Lytic lesion of skull: a rare presentation of chronic granulomatous disease.

An 18-month-old boy presented with lytic lesion of skull and recurrent abscesses with Serratia marcescens The extensive work up revealed a gene mutation confirming the diagnosis of chronic granulomatous disease (CGD). This case scenario underscores the importance of exploring the possibility of immunodeficiency if there is a history of recurrent abscesses with atypical organism. The case also demonstrates that CGD can present as lytic lesion of skull.

Does Training Innate Immunity Confer Broad-spectrum Protection Against Bone and Joint Infection in a Mouse Model?

BACKGROUND: The innate immune system can recall previous immunologic challenges and thus respond more effectively to subsequent unrelated challenges, a phenomenon called trained immunity. Training the innate immune system before surgery might be a potential option to prevent bone and joint infection. QUESTIONS/PURPOSES: (1) Does the training process cause adverse effects such as fever or organ injury? (2) Does training the innate immune system confer broad-spectrum protection against bone and joint infection in a mouse model? (3) Does trained immunity remain effective for up to 8 weeks in this mouse model? METHODS: After randomization and group information blinding, we trained the innate immune system of C57BL/6 mice (n = 20 for each group) by intravenously injecting them with either 0.1 mg of zymosan (a toll-like receptor 2 agonist), 0.1 mg of lipopolysaccharide (a toll-like receptor 4 agonist), or normal saline (control). For assessing the host response and possible organ injury after training and infection challenge, we monitored rectal temperature, collected blood to determine leukocyte counts, and performed biochemical and proinflammatory cytokine analyses. After 2 weeks, we then assessed whether trained immunity could prevent infections in an intraarticular implant model subjected to a local or systemic challenge with a broad spectrum of bacterial species (Staphylococcus aureus, Escherichia coli, Enterococcus faecalis, Streptococcus pyogenes, or Pseudomonas aeruginosa) in terms of culture-positive rate and colony counts. The proportion of culture-positive joint samples from trained and control groups were compared after 4 weeks. Finally, we increased the interval between training and bacterial challenge up to 8 weeks to assess the durability of training efficacies. RESULTS: Training with zymosan and lipopolysaccharide caused mild and transient stress in host animals in terms of elevated rectal temperature and higher blood urea nitrogen, creatinine, alanine aminotransferase, and aspartate aminotransferase levels. Trained mice had fewer culture-positive joint samples after local inoculation with S. aureus (control: 100% [20 of 20]; zymosan: 55% [11 of 20], relative risk 0.55 [95% CI 0.37 to 0.82]; p = 0.001; lipopolysaccharide: 60% [12 of 20], RR 0.60 [95% CI 0.42 to 0.86]; p = 0.003) and systemic challenge with S. aureus (control: 70% [14 of 20]; zymosan: 15% [3 of 20], RR 0.21 [95% CI 0.07 to 0.63]; p = 0.001; lipopolysaccharide: 15% [3 of 20], RR 0.21 [95% CI 0.07 to 0.63]; p = 0.001) than controls. We observed similar patterns of enhanced protection against local and systemic challenge of E. coli, E. faecalis, S. pyogenes, and P. aeruginosa. Zymosan-trained mice were more effectively protected against both local (control: 20 of 20 [100%], zymosan: 14 of 20 [70%], RR 0.70 [95% CI 0.53 to 0.93]; p = 0.02) and systemic (control: 70% [14 of 20]; zymosan: 30% [6 of 20], RR 0.43 [95% CI 0.21 to 0.89]; p = 0.03) challenge with S. aureus for up to 8 weeks than controls. CONCLUSIONS: Trained immunity confers mild stress and broad-spectrum protection against bone and joint infection in a mouse model. The protection conferred by immunity training lasted up to 8 weeks in this mouse model. The results of the current research support further study of this presurgical strategy to mitigate bone and joint infection in other large animal models. CLINICAL RELEVANCE: If large animal models substantiate the efficacy and safety of presurgical immunity training-based strategies, clinical trials would be then warranted to translate this strategy into clinical practice.

Infection burden and immunological responses are equivalent for polymeric and metallic implant materials in vitro and in a murine model of fracture-related infection.

The development of an infection is a major complication for some patients with implanted biomaterials. Whether the material or surface composition of the used biomaterial influences infection has not been directly compared for key biomaterials currently in use in human patients. We conducted a thorough in vitro and in vivo investigation using titanium (Ti) and polyether-ether-ketone (PEEK) as both commercially available and as modified equivalents (surface polished Ti, and oxygen plasma treated PEEK). Complement activation and cytokine secretion of cell of the immune system was assessed in vitro for all materials in the absence and presence of bacterial stimulants. In a follow-up in vivo study, we monitored bacterial infection associated with clinically available and standard Ti and PEEK inoculated with Staphylococcus aureus. Complement activation was affected by material choice in the absence of bacterial stimulation, although the material based differences were largely lost upon bacterial stimulation. In the in vivo study, the bacterial burden, histological response and cytokine secretion suggests that there is no significant difference between both PEEK and Ti. In conclusion, the underlying material has a certain impact in the absence of bacterial stimulation, however, in the presence of bacterial stimulation, bacteria seem to dictate the responses in a manner that overshadows the influence of material surface properties. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1095-1106, 2019.

Bone involvement by Sporothrix schenckii in an immunocompetent child.

Sporotrichosis in children is rare, and its osteoarticular form is very unusual. Disseminated forms are described mostly in immunocompromised patients. We report a case of a 5-year-old immunocompetent boy with multiple suppurated cutaneous lesions that progressed to polyarthritis of the hands and feet. Radiographic imaging demonstrated multifocal lytic lesions. Sporotrichosis was diagnosed through biopsy and culture. This article describes the radiographic appearance of a rare manifestation of this disease. In areas of high prevalence, the diagnosis of sporotrichosis should be taken into account, even in immunocompetent patients, when dactylitis with lytic lesions is present.

Differential roles for NOD2 in osteoblast inflammatory immune responses to bacterial pathogens of bone tissue.

Osteoblasts produce an array of immune molecules following bacterial challenge that can contribute to inflammation and the recruitment of leukocytes to sites of infection during bone diseases such as osteomyelitis. However, the mechanisms by which osteoblasts perceive and respond to facultative intracellular pathogens such as Salmonella species and Staphylococcus aureus have not been determined. Recently, our laboratory has described the expression in osteoblasts of members of the nucleotide-binding domain leucine-rich repeat region containing family of proteins that include nucleotide-binding oligomerization domain-2 (NOD2), a molecule that functions as an intracellular receptor for bacterial peptidoglycans. In the present study, we demonstrate that NOD2 expression is required for select inflammatory mediator production by osteoblasts following infection with the invasive pathogen Salmonella. In contrast, we have found that the inflammatory immune responses of osteoblasts to the passively internalized bacterial species Staphylococcus aureus, heat-killed pathogenic Salmonella, a non-invasive Salmonella strain and specific Toll-like receptor ligands are not reduced in the absence of NOD2 expression but are, in fact, elevated. Based upon these findings, we suggest that NOD2 serves differential roles in osteoblasts, promoting inflammatory responses to invasive bacteria while tempering cell responses to extracellular and/or passively internalized bacterial species.

Signaling via Toll-like receptor 5 can initiate inflammatory mediator production by murine osteoblasts.

Murine osteoblasts express Toll-like receptor 5 (TLR5), and this expression is upregulated following exposure to bacteria or to the TLR5 agonist, flagellin. Importantly, flagellin activates transcriptional regulators and elicits proinflammatory cytokine production, suggesting TLR5 functionality. TLR5 may represent an important mechanism underlying the recognition of bacterial pathogens by osteoblasts during bone infections.

Experimental chronic infection induced in mice by Actinomyces israelii entrapped in alginate gel.

Tissue responses to experimentally induced actinomycotic lesions were investigated in mice by both light and transmission electron microscopy. Micro-organisms of Actinomyces israelii were entrapped in alginate gel and injected into the subcutaneous tissue over the periosteum of the mouse cranium. One day after the injection (initial stage), a non-stained amorphous structure was located in the core of the lesion, corresponding to the injected gel with bacteria. Numerous neutrophils surrounded the core region and phagocytized the injected complex actively. At days 3-7 (intermediate stage), the lesion became well developed. The core structure became eosinophilic and separated to form island-like structures. No lesion was recognized in the control group (gel without bacteria) until day 14. After 30 days (late stage), the lesions displayed more static features, similar to the "sulphur granules" characteristic of actinomycotic lesions. At the late stage, foamy cells increased in number and took the place of neutrophils in the alginate islands. By transmission electron microscopy these foamy cells were seen to be filled with lysosomal vesicles containing electron-dense foreign material. Thus, these cells appeared to be macrophages that had phagocytized degenerated neutrophils containing bacteria. Along with the active phagocytosis by foamy cells that progressed in the late stage, a collagenous capsule became conspicuous and separated the lesion from the intact tissue. The bacteria remained in the gel islands until at least day 60, although they considerably decreased in number with time. Serum IgG antibody titres began to rise within 24 h of the injection, reached a peak concentration at day 14 and remained a significantly high (p < 0.01, vs 0 time) until day 120. These results suggest that this animal model is useful for inducing experimental chronic infectious lesions.