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Eikenella corrodens Brain Abscess after Repeated Periodontal Manipulations

Cured with Imipenem and Neurosurgery

Article  in  Infection · September 2002

DOI: 10.1007/s15010-002-2004-6 · Source: PubMed

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Infection
Eikenella corrodens Brain Abscess after Repeated
Periodontal Manipulations Cured with Imipenem
and Neurosurgery
V. Asensi, M. Alvarez, J.A. Carton, M. Lago, J.A. Maradona, J.M. Asensi, J.M. Arribas
Abstract
Eikenella corrodens is a facultatively anaerobic gram-
negative rod that colonizes the oral cavity and very rarely
produces central nervous system (CNS) infections. Frontal
lobe abscesses are occasionally associated with a dental
source of infection. We report a case of an adult man with
overzealous dental cleaning habits who developed a right
frontal brain abscess caused by E. corrodens. He underwent
neurosurgical drainage of the pus and was successfully
treated with imipenem 4 g/iv/day for 4 weeks with no
complications. Repeated periodontal trauma could explain
the Eikenella brain abscess in this case.
Key Words
Eikenella corrodens · Brain abscess · Imipenem ·
Neurosurgery · Periodontal prophylaxis
Infection 2002; 30: 240–242
DOI 10.1007/s15010-002-2004-6
Introduction
Eikenella corrodens is a small gram-negative facultatively
anaerobic bacillus. The natural habitats of this microrgan-
ism are the oral cavity and the upper respiratory tract. Al-
though rarely a pathogen, it has been associated with sev-
eral different infections [1–4] including a few reports of
CNS infections. E. corrodens brain abscesses are extremely
rare [5–12]. We report a patient who developed an E. cor-
rodens brain abscess following overzealous periodontal
cleaning, who was treated and cured with imipenem and
neurosurgical drainage.
Case Report
A 54-year-old policeman was admitted to our hospital for bizarre
behavior and vomiting. His past history was unremarkable except
for long-standing hypertension and bacterial pneumonia 6 years
before. He compulsively indulged in tooth-picking, brushed his
teeth and gums vigorously twice a day with a hard brush to the
point of bleeding and afterwards repeatedly used a dental floss.
He had complained of severe headache during the previous 24 h,
although he remained afebrile. His ears, oral cavity, heart, lung and
skin appeared normal. He was sluggish mentally with conjugate
240
Case Report
deviation of both eyes to the right. No other abnormal neurolog-
ical signs were detected. In the emergency room he developed a
generalized seizure that was controlled with clonazepam. Com-
plete blood cell counts, automated blood chemistry studies and
serum electrolyte determinations were normal. A computed to-
mographic (CT) scan showed a right hypodense frontal lesion with
contrast ring enhancement and peri-lesional edema. Sinusitis was
not evident in the CT scan (Figure 1, left). An orthopantomogra-
phy was also normal. He was empirically treated with intravenous
imipenem/cilastatin. Three weeks after admission a right-sided
frontal craniectomy was done with the removal of an encapsulated
4 cm mass containing white-yellowish pus. The pathologic diagno-
sis of the removed tissue was a pyogenic brain abscess. Gram stain
of the pus showed small gram-negative rods and numerous leuko-
cytes. The aspirated pus was inoculated into thioglycollate broth
and onto blood agar and chocolate agar plates that were incubated
anaerobically and in a 10% CO2 atmosphere at 37 ºC. The pus
yielded a pure culture of E. corrodens from the plates that were
incubated anaerobically and under 10% CO2. Biochemically the
microorganism was nitrate and oxidase–positive, catalase, indol,
and urease-negative and did not ferment glucose. The microor-
ganism was sensitive to ampicillin, amoxicillin-clavulanic acid,
chloramphenicol, cefotaxime, imipenem and ciprofloxacin and was
resistant to trimethoprim-sulfamethoxazole and clindamycin by
agar dilution techniques. Oral and gum cultures taken using wet
swabs did not grow Eikenella, probably because the patient was
already being treated with imipenem. He completed a 4-week
course of this antibiotic, 1 g/iv/6 h, with complete resolution of the
brain lesion in a head CT scan done 2 weeks after neurosurgery
(Figure 1, right). He was also treated with phenytoin without re-
currence of the seizures. One year later he remained well without
evidence of the brain abscess on CT scan.
V. Asensi (corresponding author), J.A. Carton, J.A. Maradona, J.M. Arribas
Infectious Diseases Unit, Hospital Central de Asturias, Oviedo University
Medical School, C/Celestino Villamil s/n, E-33006 Oviedo,Spain,
e-mail:vasensia@medynet.com
M. Alvarez
Dept. of Microbiology, Hospital Central de Asturias, Oviedo University
Medical School, Spain
M. Lago, J.M. Asensi
Depts. of Neurology and Neurosurgery, Hospital Central de Asturias,
Oviedo University Medical School, Spain
Received: January 12, 2001 • Revision accepted: Decmber 8, 2001
Infection 30 · 2002 · No. 4 © URBAN & VOGEL

Figure 1. A computed tomographic (CT) scan done on hospital admission showed a right hypodense frontal lesion with contrast ring enhance-
ment and peri-lesional edema (left). A sequential CT done 2 weeks after neurosurgery and after having received a 4-week course of imipenem
showed abscess resolution (right).
Discussion
E. corrodens is part of the normal flora of the oral cavity,
the gastrointestinal and respiratory tracts and mucous
membranes. It is often a component of the dental plaque
and is present in 40% of healthy gums [12]. It has been iso-
lated from patients with endocarditis, head and neck infec-
tions, soft-tissue and bone infections and from pulmonary,
intra-abdominal and thyroid abscesses [1–4]. In a Medline
search of the world literature we found only 26 cases of E.
corrodens brain abscesses published as of December 2000
[5–12]. These brain abscesses developed in children and
adults alike and many of them were related to sinusitis, oti-
tis media, mastoiditis, oral trauma or dental sepsis [7, 8, 12].
Frontal brain abscesses caused by E. corrodens have been
associated with upper teeth infections because apical ve-
nous drainage is connected with the cavernous sinus and a
septic embolus could move in the reverse flow that occurs
during yawning and mastication [7]. We did not demon-
strate any dental or sinus infection in our patient, so the ori-
gin of his brain abscess remains unknown. In the absence
of fever and heart murmurs blood cultures were not done,
thus we can not absolutely rule out Eikenella endocarditis.
However the absence of signs or symptoms of valvular
Infection 30 · 2002 · No. 4 © URBAN & VOGEL
V. Asensi et al. Eikenella corrodens Brain Abscess and Imipenem
heart disease after 1 year makes that highly unlikely. Per-
haps his compulsive tooth-picking and overzealous peri-
odontal prophylaxis played some role in spreading the bac-
teria from the mouth via the blood, as was suggested by
some authors [12]. The fact that oral cultures did not show
Eikenella does not rule out the oral source of infection,
since he was already being treated with imipenem. Al-
though E. corrodens has often been isolated with other bac-
teria from brain abscesses, especially Streptoccocus and
Staphylococcus spp. [5–7, 9], we grew only Eikenella in pure
culture from our patient. Since he was treated with
imipenem for 3 weeks before neurosurgery, this antibiotic
could have eliminated all other microorganisms from the
pus. However this seems unlikely since E. corrodens was ex-
quisitely sensitive to imipenem.
Since 1987 we have used imipenem monotherapy to
treat brain abscesses in our institution. Imipenem-cilastatin
is a very effective way to treat brain abscesses, either alone
or in combination with neurosurgical procedures to drain
the abscesses. Imipenem penetrates the blood/CSF barrier
well and its mean concentration in the abscess material is
above the MIC90 values reported for streptococci, anaer-
obes and other oral microorganisms commonly isolated
241
 V. Asensi et al. Eikenella corrodens Brain Abscess and Imipenem
from brain abscesses [13, 14].As of December 2000 we have
used imipenem/cilastatin to successfully treat 29 brain ab-
scess patients, 27 in conjunction with neurosurgical
drainage and two without neurosurgery. 40% of the ab-
scesses were due to anaerobes (Bacteroides and Pep-
tostreptococcus), 35% to gram-positive aerobic cocci
(mostly viridans streptococci) and 25% to gram-negative
bacilli (mostly Proteus mirabilis and secondary to previous
neurosurgical procedures) [14]. Imipenem can cause
seizures and many authorities have advised against its use
to treat CNS infections [15]. However, in our 29 cases we
observed seizures in only three cases (10.3%) and these
were more likely related to the size and location of the
brain lesions than to imipenem itself. In two of these three
cases seizures were easily controlled with phenytoin with-
out stopping imipenem [14, 16]. In the third case general-
ized seizures persisted after switching from imipenem to
penicillin and the addition of phenytoin and clonazepam.
Meropenem, another carbapenem with excellent in vitro
activity against gram-negative rods, is less epileptogenic and
potentially could be an excellent alternative to imipenem
[17, 18]. E. corrodens is also sensitive to ampicillin and third-
generation cephalosporins (cefotaxime, ceftriaxone and
ceftazidime) [11, 19].
In summary, E. corrodens is an unusual cause of brain
abscesses and imipenem, among other antibiotics, is an ex-
cellent treatment choice for this infection. Regarding the
periodontal manipulations of the patient, it can be said that
overzealous peridontal cleaning and compulsive tooth-
picking can be risky habits, even for a policeman.
Acknowledgment
We thank Professor Dr. Joshua Fierer, Head of the Infectious Dis-
eases Section of the University of California at San Diego, USA,
for critical review of this manuscript
References
1. Dorff GJ, Jackson LJ, Rytel MW: Infections with Eikenella corro-
dens. A newly recognized human pathogen. Ann Intern Med
1974; 80: 305–309.
2. Stoloff AL, Gillies ML: Infections with Eikenella corrodens in a
general hospital: a report of 33 cases. Rev Infect Dis 1986; 8:
50–53.
242
View publication stats
3. Joshi N, O’Brian T, Appelbaum PC: Pleuropulmonary infections
caused by Eikenella corrodens. Rev Infect Dis 1991; 13: 1207–1212.
4. Paul K, Patel SS: Eikenella corrodens infections in children and
adolescents: case reports and review of the literature. Clin Infect
Dis 2001; 33: 54–61.
5. Rubenstein JE, Lieberman MF, Gadoth N: Central nervous system
infection with Eikenella corrodens: report of two cases. Pedi-
atrics 1976; 57: 264–265.
6. Emmerson AM, Mills F: Recurrent meningitis and brain abscess
caused by Eikenella corrodens. Postgrad Med J 1978; 54: 343–345.
7. Ingham HR, High AS, Kalbag RM, Sengupta RP, Tharagonnet D,
Selkon JB: Abscesses of the frontal lobe of the brain secondary
to covert dental sepsis. Lancet 1978; 2: 497–499.
8. De Mello FJ, Leonard MS: Eikenella corrodens: a new pathogen.
Oral Surg 1979; 47: 401–404.
9. Brill CB, Pearlstein LS, Kaplan J, Mancall EL: CNS infections
caused by Eikenella corrodens. Arch Neurol 1982; 39: 431–432.
10. Porphyris H: Central nervous system infections due to Eikenella
corrodens. Surg Neurol 1983; 19: 150–153.
11. Cheng AF, South JR, French GL: Eikenella corrodens as a cause of
brain abscess. Scand J Infect Dis 1988; 20: 667–671.
12. Burdick CO, Erasmus D, Jayaram A, Schield PN, Kosch W: Eikenella
brain abscess. JAMA 1982; 248: 1973–1974.
13. Cartón JA, Pérez F , Maradona JA, Mendez FJ : Successful treat-
ment of recurrent cerebral empyema and brain abscesses with
imipenem. Eur J Clini Microbiol Infect Dis 1987; 6: 578–580.
14. Asensi V, Cartón JA., Maradona JA, Asensi JM, Pérez F, Redondo P,
López A, Arribas JM: Imipenem therapy of brain abscesses. Eur J
Clini Microbiol Infect Dis 1996; 15: 653–657.
15. Calandra G, Lydick E, Carrigan J, Weiss I, Guess H: Factors predis-
posing to seizures in seriously ill infected patients receiving an-
tibiotics: experience with imipenem/cilastatin. Am J Med 1988;
89: 911–918.
16. Asensi V, Cartón JA, Maradona JA, Asensi J, Pérez F, Redondo P,
López A, Arribas JM: Therapy of brain abscess with imipenem – a
safe therapeutic choice? J Antimicrob Chemother 1996; 37:
200–203.
17. Meis JF, Groot-Loonen J, Hoogkamp-Korstanje JA: A brain ab-
scess due to multiply-resistant Enterobacter cloacae successfully
treated with meropenem. Clin Infect Dis 1995; 20:1567.
18. Pafetti A, D’Aviera L, Le Foche F, Mannozzi P, Mastropietro C,
Croce GF, Ferretti G, Rossi F: Successful meropenem therapy of a
brain abscess and meningitis arising from acute purulent
otomastoiditis: case report. J Chemother 1998; 10: 132–135.
19. Sjolin J, Lilja A, Eriksson N, Arneborn P, Cors O: Treatment of brain
abscess with cefotaxime and metronidazole: prospective study
of 15 consecutive patients. Clin Infect Dis 1993; 17: 857–863.
Infection 30 · 2002 · No. 4 © URBAN & VOGEL