Contributed by Nicole Esposito, MD
Published on line in April 2004
The patient is a Caucasian male in his 50s with a past medical history of hypertension complaining of "fever, headache, and sore throat." The patient stated that his symptoms began with a sore throat approximately five days prior to admission, followed by fever with a Tmax of 38oC and headache one day prior to admission. He described the headache as moderate to severe in intensity, sharp in nature, and unilateral, being present on the right maxillary and mandibular areas of his face, with radiation to the right neck. He denied cough, dyspnea, photophobia, rash, rhinorrhea, dysphagia, diarrhea, recent travel or sick contacts.
The patient's only outpatient medications are anti-hypertensives. He has chewed tobacco for over 30 years. He denied intravenous or other illicit drug use. Family history is noncontributory.
Physical examination revealed a temperature of 38.3oC, respiratory rate 15, pulse 99, blood pressure 182/110 and pulse oximetry 98% on room air. The remainder of the exam was negative except for poor dentition and pain with palpation of the right mandible and right submandibular region. There was no meningismus, neurologic deficits, or heart murmurs.
Laboratory results were significant for a white blood cell count of 12.5 x 109/L with 91% neutrophils and 4% lymphocytes.
RADIOLOGY FINDINGS: Chest X-ray and head and pelvic CT were negative except for an enlarged prostate. Panorex radiographs are shown below.
The patient was taken to the operating room on hospital day 4 for teeth extraction and incision and drainage of an abscess (see surgical specimen below).
MICROSCOPIC AND MICROBIOLOGIC FINDINGS:
A blood culture obtained on hospital day one grew small to medium, raised, translucent to opaque colonies from the anaerobic bottle only. Aerobic as well as subsequent cultures were negative.
Gram Stain - Gram stain of the colonies pictured above showed fusiform gram-negative rods with swollen forms.
Periapical Cyst (Gross) - The specimen submitted was labeled "periapical lesion" and consisted of a triangular portion of firm red-tan tissue, measuring 1.3 x 0.6 x 0.3 cm.
The specimen was composed of squamous mucosa with an abundant chronic inflammatory infiltrate and fibrosis with focal fibrinopurulent exudate. These findings were consistent with a periapical (radicular) cyst with acute and chronic inflammation. Grocott stains were negative, and a gram stain did not readily demonstrate organisms.
Can you identify the organism that grew out of the anaerobic blood culture on hospital day one? Based on your answer and the clinical picture described, what syndrome should be ruled in or out in this patient?