ORAL MICROBIOLOGY
woman with interstitial pneumonia. Stereotactic
burr-hole drainage and antibiotic treatment
(vancomycin, piperacillin and cefotaxime) were
applied.28 An unusual etiological agent association
has been found in a case of a 56-year-old man with
a right fronto-ethmoido-maxillary sinusitis, type
II diabetes and a history of myocardial infarction,
who developed a subdural empyema in the right
fronto-temporo-parietal region and a right frontal
lobe abscess.29 Culture and polymerase chain
reaction performed with pus sample collected by
needle-aspiration revealed S. intermedius, while
the abscess aspirate imaged by both Nomarski
differential interference contrast microscopy and
transmission electron microscopy indicated the
presence of Encephalitozoon cuniculi. In addition,
the genotype of this microsporidian was detected
by a polymerase chain reaction in the abscess
aspirate, urine and stool samples. The patient
was cured with intravenous chloramphenicol and
antiparazitic agents (first albendazol, which was
changed to mebendazol due to circumstances).
The other 2 species of the anginosus group
may express pathogenic factors too. One of the
putative virulence factors responsible for the betahemolytic activity of the S. anginosus strains is the
streptolysin S-like peptide with a different amino
acid structure than streptolysin S of S. pyogenes,
which is encoded by two sagA homologues.30
A brain abscess often requires both surgery
treatment and antibiotic administration for a
period of 1-2 months. Sim and Watson published
a case of brain abscess due to S. anginosus in
a 23-year-old woman who previously suffered
several tooth extractions.31 The patient recovered
after intravenous penicillin G administration for a
period longer than one month.
Lin presented a case of a temporal lobe abscess
and a thalamus haematoma in a 78-year-old man
with fever and haemiplegia after 5 days from the
incision of a masticator space abscess due to a
tooth extraction.32 The culture of the aspirated
pus was positive for S. anginosus and the patient
was treated intravenously with penicillin G for 2
months, but was left with hemiparesis. This species
may produce multiple intracranial abscesses even
in previously healthy individuals.33 A 30-year-old
man with a medical history of asthma developed
a left lower lobe lung abscess and multiple
brain abscesses located in both frontal lobes
and in parietal-occipital junction with extension
in the ventricle and cerebellum.34 Treatment
with vancomycin intrathecally and ceftriaxone
intravenously has been started, but the patient
developed an extensive venous thromboembolism
and died despite the urgent fasciotomy.
Specialist literature offers several case reports
with concomitant brain and other deep seated
abscesses caused by S. anginosus, such as lung
abscess35 or spleen and liver abscesses.36
Walsh et al. described a case of a 53-year-old
woman with fronto-parietal abscess with atrial
septal aneurysm and patent foramen ovale, and
156
a history of asthma and epilepsy.37 The cerebral
abscess was found during the neuronavigationguided left fronto-parietal craniotomy, performed
in order to debulk the presumed brain neoplasm
revealed by neuroimaging. The microorganism
grown from the drained pus was S. constellatus
and the authors assumed that it originated from
the mouth flora, entered the bloodstream during
the dental extraction underwent by the patient
3 weeks prior to admission, and bypassed the
pulmonary circulation developing an embolism
through foramen ovale. The clinical status
improved very much after neurosurgery and
antimicrobial treatment for 7 weeks.
Chheda et al. isolated S. constellatus from a biopsy
sample collected from a frontal brain lesion in
a 54-year-old male patient with endogenous
endophthalmitis and multiple brain abscesses. The
patient also suffered from diabetes mellitus and
had undergone a tooth extraction 2 months before
admission.38 Ceftriaxone and metronidazole
were given initially and the treatment continued
with intravenous cephalosporine. The patient
left the hospital after 3 months, with improved
neurological status.
A Polish patient with orbital complication during
an acute episode of rhinosinusitis was diagnosed
with brain abscess by computed tomography,
which is strongly recommended for both sinus and
brain in most acute rhinosinusitis complications.39
The pus culture of the surgical evacuated abscess
was positive for S. constellatus and Parvimonas
micra, and the patient recovered after half a month
of treatment with penicillin and metronidazol.
Besides cranial computed tomography, magnetic
resonance imaging is very often necessary
to confirm the diagnosis. It is also the case
of a 38-year-old female patient with a frontoparietal lobe abscess who was diagnosed
during the hospitalization with Osler’s disease
too.40 S. constellatus was isolated in association
with Fusobacterium spp. and Aggregatibacter
aphrophilus.
The empiric treatment with chloramphenicole and
metronidazole has been replaced by cefotaxime,
due to acquired thrombocytopenia.
The diffusion-weighted imaging has already
demonstrated its usefulness in distinguishing a
pyogenic abscess from necrotic and cystic tumors.
Thus, the gadolinium enhanced T1-weighted
images indicated the presence of a pituitary
abscess in a 74-year old man who suffered a
transsphenoidal surgery for pituitary adenoma
one year ago.41 Neurosurgery was repeated and a
pituitary abscess was revealed, with detection of
S. intermedius in the abscess pus.
A national prospective research focusing on the
microbiology of the brain abscess was performed
in Norway between 2011 - 2013.42 One hundred
and sixty strains were detected by massive
parallel sequencing in 31 samples originated
from spontaneous abscesses. Most of the strains
originated from dental or oro-maxillo-facial