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To the Editor, On December 04, 2012, a 47-year-old immunocompetent woman, with a past history of obesity, chronic alcoholism, diverticulitis, and intrauterine device (IUD) in place for at least fifteen years, was admitted to the emergency department because of confusion, agitation, and vomiting lasting for several hours. In June 2012, an ovarian mass of possible functional origin was diagnosed using ultrasounds at her usual gynecologic examination. In November 2012, due to the sudden onset of headaches and tremor, she was referred to the gynecologic emergency ward. Gynecologic examination was normal. Her complaints were considered as anxiety disorders. IUD withdrawal was planned for her next medical visit. In the following days, she continuously suffered from headaches and used non-steroidal anti-inflammatory drugs (NSAID) along with paracetamol as self-medication. On admission in the emergency department, severe intracranial hypertension was immediately suspected while physical examination ruled out meningeal irritation. The patient was intubated, mechanically ventilated, sedated, and transferred to the intensive care unit (ICU). The IUD was removed and cultured. Computed tomography (CT) scan showed several intracerebral hypodense lesions with loss of cortical sulci of the convexity and cerebral herniation. After the injection of contrast material, four round lesions with contrast enhancement and important peri-lesional edema were evidenced (Fig. 1). No sign of cerebral venous thrombosis was found. All the clinical, biological, and radiological investigations searching for a primary cancer were negative. Pelvic CTscan revealed the presence of salpingitis and ovarian cysts of functional origin as evidenced by the histological examination of a biopsy sample. The anaerobic blood cultures obtained before the administration of antibiotics were positive for Fusobacterium nucleatum, sensitive to all major antibiotics. Lumbar puncture was not performed due to the presence of cerebral herniation. Neurosurgical drainage was not indicated. Bacteriological culture suggested IUD colonization by F. nucleatum. No other origin for the infection was found. All other investigations were negative, including ear, nose, throat (ENT) examination and dental imaging. Probabilistic treatment combining 4 g x4/d cefotaxime, 16 g/d fosfomycin, and 500 mg x3/d metronidazole was started upon admission, in association with 120 mg/d methylprednisolone. Later, fosfomycin was stopped and cefotaxime continued to treat simultaneous hospital-acquired Hafnia alvei pneumonia. Initial seizures were treated with levetiracetam and phenobarbital. Intracranial hypertension progressively decreased without persistent neurological deficit. Significant clinical improvement was observed after eight days, allowing weaning from mechanical ventilation and extubation. Only fatigue and mild regressive frontal behavior disorders were present. Brain CTscan performed on day 13 and day 45 confirmed the regression of all the nodular lesions and the decrease of the peri-lesional edema. After one month, the patient was discharged from hospital with normal cognitive functions and autonomy.

Multiple brain abscesses of gynecologic origin caused by Fusobacterium nucleatum