Case Reports in Infectious Diseases
Volume 2015 (2015), Article ID 190134, 3 pages
http://dx.doi.org/10.1155/2015/190134

Case Report

Deep Neck Infection and Descending Mediastinitis as a Complication of Propionibacterium acnes Odontogenic Infection

Evgeni Brotfain,¹ Leonid Koyfman,¹ Lisa Saidel-Odes,² Abraham Borer,² Yael Refaely,³ and Moti Klein¹

¹Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
²Department of Infectious Disease, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
³Department of Thoracic Surgery, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel

Received 3 October 2015; Accepted 9 November 2015

Academic Editor: Larry M. Bush

Copyright © 2015 Evgeni Brotfain et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Propionibacterium acnes is an anaerobic, Gram-positive bacterium which causes numerous types of infections. Isolated Propionibacterium acnes deep neck infections are very rare. We present an interesting case of deep neck infection complicated by descending mediastinitis of isolated Propionibacterium acnes infection.

1. Introduction

Propionibacterium acnes is an anaerobic, Gram-positive bacterium, comprising a large part of the skin flora of healthy individuals [1]. Propionibacterium can cause numerous types of infections, including skin [2], corneal [2], dental (periodontitis, periodontal abscess, etc.) [2], orthopedic (septic arthritis) [3, 4], and also heart valve (endocarditis) infections [3, 4]. Deep neck infections caused by Propionibacterium are very rare [5]. They are generally polymicrobial (Propionibacterium acnes and other anaerobic bacteria, such as Prevotella or Porphyromonas, and staphylococci or streptococci group) and also have been associated with foreign bodies [5, 6]. Descending mediastinitis is a serious, life-threatening, and usually polymicrobial aerobic and anaerobic infectious complication of common odontogenic and deep neck infections [7]. Even with appropriate management (antibacterial therapy, surgical drainage) the mortality remains higher than 20% [8].

We present interesting case of deep neck infection and descending mediastinitis complicating an isolated Propionibacterium acnes odontogenic infection successfully treated in our General Intensive Care Unit (GICU).

2. Case Report

A 21-year-old female, previously healthy, was admitted to the ear-nose-throat (ENT) ward with severe left submandibular nonfluctuant swelling, being erythematous and warm to palpation. Furthermore, mild trismus and sublingual edema were noted. Otherwise, physical and neurological examination was unremarkable. She had a sinus tachycardia of 130 b/min, fever 39°C, and blood pressure 150/90. The chest X-ray on admission was normal. She had a one-week history of a left mandibular second and third molar teeth untreated infection (periodontitis). The patient was urgently transferred to the operating room (OR) where she underwent surgical drainage of the abscess and thereafter admitted to our GICU while sedated, mechanically ventilated, hemodynamically stable, and febrile (38.7°C). Laboratory tests were noted for extensive leukocytosis (30000 cellsul). Immediately on ICU admission broad-spectrum antibiotic therapy (ciprofloxacin 400 mg bid and clindamycin 900 mg tid) was initiated. On the following day, extensive bilateral abscesses in parapharyngeal, retropharyngeal, and paratracheal spaces were shown on an urgently performed CT (Figure 1) and the patient was transferred to the OR again for exploration of deep neck infection.

Figure 1: Neck abscesses.

A large amount of purulent fluid was drained; three days later cultures were positive for Propionibacterium acnes. The patient remained febrile (39.3°C, WBC of 24.5) though hemodynamically stable. An additional CT scan of the head, neck, and chest with contrast iodine two days later (Figure 2) showed a new abscess in the anterior superior mediastinal space. An urgent right thoracotomy was performed.

Figure 2: Mediastinal abscesses.

A large amount (about 30 cc) of purulent fluid, pH 7.18, was drained from anterior mediastinum and subcarinal space; the patient was transferred back to the GICU. Bacterial culture samples of serous fluid were positive again for Propionibacterium acnes. The patient continued antibacterial therapy by clindamycin only due to bacterial susceptibility and isolated growth of Propionibacterium. During the next four days she went to OR two additional times for surgical debridement, drainage, and washout of neck wounds. The patient continued the neck wound washout and antibiotic therapy over the next three weeks. She was discharged from the unit four weeks after admission.

3. Discussion

Deep neck infections from odontogenic origin are usually a multiple space process [9]. It may be explained by the delay in clinical presentation, which allows the infection to continue spreading along the cervical soft tissue [10]. Mandibular molars are most often the cause of odontogenic infections [11]. Whenever untreated, the infection will spread downwards into the mediastinum and cause a descending mediastinitis, a serious and fatal complication [12]. Both neck and mediastinum infectious processes include mixed aerobic (Gram-positive cocci, commonly streptococci) and anaerobic (Bacteroides spp., Prevotella, and Peptostreptococcus spp.) pathogens in up to 80% of cases [11, 13, 14].

Our data correlated well with previously published literature. In our case the patient had a preexisting history of untreated teeth infection. This may explain a rapid and down dissemination of the infectious process which involved a large part of neck and anterior mediastinum tissue. The primary and single pathogen isolated in both neck and mediastinum samples of our patient was Propionibacterium acnes. Propionibacterium acnes is a very rare cause of mediastinitis and deep neck infection [11, 13, 14]. Farmahan et al. (41 patients) [11] and Boscolo-Rizzo et al. [12] found isolation of a single Propionibacterium growth only in two cases of deep neck infection. Diamantis et al. [7] described an interesting case of odontogenic infection complicated by descending necrotizing mediastinitis. In that case the infectious process was caused by polymicrobial flora (Streptococcus constellatus and Propionibacterium acnes) [7]. Boyanova et al. [15] reported two cases of Propionibacterium growth (of 118 patients) in deep space head and neck infections. Both of those cases were associated with another anaerobic (Clostridium tertium and Prevotella corporis) pathogen. There was no growth of other microbial pathogens in the bacterial cultures from our patient. Tammelin et al. described 32 cases of postsurgical mediastinitis after cardiac bypass grafting (CABG) [16]. At least in 25% of mediastinitis P. acnes was the primary pathogen [16].

Delay in diagnosis of mediastinitis is believed to be the most significant risk factor for patients’ mortality [17]. In the present case we had a high index of suspicion of a disseminating process; therefore repeated CT scans were conducted, demonstrating the spreading of an inflammatory process into the mediastinum space three days after her hospital admission.

An appropriate management of deep neck infection and mediastinitis includes intravenous antibacterial therapy and surgical drainage of the cervical and mediastinal collections [14]. In our case immediate, extensive, and recurrent surgical drainage allowed for a successful and early control of the source of infection.

4. Conclusion

Unrecognized and untreated odontogenic infection might be complicated by fatal and life-threatening deep neck infection and mediastinitis. A commonly known pathogen of dental infection, Propionibacterium acnes, might be isolated as a single microbial agent of extended deep neck abscesses and even descending necrotizing mediastinitis.

Disclosure

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Conflict of Interests

There is not any financial or other potential conflict of interests between the authors.

Authors’ Contribution

Evgeni Brotfain and Leonid Koyfman are equal contributors in this paper.

References

S. M. Finegold, “Anaerobic infections in humans: an overview,” Anaerobe, vol. 1, no. 1, pp. 3–9, 1995.

A. Perry and P. Lambert, “Propionibacterium acnes: infection beyond the skin,” Expert Review of Anti-Infective Therapy, vol. 9, no. 12, pp. 1149–1156, 2011.

I. Brook and E. H. Frazier, “Infections caused by Propionibacterium species,” Reviews of Infectious Diseases, vol. 13, no. 5, pp. 819–822, 1991.

V. Zeller, A. Ghorbani, C. Strady, P. Leonard, P. Mamoudy, and N. Desplaces, “Propionibacterium acnes: an agent of prosthetic joint infection and colonization,” Journal of Infection, vol. 55, no. 2, pp. 119–124, 2007.

I. Brook, “Anaerobic bacteria in upper respiratory tract and head and neck infections: microbiology and treatment,” Anaerobe, vol. 18, no. 2, pp. 214–220, 2012.

I. Brook, “Antibiotic resistance of oral anaerobic bacteria and their effect on the management of upper respiratory tract and head and neck infections,” Seminars in Respiratory Infections, vol. 17, no. 3, pp. 195–203, 2002.

S. Diamantis, H. Giannakopoulos, J. Chou, and J. Foote, “Descending necrotizing mediastinitis as a complication of odontogenic infection,” International Journal of Surgery Case Reports, vol. 2, no. 5, pp. 65–67, 2011.

S. Kinzer, J. Pfeiffer, S. Becker, and G. J. Ridder, “Severe deep neck space infections and mediastinitis of odontogenic origin: clinical relevance and implications for diagnosis and treatment,” Acta Oto-Laryngologica, vol. 129, no. 1, pp. 62–70, 2009.

A. J. Rega, S. R. Aziz, and V. B. Ziccardi, “Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin,” Journal of Oral and Maxillofacial Surgery, vol. 64, no. 9, pp. 1377–1380, 2006.

E. F. Morey, A. J. Moule, and T. J. Higgins, “Pyogenic dental infections—a retrospective analysis,” Australian Dental Journal, vol. 29, no. 3, pp. 150–153, 1984.

S. Farmahan, D. Tuopar, P. J. Ameerally, R. Kotecha, and B. Sisodia, “Microbiological examination and antibiotic sensitivity of infections in the head and neck. Has anything changed?” British Journal of Oral and Maxillofacial Surgery, vol. 52, no. 7, pp. 632–635, 2014.

P. Boscolo-Rizzo, M. Stellin, E. Muzzi et al., “Deep neck infections: a study of 365 cases highlighting recommendations for management and treatment,” European Archives of Oto-Rhino-Laryngology, vol. 269, no. 4, pp. 1241–1249, 2012.

T. Wakahara, Y. Tanaka, Y. Maniwa, W. Nishio, and M. Yoshimura, “Successful management of descending necrotizing mediastinitis,” Asian Cardiovascular and Thoracic Annals, vol. 19, no. 3-4, pp. 228–231, 2011.

I. Brook and E. H. Frazier, “Microbiology of mediastinitis,” Archives of Internal Medicine, vol. 156, no. 3, pp. 333–336, 1996.

L. Boyanova, R. Kolarov, G. Gergova et al., “Anaerobic bacteria in 118 patients with deep-space head and neck infections from the University Hospital of Maxillofacial Surgery, Sofia, Bulgaria,” Journal of Medical Microbiology, vol. 55, no. 9, pp. 1285–1289, 2006.

A. Tammelin, A. Hambræus, and E. Ståhle, “Mediastinitis after cardiac surgery: improvement of bacteriological diagnosis by use of multiple tissue samples and strain typing,” Journal of Clinical Microbiology, vol. 40, no. 8, pp. 2936–2941, 2002.

G. J. Ridder, W. Maier, S. Kinzer, C. B. Teszler, C. C. Boedeker, and J. Pfeiffer, “Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome,” Annals of Surgery, vol. 251, no. 3, pp. 528–534, 2010.