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However, the presentation of brain abscesses can be variable, and patients may initially present with non-specific symptoms. We present a case of occipital lobe abscess following wisdom tooth extraction and review the literature to re-emphasize the importance of routine confrontational visual field assessment, especially in patients presenting with headache and visual disturbance.
A 37-year-old male presented 8 days after wisdom teeth extraction with left-sided “fuzzy vision”, which he thought was monocular. On presentation, he complained of headache and visual disturbances for the past 5 days that had been diagnosed as migraine. The headache was initially mild and localized to the right side, but it had evolved to a throbbing pain of the whole head. This was associated with progressive worsening visual disturbances described as blurred vision, coloured lights and “blotches and fuzzy spots in both eyes”. He also complained of photophobia, phonophobia, vertigo and chills. He denied any past history of migraine or headaches. He presented twice to a peripheral emergency department for this headache. He was managed with morphine for analgesia, but his pain persisted.
Past medical and ocular histories were unremarkable, except that his left upper and lower wisdom teeth had been removed 3 days prior to the onset of his symptoms. He did not have a history of diabetes mellitus, intravenous drug use, immunodeficiency or any other predispositions for infection. His dentist noted no infection at the time of extraction and denied infection of the site at a follow-up visit.
In our clinic, visual acuity was 20/20 for distance and J1 for near acuity bilaterally. Intraocular pressures were 17 and 15 mmHg in the right eye and left eye respectively. There was no relative afferent pupillary defect. Confrontational visual fields revealed a left-sided visual field defect. Anterior and posterior segment examination was unremarkable. A screening neurological examination revealed abnormal gait, a mild right pronator drift and neck rigidity.
Imaging of the nerves with Optical Coherence Tomography (OCT) was unremarkable. A Humphrey 24-2 visual field showed complete left homonymous hemianopsia. (Fig. 1).
After discussion with the neurologist on call, the patient was transferred emergently to the hospital for further evaluation and management. In hospital, he had a blood pressure of 145/89 mmHg, heart rate of 86 bpm, respiratory rate of 18 breaths/min, 100% saturation of oxygen on room air, and an oral temperature of 37.5°C.
A computed tomography (CT) scan showed a ring-enhancing lesion in the right occipital lobe measuring 1.5 × 1.8 cm with adjacent edema. A magnetic resonance imaging (MRI) scan was performed to further characterize the lesion, revealing a 1.8 × 2.2 × 3.2 cm ring-enhancing fluid collection within the right occipital lobe that was highly suggestive of an abscess (Fig. 2). Further investigation with blood cultures and human immunodeficiency virus screening were negative. An echocardiogram was ordered to rule out any infectious or structural etiologies and was unremarkable.
Neurosurgery was consulted but felt the patient should be managed medically. Treatment with intravenous ceftriaxone and metronidazole was started on the recommendation of Infectious Diseases, with a planned course of 6 weeks. After a 6-day admission, he was transferred to a peripheral hospital closer to his home address.
Seven days following discharge, the patient again presented to a peripheral emergency department. He was assessed by emergency physicians and found to have persisting and worsening headache and increased gait difficulties.
A repeat CT scan showed significant progression of the right occipital lobe abscess, with subfalcine and uncal herniation resulting in 8.0 mm midline shift to the left. The intravenous ceftriaxone and metronidazole were continued after consultation with Infectious Disease, who felt broadening antibiotic coverage would limit the chance of identification of an organism on culture. The patient was started on oral dexamethasone by Neurosurgery and surgical evacuation of the abscess was arranged. Fluid collected intraoperatively was sent for microbiology, which did not yield a positive culture. The patient was discharged from hospital with a repeat 6-week course of ceftriaxone and metronidazole. At the time, he had considerable improvement of his headache and photophobia, but his visual field defect never resolved.
Haymaker et al. was the first to describe brain abscesses following tooth extraction in 1945,
Hematogenous seeding is thought to be accomplished through transit of bacteria through the valveless emissary veins draining the surrounding regions, which can allow both forward and retrograde flow into the venous system of the brain.
. Other known risk factors for developing abscesses include operative dentistry, periodontal therapy, injection of local anesthetic, dental prophylaxis, general poor dental hygiene and significant dental infection.
A literature review of Medline and Embase revealed approximately 100 cases of brain abscess associated with odontogenic infection. We identified nine cases of occipital lobe abscesses related to a recent history of dental pathology or procedure. (Table 1). All nine patients presented symptomatically with headache. Five patients presented with fever and two presented with hemiparesis. Seven of nine cases reported visual disturbance, and the other two case reports did not comment on visual status. Reported visual symptoms include flashes, floaters, blurred vision and symptomatic visual field defect. Seven of nine cases reported performing visual field testing, and all patients had either hemianopsia or homonymous field defect. Streptococcus sp. bacteria was isolated in four of nine cases. Three of nine cases did not isolate any bacteria. Most patients had some resolution of their visual field defect following treatment.
Table 1Cases of occipital lobe abscesses following dental procedure or with identified dental pathology.
In conclusion, we present a case of occipital lobe abscess following routine wisdom tooth extraction in a healthy patient with no identifiable risk factors for infection. Brain abscesses following dental procedures or dental pathology remains a rare complication. Headache, fever, altered mental status, focal neurological deficits or other symptoms may be elicited, but presentation can be variable. In a patient presenting with a new headache and visual disturbances, screening for a visual field defect is essential. Visual field prognosis following occipital lobe abscess varies from residual hemianopsia to full recovery.
The authors have no proprietary or commercial interest in any materials discussed in this article.