Q J Med 2014; 107:671–672 doi:10.1093/qjmed/hct229 Advance Access Publication 11 December 2013
Clinical picture Streptococcus anginosus, tooth extraction and brain abscess A 78-year-old man presented with shortness of breath and fever following tooth extraction. Computed tomography of the neck revealed an infection in the left masticator space with an abscess measuring 3.1 3.4 4.5 cm. Blood tests revealed leukocytosis (36.82 109 cells/l) and elevated C-reactive protein levels (25.62 mg/dl); the blood cultures were negative. Five days following surgical drainage of the abscess, the patient suddenly developed fever, became drowsy and experienced left side hemiplegia. Magnetic resonance imaging of the brain revealed an abscess in the left temporal lobe (Figure 1A) and an intracerebral hematoma in the right thalamus (Figure 1B). Streptococcus anginosus was isolated from pus aspirates. Following 8 weeks of intravenous antibiotic (penicillin G), the patient was discharged with hemiparesis of the left side. Since S. anginosus is part of the normal oral/ genital flora, this bacteria is rarely associated with meningitis.1 For example, one study found 7 of 78
meningitis cases to be associated with viridans streptococci, and only 2 of those 7 were due to S. anginosus.2 Furthermore, only two case reports3,4 have described brainstem infarctions associated with meningitis caused by S. anginosus. To our knowledge, this is the first account of a patient presenting with an intracerebral hematoma with concomitant brain abscess associated with S. anginosus-related meningitis. Failure to recognize the early clinical manifestations associated with S. anginosus infection may lead to inappropriate treatment and poor prognosis; successful treatment of this case was attributable to early diagnosis and broad-spectrum antibiotic administration. Photographs and text from: Guan-Yu Lin, Fu-Chi Yang and Jiunn-Tay Lee, Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan, R.O.C.; Chih-Wei Wang, Department of
Figure 1. MRI analysis. (A) T1-weighted gadolinium-enhanced image showing a rim-enhancing lesion with central necrosis in the left temporal lobe and mild perifocal edema. The arrow indicates the brain abscess. (B) T2* image demonstrating a hemosiderin lesion in the right thalamus, consistent with the findings for an intracerebral hematoma (arrow).
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Clinical picture
Radiology, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan, R.O.C. email:
[email protected] Conflict of interest: None declared.
‘‘Streptococcus milleri group’’. J Clin Microbiol 1990; 28:1497–501. 2. Chang WN, Wu JJ, Huang CR, Tsai YC, Chien CC, Lu CH. Identification of viridans streptococcal species causing bacterial meningitis in adults in Taiwan. Eur J Clin Microbiol Infect Dis 2002; 21:393–6. 3. Perry JR, Bilbao JM, Gray T. Fatal basilar vasculopathy complicating bacterial meningitis. Stroke 1992; 23:1175–8.
References 1. Whiley RA, Fraser H, Hardie JM, Beighton D. Phenotypic differentiation of Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus strains within the
4. Lee SB, Jones LK, Giannini C. Brainstem infarcts as an early manifestation of Streptococcus anginosus meningitis. Neurocrit Care 2005; 3:157–60.
