomiting without nausea. Initially clinical presentation was without any focal neurological deficit or confusion, however level of consciousness decreased rapidly and the patient experienced nuchal stiffness, photophobia and high fever.
Routine blood tests showed slightly elevated Reactive C Protein (1.08 mg/dl) with normal white cell count, liver enzymes and renal function parameters. Blood cultures were negative. Emergency regimen included basic electrocardiogram (ECG) and imaging. The ECG showed negative T waves in D3 and QRS abnormalities: strange findings considering
Page 2 of 13
3
the patient's age and clinical history. Echocardiography showed mitral and aortic valve insufficiency, bicuspid aortic valve with without stenosis, minor tricuspid valve regurgitation/insufficiency, normal pulmonary artery pressure and cardiac thickness and volume within normal limits. No valve vegetations were found. A trans-esophageal echocardiogram (TEE) with Doppler effect revealed persistent foramen ovale (PFO)
ip t
(diameter about 3 mm) showing a small right-to-left shunt. No bubble study was
performed due to low patient compliance. The patent was unaware that he had
cr
congenital heart disease.
After laboratory and clinical examination, a computed-tomography (CT) scan of the
us
brain detected two low density lesions, similar to infarctions, in the left occipital and left parietal lobes (Figure 1, 2). Brain magnetic resonance imaging with perfusion and diffusion enhancement showed two ring-enhancing lesions: the larger was in the left
an
occipital region (21 x 18 mm maximum axial dimension), the smaller (15 x 8 mm) in the parietal lobe (Figure 3). The lesions showed perilesional edema that had a
M
compressive effect on the parenchymal structures and ventricles. The hypothesis of brain tumor was excluded due to absence of capillary formation and presence of areas of
abdominal ultrasound scan.
d
necrosis. No evidence of lesions elsewhere in the body was obtained by chest x-ray and
Ac ce pt e
To identify the source of infection, we concentrated on the head and neck area. Ear and nose infections were excluded clinically and CT scan of the paranasal sinuses was negative. Oral examination and orthopantomogram confirmed the absence of dental caries and periapical pathology but showed widespread evidence of gingivitis (Figure 4).
The patient was conscious, with no epileptic seizures, and was medicated empirically with intravenous ceftriaxone (2000 mg twice daily), metronidazole (500 mg three times daily), vancomycin (1000 mg twice daily) and anti-edema therapy (mannitol 18% 2 g/Kg/day i.v.; dexamethasone 1 mg/Kg/day i.v.). In the absence of improvement after 9 days of empirical therapy, the neurosurgeons opted for craniotomy and drainage of pus from the two abscesses: the smaller in the left parietal lobe and the larger in the occipital lobe. Purulent material was routinely cultured to isolate organisms. Two tissue specimens were submitted for pathology examination. The infectious disease specialist requested microbiological culture of
Page 3 of 13
4
saliva from the periodontal pocket, because the patient had recently undergone oral hygiene intervention. Cytological examination showed necrotic debris, neutrophilic granulocytes and corpuscles consistent with bacteria (some Gram-positive). Histochemistry (tissue-Gram stain) confirmed the presence of major filamentous bacteria Streptococcus intermedius
ip t
and Actinomyces. Microbiological culture of saliva confirmed the presence of Streptococcus intermedius and Actinomyces in addition to normal oral saprophytic flora.
cr
Infectious disease specialists suggested therapy with clindamycin 600 mg/day, ampicillin 3 g/day associated with anticonvulsant (levetiracetam 1 g twice a day) and
us
antithrombotic therapy with enoxaparin sc 4000 IU/daily.
Repeated after surgery, CT scan showed partial recovery of the lesion and slight reduction in edema. Seven days later, after overall clinical improvement, the patient was
an
reassessed: neurological exam was normal, ECG and TEE were unchanged, HIV test negative, Mantoux test negative, C-reactive protein normal, no histochemical evidence
M
of increased inflammatory protein, T and B cell counts normal.
After 36 days, the patient was discharged on prolonged antimicrobial therapy and
d
referred to a cardiologist for correction of PFO. Home therapy was continued for more than 2 months: amocillin+clavulanate 3 g/day, clindamycin 150 mg four times daily,
Ac ce pt e
antiepileptic therapy (levetiracetam 500 mg twice daily), Lactobacillus acidophilus (twice daily). It was suspended when symptoms improved and when there was no longer contrast-enhanced Magnetic Resonance Imaging (MRI) evidence of brain lesions. Five months after surgery, brain MRI showed nearly complete resolution of the brain abscesses.
Discussion
A literature search conducted in PubMed, Scopus, Springerlink, Sage Journal Online, ScienceDirect and Wiley Online Library.and other health journals between 1990 and 2017using re“brain abscess” AND “tooth cleaning”, “periodontology”, “periodontitis”, “cardiac defect”s, “PFO”, “pyorrhea”, “odontogenic”, “Actinomyces”, “Streptococcus intermedius”, “multiple brain abscess" as search terms, showed that brain abscesses are an extremely rare complication following professional tooth cleaning. Approximately 60% of brain abscesses are multimicrobial (i.e. streptococci, staphylococci, enteric and
Page 4 of 13
5
anaerobic bacteria) and microbes vary in relation to patent age and the underlying medical or surgical condition. The oral cavity hosts abundant heterogeneous microflora. More than 1200 different types of microbes have been identified in the human mouth (Human Microbiome Project) [13]. 350 different bacterial strains have been isolated in marginal periodontitis
ip t
and 150 in endodontic infections.
Oral cavity microorganisms may reach the brain by different routes: 1) systemic
cr
hematogenous bacteremia, 2) direct venous drainage, 3) lymphatic route, 4) direct extension through the fascial planes [5].
us
Dental conditions that predispose to bacterial dissemination are gingivitis, periodontitis and procedures such as tooth extractions, endodontic treatments and oral surgery [1,6,7]. Even simple tooth brushing has been shown to induce transient bacteremia: it is
an
reasonable to believe that the bacterial load could be significantly greater in persons with poor dental hygiene [8].
M
More invasive dental procedures may induce massive bacteremia [8,9]: in healthy subjects these microorganisms are quickly eliminated by the reticuloendothelial system.
d
However, a heart defect such as patent foramen ovale (PFO) or a pulmonary arteriovenous fistula may form a shunt, allowing bacteria to bypass the pulmonary
Ac ce pt e
circulation [1,3,10]. For example, a right-to-left shunt would bypass these defenses and allow bacteria to enter the arterial circulation and reach the brain [11]. In the study by Moazzam et al. [5], 60% of a total 57 patients with brain abscess had undergone tooth extractions but only 4% had undergone scaling and root planing. The literature suggests that brain abscess formation after professional tooth cleaning is extremely rare [6]. Periodontal inflammation and flora normally found in the oral cavity can therefore be a cause of brain abscess. . The relationship between brain abscesses and professional tooth cleaning is substantiated by the finding of causal organisms in both oral and cranial sites [12,13] as in our patient.
The diagnosis of BA is sustained by contrast-enhanced MRI, where the abscesses appears as typical ring-like structures surrounded by edema. Differential diagnosis between brain abscess and tumor is of extreme importance, infection being
Page 5 of 13
6
differentiated from neoplastic disease by virtue of hyperintense signals in diffusionweighted MRI scans [6]. In a recent study [14], it has been used the (18)F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) to detect a chronic odontogenic infection as the possible origin of a BA. This represents a pioneering study that could represent a new
ip t
diagnostic approach in the future.
In case of known heart defects, simple antibiotic prophylaxis before the dental
cr
procedure reduces the probability of such cases of infectious complications.
All patients developing a brain abscess caused by flora commonly found in the
us
oropharynx should be screened for PFO.
Regarding the scientific literature, there was only one case about the relationship between brain abscess and professional tooth cleaning [6]. The first therapy of BA
an
associated with PFO includes immediate high-dose intravenous antibiotics and surgical evacuation of the abscess. Third-generation cephalosporin and metronidazole are
M
recommended empirically [6] and vancomycin may be added in cases of infection with multiresistant bacteria. Several antibiotics with an extended spectrum of activity should
d
be administered in combination at the beginning of treatment. Antibiotic therapy should then be prolonged until there is no radiographic evidence of BA and serial blood
Ac ce pt e
cultures are negative. Definitive treatment requires closure of PFO, because anticoagulation alone does not prevent embolisms [15]. Finally, to reduce the risk of BA in patients with cardiac defects, excellent oral hygiene and antibiotic therapy before dental procedures are recommended.
Disclosure of interest
The authors declare that they had no competing interests or financial support for this study.
Page 6 of 13
7
LEGENDS
Figure 1. CT scan (axial view) showing brain abscess in the left parietal lobe. Figure 2. CT scan (axial view) showing abscess in the left occipital lobe. Figure 3. RMI (sagittal view) showing multiple ring-enhancing lesions in the left
ip t
parietal and occipital lobes.
Figure 4. Orthopantomogram showing absence of periapical pathology and dental
Ac ce pt e
d
M
an
us
cr
caries and presence of a small periodontal defect between teeth 26 and 27.
Page 7 of 13
8
REFERENCES [1] Milli B, Rocci A, Paganelli E, Degli Antoni G, Monaco D, Quintavalla R. Brain
abscess of odontogenic origin in a man with interatrial defect. Acta Biomed 2010;81:225-9. [2] Sonneville R, Ruimy R, Benzonana N, Riffaud L, Carsin A, Tadié JM, et al. An
ip t
update on bacterial brain abscess in immunocompetent patients. Clin Microbiol Infect 2017;23:614-20.
cr
[3] Khouzam RN, El-Dokla AM, Menkes DL. Undiagnosed patent foramen ovale
presenting as a cryptogenic brain abscess: case report and review of the literature.
us
Heart Lung 2006;35:108-11.
[4] Dewhirst FE, Chen T, Izard J, et al. The human oral microbiome. J Bacteriol
2010;192:5002–17.
an
[5] Moazzam A, Rajagopal SM, Sedghizadeh PP, Zada G, Habibian M. Intracranial
bacterial infections of oral origin. J Clin Neurosci 2015;22:800-6.
M
[6] Pallesen LP, Schaefer J, Reuner U, Leonhardt H, Engellandt K, Schneider H, et
al. Multiple brain abscesses in an immunocompetent patient after undergoing
d
professional tooth cleaning. J Am Dent Assoc 2014;145:564-8. [7] Rae Yoo J, Taek Heo S, Kim M, Lee CS, Kim YR. Porphyromonas gingivalis
abscess in
patient
Ac ce pt e
causing brain
with
recurrent periodontitis.
Anaerobe
2016;39:165-7.
[8] Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ, Bahrani-Mougeot FK.
Bacteremia associated with toothbrushing and dental extraction. Circulation 2008;117:3118-25.
[9] Clancy U, Ronayne A, Prentice MB, Jackson A. Actinomyces meyeri brain
abscess
following
dental
extraction.
BMJ
Case
Rep. 2015;2015.
pii:
bcr2014207548
[10] Sadahiro H, Nomura S, Inamura A, Yamane A, Sugimoto K, Fujiyama Y, et al.
Brain abscess associated with patent
foramen ovale. Acta Neurochir
(Wien) 2014;156:1971-6. [11] Han SR, Choi CY, Kwak JJ. Prevotella brain abscess in a healthy young patient
with a patent foramen ovale. Clin Neurol Neurosurg 2016;142:128-31.
Page 8 of 13
9
[12] Mueller AA, Saldamli B, Stübinger S, Walter C, Flückiger U, Merlo A. Oral
bacterial cultures in nontraumatic brain abscesses: results of a first-line study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:469-76. [13] Rahamat-Langendoen JC, van Vonderen MG, Engström LJ, Manson WL, van
Winkelhoff
AJ,
Mooi-Kokenberg
EA.
Brain
abscess
associated
with
ip t
Aggregatibacter actinomycetemcomitans: case report and review of literature. J Clin Periodontol 2011;38:702-6.
cr
[14] Sato J, Kuroshima T, Wada M, Satoh A, Watanabe S, Okamoto S, Shiga T,
Tamaki N, Kitagawa Y. Use of FDG-PET to detect a chronic odontogenic
us
infection as a possible source of the brain abscess. Odontology 2016;104:239-43. [15] LaBarbera M, Berkowitz MJ, Shah A, Slater J. Percutaneous PFO closure for the
prevention of recurrent brain abscess. Catheter Cardiovasc Interv 2006;68:957-
Ac ce pt e
d
M
an
60.
Page 9 of 13
d
Ac ce pt e us
an
M
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ip t
10
Page 10 of 13
d
Ac ce pt e us
an
M
cr
ip t
11
Page 11 of 13
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an
M
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ip t
12
Page 12 of 13
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Page 13 of 13
S2468-7855(18)30108-3 https://doi.org/doi:10.1016/j.jormas.2018.04.016 JORMAS 183
To appear in: Received date: Accepted date:
6-5-2017 30-4-2018
Please cite this article as: Massimo VivianoSerena Cocca Multiple brain abscess after professional tooth cleaning: case report and literature review (2018), https://doi.org/10.1016/j.jormas.2018.04.016 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
Multiple brain abscess after professional tooth cleaning: case report and literature review.
Massimo Viviano, Serena Cocca, M.D
ip t
University of Siena First Author: Massimo Viviano, MD
cr
ABSTRACT
Brain abscess (BA) is an encapsulated infection and can be the consequence of head and
us
cranio-maxillo-facial surgery or trauma, or may be secondary to cavernous thrombophlebitis, but is most frequently due to hematogenous septic dissemination from
an
an adjacent site of infection, such as the paranasal sinuses, middle ear or oral cavity. We report a rare and unfortunate case of multiple BA caused by dental procedures in a young man with undiagnosed patent foramen ovale (PFO).
M
Simple routine dental procedures, such as tooth brushing and professional oral hygiene, can predispose to life-threatening conditions.
d
This case report and literature review highlights that multiple BA after professional tooth cleaning is extremely rare, but cardiac defects (in first place PFO which is a
Ac ce pt e
potential source of paradoxical embolism) promote BA formation.
Key words: oral hygiene, brain abscess, patent foramen ovale, periodontitis, odontogenic, tooth brushing.
Page 1 of 13
2
TEXT
Introduction Brain abscess (BA) is a focal purulent encapsulated infection. It may involve different regions of the brain but mainly the frontal lobe, temporal lobe and cerebellar area [1]. It
ip t
can be a consequence of head and cranio-maxillo-facial surgery, or secondary to
cavernous thrombophlebitis, but is most often due to hematogenous septic
cr
dissemination from a primary focus at a distant site (i.e. bacterial endocarditis) [2]. It
may also arise by dissemination from an adjacent site of infection, such as the paranasal
us
sinuses, middle ear, teeth and gums. No underlying cause of infection is found in 1060% of patients with BA. Such abscesses are termed cryptogenic.
Predisposing conditions may be diabetes, organ transplant, steroid therapy, congenital
an
hypogammaglobulinemia, myelodysplasia and cyanotic congenital heart disease. In adults, BA due to paradoxical embolism is a rare complication of patent foramen ovale
M
(PFO) [3].
d
Case report
A healthy 28-year-old male patient was admitted to our hospital with fever (38.5°C),
Ac ce pt e
severe headache, nuchal pain and vomiting. Previous medical history included frequent sinusitis. Recent medical history was negative for head trauma, falls, flu, medications and drug abuse. The patient was given antipyretics to control fever. No other pathology was noted. Seven days previously the patient had undergone oral hygiene with scaling and root planing. He experienced generalized malaise after the treatment and five days later manifested fever and vomiting without nausea. Initially clinical presentation was without any focal neurological deficit or confusion, however level of consciousness decreased rapidly and the patient experienced nuchal stiffness, photophobia and high fever.
Routine blood tests showed slightly elevated Reactive C Protein (1.08 mg/dl) with normal white cell count, liver enzymes and renal function parameters. Blood cultures were negative. Emergency regimen included basic electrocardiogram (ECG) and imaging. The ECG showed negative T waves in D3 and QRS abnormalities: strange findings considering
Page 2 of 13
3
the patient's age and clinical history. Echocardiography showed mitral and aortic valve insufficiency, bicuspid aortic valve with without stenosis, minor tricuspid valve regurgitation/insufficiency, normal pulmonary artery pressure and cardiac thickness and volume within normal limits. No valve vegetations were found. A trans-esophageal echocardiogram (TEE) with Doppler effect revealed persistent foramen ovale (PFO)
ip t
(diameter about 3 mm) showing a small right-to-left shunt. No bubble study was
performed due to low patient compliance. The patent was unaware that he had
cr
congenital heart disease.
After laboratory and clinical examination, a computed-tomography (CT) scan of the
us
brain detected two low density lesions, similar to infarctions, in the left occipital and left parietal lobes (Figure 1, 2). Brain magnetic resonance imaging with perfusion and diffusion enhancement showed two ring-enhancing lesions: the larger was in the left
an
occipital region (21 x 18 mm maximum axial dimension), the smaller (15 x 8 mm) in the parietal lobe (Figure 3). The lesions showed perilesional edema that had a
M
compressive effect on the parenchymal structures and ventricles. The hypothesis of brain tumor was excluded due to absence of capillary formation and presence of areas of
abdominal ultrasound scan.
d
necrosis. No evidence of lesions elsewhere in the body was obtained by chest x-ray and
Ac ce pt e
To identify the source of infection, we concentrated on the head and neck area. Ear and nose infections were excluded clinically and CT scan of the paranasal sinuses was negative. Oral examination and orthopantomogram confirmed the absence of dental caries and periapical pathology but showed widespread evidence of gingivitis (Figure 4).
The patient was conscious, with no epileptic seizures, and was medicated empirically with intravenous ceftriaxone (2000 mg twice daily), metronidazole (500 mg three times daily), vancomycin (1000 mg twice daily) and anti-edema therapy (mannitol 18% 2 g/Kg/day i.v.; dexamethasone 1 mg/Kg/day i.v.). In the absence of improvement after 9 days of empirical therapy, the neurosurgeons opted for craniotomy and drainage of pus from the two abscesses: the smaller in the left parietal lobe and the larger in the occipital lobe. Purulent material was routinely cultured to isolate organisms. Two tissue specimens were submitted for pathology examination. The infectious disease specialist requested microbiological culture of
Page 3 of 13
4
saliva from the periodontal pocket, because the patient had recently undergone oral hygiene intervention. Cytological examination showed necrotic debris, neutrophilic granulocytes and corpuscles consistent with bacteria (some Gram-positive). Histochemistry (tissue-Gram stain) confirmed the presence of major filamentous bacteria Streptococcus intermedius
ip t
and Actinomyces. Microbiological culture of saliva confirmed the presence of Streptococcus intermedius and Actinomyces in addition to normal oral saprophytic flora.
cr
Infectious disease specialists suggested therapy with clindamycin 600 mg/day, ampicillin 3 g/day associated with anticonvulsant (levetiracetam 1 g twice a day) and
us
antithrombotic therapy with enoxaparin sc 4000 IU/daily.
Repeated after surgery, CT scan showed partial recovery of the lesion and slight reduction in edema. Seven days later, after overall clinical improvement, the patient was
an
reassessed: neurological exam was normal, ECG and TEE were unchanged, HIV test negative, Mantoux test negative, C-reactive protein normal, no histochemical evidence
M
of increased inflammatory protein, T and B cell counts normal.
After 36 days, the patient was discharged on prolonged antimicrobial therapy and
d
referred to a cardiologist for correction of PFO. Home therapy was continued for more than 2 months: amocillin+clavulanate 3 g/day, clindamycin 150 mg four times daily,
Ac ce pt e
antiepileptic therapy (levetiracetam 500 mg twice daily), Lactobacillus acidophilus (twice daily). It was suspended when symptoms improved and when there was no longer contrast-enhanced Magnetic Resonance Imaging (MRI) evidence of brain lesions. Five months after surgery, brain MRI showed nearly complete resolution of the brain abscesses.
Discussion
A literature search conducted in PubMed, Scopus, Springerlink, Sage Journal Online, ScienceDirect and Wiley Online Library.and other health journals between 1990 and 2017using re“brain abscess” AND “tooth cleaning”, “periodontology”, “periodontitis”, “cardiac defect”s, “PFO”, “pyorrhea”, “odontogenic”, “Actinomyces”, “Streptococcus intermedius”, “multiple brain abscess" as search terms, showed that brain abscesses are an extremely rare complication following professional tooth cleaning. Approximately 60% of brain abscesses are multimicrobial (i.e. streptococci, staphylococci, enteric and
Page 4 of 13
5
anaerobic bacteria) and microbes vary in relation to patent age and the underlying medical or surgical condition. The oral cavity hosts abundant heterogeneous microflora. More than 1200 different types of microbes have been identified in the human mouth (Human Microbiome Project) [13]. 350 different bacterial strains have been isolated in marginal periodontitis
ip t
and 150 in endodontic infections.
Oral cavity microorganisms may reach the brain by different routes: 1) systemic
cr
hematogenous bacteremia, 2) direct venous drainage, 3) lymphatic route, 4) direct extension through the fascial planes [5].
us
Dental conditions that predispose to bacterial dissemination are gingivitis, periodontitis and procedures such as tooth extractions, endodontic treatments and oral surgery [1,6,7]. Even simple tooth brushing has been shown to induce transient bacteremia: it is
an
reasonable to believe that the bacterial load could be significantly greater in persons with poor dental hygiene [8].
M
More invasive dental procedures may induce massive bacteremia [8,9]: in healthy subjects these microorganisms are quickly eliminated by the reticuloendothelial system.
d
However, a heart defect such as patent foramen ovale (PFO) or a pulmonary arteriovenous fistula may form a shunt, allowing bacteria to bypass the pulmonary
Ac ce pt e
circulation [1,3,10]. For example, a right-to-left shunt would bypass these defenses and allow bacteria to enter the arterial circulation and reach the brain [11]. In the study by Moazzam et al. [5], 60% of a total 57 patients with brain abscess had undergone tooth extractions but only 4% had undergone scaling and root planing. The literature suggests that brain abscess formation after professional tooth cleaning is extremely rare [6]. Periodontal inflammation and flora normally found in the oral cavity can therefore be a cause of brain abscess. . The relationship between brain abscesses and professional tooth cleaning is substantiated by the finding of causal organisms in both oral and cranial sites [12,13] as in our patient.
The diagnosis of BA is sustained by contrast-enhanced MRI, where the abscesses appears as typical ring-like structures surrounded by edema. Differential diagnosis between brain abscess and tumor is of extreme importance, infection being
Page 5 of 13
6
differentiated from neoplastic disease by virtue of hyperintense signals in diffusionweighted MRI scans [6]. In a recent study [14], it has been used the (18)F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) to detect a chronic odontogenic infection as the possible origin of a BA. This represents a pioneering study that could represent a new
ip t
diagnostic approach in the future.
In case of known heart defects, simple antibiotic prophylaxis before the dental
cr
procedure reduces the probability of such cases of infectious complications.
All patients developing a brain abscess caused by flora commonly found in the
us
oropharynx should be screened for PFO.
Regarding the scientific literature, there was only one case about the relationship between brain abscess and professional tooth cleaning [6]. The first therapy of BA
an
associated with PFO includes immediate high-dose intravenous antibiotics and surgical evacuation of the abscess. Third-generation cephalosporin and metronidazole are
M
recommended empirically [6] and vancomycin may be added in cases of infection with multiresistant bacteria. Several antibiotics with an extended spectrum of activity should
d
be administered in combination at the beginning of treatment. Antibiotic therapy should then be prolonged until there is no radiographic evidence of BA and serial blood
Ac ce pt e
cultures are negative. Definitive treatment requires closure of PFO, because anticoagulation alone does not prevent embolisms [15]. Finally, to reduce the risk of BA in patients with cardiac defects, excellent oral hygiene and antibiotic therapy before dental procedures are recommended.
Disclosure of interest
The authors declare that they had no competing interests or financial support for this study.
Page 6 of 13
7
LEGENDS
Figure 1. CT scan (axial view) showing brain abscess in the left parietal lobe. Figure 2. CT scan (axial view) showing abscess in the left occipital lobe. Figure 3. RMI (sagittal view) showing multiple ring-enhancing lesions in the left
ip t
parietal and occipital lobes.
Figure 4. Orthopantomogram showing absence of periapical pathology and dental
Ac ce pt e
d
M
an
us
cr
caries and presence of a small periodontal defect between teeth 26 and 27.
Page 7 of 13
8
REFERENCES [1] Milli B, Rocci A, Paganelli E, Degli Antoni G, Monaco D, Quintavalla R. Brain
abscess of odontogenic origin in a man with interatrial defect. Acta Biomed 2010;81:225-9. [2] Sonneville R, Ruimy R, Benzonana N, Riffaud L, Carsin A, Tadié JM, et al. An
ip t
update on bacterial brain abscess in immunocompetent patients. Clin Microbiol Infect 2017;23:614-20.
cr
[3] Khouzam RN, El-Dokla AM, Menkes DL. Undiagnosed patent foramen ovale
presenting as a cryptogenic brain abscess: case report and review of the literature.
us
Heart Lung 2006;35:108-11.
[4] Dewhirst FE, Chen T, Izard J, et al. The human oral microbiome. J Bacteriol
2010;192:5002–17.
an
[5] Moazzam A, Rajagopal SM, Sedghizadeh PP, Zada G, Habibian M. Intracranial
bacterial infections of oral origin. J Clin Neurosci 2015;22:800-6.
M
[6] Pallesen LP, Schaefer J, Reuner U, Leonhardt H, Engellandt K, Schneider H, et
al. Multiple brain abscesses in an immunocompetent patient after undergoing
d
professional tooth cleaning. J Am Dent Assoc 2014;145:564-8. [7] Rae Yoo J, Taek Heo S, Kim M, Lee CS, Kim YR. Porphyromonas gingivalis
abscess in
patient
Ac ce pt e
causing brain
with
recurrent periodontitis.
Anaerobe
2016;39:165-7.
[8] Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ, Bahrani-Mougeot FK.
Bacteremia associated with toothbrushing and dental extraction. Circulation 2008;117:3118-25.
[9] Clancy U, Ronayne A, Prentice MB, Jackson A. Actinomyces meyeri brain
abscess
following
dental
extraction.
BMJ
Case
Rep. 2015;2015.
pii:
bcr2014207548
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