Multiorgan Involvement in a Complicated Case of Gum Abscess (Multiorgan Abscesses)

Multi-organ abscesses which has high morbidity and mortality rates, usually develops after infective endocarditis. Clinical sepsicemia another rare cause of this contidition. The pathogenic agents can be different and sometimes multiple. Clinical findings, laboratory and imaging results are important for diagnosis. The identification of causative pathogen and appropriate antibiotic treatment, and if necessary abscess drainage are very important for the treatment. We present a case with multipl colon, liver and lung abcesses which was a result of septicemia triggered by gum abscess. The causative agent has been found meticyllin resistant, coagulase negative Staphylococus cohnii ssp urealyticus.


Introductıon
Pyogenic abscess occurs as a result of parenchyma tissue necrosis due to microorganisms and open cavity results the formation of localized suppurative lesion [1]. Multiorgan pyogenic abscesses rarely develops secondary to any focal origin without endocarditis [2]. Often, gum (periodontal) disease is the source of the bacteria that cause a lung abscesses. Primary focus in multiorgan abscesses' pathogens vary widely and can be multiple. Predisposing factors are immunosuppression, drug addiction and malignancy. The treatment is the appropriate use of antibiotics and abscess drainage [3].
We present a case with multiorgan (liver, lung, and sigmoid colon) abcesses originates from gum disease which is probably caused by anaerobic microbes and staphylococcus cohn ssp urealyticum.

Case Report
Fifty-year-old male patient who had engaged in veterinary medicine was admitted to our clinic with complaints of abdominal pain for two weeks, foul-smelling diarrhea and cough, sputum, chills, fever, night sweat for one week. The patient's posterior-anterior chest radiograph showed a subpleural cavitating lesion on the left upper zone ( Figure 1). He was admitted to the pulmonology service for further investigation. Also he was a actively working vetenerian and had no chronic illness. He had a history of smoking but did not use alcohol.
Physical examination; fever of 39°C, artery blood pressure (TA): 110/60 mmHg, pulse 100 beats / min, heart sounds were heard rhythmic without any additional sounds and murmurs. Lung examination was normal. There was mildly liver enlargement. Spleen was nonpalpable. Abdomen was nontender, bowel sounds hyperkinetic and a mass was felt on deep palpation in the suprapubic region. Orofaringial examination showed first molar mandibular tooth swelling and hyperemia compatible with the existing line abscess with intensive tooth decay. The other system examinations were normal. Laboratory parameters was showed in Table 1. Whole urine examination revealed normal.
The patient's stool culture, parasites examination was evaluated for two weeks of diarrhea and abdominal discomfort. The direct stool examination revealed abundant leukocytes and erythrocytes. There were no evidence of parasitic cysts and eggs. No aerobic fecal culture was isolated. The patient had purulent sputum. Aerobic growth and acid-fast bacilli were not detected in sputum using Erlich -Ziehl -Nielsen staining.
According to the patient's clinical findings as well as suspicious mass image in posterior-anterior chest X-ray in Figure 1 and lower abdominal palpable pathology, contrast enhanced thoracoabdominal computed tomography scan (CT) was obtained. There was a slightly irregular cavity on the left upper lobe of the lateral, subpleural region, 43 × 30 mm in size, lightly lobulated with smooth inner slightly irregular contour. There was no other lesion in the other lung areas (Figure 2A). There were ring enhanced hypodense lesions in the right and left lobes of the liver up to 3 cm in diameter ( Figure 2B). There were sigmoid colon diverticulae also accompanied with sigmoid mesentery abscess ( Figure 2C).
Moderate liver enlargement with peripherally echogenic, hypoechoic foci close to Vena Cava Inferior (VCI), compatible with abscesswere shown at abdominal ultrasound.
Due to the patient's symptoms and radiological findings, control fecal examinations were sent for re-evaluation. Control of stool revealed no evidence of parasitic cysts and eggs again. The serologic tests for  There was no evidence of infective endocarditis such as vegetations during transthoracic echocardiography. Cardiac functions were within normal limits in cardiac examinations. In the febrile period of hospitalization, peripheral blood cultures from right and left brachial veins were taken in three sets, then cultures were repeated.
During the hospitalization, Cefuroxime axetil (3 x 750 mg/IV) and metronidazol (4 x 500 mg/IV) were given empirically to patient. Due to the patients's persistent fever (in the high 39-40°C range) and clinical deteriotion, the drugs were changed and meropenem (3x 1000 mg) and vancomycin (2 × 1000 mg) has been replaced. The patient's fever went down to normal levels 24 hour later also the chills, night sweats and diarrhea decreased. The infectious parameters were lessened soon. The liver abcess was consulted by radiology departmentwhether to perform sampling. This procedure could not been done because of the lesions proximity to vena cava inferior and shrinkage related to the treatment. Blood cultures which was taken before starting antibiotics in febrile period had been found to be positive for methicillin resistant Staphylococcus spp ürealyticus cohnii. No changes were made in the drugs as patient's had been receiving effective broad-spectrum antibiotics.
The patient's colonoscopy could not be done due to his unwilingness of the procedure.
The patients had control CT on day 16. of meropenem treatment, after the clinical complete improvement and without having any symptoms. The size of the lung abscess decreased to 24 × 12 mm ( Figure  3A). The liver abcess had shrunk and there were fibrous like structure around them ( Figure 3B). Also the abcess in the sigmoid colon was disappeared ( Figure 3C).
Repeated blood cultures were negative, laboratory parameters was shown in Table 2; All the parametes showed normalized levels. Antibiotic therapy was continued as an oral therapy for an additional 3 weeks after parenteral route and ambulatory process completed 4 weeks. There were no complications and follow-up in the hospital were discharged healthy ( Figure 4A-C).

Conclusion
Multiorgan pyogenic abscesses which are usually secondary to infective endocarditis or infected vascular complications of the mycotic aneurysms, rare infectious disease with serious clinical outcome. Artificial heart valves, the structure of degraded natural valves, congenital heart disease, immunosuppression, substance abuse, diabetes mellitus and malignancy may be predisposing factors for multiple organ abscesses [1,2].
Multiorgan pyogenic abscesses can spread to directly between adjacent tissue or to distant organs via sepsis, through the thoracic spread, through the bile-hepatik-aperture [3,4]. Yang et al. reported a case pyogenic lung abscess caused by septic pulmonary embolism [5].
In our case, there were multiorgan abcess as a result of gum abscess without infective endocarditis. The biggest protective factor for infective endocarditis development is normally developed cardiac structures which was confirmed by transthoracic echocardiography. Direct tissue infiltration was not considered for the abscesses due to the remote location of the lesions from each other. Septisemia was considered the cause.
Pyogenic multiorgan abscess usually shows a fulminant course. Due to the use of broad-spectrum antibiotics in recent years, increasing the quality of development and intensive care services and improvement of the imaging methods provides relatively positive results. But mortality and morbidity due to the seriousness of sepsisemia is high [6,7].
There was no predisposing factor in our case. The patient's clinical remained relatively lighter. The significant permanent damage to the tissue to disrupt the function did not occur in the involved organs. The patient's lack of comorbid pathology, young age and rapid respond early broad-spectrum antibiotics were the concluded the cause of the result.
Appropriate use of antibiotics is very important in effective treatment of pyogenic liver abscess. In the cases of, inadequate/ failure of antibiotic theraphy, life-threatening organ involvement  (etc. intracranial involvement), uncontrolled abcess focus surgical or percutaneous intervention is required [8]. Rapid diagnosis and initiation of broad-spectrum antibiotic treatment increases the chances of success are the most important factors.
According to the responsible pathogen primary focus of multiple organ abscesses varies enormously. Streptococci viridans, coagulase positive and negative staphylococci, Escherichiacol, Klebsiella pneumoniae, and Bacteroides fragilis can be isolated [7][8][9][10]. The multiple agents may be cause as well. While the sampling rate was around 80% of the abscess culture, the rate of blood culture isolate the factor is about 50% [10].
Empirical therapy should be selected according to the source of the abscess and underlying disease [11]. General empirical approach applied in the treatment protocol ampicillin-sulbactam/second-generation cephalosporins, and aminoglycosides and/or the combination of metronidazol [12][13][14][15]. Average treatment time is four weeks.
Antibiotics should be given intravenously during the first two weeks of treatment, then be administered orally [12][13][14][15][16][17]. In our case, after obtaining blood cultures in febrile period, cefuroxime axsetil and metronidazole was started empirically. Combination of meropenemvancomycin was started due to continued fever. Twenty-one days after oral treatment with outpatient parenteral antibiotic therapy was completed in four weeks.
Contrast-enhanced computed tomography (CT) is the gold standard method for the diagnosis of pyogenic abscess and sensitivity is close to 100%. Ultrasonography (USG) is a cheap, widely available method for diagnostic evaluation of abdominal organs. Clinical and and ultrasonographic co-evaluation is quite pathognomonic (greater than 90%) for diagnosing abdominal abcess. This procedure can be done in any stage of the disease due to non invasiveness and high sensitivity (90%) especially in good hands [4]. In our case diagnosis of multiple abscesses was made by contrast thoracoabdominal CT and liver abscesses were confirmed by abdominal ultrasound.
The most feared complication of mutiorgan abcess are permanent damage to the tissue disturbance function, sepsis, septic shock. Our case, was discharged from hospital monitoring progress without any complication ( Figure 4A-C).
Lung abscess can be caused by dental infections, but simultaneous development of multiple abscesses in different organs is a rare condition. The general approach has been reviewed by the principles of diagnosis and therapy.