The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–5, 2017
Ó 2017 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2016.12.034

Clinical
Communications: Pediatric

PEDIATRIC SEPSIS SECONDARY TO AN OCCULT DENTAL ABSCESS:

A CASE REPORT

Peter Holmberg, MD,* Thomas Hellmich, MD,† and James Homme, MD†
*Department of Pediatric and Adolescent Medicine, Mayo Clinic and †Pediatric Emergency Medicine, Mayo Clinic, Rochester, Minnesota
Reprint Address: Peter Holmberg, MD, Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 1st St. SW, Rochester, MN 55902

, Abstract—Background: In general, hematogenous , Keywords—bacteremia; odontogenic; dentoalveolar;

spread of bacteria in children is uncommon. Bacteremia, abscess; Veillonella; Lactobacillus; anaerobic; bacteria; he-
however, is a known complication of dental procedures matogenous; dental; pediatric; emergency; occult
and severe caries, but is infrequently associated with
primary, asymptomatic, non-procedural-related, dentoal-
veolar infection. Case Report: The patient is a 7-year-old INTRODUCTION
previously healthy boy who presented to the Emergency
Department (ED) with ‘‘fever, mottling, and shaking Odontogenic bacteria are a known cause of bacteremia in
chills.’’ In the ED, he appeared systemically ill with fever, the setting of dental procedures, severe caries, and even
mottling, delayed capillary refill, and rigors. Physical tooth brushing (1,2). However, it is extremely rare to
examination by three different physicians failed to reveal have symptomatic hematogenous spread of bacteria in
any focus of infection. Laboratory evaluation, including clinically inapparent dentoalveolar infections. We
blood cultures, was obtained. The patient later developed
present one of the first known cases of pediatric sepsis
unilateral facial swelling and pain, and a dentoalveolar
with two different anaerobic organisms secondary to an
abscess was found. He was started on antibiotics, under-
went pulpectomy and eventually, extraction, prior to occult dentoalveolar abscess in a pediatric patient.
improvement in symptoms. Blood cultures grew two
separate anaerobic bacteria (Veillonella and Lactobacillus). CASE PRESENTATION
This is, to our knowledge, one of the first reported cases of
pediatric sepsis with two different anaerobic organisms A previously healthy, fully vaccinated, 7-year-old boy
secondary to occult dentoalveolar abscess in a pediatric was brought into the Emergency Department (ED) by
patient. Why Should an Emergency Physician Be Aware of his father for evaluation of ‘‘fever, mottling and shaking
This?: It is imperative for emergency physicians to chills.’’ On the day of evaluation, the patient had started
recognize the possibility of pediatric sepsis in the setting to complain of mild, right-sided tooth and jaw pain.
of acute maxillary or mandibular pain, as well as in
This was nonprogressive in nature and did not interfere
patients for whom no clear focus of infection can be found.
with eating or other activity. However, about 3 h prior
This is particularly important for those who appear ill at
presentation or meet systemic inflammatory response to evaluation, he developed fever at home, with progres-
syndrome criteria and would benefit from further labo- sion to shaking chills and lower-extremity mottling. In
ratory evaluation, including blood cultures, and possibly the ED, he was noted to be febrile to 39.6 C (103.3 F),
antibiotic therapy. Ó 2017 Elsevier Inc. All rights and on examination had lower-extremity mottling, cool
reserved. feet, delayed capillary refill (4 s), and rigors. Cardiac,

RECEIVED: 12 January 2016; FINAL SUBMISSION RECEIVED: 22 December 2016;

ACCEPTED: 27 December 2016

1
2 P. Holmberg et al.

lung, and abdominal examination were normal without A pulpectomy was performed to release the abscess,
murmurs or focal sounds on lung auscultation, and no but the tooth was not removed. The patient was started
tenderness to abdominal palpation. Lymphadenopathy on amoxicillin and was discharged to home. Despite the
was absent at this time as well. Other vitals showed antibiotics and pulpectomy, the patient continued to
mild tachycardia (heart rate 127 beats/min) and mild ta- have fevers, as well as increasing right lower jaw swelling
chypnea (respiratory rate 24), but otherwise no hypoten- and tenderness.
sion (blood pressure 126/83 mm Hg). He did complain of At 29 h after blood cultures were drawn, an anaerobic
intermittent, mild, right mandibular/tooth pain but blood culture bottle revealed growth of a Gram-negative
without evidence of swelling, tenderness, trismus, or bacterium. As such, the patient was contacted to return to
other abnormality indicative of infection despite close the ED for evaluation. Given positive growth from blood
examination by three separate providers. cultures, he retrospectively met criteria for sepsis at his
Given the child’s age group, vital signs, and physical initial visit to the ED (Table 1). At presentation, the fam-
examination findings, he met the classification for sys- ily acknowledged that he continued to have fevers,
temic inflammatory response syndrome (Table 1). Given swelling, and discomfort. On examination, he had mild
concern for systemic bacterial infection, intravenous ac- tachypnea (respiratory rate 22 breaths/min) but was
cess was obtained, laboratory studies including complete afebrile (36.8 C) and not tachycardic (heart rate 67
blood count (CBC), electrolytes, C-reactive protein beats/min). He appeared well, with normal capillary refill
(CRP), and two sets of blood cultures were drawn. The (2 s), but had a marked increase in swelling over his right
patient was given a 20-cc/kg bolus of normal saline and mandible. Further examination revealed a first molar on
a dose of acetaminophen for defervescence. Upon re- the right side of the mandible that had been drilled and
evaluation, the patient appeared clinically improved. He capped, with a small amount of gingival swelling sur-
remained febrile to 39.1 C (102.4 F) but had resolution rounding the tooth. There was tenderness to percussion
of rigors and mottling, and capillary refill had normal- of the tooth as well as tenderness and swelling along
ized. Laboratory evaluation revealed normal CRP the mandible inferior to the tooth. There was no signifi-
(< 3.0 mg/L), white blood count (6.9  109/L), and elec- cant lymphadenopathy noted and a skin examination
trolytes (Na 136; K 3.6; Cl 103; HCO3 20; blood urea ni- was normal, and specifically, there was no evidence of
trogen 8; Cr 0.4; Glu 110). Given clinical improvement splinter hemorrhages.
after intravenous fluids and antipyretics, as well as a Given the growth of Gram-negative cocci in an anaer-
normal white blood cell count and CRP, he was dis- obic bottle and persistent symptoms, repeat CBC, CRP,
charged to home with a discharge impression of fever and blood cultures were obtained. CBC still had an insig-
of unclear etiology. The family was provided instructions nificant white count (5.5  109/L) but CRP was elevated
for follow-up the next day with the patient’s primary care at 33.9 mg/L (39 h after initial CRP was obtained and
physician and with the agreement that the family would found to be < 3.0 mg/L). The patient was started on clin-
be contacted if blood cultures had any growth. damycin, in addition to the previously prescribed amoxi-
The patient awoke the following day with a markedly cillin, and discharged to home from the ED after
swollen, tender, and erythematous right mandibular area. arrangements were made to have the tooth extracted as
He was taken to a dentist, where an abscess in tooth #LR6 an outpatient. The tooth was extracted the following
(lower right first molar) was identified (Figure 1). day and the patient was seen in primary care clinic for

Table 1. Definitions of Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock

Systemic Inflammatory Response Syndrome

At least two of the following four criteria, one of which must be abnormal temperature or leukocyte count
Core temperature of > 38.5 C or < 36 C
Tachycardia (mean HR > 2 SD above normal for age)
Tachypnea (mean RR > SD above normal for age)
Leukocyte count elevated or depressed for age or > 10% immature neutrophils
Sepsis
SIRS in the presence of, or as a result of, suspected or proven infection
Severe sepsis
Sepsis plus organ dysfunction as described in one of the following: cardiovascular organ dysfunction OR acute respiratory distress
syndrome OR two or more other organ dysfunctions
Septic shock
Sepsis and cardiovascular organ dysfunction

HR = heart rate; RR = respiratory rate; SD = standard deviation.

Adapted from ref. (3): Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric
sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2–8.
Pediatric Sepsis Secondary to an Occult Dental Abscess 3

Figure 1. Pediatric dental anatomy and approximate age of

eruption (4).

Figure 2. Normal dental anatomy (6).

re-evaluation 64 h after the initial ED visit. At that point,
he was markedly improved, with significant decrease in
Speck et al., Strep. viridans was present in all blood
symptoms, and was afebrile. It was also noted that a sec-
cultures during episodes of postextraction bacteremia
ond blood culture bottle was growing Gram-positive
(2). However, it is becoming apparent that there is an in-
cocci. Final speciation revealed Veillonella and Lactoba-
crease in the isolation of strictly anaerobic bacteria from
cillus rhamnosus grown at 29 and 44 h, respectively. Of
abscesses (9). Up to 40% of patients with infection sec-
note, he had not consumed any probiotics previous to
ondary to dental caries have odontogenic anaerobic
this event and was on no immunosuppressive medica-
tions. There had been no murmurs on examination and
no cutaneous sequelae of infective endocarditis at any
point. Given an absence of other risk factors for endocar-
ditis, no further imaging was warranted at that time, as the
patient had returned to baseline with resolution of fevers
after pulpectomy.

DISCUSSION

Odontogenic infections, including dental caries, peri-

odontitis, gingivitis, pericoronitis, and even abscesses,
are relatively common and known to result in edentu-
lism (5). These infections often present with signs
and symptoms typical of infection, including pain,
redness, warmth, swelling, and fever (6). Specific
symptoms are generally attributable to location of
infection and can include jaw pain, trismus, dysphagia,
and possibly dyspnea, depending on area of involve-
ment (Figures 2 and 3) (7).
Dentoalveolar abscesses are commonly polymicrobial
and contain various facultative as well as strictly anaer-
obic bacteria (8). The most commonly isolated bacteria
from dentoalveolar infections continue to be Strepto-
coccus viridans (9,10). For example, in a study by Figure 3. Locations of various dental infections (6).
4 P. Holmberg et al.

bacteria present within the infection (10). It is plausible, Although untreated or improperly treated odonto-
and even likely, that the same bacteria found in abscesses genic infections can become severe, it is exceedingly
would be the most likely to be isolated from blood cul- rare to have a bacteremic load significant enough to
tures in the setting of secondary bacteremia. In this report, produce physical manifestations of sepsis, including
two bacteria were isolated, both of which were anaerobic mottling, delayed capillary refill, rigors, and to result
in nature. These included Lactobacillus rhamnosus, a in positive blood cultures from an occult dentoalveolar
facultative Gram-positive anaerobe and Veillonella, a abscess (3). Furthermore, in this case, there was no
Gram-negative anaerobe, both of which are routinely known preceding trauma, procedure, or other interven-
found to inhabit the oral cavity (11). tion that would increase the risk of bacteremia. Despite
Bacteremia is a known complication of dental surgery initial presentation, with appropriate dental and antimi-
and severe caries (1,2,12). In fact, oral surgery is itself an crobial treatment, the patient recovered without
indication for antibiotic prophylaxis in pediatric patients sequelae. In conclusion, we report one of the first cases
with certain cardiac conditions, impaired immunity, or of pediatric sepsis with two different anaerobic organ-
foreign indwelling catheters, joints, and other devices isms secondary to a clinically occult dentoalveolar ab-
as outlined in summary guidelines both from the scess in a pediatric patient.
American Heart Association in 2007 and the American
Academy of Pediatric Dentistry in 2008 (13,14). These WHY SHOULD AN EMERGENCY PHYSICIAN BE
are meant to reduce the risk of hematogenously spread AWARE OF THIS?
infections secondary to dental procedures, the
complications of which can be severe (15,16). Odontogenic sources of bacteremia/sepsis are often
As noted, odontogenic infections are often polymi- obvious based on history and physical examination, but
crobial in nature, but progress has been made in the can also be causative even without a clear focus of infec-
speciation of causative organisms, and several types of tion. As has been recommended in other areas of critical
bacteria are now known to be more commonly patho- care medicine, it is important for emergency physicians to
genic. For example, many of the bacteria that are impli- recognize the possibility of a dentoalveolar source of
cated in dental caries are of the Gram-positive genus illness in cases with no traditional focus of infection,
Streptococcus, and often include members of the facul- especially in those appearing acutely ill (21). Laboratory
tatively anaerobic viridans group such as S. mutans and evaluation, imaging, and antimicrobial choices depend
S. sanguinis. Lactobacillus, a genus of Gram-positive on, and can be affected by, suspected location of the cause
anaerobic bacteria, as well as Actinomyces spp., are of bacteremia/sepsis.
other commonly implicated groups of organisms in Furthermore, sepsis and its early identification con-
dental caries and odontogenic infections (17). With tinues to be one of the greatest challenges in caring for
increasing involvement of the surrounding soft tissue, acutely ill children. Diagnosis can often be delayed,
the microbiota subsequently change. As infection pro- which can result in significant morbidity and mortality.
gresses, an increasing involvement of Gram-negative, The International Pediatric Consensus Conference held
anaerobic bacteria takes place (18). Given this knowl- in 2005 clearly delineated signs and symptoms, based
edge, the choice of antibiotic use in odontogenic infec- on age categories, that are suggestive of pediatric sepsis.
tions should be relatively clear. In treating dental These guidelines, when implemented, can help to
infections, antimicrobials must cover Gram-positive increase the identification of, and reduce the burden of
and anaerobic bacteria. Penicillins, with a beta- disease from, pediatric sepsis (3).
lactamase inhibiting component (i.e., amoxicillin-
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