SEPTIC PULMOMARY EMBOLI SECONDARY TO UNREPORTED PARTIALLY TREATED DENTAL INFECTION

Abstract

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Septic pulmonary emboli are usually caused by infected intravenous catheters and endocarditis. Dental infection is an extremely rare cause. We present a case of septic pulmonary emboli attributed to dental infection. Antibiotics, proper oral care and extraction of the causative teeth are key components of treatment. CASE PRESENTATION: Patient is a 60 year old male with no significant past medical history presented with complaints of fever, chills, myalgia. Patient states that about 2 weeks prior to presentation to the emergency department he had toothache and took antibiotics for two days with resolution of the pain. At the time of presentation, patient was afebrile, normotensive and was saturating 97 percent on room air. Patient underwent portable chest x-ray and Computerized tomography scan that revealed multiple bilateral patchy infiltrates with a lucent center suggestive of septic emboli. Physical examination was consistent with clear breath sounds bilaterally, no murmurs on cardiovascular examination. Oral examination revealed dental caries with no apparent gingivitis. Labs on admission showed hemoglobin of 13 gm/dL, white blood cell count of 12,000/mL, platelet count of 281,000/mm3, BUN of 13 mg/dL, creatinine of 0.58 mg/dL, sodium of 132 mEq/L, potassium of 3.8 mEq/L, sedimentation rate of 52 mm. TB Quantiferon test, HIV, ANCA panel were negative. Blood cultures were negative. Patient underwent a trans-esophageal echocardiogram that did not show endocarditis. He also underwent a whole body Gallium scan that showed increased uptake in the thorax and no other sites of infection. Consultation with oral maxillofacial surgery was sought due to the concern for dental source of infection. Patient underwent Orthopantogram that demonstrated lucency over the right maxillary suspicious for a fracture, partially edentulous oral cavity and extensive dental disease. Patient was started on broad spectrum antibiotic coverage with Vancomycin and Piperacillin- Tazobactam on which he developed acute interstitial nephritis presumed secondary to beta lactam antibiotics. Antibiotics were changed to Clindamycin and Doxycycline. Patient was subsequently discharged on oral antibiotics. He was followed in the pulmonary clinic with a repeat CAT scan that showed radiographic improvement in the septic emboli. DISCUSSION: Sustained Bacteremia and seeding in the lungs can occur in patients with periodontal infection. Indigenous oral florae include various Streptococci, Lactobacillus, Corynebacterium, and Actinomyces species. Antibiotics to cover oral flora is the main stay of treatment. Complications include pleural effusion and empyema. CONCLUSIONS: Dental infections are a rare cause of septic pulmonary emboli and are usually under reported by the patient. Antibiotics are the main stay of treatment. History and thorough physical examination are crucial in pointing towards the possible source of infection. Reference #1: Watanabe, Tsuyoshi et al. “Septic pulmonary embolism associated with periodontal disease: a case report and literature review.” BMC infectious diseases vol. 19,1 74. 21 Jan. 2019, doi:10.1186/s12879-019-3710-3 DISCLOSURES: No relevant relationships by Medhat Ismail, source=Web Response No relevant relationships by Rishitha Yelisetti, source=Web Response