- Email: [email protected]
Multiple brain abscesses secondary to dental caries and severe periodontal disease
British Journal of Oral and Maxillofacial Surgery (1988) 26, 244-247 0 1988 The British Association of Oral and Maxillofacial Surgeons
MULTIPLE BRAIN ABSCESSES SECONDARY TO DENTAL CARIES AND SEVERE PERIODONTAL DISEASE P. V.
MARKS*,
Department
F.R.c.s.,
K.
of Neurosurgery,
S.
PATEL,
B.SC.,
Oldchurch
M.B.,
B.S.
and
E.
Hospital, Romford,
W.
MEE,
F.R.C.S.
Essex RM7 OBE
Summary. A case is reported in which an intra-oral focus of sepsis is thought to have resulted in the patient developing multiple brain abscesses without the presence of lung infection or cardiac valvular disease. The link between the two sites of infection is supported by the isolation of two Streptococcus viriduns species normally associated with dental caries and periodontal disease. The management of multiple brain abscesses is discussed.
Introduction Brain abscesses are a well known and feared complication of ear and sinus disease as well as of intrathoracic sepsis and congenital cyanotic heart disease. It is, however, comparatively rare for dental and intra-oral sepsis to be implicated as an infective focus from which brain abscesses have subsequently developed, and moreover when this has occurred a discrete lesion such as an apical abscess has been uncovered (Morgan et al., 1973). We report a case which is exceptional in that multiple abscesses developed in association with severe dental caries and periodontal disease in the absence of a dental abscess or valvular cardiac lesion. Case report A 26-year-old man initially presented to a neighbouring hospital with a 7 week history of frontal headache. It transpired that 48 h prior to admission he had become confused and disorientated, and his relatives reported that he had been suffering from early morning nausea and vomiting for 6 weeks and had lost two stone in weight since the onset of his illness. He had also been complaining of toothache and bad breath. Until the onset of his current problems he had been fit and healthy, and his only previous hospital admission was for tonsillectomy. He was noted to have early papilloedema and was referred to the Neurosurgical Unit for further investigation and management. Examination confirmed the presence of papilloedema and he was noted to be markedly disorientated in time and place. He was apyrexial, neck stiffness was absent and Kernig’s sign was negative. His cranial nerves were intact, and moreover there were no abnormal sensory or motor signs in the limbs, the reflexes being symmetrical with bilaterally flexor plantar responses. Examination of the buccal cavity revealed that the premolars and molars in the upper jaw had extensive caries and gross periodontal disease. The incisors and canines in both arches had evidence of minimal cervical caries, and in addition, mesial and distal carious lesions were present in all (Received
11 December
*Address for correspondence: Mr. P. Marks, Hills Road, Cambridge CB2 2QQ.
1986; accepted 12 March Senior Neurosurgical 244
Registrar,
1987) Addenbrooke’s
Hospital,
MULTIPLE
BRAIN
245
ABSCESSES
premolars. The 7 6 / 6 7 showed gross carious invasion of the pulp chambers which was easily visible in the mouth. The 76167 were also affected with soft carious lesions but were not as severelvi involved as their unner counterparts. The !U ha .d not en ‘P’ted. “Vfe also h ad se vere halitosis, coating of the tongue, as well as acute marginal ‘I
Fig.
1 (A)
Fig.
1 (B)
Figure l-(A) C.T. Scan of the brain showing multiple enhancing space occupying lesions (arrows) with associated surrounding oedema. There is compression of the anterior horn of the right lateral ventricle and shift of the midline towards the left. Figure l-(B) A higher cut showing two further enhancin g lesions with associated oedema (arrows). The body of the right lateral ventricle has collapsed due to the oedema excited by the lesions.
246
BRITISH
JOURNAL
OF
ORAL
&
MAXILLOFACIAL
SURGERY
gingivitis superimposed on chronic periodontal disease. The gums were noted to bleed easily on gentle probing. All other systems revealed no abnormality on clinical examination. Plain radiographs of the chest and skull were normal, as were routine blood tests. C.T. scans of the brain showed multiple space occupying lesions in both the right and the left cerebral hemispheres with associated oedema. Following the injection of intravenous contrast medium, the lesions demonstrated enhancement (Fig. 1A & B). Four hours after admission he suffered a cardiac arrest but was expeditiously resuscitated and remained on artificial ventilation with fixed, dilated pupils, but unfortunately one hour later he had a further cardiac arrest which proved refractory to treatment. In view of his sudden death before a definite diagnosis was made, an autopsy was performed to establish the cause of death. At autopsy it was revealed that the multiple parenchymal lesions in the brain were abscesses. The paranasal air sinuses were normal, as were the middle ear clefts. There was no evidence of any dental apical abscesses associated with any of the carious teeth, and furthermore, there was no evidence of intrathoracic or intra-abdominal sepsis, and specifically, the heart valves were normal and free from any vegetations. Pus was cultured from the brain abscess cavities and this grew alpha-haemolytic streptococci (Streptococcus &duns). Further tests revealed that a mixed growth of Streptococcus rnuta~l~ and Streptococcus milleri was present. Discussion
Streptococcus viridans refers not to a single defined species but rather to a group of alpha-haemolytic streptococci which include Strep. mitior, Strep. milleri, Strep. sanguis and Strep. mutans (Joklik et al., 1984). These organisms are commensals of the mouths and upper respiratory tracts of all normal healthy people and under most circumstances are not pathogenic. A bacteraemia occurs quite frequently during normal mastication and more so during dental treatment, so individuals with congenitally deranged or rheumatically damaged heart valves are at risk of developing a subacute infective endocarditis based on one of these organisms. The Streptococcus mutans, moreover, has long been known to be associated with dental caries (Wilson & Miles, 1975; Joklik et al., 1984) and furthermore it has been recognised that Streptococcus milleri species have an unusual predilection amongst the alpha-haemolytic streptococci to produce abscesses in the brain and liver. Although any organism may be found in a brain abscess cavity, certain organisms are particularly common (Weller et al., 1982), hence when an abscess arises through infection from a contiguous source e.g. from the middle ear cleft or the paranasal air sinuses, the organisms isolated from the abscess cavity reflect those found in the upper respiratory tract; mixed infections being especially common in such circumstances. Alpha-haemolytic streptococci have certainly been isolated from brain abscess cavities (Rosenblum et al., 1978; Barsoum et al., 1981). The introduction of C.T. scanning has revolutionised the diagnosis and treatment of brain abscesses which formerly have been associated with a high mortality, that for solitary lesions being between 17%-56% whilst that for mutiple abscesses which occur in 2%-15% of instances has variously been quoted as being between 62%-100% (Garfield, 1969; Carey et al., 1972; Morgan et al., 1973; Samson & Clark, 1973; Brewer et al., 1975; Shaw & Russell, 1975). Now, most series have shown striking reductions in the mortality associated with multiple
MULTIPLE
BRAIN
247
ABSCESSES
abscesses and have ascribed this to the better imaging techniques which CT. scanning have afforded, along with the use of high dose antibiotic therapy (Berg et al., 1978; Rosenblum et al., 1978; Boom & Tuazon, 1985). The multiplicity and anatomical location of multiple brain abscesses usually renders surgical treatment an impractical proposition, and hence the only logical therapeutic modality is the use of high doses of broad spectrum antibiotics without specific knowledge of the causative organism. If surgery is considered it should be restricted to the aspiration of an easily accessible lesion for bacteriological investigation, or to the aspiration of a lesion which continues to enlarge despite treatment, and produces neurological deterioration. (Burke et al., 1981; Kobrine et al., 2981). In this case, although no material was submitted for culture from the affected areas in the buccal cavity, the known association of the streptococcus species isolated from the pus in the brain abscess with oral pathology of this nature provides very strong evidence of a causal role. Acknowledgement The authors report details
would like to thank Mr J. C. M. Currie, of a patient under his care.
Consultant
Neurosurgeon,
for permission
to
References Barsoum, 4. H., Lewis, H. C. & Cannillo, P. A. (1981). Nonoperative treatment of multiple brain abscesses. Surgical Neurology, 16, 283. Berg, B., Franklin, G., Cuneo, R., Boldrey, E. & Strimling, B. (1978). Nonsurgical care of brain abscess: early diagnosis and follow-up with computerised tomography. Annals of Neurology, 3,474. Boom, W. H. & Tuazon, C. U. (1985). Successful treatment of multiple brain abscesses with antibiotics alone. Reviews of Infectious Diseases, 7, 189. Brewer, N. S., MacCarty, C. S. & Wellman, W. E. (1975). Brain abscess: a review of recent experience. Annals of Internal Medicine, 82, 571. Burke, L. P., Ho, S. U., Cerullo, L. H., Kim, K. S. & Harter, D. H. (1981). Multiple brain abscesses. Surgical Neurology, 16, 452. Carey, M. E., Chou, S. N. & French, L. A. (1972). Experience with brain abscesses. Journal of Neurosurgery, 36, 1. Garfield, J. (1969). Management of supratentorial intracranial abscess: a review of ZOO cases. British Medical Journal, 2, 7. Joklik, W. K., Willett, H. P. & Amos, D. B. (1984). In: Zinsser’s Microbiology, 18th Ed., p. 474. Connecticut: Appleton-Century-Crofts. Kobrine, A. I., Davis, D. 0. & Rizzoli, H. V. (1981). Multiple abscesses of the brain. Journal of Neurosurgery, 54, 93. Morgan, H., Wood, M. W. & Murphey, F. (1973). Experience with 88 consecutive cases of brain abscess. Journal of Neurosurgery, 38, 698. Rosenblum, M. L., Hoff, J. T., Norman, D., Weinstein, P. R. & Pitts, L. (1978). Decreased mortality from brain abscesses since the advent of computerised tomography. Journal of Neurosurgery, 49, 658. Samson, D. S. &Clark, K. (1973). A current review of brain abscess. American Journal of Medicine, 54, 201. Shaw, M. D. M. &Russell, J. A. (1977). Value of computed tomography in the diagnosis of intracranial abscess. Journal of Neurology, Neurosurgery and Psychiatry, 40, 214. Weller, R. O., Swash, M., McLellan, D. L. & Scholtz, C. L. (1982). In: Clinical Neuropathology, 1st Ed., p. 169-172. Berlin: Springer Verlag. Wilson, G. S. & Miles, A. (1975). In: Topley and Wilson’s Principles of Bacteriology, Virology and Immunity, 6th Ed., p. 753. Vol. 1, London: Edward Arnold.
MULTIPLE BRAIN ABSCESSES SECONDARY TO DENTAL CARIES AND SEVERE PERIODONTAL DISEASE P. V.
MARKS*,
Department
F.R.c.s.,
K.
of Neurosurgery,
S.
PATEL,
B.SC.,
Oldchurch
M.B.,
B.S.
and
E.
Hospital, Romford,
W.
MEE,
F.R.C.S.
Essex RM7 OBE
Summary. A case is reported in which an intra-oral focus of sepsis is thought to have resulted in the patient developing multiple brain abscesses without the presence of lung infection or cardiac valvular disease. The link between the two sites of infection is supported by the isolation of two Streptococcus viriduns species normally associated with dental caries and periodontal disease. The management of multiple brain abscesses is discussed.
Introduction Brain abscesses are a well known and feared complication of ear and sinus disease as well as of intrathoracic sepsis and congenital cyanotic heart disease. It is, however, comparatively rare for dental and intra-oral sepsis to be implicated as an infective focus from which brain abscesses have subsequently developed, and moreover when this has occurred a discrete lesion such as an apical abscess has been uncovered (Morgan et al., 1973). We report a case which is exceptional in that multiple abscesses developed in association with severe dental caries and periodontal disease in the absence of a dental abscess or valvular cardiac lesion. Case report A 26-year-old man initially presented to a neighbouring hospital with a 7 week history of frontal headache. It transpired that 48 h prior to admission he had become confused and disorientated, and his relatives reported that he had been suffering from early morning nausea and vomiting for 6 weeks and had lost two stone in weight since the onset of his illness. He had also been complaining of toothache and bad breath. Until the onset of his current problems he had been fit and healthy, and his only previous hospital admission was for tonsillectomy. He was noted to have early papilloedema and was referred to the Neurosurgical Unit for further investigation and management. Examination confirmed the presence of papilloedema and he was noted to be markedly disorientated in time and place. He was apyrexial, neck stiffness was absent and Kernig’s sign was negative. His cranial nerves were intact, and moreover there were no abnormal sensory or motor signs in the limbs, the reflexes being symmetrical with bilaterally flexor plantar responses. Examination of the buccal cavity revealed that the premolars and molars in the upper jaw had extensive caries and gross periodontal disease. The incisors and canines in both arches had evidence of minimal cervical caries, and in addition, mesial and distal carious lesions were present in all (Received
11 December
*Address for correspondence: Mr. P. Marks, Hills Road, Cambridge CB2 2QQ.
1986; accepted 12 March Senior Neurosurgical 244
Registrar,
1987) Addenbrooke’s
Hospital,
MULTIPLE
BRAIN
245
ABSCESSES
premolars. The 7 6 / 6 7 showed gross carious invasion of the pulp chambers which was easily visible in the mouth. The 76167 were also affected with soft carious lesions but were not as severelvi involved as their unner counterparts. The !U ha .d not en ‘P’ted. “Vfe also h ad se vere halitosis, coating of the tongue, as well as acute marginal ‘I
Fig.
1 (A)
Fig.
1 (B)
Figure l-(A) C.T. Scan of the brain showing multiple enhancing space occupying lesions (arrows) with associated surrounding oedema. There is compression of the anterior horn of the right lateral ventricle and shift of the midline towards the left. Figure l-(B) A higher cut showing two further enhancin g lesions with associated oedema (arrows). The body of the right lateral ventricle has collapsed due to the oedema excited by the lesions.
246
BRITISH
JOURNAL
OF
ORAL
&
MAXILLOFACIAL
SURGERY
gingivitis superimposed on chronic periodontal disease. The gums were noted to bleed easily on gentle probing. All other systems revealed no abnormality on clinical examination. Plain radiographs of the chest and skull were normal, as were routine blood tests. C.T. scans of the brain showed multiple space occupying lesions in both the right and the left cerebral hemispheres with associated oedema. Following the injection of intravenous contrast medium, the lesions demonstrated enhancement (Fig. 1A & B). Four hours after admission he suffered a cardiac arrest but was expeditiously resuscitated and remained on artificial ventilation with fixed, dilated pupils, but unfortunately one hour later he had a further cardiac arrest which proved refractory to treatment. In view of his sudden death before a definite diagnosis was made, an autopsy was performed to establish the cause of death. At autopsy it was revealed that the multiple parenchymal lesions in the brain were abscesses. The paranasal air sinuses were normal, as were the middle ear clefts. There was no evidence of any dental apical abscesses associated with any of the carious teeth, and furthermore, there was no evidence of intrathoracic or intra-abdominal sepsis, and specifically, the heart valves were normal and free from any vegetations. Pus was cultured from the brain abscess cavities and this grew alpha-haemolytic streptococci (Streptococcus &duns). Further tests revealed that a mixed growth of Streptococcus rnuta~l~ and Streptococcus milleri was present. Discussion
Streptococcus viridans refers not to a single defined species but rather to a group of alpha-haemolytic streptococci which include Strep. mitior, Strep. milleri, Strep. sanguis and Strep. mutans (Joklik et al., 1984). These organisms are commensals of the mouths and upper respiratory tracts of all normal healthy people and under most circumstances are not pathogenic. A bacteraemia occurs quite frequently during normal mastication and more so during dental treatment, so individuals with congenitally deranged or rheumatically damaged heart valves are at risk of developing a subacute infective endocarditis based on one of these organisms. The Streptococcus mutans, moreover, has long been known to be associated with dental caries (Wilson & Miles, 1975; Joklik et al., 1984) and furthermore it has been recognised that Streptococcus milleri species have an unusual predilection amongst the alpha-haemolytic streptococci to produce abscesses in the brain and liver. Although any organism may be found in a brain abscess cavity, certain organisms are particularly common (Weller et al., 1982), hence when an abscess arises through infection from a contiguous source e.g. from the middle ear cleft or the paranasal air sinuses, the organisms isolated from the abscess cavity reflect those found in the upper respiratory tract; mixed infections being especially common in such circumstances. Alpha-haemolytic streptococci have certainly been isolated from brain abscess cavities (Rosenblum et al., 1978; Barsoum et al., 1981). The introduction of C.T. scanning has revolutionised the diagnosis and treatment of brain abscesses which formerly have been associated with a high mortality, that for solitary lesions being between 17%-56% whilst that for mutiple abscesses which occur in 2%-15% of instances has variously been quoted as being between 62%-100% (Garfield, 1969; Carey et al., 1972; Morgan et al., 1973; Samson & Clark, 1973; Brewer et al., 1975; Shaw & Russell, 1975). Now, most series have shown striking reductions in the mortality associated with multiple
MULTIPLE
BRAIN
247
ABSCESSES
abscesses and have ascribed this to the better imaging techniques which CT. scanning have afforded, along with the use of high dose antibiotic therapy (Berg et al., 1978; Rosenblum et al., 1978; Boom & Tuazon, 1985). The multiplicity and anatomical location of multiple brain abscesses usually renders surgical treatment an impractical proposition, and hence the only logical therapeutic modality is the use of high doses of broad spectrum antibiotics without specific knowledge of the causative organism. If surgery is considered it should be restricted to the aspiration of an easily accessible lesion for bacteriological investigation, or to the aspiration of a lesion which continues to enlarge despite treatment, and produces neurological deterioration. (Burke et al., 1981; Kobrine et al., 2981). In this case, although no material was submitted for culture from the affected areas in the buccal cavity, the known association of the streptococcus species isolated from the pus in the brain abscess with oral pathology of this nature provides very strong evidence of a causal role. Acknowledgement The authors report details
would like to thank Mr J. C. M. Currie, of a patient under his care.
Consultant
Neurosurgeon,
for permission
to
References Barsoum, 4. H., Lewis, H. C. & Cannillo, P. A. (1981). Nonoperative treatment of multiple brain abscesses. Surgical Neurology, 16, 283. Berg, B., Franklin, G., Cuneo, R., Boldrey, E. & Strimling, B. (1978). Nonsurgical care of brain abscess: early diagnosis and follow-up with computerised tomography. Annals of Neurology, 3,474. Boom, W. H. & Tuazon, C. U. (1985). Successful treatment of multiple brain abscesses with antibiotics alone. Reviews of Infectious Diseases, 7, 189. Brewer, N. S., MacCarty, C. S. & Wellman, W. E. (1975). Brain abscess: a review of recent experience. Annals of Internal Medicine, 82, 571. Burke, L. P., Ho, S. U., Cerullo, L. H., Kim, K. S. & Harter, D. H. (1981). Multiple brain abscesses. Surgical Neurology, 16, 452. Carey, M. E., Chou, S. N. & French, L. A. (1972). Experience with brain abscesses. Journal of Neurosurgery, 36, 1. Garfield, J. (1969). Management of supratentorial intracranial abscess: a review of ZOO cases. British Medical Journal, 2, 7. Joklik, W. K., Willett, H. P. & Amos, D. B. (1984). In: Zinsser’s Microbiology, 18th Ed., p. 474. Connecticut: Appleton-Century-Crofts. Kobrine, A. I., Davis, D. 0. & Rizzoli, H. V. (1981). Multiple abscesses of the brain. Journal of Neurosurgery, 54, 93. Morgan, H., Wood, M. W. & Murphey, F. (1973). Experience with 88 consecutive cases of brain abscess. Journal of Neurosurgery, 38, 698. Rosenblum, M. L., Hoff, J. T., Norman, D., Weinstein, P. R. & Pitts, L. (1978). Decreased mortality from brain abscesses since the advent of computerised tomography. Journal of Neurosurgery, 49, 658. Samson, D. S. &Clark, K. (1973). A current review of brain abscess. American Journal of Medicine, 54, 201. Shaw, M. D. M. &Russell, J. A. (1977). Value of computed tomography in the diagnosis of intracranial abscess. Journal of Neurology, Neurosurgery and Psychiatry, 40, 214. Weller, R. O., Swash, M., McLellan, D. L. & Scholtz, C. L. (1982). In: Clinical Neuropathology, 1st Ed., p. 169-172. Berlin: Springer Verlag. Wilson, G. S. & Miles, A. (1975). In: Topley and Wilson’s Principles of Bacteriology, Virology and Immunity, 6th Ed., p. 753. Vol. 1, London: Edward Arnold.