Silent diabetes mellitus, periodontitis and a new case of thalamic abscess

Abstract

Brain abscess is an unusual complication of uncontrolled diabetes. A solitary thalamic abscess is an uncommon type of brain abscess. We report a case of thalamic abscess, whereupon diabetes mellitus and periodontitis were diagnosed. The diagnosis and management of thalamic abscess, and the interplay of type 2 diabetes and periodontitis are discussed. A 56-year-old, Caucasian, man with no medical or travel history, presented with 5-day symptoms of meningeal irritation. Body mass index 30.6 kg/m(2). CT demonstrated a solitary midline lesion with neoplasia as a differential diagnosis. It was biopsied and cultures grew Streptococcus milleri. He was treated by stereotactic puncture, external drainage and targeted intrathecal and systemic antibiotic therapy. HIV negative but glycated haemoglobin (HbA1c) 10.7% (93 mmol/mol). Dental examination revealed a small molar abscess. Radiological resolution of the thalamic abscess occurred within 2 months. Diabetes improved with 7 weeks of insulin, and maintained on metformin, HbA1c 6.9% (51 mmol/mol). There was no residual neurological disability.

Thalamic bacterial abscess presenting with hemiparesis and expressive aphasia

“…Important risk factors for thalamic abscesses due to S. anginosus include liver cirrhosis, malignancy, diabetes mellitus, malnourishment and immunosuppression [ 1 , 5 , 7 ]. Periodontal disease is also an independent risk factor for brain abscesses, including thalamic abscesses [ 8 , 9 ].…”

“…Deep-seated abscesses are complex due to difficult access and are associated with an increased risk of intraventricular rupture and antibiotic resistance [ 3 ]. Treatment options include stereotactic aspiration with or without continuous drainage, free hand aspiration with burr hole, stereo-endoscopic aspiration, ultrasound guided aspiration, surgical transventricular approach, and pharmacological management alone [ 1 , [3] , [4] , [5] , [6] , [7] ] Controversy exists as to which of these is the best surgical intervention. Nonetheless, stereotactic aspiration remains the preferred option for many neurosurgeons as it drains the abscess, reduces mass effect, carries less risk of intraventricular rupture and confirms the diagnosis [ [3] , [4] , [5] ].…”

“…Medical therapy alone should be reserved for patients with multiple and/or small abscesses, specifically those smaller than 2 cm or 2.5 cm in diameter, or when patients are at high risk for surgical complications [ 3 ]. In the literature, length of antimicrobial therapy varies from 4 to 8 weeks pending resolution of abscesses as evidenced by repeat imaging [ 1 , 7 , 8 ].…”

“…Brain abscesses are relatively rare in the developing world, with an incidence of 2% of all space occupying lesions [ 2 ]. Deep-seated abscesses such as thalamic and basal ganglia abscesses are much rarer than abscesses in other locations of the brain with reported incidences ranging from 1.3 to 6% of all brain abscesses [ [3] , [4] , [5] , [6] , [7] ]. We present and discuss a case of thalamic brain abscess caused by S. anginosus that presented with subcortical aphasia.…”

Streptococcus anginosus group - brief characterization and its contribution to the brain abscess pathogenesis

“…S. milleri was isolated also from a thalamic abscess in a 56-year-old man with type 2 diabetes, periodontitis and dental abscess. 53 The patient was cured within 2 months by stereotactic puncture, external drainage and both intrathecally and systemically administrated antibiotics. In 2012 a Danish team published the results of a 15-year retrospective review of 102 cases of adult patients with brain abscess, treated between January 1994 and April 2009, at the Departments of Neurosurgery, Infectious Medicine and Neurology of a university hospital in Copenhagen.…”