Actinomyces israelii and Fusobacterium nucleatum brain abscess in an immunocompetent patient: case report
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Introduction. Brain abscess is the most common focal infectious neurological injury. Until the nineteenth century this condition was fatal, however the development of neuroimaging for early diagnosis, neurosurgery and antibiotic therapy in the twentieth century has led to new therapeutic strategies decreasing mortality from 50 % in the 1970s to less than 10 % nowadays. In this context we report a case of brain abscess with a dental origin.
Case report. A immunocompetent man without any addiction presented to the emergency department with dysarthria and frontal headache at home. The clinical examination was normal. Further investigations revealed a polymicrobial brain abscess as a consequence of an ear, nose or throat (ENT) infection with locoregional extension with a dental starting point involving Actinomyces israelii and Fusobacterium nucleatum . In spite of a rapid diagnosis and a neurosurgical management associated with an optimal treatment by a dual therapy made of ceftriaxone and metronidazole the patient unfortunately died.
Conclusion. This case report shows that despite a low incidence and a good prognosis following the diagnosis, brain abscesses can lead to patient’s death. Thereby, when the patient’s condition and urgency allow, a thorough dental examination of patients with neurological signs following the recommendations would improve the diagnosis made by the clinician. The use of microbiological documentation, the respect of pre-analytical conditions, the interaction between the laboratory and the clinicians are indispensable for an optimal management of these pathologies.
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Thank you for addressing all points raised during peer review. I am now satisfied that all ethical considerations have been covered appropriately and can approve this manuscript for publication.
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Thank you to all reviewers for their careful consideration of this manuscript. During the peer review process there have been some conflicts between requests for patient metadata to be added to the manuscript and the need to remove patient identifiers for ethical reasons, as consent to publish could not be acquired from the patient's next of kin. These conflicts were not picked up by myself and I apologise for that. In the case of this manuscript, as the metadata aren't crucial to the case presentation we ask that authors remove the non-direct patient identifiers that were added during revisions, and amend the ethical statement to- “Approval from the ethical committee was not required due to the nature of this case report. Abiding by the Declaration of Helsinki, patient anonymity was guaranteed.” and add some of the explanation that …
Thank you to all reviewers for their careful consideration of this manuscript. During the peer review process there have been some conflicts between requests for patient metadata to be added to the manuscript and the need to remove patient identifiers for ethical reasons, as consent to publish could not be acquired from the patient's next of kin. These conflicts were not picked up by myself and I apologise for that. In the case of this manuscript, as the metadata aren't crucial to the case presentation we ask that authors remove the non-direct patient identifiers that were added during revisions, and amend the ethical statement to- “Approval from the ethical committee was not required due to the nature of this case report. Abiding by the Declaration of Helsinki, patient anonymity was guaranteed.” and add some of the explanation that patient consent from the next of kin could not be acquired and as such indirect identifiers were removed from the Case Report. We shall be improving journal guidelines to make these situations clearer for authors and reviewers in future.
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Comments to Author
Nothing is indicated regarding the informed consent of the patient or about the ethical aspects to be considered in the presentation of cases.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
No: Nothing is indicated regarding the …
Comments to Author
Nothing is indicated regarding the informed consent of the patient or about the ethical aspects to be considered in the presentation of cases.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
No: Nothing is indicated regarding the informed consent of the patient or about the ethical aspects to be considered in the presentation of cases.
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I have now received two peer review reports on your manuscript, which express a few queries over the work presented and question the validity of a diagnosis of periodontitis. Can you please address the reviewers comments, making amendments to your manuscript where necessary. Editorial Office note: One of the reviewers raised a concern regarding ethics. Proof of exemption from ethical approval has now been provided by the author and is available on request.
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Comments to Author
The authors reported the brain abscess of odontogenic origin in immunocompetent patient. 1. Description of the case(s), 2. Presentation of results In this report, there are no problems about description of the case and presentation of result. 3. How the style and organization of the paper communicates and represents key findings It is well described that the brain abscess caused by poor dental hygiene occurred in immunocompetent patient and the causative organisms were rare. 4. Literature analysis or discussion There are no problems about literature analysis and discussion. 5. Any other relevant comments Line 76 Is "cerebral angioscanner" a computed tomography (CT), a CT angiography, or a cerebral angiography? This term does not seem to be common. I have interests and questions in the following …
Comments to Author
The authors reported the brain abscess of odontogenic origin in immunocompetent patient. 1. Description of the case(s), 2. Presentation of results In this report, there are no problems about description of the case and presentation of result. 3. How the style and organization of the paper communicates and represents key findings It is well described that the brain abscess caused by poor dental hygiene occurred in immunocompetent patient and the causative organisms were rare. 4. Literature analysis or discussion There are no problems about literature analysis and discussion. 5. Any other relevant comments Line 76 Is "cerebral angioscanner" a computed tomography (CT), a CT angiography, or a cerebral angiography? This term does not seem to be common. I have interests and questions in the following points, although they may not particular necessary in case of focusing on infections. I am interested in post-operative images and the results of the preoperative blood culture. This patient presented no signs of sepsis pre-operatively, but rapidly developed a septic state post-operatively. Was cerebrospinal fluid drained during the drainage operation of the abscess? It is possible that the right lateral ventricle was opened and the abscess was spread to the ventricles during the drainage operation. This may have caused the severe ventriculitis that required external shunting and was fatal.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
The manuscript "Actinomyces israelii and Fusobacterium nucleatum brain abscess in an immunocompetent patient: case report." was submitted to AM. The case deals with an interesting issue; however, there are concerns related to the report. Specific comments are noted below. Abstract -. Introduction: The objective is not presented. -. Case report: Indicate the age and gender of the patient. -. Conclusion: The importance of a routine dental evaluation is indicated; however, nothing is reported about it in this case. Introduction -. Lines 58-60. Dental infections have different origins. Describe them. -. Lines 61. There is speculation regarding the diagnosis of periodontitis. The diagnosis of this disease requires a detailed clinical and radiographic evaluation. A detailed clinical dental and …
Comments to Author
The manuscript "Actinomyces israelii and Fusobacterium nucleatum brain abscess in an immunocompetent patient: case report." was submitted to AM. The case deals with an interesting issue; however, there are concerns related to the report. Specific comments are noted below. Abstract -. Introduction: The objective is not presented. -. Case report: Indicate the age and gender of the patient. -. Conclusion: The importance of a routine dental evaluation is indicated; however, nothing is reported about it in this case. Introduction -. Lines 58-60. Dental infections have different origins. Describe them. -. Lines 61. There is speculation regarding the diagnosis of periodontitis. The diagnosis of this disease requires a detailed clinical and radiographic evaluation. A detailed clinical dental and periodontal evaluation was not performed in this case. These aspects should be clarified throughout the manuscript and should be commented on in the discussion. In that same section, it should be described as limitations. Case presentation -. Please provide more sociodemographic information about the patient, in addition to age and gender. -. Line 71. Figure 1. It does not represent poor dental hygiene. It could rather be the consequences of it. However, the authors cannot ensure any type of diagnosis of the oral cavity based on an image alone. -. Please define all acronyms appropriately: CRP, MRI, CT, qSOFA, MALDI-TOF, ENT, CNS, etc. -. Line 92. Describe the anatomical sites from which cultures were taken. -. Lines 122-123. A CT cannot be the basis for a periodontal diagnosis or to determine the presence of periapical abscesses. The clinical evaluation of the patient's oral cavity is essential. Moreover, the diagnosis of "diffuse periodontitis" does not exist. -. Figure 1. The legend should consider the aspects already described. Discussion -. Lines 217-218. Periodontal abscesses and other infections of dental origin also occur. -. Limitations should be detailed. Some of them have already been described above. Nothing is indicated regarding the informed consent of the patient or about the ethical aspects to be considered in the presentation of cases.
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
No: Nothing is indicated regarding the informed consent of the patient or about the ethical aspects to be considered in the presentation of cases.