Amoebic meningoencephalitis and disseminated infection caused by Balamuthia mandrillaris in a Western lowland gorilla (Gorilla gorilla gorilla)

CASE DESCRIPTION A 22-year-old male gorilla (Gorilla gorilla gorilla) housed in a zoo was evaluated for signs of lethargy, head-holding, and cervical stiffness followed by development of neurologic abnormalities including signs of depression, lip droop, and tremors. CLINICAL FINDINGS Physical examination under general anesthesia revealed a tooth root abscess and suboptimal body condition. A CBC and serum biochemical analysis revealed mild anemia, neutrophilia and eosinopenia consistent with a stress leukogram, and signs consistent with dehydration. Subsequent CSF analysis revealed lymphocytic pleocytosis and markedly increased total protein concentration. TREATMENT AND OUTCOME Despite treatment with antimicrobials, steroids, and additional supportive care measures, the gorilla's condition progressed to an obtunded mentation with grand mal seizures over the course of 10 days. Therefore, the animal was euthanized and necropsy was performed. Multifocal areas of malacia and hemorrhage were scattered throughout the brain; on histologic examination, these areas consisted of necrosis and hemorrhage associated with mixed inflammation, vascular necrosis, and intralesional amoebic trophozoites. Tan foci were also present in the kidneys and pancreas. Immunohistochemical testing positively labeled free-living amoebae within the brain, kidneys, eyes, pancreas, heart, and pulmonary capillaries. Subsequent PCR assay of CSF and frozen kidney samples identified the organism as Balamuthia mandrillaris, confirming a diagnosis of amoebic meningoencephalitis. CLINICAL RELEVANCE Infection with B mandrillaris has been reported to account for 2.8% of captive gorilla deaths in North America over the past 19 years. Clinicians working with gorillas should have a high index of suspicion for this diagnosis when evaluating and treating animals with signs of centrally localized neurologic disease.

Microbiology of Acute Sinusitis of Odontogenic Origin Presenting with Periorbital Cellulitis in Children

Objectives:

This study was undertaken to evaluate the aerobic and anaerobic microbiology of acute maxillary sinusitis of odontogenic origin presenting with periodontal infection in children.

Methods:

Aspirates of 18 acutely infected maxillary sinuses that were associated with odontogenic infection in children who presented with periorbital cellulitis were processed for aerobic and anaerobic bacteria.

Results:

A total of 54 isolates were recovered (3.0 per specimen): 13 aerobic and facultative (0.7 per specimen) and 41 anaerobic (2.3 per specimen). The number of isolates per specimen varied from 1 to 4. Aerobic and facultative organisms alone were recovered in 2 specimens (11%), anaerobes only in 7 (39%), and mixed aerobic and anaerobic bacteria in 9 (50%). The predominant aerobic and facultative organisms were α-hemolytic streptococci (4), microaerophilic streptococci (3), and Streptococcus pyogenes and Staphylococcus aureus (2 each). The predominant anaerobic bacteria were anaerobic gram-negative bacilli (17), Peptostreptococcus spp (11), Fusobacterium spp (8), and Propionibacterium acnes (2). Twelve β-lactamase-producing bacteria were recovered from 9 specimens (50%).

Conclusions:

This study demonstrates the unique aerobic and anaerobic microbiological features of acute maxillary sinusitis of odontogenic origin presenting with periorbital cellulitis in children.

Intracranial and internal jugular vein thrombosis secondary to ENT infections: a report of 3 cases

We report 3 cases of rare, life-threatening intracranial and internal jugular vein (IJV) thrombosis that were caused by common ENT infections. These infections included otitis media in a 6-year-old girl, tonsillitis in a 21-year-old woman, and odontogenic sepsis in a 56-year-old woman. All 3 patients were treated with culture-directed systemic antibiotics; 2 of them also required surgical drainage (the child and the older adult). The 2 adults also received therapeutic anticoagulation, which was continued until venous recanalization was documented; the duration of combined antibiotic and anticoagulation treatment was 6 weeks. All 3 patients made uneventful recoveries. Significant morbidities associated with intracranial and IJV thrombosis were avoided as a result of prompt diagnosis and judicious treatment.

[Surgical treatment of acute descending necrotising mediastinitis]

INTRODUCTION

Acute descending necrotizing mediastinitis (DNM) is a severe septic inflammation of the mediastinum with necrosis, which progrediates rapidly and leads to death without adequate surgical treatment in 80% of cases.

PATIENTS AND METHOD

17 patients were treated with acute DNM between 1999 and 2012 at the Thoracic Surgical Department of Koranyi National Institute and Semmelweis University of Hungary. The infection source was primarily in the head-neck region with dental infections in eight cases, retro/parapharyngeal abscess in four patients, primary collar phlegmone and abscess in one case and two retrotonsillar abscesses. Further, in one case there was a previous operation (mediastinoscopy) in the history and in another case there was "difficult intubation process" (not recognized trachea-laesion) mentioned during abdominal operation. Primary exploration was performed from the neck in nine cases, thoracotomies plus collar incisions were carried out in four cases, athoracotomy only was done in one and orofacial exploration in further three patients. Disease progression could be evaluated by computer tomography which had to be followed by immediate surgery.

RESULTS

Four patients needed two operations, five patients underwent exploration three times, while three patients needed 4 interventions four times. More than one anatomical region was explored in 70% of the cases. Based on our experience prognosis is affected by the time elapsed between detection and surgical intervention, age of the patient and comorbidites such as diabetes mellitus. We lost nine patients (53%), eight patients recovered and symptom free (47%).

CONCLUSIONS

Successful treatment is based on early diagnosis, urgent elimination of the primary source, adequate exploration of the cervico-facial region, debridement, collar and upper mediastinal drainage. If the inflammation spreads below the azygos vein or the aortic arch, a right thoracotomy should be performed with wide mediastinal exploration, debridement, and thoracic suction-lavage drainage. Treatment should be completed with broad spectrum and targeted antibiotics as well as organ support. Mortality and morbidity can be reduced with prompt and aggressive therapy.

Cervicofacial necrotizing fasciitis following periodontal abscess

Soft tissue infections are characterized by acute inflammation, diffuse edema, and suppuration, and are often associated with symptoms such as malaise, fever, tachycardia, and chills. Necrotizing fasciitis is a destructive bacterial infection affecting subcutaneous tissue and superficial fascia and is associated with high rates of mortality. It usually involves the abdomen and extremities, but it also can occur in the head and neck. Early diagnosis is critical and the most commonly accepted treatment includes radical surgical intervention and administration of broad-spectrum antibiotics. This article reports and discusses the case of a patient with odontogenic cervicofacial necrotizing fasciitis, and emphasizes the importance of early and effective treatment.

Enamel pearls as a predisposing factor to localized periodontitis

Enamel pearls are enamel anomalies on primary and permanent teeth roots that usually appear at furcation areas, especially in maxillary second and third molars. Enamel pearls usually occur singularly, but as many as four have been observed on the same tooth. This report describes an unusual case of multiple enamel pearls associated with periodontal pockets localized on all maxillary first and second molars. Because the patient had an advanced stage of periodontitis, the maxillary right first and left second molars were extracted. The remaining two maxillary molars were included in a strict follow-up protocol. Enamel pearls were confirmed as the cause of localized periodontitis; therefore, it is very important to recognize their radiologic aspect to ensure proper treatment of the involved teeth.

[Descending necrotizing mediastinitis of odontogenic origin]

BACKGROUND

Descending necrotizing mediastinitis (DNM) following an oropharyngeal infection is a rare disease with a rapid course and a mortality rate of up to 40%. The aim of this study, is to outline the diagnosis and the appropriate treatment of DNM.

METHODS

A retrospective study (1986-2007) of patients with DNM was made. Only patients with cervical cellulitis associated with DNM were included.

RESULTS

Eight men and two women with an average age of 43 years were treated. Five had diabetes. The average for diagnosis and treatment was eight days. In eight cases, we found a dental origin and in two cases a pharyngeal origin. The diagnosis of DNM was made thanks to cervico thoracic CT scan in six cases. In the others patients, they had at presentation clinical and radiological evidence of mediastinal diffusion. All patients were treated by broad spectrum antibiotherapy. All had cervical drainage. Mediastinal drainage was made by cervical approach in 2 two cases and via a right thoracotomy in eight cases. Eight patients died.

CONCLUSION

Odontogenic DNM is a rare disease with rapid course. Clinical diagnosis is difficult and early recognition with a low thresold for CT scanning is essential. CT is also useful for the treatment and in the post operative assessment. All affected tissue plane must be debrided. Surgical management and mediastinal drainage remain controversial about the indication of thoracotomy.

[Clinical and therapeutical considerations regarding odontogenic acute mediastinitis]

Odontogenic acute mediastinitis is an polymicrobial infections caused in most cases by gram negative and anaerobic germs. The odontogenic origin of the cases in this study was based on anamnestic inquiry of the patients, which reveales a dental treatment 7-15 days before the diagnosis of acute mediastinitis was established. Clinical features are often nonspecific at the debut of this affection; septic shock could appear suddenly associated with multiple systems and organs failure. This is the explication why, some of these patients presented septic shock when are diagnosed. In this situations, when acute mediastinitis is suspected, based on clinical and imaging findings, it must be confirmed by surgical exploration and perioperative bacteriological evaluations. Positive diagnosis is based on clinical features associated with labs and imaging studies. Surgery plays an important role in therapy of acute mediastinitis: debridement and drainage of mediastinum with subsequently lavage of it, using antiseptic solutions. Broad spectrum antibiotherapy should be administrated immediately, before antibiogram is ready.

Phlegmon of the face and neck: a case report

Deep face and neck infections are potentially life threatening if they are not diagnosed in time and then treated quickly. This report describes a case of face and deep neck infection, associated with a semi-impacted and decayed wisdom tooth in a cardiopathic, immunosuppressed patient suffering from, diabetes, hypothyroidism, osteoporosis, breathlessness, chronic bronchitis, with oral, cutaneous and vaginal erythematous lichen, Cushing's Syndrome, penicillin allergy, subjected to past hypophysectomy. The swelling was, first of all, treated in urgency, with an intravenous antibiotic therapy and, immediately afterwards, the phlegmonous infiltration linked to the avulsion of the lower third molar was surgically drained. The patient was then treated with intravenous multiple antibiotics, with the aim of eradicating the predominating bacteria that was encountered in the microbiological culture test. A complete remission of the pathological picture was obtained .

Unusual outcome of Ludwig's angina

This is a report of 2 cases of Ludwig's angina. An Indonesian young female patient developed severe stridor after oral examination. Then she underwent tracheostomy and developed post decannulation dyspnea due to huge surgical emphysema. The second case regards an Indian young male who developed disseminated intravascular coagulation and died from hemorrhage. The objectives of our cases presentation are to avoid mouth examination of Ludwig's angina if we are not ready for performing tracheotomy and to be aware of the possible development of disseminated intravascular coagulation and post decannulation emphysema.

Cervical necrotizing fasciitis: an unusual sequel of odontogenic infection

Cervical necrotizing fasciitis is a rare infection of the fascial planes, which is less common in head and neck, because of the rarity and higher vascularity in the region. We reviewed five patients with cervical necrotizing fasciitis of odontogenic infection managed at a teaching hospital at Chennai, India. There were four men and one woman, of whom four patients were diabetic and hypertensive, with a mean age of 53 years. Mandibular molars (periapical or pericoronal abscess) were found to be the source of infection in all of the cases. The treatment involved incision and drainage and debridement. Anti-microbial drugs were given for all the patients, which included cephalosporins, metronidazole and gentamycin. In four patients the wound healed by contracture and one patient required split skin grafting. Due to the smaller extent of the necrosis, better control of the systemic disease and small size of the sample, there was neither a major complication nor death. This paper reminds us that cervicofacial necrotizing fasciitis (CNF) remains one of the potential complications of long standing odontogenic infections in patients with immune-compromised status, particularly in lower dentition.

[Descending necrotising mediastinitis: report of two cases]

Descending necrotising mediastinitis is a severe infection spreading from the cervical region to the mediastinal connective tissue. It represents a virulent form of mediastinal infection, requiring prompt diagnosis and treatment to reduce the high mortality associated. An optimal debridement and drainage through an open thoracotomy access are the keys for a successful outcome. Two patients, males, 70 and 75-years-old with descending necrotising mediastinitis were treated in our Institution in April '05. One had an odontogenic abscess and the other had a retropharyngeal abscess. Operative procedures included thoracotomy with radical surgical debridement of the mediastinum and excision of necrotic tissue associated with transcervical surgical debridement and drainage. Postoperatively mediastinum-pleural and cervical irrigation with iodopovidone 2 per thousand was performed until a culture of pleural effusion become negative. Postoperatively both patients suffered from severe complication including septic shock and acute respiratory distress syndrome. The 70-years-old patient had an acute renal failure too. Postoperatively the length of the intensive care unit stay was 40 and 42 days, respectively. The outcome was favorable in both patients. Early detection and immediate open surgical treatment could be the best way to reduce morbidity and mortality rate. Descending Necrotising Mediastinitis cannot be adequately treated without mediastinal and cervical excision of necrotic tissue and drainage including an open thoracic and cervical approach.

Multidisciplinary approach to the rehabilitation of a crown fracture with glass-fibre-reinforced composite: a case report

Traumatic tooth injuries are common in children. When permanent teeth are involved, it can be a challenge to save these teeth. This clinical case study describes the multidisciplinary treatment of a complex crown fracture and luxation of a right maxillary incisor along with esthetic management. After periodontal surgery including guided bone regeneration and endodontic treatment, we used a glass-fibre-reinforced composite post to increase retention and distribute stress along the root. The restoration was completed using composite in an incremental technique. During follow-up appointments, clinical and radiographic examinations revealed no root canal or periodontal problems, suggesting the efficacy of the treatment in retaining the fractured tooth. Periodontal surgery with endodontic treatment is an alternative treatment for severe trauma in permanent teeth.

[Odontogenic mediastinitis. Diagnostics and treatment]

The aim of our work was to evaluate the diagnostic and treatment of patients with odontogenic mediastinitis.

METHODS

The last 10 years (1991-2001) 13 males and 4 females, mean age 43 years, with odontogenic mediastinitis were submitted to surgical treatment. Primary odontogenic abscess occurred in all. Before admission to our clinic, 14 patients were treated at stomatological department. Diagnosis was made by clinical manifestation, roentgenographical features and confirmed by findings at mediastinum tissues during operation.

RESULTS

All patients at the admission day underwent broad cervicotomies with transcervical mediastinal drainage. In 5 cases this management was associated with mediastinal drainage by transthoracic approach. For another 5 patients thoracotomies were performed late, the last 7 survived without thoracotomy. Six patient died, mortality rate was 35.2%. The reason of the high mortality rate-delay of transthoracic mediastinal drainage in 5 cases, when transcervical was inadequate.

CONCLUSION

Ample cervicotomy, associated with transcervical and transthoracic mediastinal drainage can significantly reduce the mortality rate for odontogenic mediastinitis.

Optimal surgical management of descending necrotising mediastinitis: our experience and review of literature

INTRODUCTION

Descending necrotising mediastinitis is a form of mediastinitis caused by odontogenic infection or deep cervical infections, which spreads to the mediastinum via the cervical fascial planes. Despite the increased use of CT scan as a diagnostic aid and the improvement in antibiotics, mortality in patients with descending necrotising mediastinitis remains high, reported between 25 and 40% in the literature. Surgical management and optimal form of mediastinal drainage remain controversial.

PATIENTS AND METHODS

We have treated three patients with descending necrotising mediastinitis at our institution. Two patients were male and one was female with mean age 54.3+/-12.5 years. One of the patients was a known diabetic. The primary oropharyngeal infection was Ludwig's angina, odontogenic abscess and parapharyngeal abscess. All patients underwent mediastinal drainage, one through midsternotomy and two through right thoracotomy in addition to cervical drainage. All the three patients had mixed aerobic and anaerobic infection.

RESULTS

There was no perioperative mortality. Mean ICU stay was 32 days (12-53 days). All three patients had septicaemic shock requiring prolonged inotropic support. Two patients required tracheostomy because of prolonged ventilation. All the patients had recurrent abscesses and collections either in neck or in chest requiring drainage either surgically or percutaneously under CT scan or ultrasound guidance, thus decreasing the need of repeated surgical procedures.

CONCLUSION

Descending necrotising mediastinitis is a potentially fatal condition. Early diagnosis, prompt surgical drainage, monitoring of disease process, appropriate medical management in an intensive care unit and a multi-disciplinary approach can significantly reduces the mortality in this otherwise fatal condition. Percutaneous drainage of recurrent abscesses and collections can decrease the need of repeated surgical procedures in these critically ill patients.

Mandibular fracture caused by periodontal abscess: Radiological, US, CT and MRI findings

Mandibular fracture is a rare but possible outcome of a periodontal abscess. A case of complete fracture of the mandible with abscess infiltrating the surrounding soft tissues is described. The patient reported nor trauma, nor locoregional surgery. Ultrasonography and orthopantomography revealed the fracture of the mandible and the abscess at the masseter muscle. Further preoperative diagnostic examinations included CT and MRI. CT revealed the complete fracture line more clearly; MR the extension of the abscess.

Case report: brain and liver abscesses caused by oral infection with Streptococcus intermedius

Organ abscesses are a rare and life-threatening complication mostly of hematogenously disseminated infections. We report a case of brain and liver abscesses. Identification of the lesions was made by contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), respectively. An oral examination comprised an oral focus of infection. Streptococcus intermedius was isolated from oral smear, liver and ventricular drainage, and blood sample. After the commencement of antibiotic therapy, drainage of abscesses and oral rehabilitation, complete recovery was noted.

Septicemia due to Solobacterium moorei in a patient with multiple myeloma

We report a case of bacteremia caused by Solobacterium moorei, an anaerobic, non-sporulated Gram-positive bacillus in a patient with a multiple myeloma. The source of infection was presumably related to multiple dento-alveolar abscesses. This is the first recovery of S. moorei from blood cultures.

Decision making for the patient who presents with acute dental pain

Patients who require dental emergency care for pain or trauma may not be able to see a dental practitioner for treatment. The patients often seek care in alternative medical facilities when the symptoms are too severe to be managed by over-the-counter medications. Nurses, physicians, and allied medical staff may be required to triage these patients and provide palliative treatment until the patient is able to seek definitive dental treatment. By using criteria to assess the etiology of the dental pain and implementing possible alternative treatments, these patients can receive palliative care until dental treatment becomes accessible. With the potential for development of resistant forms of microorganisms, the indiscriminate use of antibiotics for dental pain is to be avoided. Occasionally, dental patients presenting to medical settings exhibit symptoms and signs of dental-related problems that are potentially life threatening. Identification of signs of impending life-threatening complications is of paramount importance, since prompt treatment will significantly affect the prognosis.

Supernumerary premolars associated with dens evaginatus: report of 2 cases

Dens evaginatus is a dental anomaly found predominantly in people of Mongoloid origin. Dentists practising in Western countries should also be aware of this condition because of the increasing migration of people from Asia. Supernumerary premolars are uncommon but may be found incidentally during radiographic examination of teeth with dens evaginatus. This article reports 2 cases of concomitant occurrence of supernumerary premolars and dens evaginatus. The presence of a supernumerary premolar in 1 quadrant is an indication for radiographic examination of all other premolar regions.

Craniocervical necrotizing fasciitis of odontogenic origin with mediastinal extension

We review an interesting case of craniocervical necrotizing fasciitis with thoracic extension in an immunocompetent 44-year-old man. The patient underwent aggressive medical and surgical management during a long hospitalization. Multiple surgical debridements, including transcervical mediastinal debridement, and eventually a thoracotomy for mediastinal abscess were required. The patient eventually recovered, and 3 months later he showed no sign of complications or recurrence. Craniocervical necrotizing fasciitis is a fulminant soft-tissue infection, usually of odontogenic origin, that requires prompt identification and treatment to ensure survival. Broad-spectrum intravenous antibiotics, aggressive surgical debridement and wound care, hyperbaric oxygen, and good intensive care are the mainstays of treatment.

Streptococcal infection and necrotizing fasciitis—implications for rehabilitation: a report of 5 cases and review of the literature

Five cases are presented of patients who were diagnosed with necrotizing fasciitis secondary to (1) hip disarticulation (in a paraplegic patient); (2) tooth abscess with extensive neck dissection, complicated by sepsis and hypotension with resultant dysphagia and ischemic encephalopathy; (3) below-knee amputation, anoxia, and severe debility; (4) emergent above-knee amputation; and (5) percutaneous endoscopic gastrostomy placement. The latter patient developed abdominal and chest wall necrotizing fasciitis that required skin grafting. Four patients were treated in an acute rehabilitation setting and returned home, and the fifth was rehabilitated in a subacute facility. This report emphasizes the importance of carefully monitoring rehabilitation patients, especially those with impaired sensation.

An objective method of assessing facial swelling in patients with dental abscesses treated with clarithromycin

AIM

The study evaluates the efficacy of a set of objective parameters for monitoring facial swelling in a group of patients treated with clarithromycin.

METHODS

Fifty consecutive patients suffering from dental abscesses (22 in the maxillary arch and 28 in the mandibular arch) were enrolled. All these patients underwent antibiotic treatment with clarithromycin in a new formulation as a single daily dose (500 mg/day for 6 days). Pain and changes in facial swelling were evaluated at baseline and each day for 6 days through subjective parameters (visual analogic scale, VAS) and objective parameters (6 different tape measurements on the skin surface above the abscess).

RESULTS

Pain and swelling recorded by patient and dentist (using VAS scores) showed statistically significant decreases (p<0.01) on days 2, 3 and 4, while no further significant variation was observed during days 4, 5 or 6. As regards the objective parameters to quantify facial swelling, the maximum dimensional change (from baseline to final values) in the mandibular arch was obtained with measurement 6 (mean value 2.27+/-0.53 cm); the maximum dimensional change in the maxillary arch was obtained with the sum of the other 5 measurements (mean value 6.34+/-4.09 cm).

CONCLUSION

The use of a single or a combination of linear measurements might provide a sensitive and reproducible method to evaluate facial swelling objectively and could be very useful in monitoring the efficacy of new antibiotics and to compare the results from different studies.

[The adverse effect of gas formation on prognosis in a patient with deep neck infection]

A seventy-one-year-old woman was hospitalized with a suspicion of deep neck infection and poor general health. She had been receiving treatment for hepatitis, diabetes mellitus, and cardiac failure and had a history of tooth ache and severe neck pain lasting for the past 10 days. She had been admitted to another center where she had received antibiotic treatment for five days for widespread swelling in the neck and lower extremities, fatigue, and difficulty in breathing and swallowing. Upon admission, computed tomography showed gas formation in the neck and facial regions. Prompt abscess drainage was performed and intense treatment with antibiotics was continued. Despite all efforts, the patient died on the second day of hospitalization from cardiopulmonary arrest. This case emphasizes how urgent drainage is when gas formation is detected in deep neck infections, with inevitable poor prognosis with antibiotic treatment alone.

Eradication of invasive mucormycosis--effectiveness of the Echinocandin FK463

BACKGROUND

Invasive rhinocerebral mucormycosis is a rare and often fatal opportunistic fungal infection. It is encountered in immunocompromised hosts exemplified by those with diabetes, human immunodeficiency viruses and particularly haematologic malignancies typically after high-dose chemotherapy and stem cell transplantation. In contrast to the more usual outcome with rapid progression and death. We now describe a successful eradication attributable to the use of a newly available antifungal agent.

SETTING

Haematology department and bone marrow transplantation unit.

MATERIAL AND METHOD

Two patients are contrasted. The first with acute leukaemia developed rapidly progressive facial swelling with mucormycosis proven on biopsy. Treatment over 2 months with maximally tolerated doses of amphotericin failed to halt intracranial extension and death resulted. The second, presented with acute lymphoblastic leukaemia in August 1997, underwent successful autologous bone marrow transplantation in February 1998. Relapse followed in March 1999 and after reinduction and consolidation receive a matched unrelated volunteer allograft in September 1999. A second recurrence was documented in April 2000 and in spite of achieving remission he developed a fever that was managed empirically with intravenous amphotericin and, on discharge, oral itraconazole. Left-sided facial swelling expanded rapidly and biopsy showed extensive invasion of the maxillary sinus with mucormycosis. FK463 was added on 5 June 2000 with gradual reduction in facial pain and within 1 month all clinical signs and resolved. Serial biopsies that included histopathologic investigation and microbiologic cultures confirmed eradication of the invasive mucor. In view of the potential danger of recrudescence this treatment regimen was continued through further chemotherapy and, once again disease-free, a second matched unrelated volunteer allograft took place in August 2000. Full reassessment at the time failed to demonstration any residual fungus. Engraftment was confirmed but neutropenic sepsis resulted in severe inflammatory response syndrome with progression to multiple organ dysfunction to which he succumbed without any evidence of leukaemic or systemic mycosis.

CONCLUSION

Echinocandin FK463 is of documented value in managing invasive candidiasis and aspergillosis. This is believed to be the first case of successful outcome with one of the angiotrophic zygomycetes.

Subdurales Empyem und Zerebritis als Folge einer dentogenen, eitrigen Pansinusitis

BACKGROUND

Complications and local extension of dentogenous and paranasal sinus infections most often involve the periorbit and frontal cranium. Because of the widespread use of antibiotics, intracranial extension of maxillofacial sinusitis is rarely seen today. Nevertheless, the clinician must be aware of the potential for these complications, because late recognition of this condition and delay in treatment can increase morbidity and mortality rates.

CASE REPORT

A case report of sinogenic intracranial complications is presented, with sinogenic empyema, cerebritis, and subdural empyema. The mechanisms and potential for intracranial spread of infection from the frontal, sphenoid, and ethmoid sinuses are discussed. The management of complications is outlined, including the use of computed tomography and the role of surgical drainage.

Diabetic ketoacidosis secondary to dento-alveolar infection

Diabetic ketoacidosis (DKA) is a medical emergency with a potentially fatal outcome if not recognized and treated appropriately. Infective processes are a common precipitant of DKA. We report two cases of dentoalveolar infections in patients with type I diabetes mellitus who presented with DKA. The management of such cases requires both specialist surgical and medical intervention.

[Clinical study of dental and periodontal infectious complications observed at the Central Hospital of Yaounde--apropos of 161 cases]

The septic condition resulting from an apical infection, a peridontal infection, an accident of dental eruption or post-extraction can be disseminated and can lead to complications. A retrospective study of 161 cases admitted at the Central Hospital of Yaounde from 1995 to 1998 was done with the aim of establishing a distribution according to sex, age, profession, infectious stage and causes of late consultation as well as the relation between the infectious stage, aetiology, age and profession. It was observed that: the age group mostly affected were: 10-19 years (25.46%) and 20-29 years (30.43%), it was at the late stage of abscess (54.03%) and of phlegmon (32.91%) that the patients came for consultation and this was primarily due to poor socio-economic conditions (55.90%), abscess was formed mostly among the students of 10-19 years and 0-9 years while phlegmon was observed mostly among the students between 20-29 years. It was for these reasons that we suggest: a better prevention of infectious dental diseases in schools and universities, a sensibilisation of parents and educators on the economic interest of early treatment of these infections.

[Clinical manifestations and lethality of descending necrotizing mediastinitis]

OBJECTIVE

To describe the clinical manifestations, treatment and lethality of a series of patients with descending necrotizing mediastinitis (DNM).

DESIGN

Retrospective study of a series of cases. SITE OF STUDY: The Infectious Diseases Hospital (IDH) of the Mexican Social Security Institute, Mexico City; a national reference hospital.

PATIENTS AND METHODS

From January 1996 through December 1998, 18 consecutive patients with diagnostic criteria for DNM were treated in the IDH. Demographic variables, precedents, clinical manifestations, characteristics of paraclinical studies, and treatment results were recollected from the chart of each patient. We made a comparison between patients who survived and the patients who died.

RESULTS

The mean age of the patients was 48.8 +/- 19.1 years; 13 (72.5%) were men. Nine (50%) had an underlying disease, being diabetes mellitus the most frequent one. In 13 (72.5%) cases an odontogenic abscess was the original infection; three (16.6%) patients had retropharyngeal abscesses. The mean time between the beginning of symptoms and admission to the hospital was 10.6 +/- 6.7 days. The most frequent symptoms were fever, dyspnea, dysphagia, and hypotension. The treatment was medical and surgical in all cases, with antibiotics, thoracotomy, drainage and debridement. The most frequent complications were septic shock, nosocomial pneumonia and ARDS. Nine patients died, the lethality rate was 50%. Patients who died had, at admission lower leukocytes and platelets counts; higher glycemia, and developed more frequently cardiovascular complications and septic shock.

CONCLUSIONS

Odontogenic abscesses are the most frequent primary infections in patients with DNM. This is an infectious problem with high lethality. Septic shock is the principal cause of death.

The swollen face. Severe odontogenic infections

Owing to the widespread availability of preventive dental care and the development of effective antibiotics for the treatment of orofacial infection, the incidence of serious odontogenic infections has decreased dramatically over the past 50 years. Serious dental infections still occur, however, and their occasionally severe complications or even mortality warrant serious study of the clinical presentation, anatomy, and pathophysiology of orofacial infections. The goal of this review is to provide the emergency practitioner with a concise description of the clinical presentation, relevant anatomy, and treatment principles of odontogenic infection in the patient who presents to the ED with a swollen face or difficulty in opening the mouth widely. Prompt institution of surgical therapy for the infection, aided by appropriate antibiotic therapy enables the healthcare professions to continue their remarkable progress in treating these once-dreaded infections.

The periodontal abscess: a review

BACKGROUND/AIMS

The periodontal abscess is a frequent periodontal condition in which periodontal tissues may be rapidly destroyed. Its importance is based on the possible need of urgent care, the affectation of tooth prognosis, and the possibility of infection spreading. There is scant information in the scientific literature regarding this condition and most of it has been published as case reports and text books, where conclusions are not evidence-based, but rather empirical observations made by recognised clinicians. The aim of this review was to critically analyse all available information on this subject in the dental and medical literature, including information on its prevalence, proposed etiologies and pathogenesis, diagnosis, microbiology and treatment alternatives.

SUMMARY

The periodontal abscess is the 3rd most frequent dental emergency, and it is specially prevalent among untreated periodontal patients and periodontal patients during maintenance. Different etiologies have been proposed, and 2 main groups can be distinguished, depending on its relation with periodontal pockets. In the case of a periodontitis-related abscess, the condition may appear as an exacerbation of a non-treated periodontitis or during the course of periodontal therapy. In non-periodontitis related abscesses, impaction of foreign objects, and radicular abnormalities are the 2 main causes. The abscess microflora seems to be similar to that of adult periodontitis, and it is dominated by gram-negative anaerobic rods, including well-known periodontal pathogens. Complications and consequences include tooth loss and the spread of the infection to other body sites. Diagnosis and treatment is mainly based on empiricism, since evidence-based data are not available. The role of systemic antibiotics, in the treatment of periodontal abscesses, is especially controversial.

Branch retinal artery occlusion: a case complicating acute rheumatic fever and dental abscess

A15-year-old boy presented with a 2-month history of lethargy, weight loss and migratory arthralgia following an episode of pharyngitis while on holiday in the Mediterranean. Examination revealed the murmurs of mitral and aortic regurgitation which were confirmed on echocardiogram. The serum C-reactive protein (CRP) was high at 124 mg/litre and the streptococcal antibody titre markedly elevated at >1440 units. A diagnosis of acute rheumatic fever was made and penicillin commenced in addition to aspirin for joint pain. Three months after diagnosis he was asymptomatic, the CRP was normal and aspirin was discontinued.

Six weeks later he presented with sudden onset of blurred vision in the right eye with a visual field defect in the nasal upper quadrant. There was no history of migraine and fundoscopy revealed an embolus at the disc with severe oedema below the macula consistent with occlusion of the inferotemporal branch of the retinal artery (Figure 1). Warfarin was commenced pending further investigation. Subsequent transoesophageal echo showed mild mitral regurgitation and minimal aortic regurgitation with no vegetations or thrombus. There was no evidence of arrhythmia and brain magnetic resonance imaging was normal. His protein C activity was transiently low at 64% (normal range 70–130%) and his CRP rose to 36 mg/litre. Aspirin was therefore substituted for warfarin. Three days later he presented with two dental abscesses requiring extraction. Fourteen months after presentation the superior altitudinal scotoma has improved and the retinal oedema resolved. Mild mitral valve regurgitation persists but aortic valve function appears normal. He continues on low dose aspirin and penicillin.