Clinical and Radiological Features in the Cases with Cryptogenic Brain Abscess in Association with Patent Foramen Ovale: A Case Report and Review of the Literature

Masayuki Sugie^1*, Takahiro Jimi², Yojiro Kashimura³, Hiroo Ichikawa¹

¹Department of Neurology, Showa University Fujigaoka Hospital, Yokohama, Japan.
²Department of Neurology, Machida-Keisen Hospital, Machida, Japan.
³Department of Neurosurgery, Showa University Fujigaoka Hospital, Yokohama, Japan.

DOI: 10.4236/ijcm.2014.521178                

Abstract

Brain abscesses are commonly associated with cranial trauma, a contiguous focus of infection, or hematogenous spread from a distant focus. However, no predisposing factors are identified in approximately 4% of the cases, being recognized as a cryptogenic brain abscess (CBA). Here we report a patient with a CBA in the left occipital lobe presumably caused by a periodontal disease. The patient displayed a patent foramen ovale (PFO), through which a spontaneous right-to-left shunt was revealed with transesophageal echocardiography. A literature review indicated that in contrast to cases of general brain abscesses, patients with CBA were older and mostly had dental disorders represented by periodontal diseases and a large PFO. In these patients, the abscess was located predominantly in the posterior circulation area, and their prognosis was worse than that of general cases. Consequently, we emphasize the significance of screening for PFO in cases of advanced age with CBA in the posterior circulation region. Furthermore, to avoid neurological sequelae, we suggest immediate surgical drainage with antibiotic administration and maintenance of oral hygiene.

Keywords

Cryptogenic Brain Abscess, Patent Foramen Ovale, Posterior Circulation Area, Aging

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Bernardini, G.L. (2004) Diagnosis and Management of Brain Abscess and Subdural Empyema. Current Neurology and Neuroscience Reports, 4, 448-456. http://dx.doi.org/10.1007/s11910-004-0067-8
[2]	Nathoo, N., Nadvi, S.S., Narotam, P.K. and van Dellen, J.R. (2011) Brain Abscess: Management and Outcome Analysis of a Computed Tomography Era Experience with 973 Patients. World Neurosurgery, 75, 716-726. http://dx.doi.org/10.1016/j.wneu.2010.11.043
[3]	Sadahiro, H., Nomura, S., Inamura, A., Yamane, A., Sugimoto, K., Fujiyama, Y. and Suzuki, M. (2014) Brain Abscess Associated with Patent Foramen Ovale. Acta Neurochirurgica, 156, 1971-1976. http://dx.doi.org/10.1007/s00701-014-2170-1
[4]	Kawamata, T., Takeshita, M., Ishizuka, N. and Hori, T. (2001) Patent Foramen Ovale as a Possible Risk Factor for Cryptogenic Brain Abscess. Report of Two Cases. Neurosurgery, 49, 204-207.
[5]	Friedlander, R.M., Gonzalez, R.G., Afridi, N.A. and Pfannl, R. (2003) Case Records of the Massachusetts General Hospital. Weekly Clinicopathological Exercises. Case 16-2003. A 58-Year-Old Woman with Left-Sided Weakness and a Right Frontal Brain Mass. New England Journal of Medicine, 348, 2125-2132. http://dx.doi.org/10.1056/NEJMcpc030011
[6]	Doepp, F., Schreiber, S.J., Wandinger, K.P., Trendelenburg, G. and Valdueza, J.M. (2006) Multiple Brain Abscesses Following Surgical Treatment of a Perianal Abscess. Clinical Neurology and Neurosurgery, 108, 187-190. http://dx.doi.org/10.1016/j.clineuro.2004.11.024
[7]	Khouzam, R.N., El-Dokla, A.M. and Menkes, D.L. (2006) Undiagnosed Patent Foramen Ovale Presenting as a Cryptogenic Brain Abscess: Case Report and Review of the Literature. Heart & Lung, 35, 108-111. http://dx.doi.org/10.1016/j.hrtlng.2005.07.007
[8]	LaBarbera, M., Berkowitz, M.J., Shah, A. and Slater, J. (2006) Percutaneous PFO Closure for the Prevention of Recurrent Brain Abscess. Catheterization and Cardiovascular Interventions, 68, 957-960. http://dx.doi.org/10.1002/ccd.20869
[9]	Stathopoulos, G.T., Mandila, C.G., Koukoulitsios, G.V., Katsarelis, N.G., Pedonomos, M. and Karabinis, A. (2007) Adult Brain Abscess Associated with Patent Foramen Ovale: A Case Report. Journal of Medical Case Reports, 1, 68. http://dx.doi.org/10.1186/1752-1947-1-68
[10]	Chen, F.C., Tseng, Y.Z., Wu, S.P., Shen, T.Y., Yang, H.P. and Chen, C.C. (2008) Vegetation on Patent Foramen Ovale Presenting as a Cryptogenic Brain Abscess. International Journal of Cardiology, 124, e49-e50. http://dx.doi.org/10.1016/j.ijcard.2006.11.200
[11]	Keith-Rokosh, J., Hussain, Z., Haig, A., Armstrong, C., Ang, L.C., Ng, W. and Lownie, S.P. (2008) Cryptogenic Methicillin-Resistant Staphylococcus aureus Brain Abscess. Canadian Journal of Neurological Sciences, 35, 115-118.
[12]	Wolf, J. and Curtis, N. (2008) Brain Abscess Secondary to Dental Braces. Pediatric Infectious Disease Journal, 27, 84-85. http://dx.doi.org/10.1097/INF.0b013e31815819a6
[13]	Ariyaratnam, S., Gajendragadkar, P.R., Dickinson, R.J., Roberts, P., Harris, K., Carmichael, A. and Karas, J.A. (2010) Liver and Brain Abscess Caused by Aggregatibacter paraphrophilus in Association with a Large Patent Foramen Ovale: A Case Report. Journal of Medical Case Reports, 4, 69. http://dx.doi.org/10.1186/1752-1947-4-69
[14]	Walsh, K., Kaliaperumal, C., Wyse, G. and Kaar, G. (2011) A Neurosurgical Presentation of Patent Foramen Ovale with Atrial Septal Aneurysm. BMJ Case Reports, 2011.
[15]	Horiuchi, Y., Kato, Y., Dembo, T., Takeda, H., Fukuoka, T. and Tanahashi, N. (2012) Patent Foramen Ovale as a Risk Factor for Cryptogenic Brain Abscess: Case Report and Review of the Literature. Internal Medicine, 51, 1111-1114. http://dx.doi.org/10.2169/internalmedicine.51.7133
[16]	Grossi, S.G., Zambon, J.J., Ho, A.W., Koch, G., Dunford, R.G., Machtei, E.E., Norderyd, O.M. and Genco, R.J. (1994) Assessment of Risk for Periodontal Disease. I. Risk Indicators for Attachment Loss. Journal of Periodontology, 65, 260-267. http://dx.doi.org/10.1902/jop.1994.65.3.260
[17]	Hagen, P.T., Scholz, D.G. and Edwards, W.D. (1984) Incidence and Size of Patent Foramen Ovale during the First 10 Decades of Life: An Autopsy Study of 965 Normal Hearts. Mayo Clinic Proceedings, 59, 17-20. http://dx.doi.org/10.1016/S0025-6196(12)60336-X
[18]	Hayashida, K., Fukuchi, K., Inubushi, M., Fukushima, K., Imakita, S. and Kimura, K. (2001) Embolic Distribution through Patent Foramen Ovale Demonstrated by 99mTc-MAA Brain SPECT after Valsalva Radionuclide Venography. Journal of Nuclear Medicine, 42, 859-863.
[19]	Ciurea, A.V., Stoica, F., Vasilescu, G. and Nuteanu, L. (1999) Neurosurgical Management of Brain Abscesses in Children. Child’s Nervous System, 15, 309-317. http://dx.doi.org/10.1007/s003810050400