Crozet Annals of Medicine: Seeds of Destruction

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by Robert C. Reiser, MD

The parents were standing vigil at the foot of the bed. Their normally healthy 22-year-old son was due to graduate from an Ivy League college in three weeks, yet suddenly, in the blink of an eye, everything had changed. Their agitation was barely masked by their attempts at stoicism.

“Look, Doctor, it’s happening again.”

I watched the groggy young man closely. His jaw clenched tightly, grinding his teeth audibly. His head arched backward at a painful angle and an unearthly groan escaped his grimacing lips. His whole body stiffened, arching backward like a bow being drawn. His arms were bent up at the elbows and pressed tight into his chest while his legs were fully and rigidly extended all the way down to his toes. His face was violaceous and plethoric, an ugly swollen shade of purple. The veins at his temples and in his neck were bulging as if he were straining to lift a great weight. Sputum bubbled from his lips and frothed down his chin.

After about 15 seconds of this agony, his entire musculature simultaneously relaxed and he flopped forward completely limp, seemingly spent. This respite would not last, I knew.

Sure enough, in several seconds the whole pattern repeated itself and repeated itself again and again in an accelerating fashion, a classic tonic-clonic or grand mal seizure. Difficult to watch, even after seeing so many of them.

Fortunately in the ED we have ready access to antiepileptic treatments and his seizures were easily mastered with the appropriate medicines. The patient dropped off into a deep sleep.

There are many causes for a new onset of seizures in a young adult. Head trauma, drug overdose, alcohol withdrawal, congenital brain abnormalities, meningitis of bacterial or viral origin and brain tumors are among the many possibilities. In migrants from Mexico, parasites in the brain are a common cause. They come from undercooked pork.

This young man had never been to Mexico, rarely drank alcohol, had no known trauma, had no fevers and in fact until today had been quite healthy other than having his wisdom teeth taken out recently.

An emergency CT scan of his brain revealed multiple masses most consistent with metatastic cancer. Ouch. This part of the job stinks. I called Neurosurgery and together we gave his stunned parents the news. By the appearance, location and numbers of the lesions Neurosurgery had little to offer the patient and suggested palliative care. The parents, numbed by the news, barely responded. Later they would fight back, but for now they were just overwhelmed.

I put the case out of my mind, I thought, but when I next saw the neurosurgeon I was reminded and asked him what had become of the young man.

“Oh, interesting case” he said. “We put him in the ICU while his parents adjusted to the news. But they never did accept it and insisted we do something, no matter how futile. About the only thing to do was biopsy one of the lesions, so we did. It wasn’t cancer after all, but a mixed bacterial infection. Remember that dental work? While extracting his wisdom teeth some oral bacteria got into his blood stream and seeded his brain. Not supposed to happen in healthy immuno-competent people, but it did. Very rare. Fatal if untreated. All he needed was some penicillin. He’s doing fine, walked out of the hospital after two weeks, and graduated with his class.”

I had heard of this association of brain abcesses and dental work but in the heat of the moment caring for the acutely seizing patient I had not really considered it as a possible diagnosis because it is so vanishingly rare. It is rare despite the fact that it is potentially so common.

Your bloodstream is nearly constantly being contaminated by bacteria principally from your teeth (also from other parts of your alimentary tract). Brushing your teeth, eating hard candy and flossing have all been shown to transiently create circulating bacteremia (bloodstream bacterial infection) which could potentially lodge in any organ and begin to grow. We call this bacterial seeding for obvious reasons. However these frequent transient bacteremias are quickly cleared by your body’s normal defenses, in anywhere from seconds to hours.  More invasive dental procedures such as cleaning, root canals and tooth extractions create much higher levels of bacterial contamination that are still quickly cleared by your body’s natural defenses. Certain types of patients, especially patients with heart valve abnormalities, require antibiotics for dental procedures, but the average dental patient needs no antibiotic prophylaxis. This was a one in a million fluke.

As I thanked the neurosurgeon for the update and said goodbye, he had one final parting thought for me.

“Penicillin,” he said ruefully, shaking his head.

“I had to look up the dose. It’s not a drug brain surgeons get to use very often these days.”