A 56-year-old man was taken to a remote hospital by his co-worker because he arrived at work looking unwell and had mental changes. The patient’s medical history was significant for hypertension, cholecystectomy and obstructive sleep apnoea with lisinopril, losartan and furosemide as his daily medications. He had recently experienced a dry cough for more than one month that was attributed to lisinopril being added to his prescribed medications. At about the same time he developed an intermittent fever. One week before presentation he experienced tunnel vision and memory lapse of recent events. Over the one-month time period he had a headache that progressively grew worse. Five days prior to presenting at hospital he developed pain in his neck and back with nausea and vomiting. His wife reported that six months earlier he had a toothache on his left side that resolved without treatment.
CT showed multiple intracranial mass effect lesions and hydrocephaly. Vancomycin, aciclovir and ceftriaxone were administered before the patient was flown to a level 1 trauma centre for a higher level of care with the suspicion of brain abscess versus neoplasm. There he was found to be sleepy but making intentional movements such as pulling out his urinary catheter. He moved all extremities spontaneously and withdrew from noxious stimuli. His pupils were sluggish to non-reactive and miotic. Nuchal rigidity was unclear. Aciclovir and lisinopril were discontinued and fuco-nazole was started.
The patient had bilateral external ventricular drains inserted, was placed on mechanical ventilation, had a sub-clavian central catheter inserted peripherally and had a nasogastric tube placed within one day of admission. Cer-ebrospinal fuid samples showed elevated protein and white blood cells. MRI and CT ruled out peripheral neoplasm and confrmed unchanged intracranial lesions of mass effect (Fig 1). Two days following his admission, abdominal CT revealed a metallic object in the abdomen similar to a dental flling that had not been seen in previous CT.
A craniotomy of the right temporal lesion confrmed brain abscesses four days following admission. Pathology tests from the brain biopsy and exudates demonstrated Gram-positive anaerobic streptococcal species commonly linked to dental infections. Oral aetiology was suspected. CT of the maxillofacial region revealed grossly decayed first and second upper left molars. The left second molar only had retained root tips and radiographic evidence of peri-odontal abscess encroaching on the maxillary sinus (Fig 2). The clinical diagnosis was gross caries, necrotic pulp and chronic periapical abscess of teeth 14 and 15.
Both decayed molars were removed surgically and sent for histopathological evaluation. An apical granuloma from the socket of the left second molar was also removed and sent for culture and sensitivity. Ceftriaxone was continued as the only antimicrobial following microbiological analysis of the biopsy specimen.
The remainder of the patient’s hospital stay included replacement of both external ventricular drains. Twenty-three days following hospital admission (nineteen days following molar extractions) the patient’s level of consciousness deteriorated. Electroencephalography revealed non-convulsive status epilepticus in the frontal lobes secondary to hydro-cephalous and failed drainage. The status epilepticus continued for six days and was managed with levetiracetam. A left ventriculoperitoneal shunt was placed to permanently divert cerebrospinal fuid; both drains were removed. His hypertension required additional measures to control and prophylactic precautions were taken for deep vein thrombosis.
The patient’s hospital stay lasted 44 days. Follow-up MRI and CT confrmed reduction of the brain abscess lesions. At discharge he had the following list of prescription medications: amlodipine, clonidine, famotidine, heparin, levetira-cetam, metoprolol, modafinil, nystatin powder, salt tablets, valsartan, vitamin D and ceftriaxone. The patient was discharged from hospital care to a skilled nurse facility to complete recovery and to continue with ceftriaxone for 14 days following discharge.
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