A 34-year-old male presented with altered mental status, fever, seizures and vomiting. Comprehensive imaging revealed multiple cerebral, spinal, mediastinal, and splenic abscesses. Blood cultures were positive for Streptococcus intermedius, and esophageal biopsy showed Neisseria and Rothia species. Further evaluation identified dental abscess as the likely source of infection. He subsequently developed multiple pulmonary emboli (PE) and deep venous thromboses (DVT) despite antibiotics and DVT prophylaxis. He was treated with an Inferior Vena Cava (IVC) filter and low dose heparin. Dental extraction and Video-Assisted Thoracoscopic Surgery (VATS) were also performed for source control. 

Systematic review identified 35 articles with key words “anticoagulation” and “cerebral abscess.”  The data of 27 cases was summarized as follows: 24/27 patients were treated with anticoagulation (15 (63%) with unfractionated heparin, 6 (25%) with low molecular weight heparin, 1 (4%) with dicumerol, and 2 (8%) with an unnamed agent).  2 (7%)  patients were treated with thrombectomy,  1 (4%) with localized catheter directed streptokinase, and 1 (4%) with aspirin. Average time until diagnosis of VTE and treatment with anticoagulation was 3.5 days. 2 (7%) cases were complicated by cerebral hemorrhage and subsequent death, but both were reported in 1969.