Acute Infectious Purpura Fulminans Complicated by Bacterial Translocation after Rectal Cancer Surgery: A Case Report.

The patient was a man in his 80s who had undergone laparoscopic anterior resection for rectal cancer. Bowel obstruction occurred on the third postoperative day but improved with a decompression tube by the fifth postoperative day. A high fever (in the 38 °C range) was also observed. Blood culture tests detected two sets of the gram-negative bacilli Klebsiella aerogenes within 24 h of collection. On the seventh postoperative day, the patient subsequently went into septic shock with disseminated intravascular coagulation (DIC). On the eighth postoperative day, the fingertips and toes became black, and the palms and dorsal surfaces of both feet were dark purple due to peripheral circulatory failure. This suggested acute infectious purpura associated with sepsis (acute infectious purpura fulminans (AIPF)). Intensive care was provided; however, the necrosis of both middle fingers worsened, both middle fingers were gangrenous, and the patient died on the thirtieth postoperative day. AIPF is rarely reported, especially in early-onset cases after elective surgery. We encountered a rare complication of bacterial translocation from postoperative bowel obstruction, leading to AIPF.

Structural and quantitative alterations of gut microbiota in experimental small bowel obstruction.

OBJECTIVE: To investigate structural and quantitative alterations of gut microbiota in an experimental model of small bowel obstruction. METHOD: A rat model of small bowel obstruction was established by using a polyvinyl chloride ring surgically placed surrounding the terminal ileum. The alterations of gut microbiota were studied after intestinal obstruction. Intraluminal fecal samples proximal to the obstruction were collected at different time points (24, 48 and 72 hours after obstruction) and analyzed by 16s rDNA high-throughput sequencing technology and quantitative PCR (qPCR) for target bacterial groups. Furthermore, intestinal claudin-1 mRNA expression was examined by real-time polymerase chain reaction analysis, and serum sIgA, IFABP and TFF3 levels were determined by enzyme-linked immunosorbent assay. RESULTS: Small bowel obstruction led to significant bacterial overgrowth and profound alterations in gut microbiota composition and diversity. At the phylum level, the 16S rDNA sequences showed a marked decrease in the relative abundance of Firmicutes and increased abundance of Proteobacteria, Verrucomicrobia and Bacteroidetes. The qPCR analysis showed the absolute quantity of total bacteria increased significantly within 24 hours but did not change distinctly from 24 to 72 hours. Further indicators of intestinal mucosa damage and were observed as claudin-1 gene expression, sIgA and TFF3 levels decreased and IFABP level increased with prolonged obstruction. CONCLUSION: Small bowel obstruction can cause significant structural and quantitative alterations of gut microbiota and induce disruption of gut mucosa barrier.

A Novel Presentation of Tuberculosis with Intestinal Perforation in a Free-Ranging Australian Sea Lion (Neophoca cinerea).

We detail a novel presentation of tuberculosis associated with intestinal perforation in an endangered Australian sea lion (Neophoca cinerea) from South Australian waters and confirm the presence of this disease in the region of highest pup production. In February 2017, a 3-yr-old juvenile male died shortly after hauling out at the Kingscote beach on Kangaroo Island. On postmortem examination, we found a mid-jejunal intestinal perforation and partial obstruction (from a strangulating fibrous and granulomatous mesenteric mass), a marked multicentric abdominal fibrosing granulomatous lymphadenitis, and a large volume serosanguinous peritoneal effusion. Acid-fast bacteria were detected postmortem in cytologic preparations of the mesenteric lymph node and in histologic sections of jejunum and the encircling mass. Mycobacterial infection was confirmed by positive culture after 3 wk. Molecular typing using mycobacterial interspersed repetitive-unit-variable-number tandem-repeat typing with 12-locus analysis identified Mycobacterium pinnipedii. This case highlights the need for vigilance of zoonotic disease risk when handling pinnipeds, including in the absence of specific respiratory signs or grossly apparent pulmonary pathology. Increased serologic population surveillance is recommended to assess the species' risk from this and other endemic diseases, especially given its endangered status.

Recurrent Talaromyces marneffei Infection Presenting with Intestinal Obstruction in a Patient with Systemic Lupus Erythematosus.

Talaromyces marneffei is an important opportunistic pathogen mainly afflicting the HIV-infected patients, in rare instance, it could cause infection in non-HIV-infected individuals. We report a 51-year-old Chinese woman who, with histories of SLE for 14 years and disseminated talaromycosis for 4 years, occurred partial intestinal obstruction that was demonstrated to be caused by Talaromyces marneffei infection. The randomly amplified polymorphic DNA results of paraffin-embedded tissues from both the present episode and the previous infection suggested that the present infection was a recurrent. The patient was performed excision of involved intestine and treated with oral itraconazole at a daily dose of 400 mg for 3 months, leading to an excellent response. However, she died with unknown reason more than a year later. We also reviewed the literature on Talaromyces marneffei infection associated with SLE as well as intestinal talaromycosis alone.

Comparative Evaluation of Translocation of GFP Producing Escherichia coli Strains in Acute Intestinal Obstruction.

Comparative evaluation of translocation of E. coli GFP-producing strains in experimental rats with obturation and strangulated intestinal obstruction was carried out. Translocation of infused GFP-producing E. coli strain was studied by bacteriological methods in male rats with experimental obturation and strangulated intestinal obstruction with various ischemia/reperfusion cycles. The maximum incidence of translocation in obturation intestinal obstruction was observed after 24 h. In strangulated intestinal obstruction, the highest incidence was recorded in ischemia/reperfusion cycles of 1 h/2 h and 2 h/6 h. No appreciable differences in the incidence of translocation in animals with two types of intestinal obstruction were detected.

[Intestinal tuberculosis revealed by acute bowel obstruction during paradoxical reaction to antituberculosis treatment in an immunocompetent patient: about a case and literature review]. / Tuberculose intestinale révélée par une occlusion intestinale aigüe au cours d'une réaction paradoxale au traitement anti-tuberculeux chez un patient immunocompétent: à propos d'un cas et revue de la littérature.

Abdominal tuberculosis accounts for 3 to 5% of all visceral diseases. Despite the demonstrated effectiveness of anti-tuberculosis treatments, some cases of exacerbation of the initial clinical presentation have been described during the initiation of treatment. However, these reactions also known as "paradoxical" have been rarely reported in immunocompetent patients and much less in the case of bowel obstruction. We report a case of intestinal tuberculosis revealed by acute bowel obstruction during paradoxical reaction to anti-tuberculosis treatment. The study included a 26-year old immunocompetent patient with occlusive syndrome after a month of treatment for pleuropulmonary tuberculosis. Abdominal computed tomography (CT) showed small bowel obstruction. Laparotomy objectified intraperitoneal mass with multiple adhesions. Anatomo-pathological examination of the surgical specimen showed intestinal tuberculosis. Patient's outcome was favorable after the continuation of initial antituberculosis treatment.

Jejunal stricture due to mucormycosis.

Mucormycosis is generally considered to be an acute, rapidly progressing, opportunistic fungal infection. Chronic manifestations are extremely rare. Mucormycosis affecting the jejunum is very rare and few cases have been reported. We report a case of mucormycosis causing jejunal stricture in an infant aged six months.

Primary enterolithiasis with intestinal tuberculosis: rare presentation of a common disease.

Enterolithiasis is the formation of intestinal calculi due to stasis. Tubercular strictures resulting in intestinal stasis provide a favourable environment for enterolith formation. Intestinal tuberculosis occurs commonly in India, but coexistent enterolithiasis has been reported rarely. We are describing three cases of enterolithiasis secondary to tubercular intestinal strictures among female patients in the fourth to fifth decades of life, all of them having pulmonary tuberculosis in the past. All the cases presented with features of subacute intestinal obstruction. X-ray abdomen done for all of them revealed single to multiple round, oval and rectangular, radio-opaque shadows suggestive of stones. Coexistence of enterolithiasis with intestinal tuberculosis may worsen the symptoms of intestinal obstruction and surgery remains the mainstay of treatment. All the patients underwent exploratory laparotomy, resection and anastomosis of the diseased bowel and antitubercular therapy was started. Two patients responded well to the treatment and the third one expired due to cardiac comorbidity.

Microbiota dysbiosis and its pathophysiological significance in bowel obstruction.

Bowel obstruction (OB) causes local and systemic dysfunctions. Here we investigated whether obstruction leads to alterations in microbiota community composition and total abundance, and if so whether these changes contribute to dysfunctions in OB. Partial colon obstruction was maintained in rats for 7 days. The mid colon and its intraluminal feces - proximal to the obstruction - were studied. OB did not cause bacterial overgrowth or mucosa inflammation, but induced profound changes in fecal microbiota composition and diversity. At the phylum level, the 16S rRNA sequencing showed a significant decrease in the relative abundance of Firmicutes with corresponding increases in Proteobacteria and Bacteroidetes in OB compared with sham controls. Daily treatment using broad spectrum antibiotics dramatically reduced total bacterial abundance, but increased the relative presence of Proteobacteria. Antibiotics eliminated viable bacteria in the spleen and liver, but not in the mesentery lymph node in OB. Although antibiotic treatment decreased muscle contractility in sham rats, it had little effect on OB-associated suppression of muscle contractility or inflammatory changes in the muscle layer. In conclusion, obstruction leads to marked dysbiosis in the colon. Antibiotic eradication of microbiota had limited effects on obstruction-associated changes in inflammation, motility, or bacterial translocation.

[DYNAMICS OF ENTEROPERITONEAL TRANSLOCATION OF MICROORGANISMS ON THE EXPERIMANTAL MODEL OF ACUTE INTESTINAL OBSTRUCTION].

The article presents an analysis of the dynamics of enteroperitoneal translocation of bacteria on the model of acute intestinal obstruction (AIO) in rats by performing an experimental study on laboratory animals. Using the proposed model of AIO we have tried to determine the level of enteroperitoneal translocation as a function of the time of the impassable obstruction. The results which presented in the article clearly demonstrate that when AIO is developing in experimental animals the greatest level of translocation was revealed on the 3rd and 5th days. Statistically significant growth of the microflora in the lumen of the intestine above the level of obturation was observed on the 1st day and the whole period of observation was maintained, and it was also revealed that the level of CFU depends on the duration of the AIO and in the abdominal cavity it increases dramatically by 7 days, compared to 1 and 3 days. However, there is no significant correlation between enteroperitoneal translocation and the level of CFU in the lumen of the intestine and abdominal cavity.

Bacterial translocation and mortality on rat model of intestinal ischemia and obstruction.

PURPOSE:: To develop an experimental model of intestinal ischemia and obstruction followed by surgical resection of the damaged segment and reestablishment of intestinal transit, looking at bacterial translocation and survival. METHODS:: After anesthesia, Wistar rats was subject to laparotomy, intestinal ischemia and obstruction through an ileal ligature 1.5cm of ileum cecal valve; and the mesenteric vessels that irrigate upstream of the obstruction site to approximately 7 to 10 cm were ligated. Abdominal wall was closed. Three, six or twenty-four hours after, rats were subject to enterectomy followed by an end to end anastomosis. After 24h, mesenteric lymph nodes, liver, spleen and lung tissues were surgically removed. It was studied survival rate and bacterial translocation. GraphPadPrism statistical program was used. RESULTS:: Animals with intestinal ischemia and obstruction for 3 hours survived 24 hours after enterectomy; 6hx24h: survival was 70% at 24 hours; 24hx24h: survival was 70% and 40%, before and after enterectomy, respectively. Culture of tissues showed positivity on the 6hx24h and negativity on the 3hx24h. CONCLUSION:: The model that best approached the clinic was the one of 6x24h of ischemia and intestinal obstruction, in which it was observed bacterial translocation and low mortality rate.

Tubercular Intestinal Strictures Show a Poor Response to Anti-Tuberculous Therapy.

BACKGROUND: The literature on resolution of intestinal strictures in patients with intestinal tuberculosis (ITB) after anti-tuberculous therapy (ATT) is sparse and ambivalent. We aimed to assess the frequency of stricture resolution after ATT and its predictors. METHODS: This ambispective cohort study included consecutive ITB patients with strictures who received ATT for ≥6 months and were on regular follow-up between January 2004 and December 2015. Resolution of stricture was assessed at the end of ATT by endoscopy/radiology. RESULTS: Of 286 patients, 128 had strictures, and 106 were finally included (63 males, median age 35 years). The stricture location was distal ileum/ileocecal in 52 (49.1%), colon in 37 (34.9%), ileocolonic in 4 (3.8%), proximal small bowel in 10 (9.4%), and gastroduodenal in 4 (3.8%) patients. Although all patients demonstrated mucosal healing (indicating resolution of active infection), stricture resolution occurred only in 25/106 (23.6%) patients. Symptoms pertaining to stricture (pain abdomen/recurrent SAIO) were present in 104/106 (98%) patients, and after a median of 6 (6-9) months of ATT, these symptoms resolved only in half, 88% (22/25) in patients with stricture resolution and 38% (30/79) in patients with persistent strictures. Colonic strictures had the least resolution (5.4%) followed by proximal small intestinal (20%) and distal ileal/ileocecal (36.5%). Although not statistically significant, stricture resolution was less frequent in patients with multiple strictures, longer strictures (>3 cm), and strictures in which scope was not negotiable prior to ATT. CONCLUSION: Only one-fourth of ITB patients with strictures show resolution of stricture following ATT. The resolution of strictures is dependent on disease location, and majority of them exhibit symptoms pertaining to stricture even after ATT.

Bacterial translocation and mortality on rat model of intestinal ischemia and obstruction

Abstract Purpose: To develop an experimental model of intestinal ischemia and obstruction followed by surgical resection of the damaged segment and reestablishment of intestinal transit, looking at bacterial translocation and survival. Methods: After anesthesia, Wistar rats was subject to laparotomy, intestinal ischemia and obstruction through an ileal ligature 1.5cm of ileum cecal valve; and the mesenteric vessels that irrigate upstream of the obstruction site to approximately 7 to 10 cm were ligated. Abdominal wall was closed. Three, six or twenty-four hours after, rats were subject to enterectomy followed by an end to end anastomosis. After 24h, mesenteric lymph nodes, liver, spleen and lung tissues were surgically removed. It was studied survival rate and bacterial translocation. GraphPadPrism statistical program was used. Results: Animals with intestinal ischemia and obstruction for 3 hours survived 24 hours after enterectomy; 6hx24h: survival was 70% at 24 hours; 24hx24h: survival was 70% and 40%, before and after enterectomy, respectively. Culture of tissues showed positivity on the 6hx24h and negativity on the 3hx24h. Conclusion: The model that best approached the clinic was the one of 6x24h of ischemia and intestinal obstruction, in which it was observed bacterial translocation and low mortality rate.

Abdominal tuberculosis: an old disease surprising young doctors.

Tuberculosis remains a worldwide public health concern. Atypical extrapulmonary presentations may delay the diagnosis and treatment. We present the case of an adult woman admitted to the emergency department with bowel obstruction. The putative intraoperative diagnostic hypothesis was ovarian cancer with peritoneal dissemination. Histopathological analysis showed a chronic granulomatous inflammatory disease with acid-fast bacilli. The patient was started on an alternative parenteral antituberculosis drug combination until oral feeding was available. Currently, 5 months after surgery, she is asymptomatic. Abdominal tuberculosis is the most frequent extrapulmonary site with a wide range of clinical presentations. Emergency laparotomy may be necessary in patients who present with acute abdomen. Bowel obstruction due to adhesions and strictures is not infrequent. However, tuberculous abdominal cocoon presentation as in our patient is rare. Treatment with parenteral alternative drug regimens for tuberculosis is mandatory until the oral route is available.

[Small bowel obstruction secondary to massive hookworm infestation complicated by fatal plurimicrobial bacteriemia]. / Occlusion iléale par infestation massive par des ankylostomes responsable d'une septicémie plurimicrobienne d'évolution fatale.

INTRODUCTION: Intestinal symptoms (cramping, flatulence) and iron deficient anemia are classical presenting manifestations of duodenal hookworm infestation in patients living in endemic area. CASE REPORT: We report a 45-year-old immunocompetent metropolitan man who presented with intestinal obstruction secondary to massive hookworm infestation complicated by fatal plurimicrobial bacteriemia with refractory septic shock. CONCLUSION: We report a case of acute surgical abdominal presentation with septicemia and refractory shock syndrome due to ileal translocation secondary to massive hookworm infestation. To the best of our knowledge, such a case has not yet been reported.

[Abdominal tuberculosis, a diagnostic dilemma: report of a series of cases]. / Tuberculosis abdominal, un dilema diagnóstico: reporte de una serie de casos.

INTRODUCTION: Abdominal tuberculosis is one of the most common non-pulmonary tuberculosis infection sites, and it relates to immunosuppression. The nonspecific features of this form of tuberculosis make an accurate diagnosis difficult. The aim of this study is to report seven (7) patients diagnosed with abdominal tuberculosis requiring surgery at the Clinical Hospital of Pontificia Universidad Católica de Chile. METHODS: A descriptive analysis of seven cases of abdominal tuberculosis treated in our center between August 2001 and June 2013 was performed to characterize its clinical presentation and diagnostic elements. RESULTS: Four men and three women (29-68 years old) were diagnosed and operated on for abdominal tuberculosis: three had the peritoneal form of tuberculosis, two had a lymph nodal form and two had the intestinal form. In three cases, abdominal tuberculosis was associated with immunosuppression (HIV and rheumatoid arthritis treatment) and six cases presented with wasting syndrome of at least one month duration. Three patients had an acute presentation with signs of intestinal obstruction. Diagnosis was made by surgical biopsy. Of the seven patients, who underwent surgery, three required bowel resection for intestinal obstruction. CONCLUSION: Abdominal tuberculosis requires a high index of suspicion for an early diagnosis, especially in populations at risk.

INTRODUCCIÓN : La tuberculosis abdominal es una de las variantes extrapulmonares más frecuentes. Se relaciona a estados de inmunodepresión y, dado su cuadro clínico inespecífico, su diagnóstico es difícil. Nuestro objetivo es presentar una serie de siete casos diagnosticados de tuberculosis abdominal que requirieron cirugía en el Hospital Clínico de la Pontificia Universidad Católica de Chile. MÉTODOS: Se realizó un análisis descriptivo de los siete casos de tuberculosis abdominal operados en nuestro centro entre agosto de 2001 y junio de 2013, caracterizando su presentación clínica y elementos diagnósticos requeridos. RESULTADOS: Cuatro hombres y tres mujeres (entre 29 y 68 años) fueron diagnosticados y operados de tuberculosis abdominal: tres en su forma peritoneal, dos ganglionar y dos intestinal. En tres casos la tuberculosis abdominal se asoció a inmunosupresión (VIH y artritis reumatoide en tratamiento) y en seis casos se presentó con síndrome consuntivo de al menos un mes de evolución. Tres pacientes tuvieron una presentación aguda con signos de obstrucción intestinal. El diagnóstico fue realizado mediante biopsia quirúrgica. Los siete pacientes fueron intervenidos quirúrgicamente, tres de ellos requirieron resección intestinal en el contexto de obstrucción intestinal. CONCLUSIÓN: La tuberculosis abdominal requiere de un alto índice de sospecha, principalmente en población de riesgo, para un diagnóstico oportuno.

The effects of caffeic acid phenethyl ester (CAPE) on bacterial translocation and inflammatory response in an experimental intestinal obstruction model in rats.

OBJECTIVE: Intestinal obstruction (IO) is a disease which generates approximately 20% of emergency surgery and tends to with high mortality. Prevention of oxidative stress, bacterial translocation and tissue damage caused by IO is an important medical issue. Caffeic acid phenethyl ester (CAPE) is an anti-inflammatory, antioxidant, anti-bacterial and immunomodulatory agent. In this experimental study, we aimed to investigate the effects of CAPE on bacterial translocation, inflammatory response, oxidative stress and tissue injury caused by intestinal obstruction in a rat model. MATERIALS AND METHODS: Breafly, thirty Wistar albino rats divided into three groups as Sham (n=10), IO (n=10) and IO + CAPE (10 µmol/kg day, intraperitoneal) (n=10). The tissues from the study groups were examined biochemically, microbiologically and histopathologically. RESULTS: In CAPE treated group, decreased serum levels of proinflammatory cytokines (TNF-α, IL-6, IL-1ß) and CRP (p < 0.05), additionally increased serum levels of antioxidant parameters (PONS, TAS) (p < 0.05), were observed after IO. Microbiologically, the rates of positive cultures of the lymph node, spleen, liver and blood were significantly decreased in CAPE treated group compared to the IO group. Also histopathological examination showed that the intestinal mucosal injury score and hepatic portal inflammation score were significantly decreased in the CAPE treated group (p < 0.05). CONCLUSIONS: It is suggested that intraperitoneal administration of CAPE might has potential antibacterial, anti-inflammatory, antioxidant and immunomodulatory effects in IO. So, further studies on IO are needed to evaluate exact antibacterial, antiinflammatory, antioxidant and immunomodulatory effects of CAPE.