18 June 2024

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The interplay among a dental procedure, infective endocarditis, and an acute ischemic stroke

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Background

This case report highlights the rare association among a dental procedure, infective endocarditis, and an acute ischemic stroke.

Case Description

A 54-year-old woman who experienced an acute ischemic stroke 5 weeks after a tooth extraction is described. The initial symptoms of this patient included mild to moderate word-finding difficulty and right facial droop. Computed tomographic angiography revealed a left M1 segment middle cerebral artery occlusion (thrombolysis in cerebral infarction scale, 0) with reconstitution of the distal middle cerebral branches through arterial collaterals. After initial administration of tissue plasminogen activator, endovascular thrombectomy was successfully performed with thrombolysis in cerebral infarction scale 3 (complete) recanalization. After the procedure, the patient showed improvement in language and neurologic deficits. Imaging showed multifocal, bilateral, cortical, and deep brain hemorrhages. Blood cultures grew Streptococcus mitis, ultimately leading to the diagnosis of endocarditis. Echocardiographic imaging revealed moderate to severe aortic insufficiency, a mitral valve vegetation, and mild mitral valve regurgitation. After evaluation by the cardiothoracic surgery team, the patient was discharged with intravenous antibiotics and short-term outpatient follow-up with the cardiothoracic surgery team.

Practical Implications

Dental procedures, although generally safe, can introduce oral bacteria into the bloodstream, leading to bacterial seeding of cardiac valves and subsequent infective endocarditis. Recognizing infective endocarditis subsequent to a dental procedure, including a tooth extraction, as a potential cause of an acute ischemic stroke is vital so that prompt treatment can be initiated.

Authors: Momodou G. Bah, BSc, Zachary M. Wilseck, MD, Leanne Y. Lin, MD, MPHS, Andrew J. Peterson, DDS, Neeraj Chaudhary, MD, Joseph J. Gemmete, MD

Source: https://jada.ada.org/article/S0002-8177(23)00686-4/abstract