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Pyogenic infections of the central nervous system secondary to dental affections—a report of six cases

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Pyogenic infections of the central nervous system of dental origin are quite uncommon in industrialized countries. We report six cases with intracerebral (n=4) and intraspinal (n=2) infections treated in our hospital. The microbial pathogen was successfully isolated in all patients. Fusobacterium nucleatum as well as Streptococcus species were found in three cases. Bacillus species were identified in two patients. Actinomyces was the etiologic agent in one case. All patients suffered from dental pathologies, so that after clinical and radiological exclusion of other sources an oral focus was presumed. Therapeutic management consisted of an operative procedure in order to obtain decompression, as well as evacuation of the pus on the one hand, followed by targeted antibiotics on the other. Clinical improvement was achieved in all patients, with one patient lost to follow-up. On magnetic resonance tomography, the inflammatory changes also disappeared in all cases. We recommend that oral infection with recurrent bacteraemia should always be considered in the pathogenesis of the so-called “cryptic” intracerebral and intraspinal infections.

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Correspondence to C. Ewald.

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Ali Kursoy, M.D., Kayseri

The current challenges in the management of intracranial abscess for the neurosurgeon are chiefly as follows. First is maintaining a high level of suspicion in appropriate patients so that catastrophic delays in diagnosis do not occur. Second is choosing an appropriate antibiotic regimen and a suitable surgical method. Third is attentive postoperative follow-up, so that recurrences are dealt with decisively.

Ewald et al. have reported six cases with cryptic infection of the CNS that occurred secondary to dental and paradental infection. It is interesting that before an operation was employed no case complained of having any trouble with his/her teeth and there was no report about preceding dental treatment or manipulation because of dental disorder. Dental or paradental infection was diagnosed with investigation by dental pantomogram.

It is impossible to disagree with the necessity that dental and paradental infection should be proven clinically or radiologically, the determined agent microorganism should be harmonious with the oral flora, and no etiological causes should have been shown except for dental or paradental source.

Although brain abscess and its causes are mentioned in detail in the textbook, this paper could be beneficial for readers because of the authors’ distinct outlook on the subject, as described above.

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Ewald, C., Kuhn, S. & Kalff, R. Pyogenic infections of the central nervous system secondary to dental affections—a report of six cases. Neurosurg Rev 29, 163–167 (2006).

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