Case: A 41-year-old female with a history of poor dentition and an untreated left maxillary abscess two months prior presented with a complaint of generalized weakness, diarrhea, abdominal pain, and hot flashes. The patient was profoundly hypotensive and appeared lethargic with dry mucous membranes and epigastric tenderness. An initial sepsis work-up was performed, but the patient eloped within hours of presentation only to return days later. Notably, the original investigation yielded findings of Streptococcus intermedius bacteremia. A CT of the abdomen and pelvis revealed multiple cystic splenic and hepatic lesions concerning for abscess versus malignancy with subtotal occlusive venous thrombi of the portal and splenic veins. The patient was treated with empiric antibiotics and anticoagulation. Infectious diseases consultants recommended additional brain imaging when the patient reported a new headache. A single, right posterior hypoattenuated area was seen on non- contrast CT Head and follow up MRI Brain with contrast revealed multiple cystic ring-enhancing
lesions, suspicious for abscesses. The patient was transferred to an outside facility for neurosurgery services and ultimately underwent bilateral craniotomies and evacuation of two right occipital abscesses and one left temporal abscess, followed by multiple tooth extractions by OMFS. Patient later taken for IR aspiration of a liver abscess. All specimens yielded negative cultures, and although the inpatient TEE was positive for a small tricuspid valve vegetation, there was no recommendation for surgical intervention. The patient completed an eight-week course of IV and PO antibiotics with negative follow up blood cultures and improved hepatic and splenic lesions on repeat imaging. Discussion: This case illustrates the severe consequences of neglecting dental health. Although rare, morbidity and mortality related to systemic complications as a result of dental infections further emphasizes the crucial role dental health plays in the overall wellbeing of patients.
THE GANGS OF GLOMUS RETURN: RECURRENT PARAGANGLIOMAS IN HEREDITARY PGL-1 SYNDROME WITH HYPERPARATHYROIDIS Parinistha Mohan, Kashish Shah, Vaishnavi Singh; Willis-Knighton Health, Shreveport, LA.
Introduction: Paragangliomas of the head and neck have a low incidence of 3-10 per million every year. Less than half are hereditary and not much is known about the association of hyperparathyroidism with hepatic paragangliomas (HPGL). Case: A 58-year-old male with PGL-1 syndrome (S23X mutation of the SDHD gene) presented to the clinic with a chronic cough, hoarseness and dysphagia. He had undergone surgical resection of the bilateral carotid body and glomus vagale tumors 22 years ago. His family history was significant for neck tumors in father and sister. The physical examination revealed a bulge in the right parapharyngeal space. Investigations revealed hypercalcemia and hyperparathyroidism. A 99mTc Sestamibi scan showed no localised uptake. A CT scan of the neck with parathyroid protocol showed a 10.1 x 9.8 mm enhancing nodule posteroinferior to the right thyroid suggesting a parathyroid adenoma. A
thyroid ultrasound confirmed the diagnosis. Plasma and urine metanephrines were negative. The CT scan also showed bilateral vascular neck masses which were confirmed by MRA as recurrence of glomus vagale tumors with a larger lesion on the right. He was referred for further evaluation where a conservative approach was recommended as opposed to surgical resection which was considered to have an excessively morbid. He returned and underwent parathyroidectomy which confirmed the presence of hypercellular parathyroid on pathology. He was then treated with 30Gy of proton-based radiation therapy (PBRT) on the right side and was asked to return in 3 months for irradiation on the left. Two of his children were also found to have neck tumors and are currently being evaluated. Discussion: Mutations in the SDHD gene are autosomal dominant and transmit via paternal inheritance. This highlights the significance of genetic
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