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Occipital lobe abscess following wisdom tooth extraction

Published:October 18, 2018DOI:https://doi.org/10.1016/j.jcjo.2018.08.001
      Brain abscesses are rare, with an incidence of approximately 1–8 per 100,0001–3, and abscesses following dental procedures are even less common.
      • Schuman NJ
      • Turner JE
      Brain abscess and dentistry: a review of the literature.
      • Azenha MR
      • Homsi G
      • Garcia IR
      Multiple brain abscess from dental origin: Case report and literature review.
      • Ewald C
      • Kuhn S
      • Kalff R
      Pyogenic infections of the central nervous system secondary to dental affections - A report of six cases.
      Most brain abscesses are diagnosed symptomatically following a latent period with fever, headache, nausea, altered mental status or other signs of central nervous system disorder.
      • Schuman NJ
      • Turner JE
      Brain abscess and dentistry: a review of the literature.
      • Azenha MR
      • Homsi G
      • Garcia IR
      Multiple brain abscess from dental origin: Case report and literature review.
      • Ewald C
      • Kuhn S
      • Kalff R
      Pyogenic infections of the central nervous system secondary to dental affections - A report of six cases.
      • Wohl TA
      • Kattah JC
      • Kolsky MP
      • Alper MG
      • Horton JC
      Hemianopsia From Occipital Lobe Abscess After Dental Care.
      • Bali RK
      • Sharma P
      • Gaba S
      • Kaur A
      • Ghanghas P
      A review of complications of odontogenic infections.
      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).
      Fig 1
      Fig. 1Humphrey 24-2 visual field on presentation.
      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.
      Fig 2
      Fig. 2Magnetic resonance imaging (MRI) scan reveals a ring-enhancing fluid collection measuring 1.8 × 2.2 × 3.2 cm within the right occipital lobe.
      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,
      • Wohl TA
      • Kattah JC
      • Kolsky MP
      • Alper MG
      • Horton JC
      Hemianopsia From Occipital Lobe Abscess After Dental Care.
      and tooth extraction appears to be the most common dental procedure associated with brain abscess formation.
      • Schuman NJ
      • Turner JE
      Brain abscess and dentistry: a review of the literature.
      • Wohl TA
      • Kattah JC
      • Kolsky MP
      • Alper MG
      • Horton JC
      Hemianopsia From Occipital Lobe Abscess After Dental Care.
      Dental pathogens may lead to systemic infection through direct extension, lymphatic routes, hematogenous routes or indirectly by extraoral odontogenic infection.
      • Schuman NJ
      • Turner JE
      Brain abscess and dentistry: a review of the literature.
      • Azenha MR
      • Homsi G
      • Garcia IR
      Multiple brain abscess from dental origin: Case report and literature review.
      • Ewald C
      • Kuhn S
      • Kalff R
      Pyogenic infections of the central nervous system secondary to dental affections - A report of six cases.
      ,
      • Horiuchi Y
      • Kato Y
      • Dembo T
      • Takeda H
      • Fukuoka T
      • Tanahashi N
      Patent foramen ovale as a risk factor for cryptogenic brain abscess: case report and review of the literature.
      Dental manipulations are known to cause bacteremia, and even simple activities such as tooth-brushing has been shown to cause transient bacteremia in up to 44% of patients.
      • Silver JG
      • Martin AW
      • McBride BC
      Experimental transient bacteraemias in human subjects with varying degrees of plaque accumulation and gingival inflammation.
      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.
      • Bali RK
      • Sharma P
      • Gaba S
      • Kaur A
      • Ghanghas P
      A review of complications of odontogenic infections.
      • Horiuchi Y
      • Kato Y
      • Dembo T
      • Takeda H
      • Fukuoka T
      • Tanahashi N
      Patent foramen ovale as a risk factor for cryptogenic brain abscess: case report and review of the literature.
      ,
      • Kawamata T
      • Takeshita M
      • Ishizuka N
      • Hori T
      Patent Foramen Ovale as a Possible Risk Factor for Cryptogenic Brain Abscess : Report of Two Cases.
      Additionally, cardiac abnormalities have been associated with increased risk of infections following dental procedure, classically associated with infective endocarditis.
      • Wohl TA
      • Kattah JC
      • Kolsky MP
      • Alper MG
      • Horton JC
      Hemianopsia From Occipital Lobe Abscess After Dental Care.
      A patent foramen ovale (PFO) has been suggested as a risk factor for brain abscesses following dental procedures,
      • Schuman NJ
      • Turner JE
      Brain abscess and dentistry: a review of the literature.
      • Horiuchi Y
      • Kato Y
      • Dembo T
      • Takeda H
      • Fukuoka T
      • Tanahashi N
      Patent foramen ovale as a risk factor for cryptogenic brain abscess: case report and review of the literature.
      with few case reports of associations with brain abscess and a concomitant PFO
      • Schuman NJ
      • Turner JE
      Brain abscess and dentistry: a review of the literature.
      • Horiuchi Y
      • Kato Y
      • Dembo T
      • Takeda H
      • Fukuoka T
      • Tanahashi N
      Patent foramen ovale as a risk factor for cryptogenic brain abscess: case report and review of the literature.
      . 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.
      • Schuman NJ
      • Turner JE
      Brain abscess and dentistry: a review of the literature.
      • Horiuchi Y
      • Kato Y
      • Dembo T
      • Takeda H
      • Fukuoka T
      • Tanahashi N
      Patent foramen ovale as a risk factor for cryptogenic brain abscess: case report and review of the literature.
      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.
      Authors (Year)Title of PublicationJournalDemo-graphicsSymptomsVisual field defectDental procedure priorBacteria culturedRemaining visual field defect
      Guilbert et al. (1974)
      • Guilbert F
      • Hochart G
      • Mignolet G
      • Christiaens JL
      Homonymous lateral hemianopsia of dental origin (in French).
      [Homonymous lateral hemianopsia of dental origin]Bulletin des societies d'ophtal-mologie de France36-year-old maleParietotemporal headache, fever, confusion, visual disturbanceMacular-sparing left homonymous hemianopisaNone, but had gingivitisNoneYes
      Wohl et al. (1991)
      • Wohl TA
      • Kattah JC
      • Kolsky MP
      • Alper MG
      • Horton JC
      Hemianopsia From Occipital Lobe Abscess After Dental Care.
      Hemianopsia from Occipital Lobe Abscess after Dental CareAmerican Journal of Ophthal-mology13-year-old femaleHeadache, fever, nausea, floatersLeft homonymous hemianopsiaTeeth cleaning four weeks prior to symptomsNoneImproved
      48-year-old maleHeadache, multiple evanescent white stars in right visual hemifieldRight homonymous para-central scotomaRoutine dental prophylaxis two weeks before symptomsStreptococcus milleriImproved
      44-year-old maleHeadache, flashing lights in right upper quadrant of visual fieldRight homonymous superior field defectEndodontic (root-canal) operation 2 – 3 weeks priorMicro-aerophilic sterptococciImproved
      60-year-old womanHeadache, fever, blurred vision, eventually stiff neck and midsystolic clickLeft homonymous hemianopsiaAnnual dental examination and prophylaxis 12 days priorViridans group streptococciImproved
      Kawamata et al. (2001)
      • Kawamata T
      • Takeshita M
      • Ishizuka N
      • Hori T
      Patent Foramen Ovale as a Possible Risk Factor for Cryptogenic Brain Abscess : Report of Two Cases.
      Patent foramen ovale as a possible risk factor for cryptogenic brain abscess: report of two casesNeuro-surgery36-year-old maleHeadache, feverNone reportedSevere periodontitis without focal orofacial inflammatory signsNonen/a
      Stepanović et al.
      • Stepanovic S
      • Tosic T
      • Savic B
      • Jovanovic M
      • K'ouas G
      • Carlier J
      Brain abscess due to Actinobacillus actinomycetemcomitans.
      (2005)
      Brain abscess due to Actinobacillus actinomycete-mcomitansActa Pathologica, Micro-biologica et Immuno-logica Scandi-navica (APMIS)47-year-old maleHeadache, nausea, vomiting, progressive weakness of left leg and armNone reportedPoor dentition but denied recent dental workActinobacillus actinomy-cetemcomitansn/a
      Ewald et al. (2006)
      • Ewald C
      • Kuhn S
      • Kalff R
      Pyogenic infections of the central nervous system secondary to dental affections - A report of six cases.
      Pyogenic infections of the central nervous system secondary to dental affections – a report of six casesNeuro-surgical Review65-year-old maleHeadache, hemianopsiaHemianopsiaNone, but periapical ostitis 36, retained tooth 48Fusobacterium nucleatum, Veillonella species, Bacillis circulans, saprophytic staphylococci, Streptococcus angionosusImproved
      Inoue et al. (2014)
      • Inoue M
      • Saito A
      • Kon H
      • Uchida H
      • Koyama S
      • Haryu S
      • et al.
      Subdural empyema due to Lactococcus lactis cremoris: case report.
      Subdural empyema due to Lactococcus lactis cremoris: Case ReportNeurologia medico-chirurgica33-year-old maleHeadache, fever, right facial pain, gait disturbance, left hemiparesis, left visual field defectLeft hemianopsiaMultiple dental caries and sinusitisL. lactis cremorisNone
      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.

      Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.

      Appendix. Supplementary materials

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