Il mal di testa più brutto della mia vita

The paper reports the case of a 17-year-old male presenting to the Emergency Room with acute, worsening headache who was undergoing periodic esophageal dilatations for a caustic stricture. Clinical deterioration with vomiting and a mild drop in GCS prompted brain CT and MRI scans, which revealed three space-occupying brain abscesses with surrounding oedema and mass effect. Following neurosurgical drainage and targeted antimicrobial therapy, cultures yielded oral commensal bacteria (Aggregatibacter aphrophilus, Eikenella corrodens and Shaalia odontolytica). Subsequent immunological workup revealed reduced CD4+ and CD8+ T-cell levels and raised suspicion for an underlying immunodeficiency. This case highlights the rare link between recurrent esophageal procedures and brain abscesses via oral bacterial translocation and emphasises the importance of recognising subtle neurological presentations even in afebrile patients and of screening for underlying immune defects.