Infectious native aortic aneurysm with negative blood cultures: do not forget the pneumococcal urinary antigen test!

Infectious native aortic aneurysm (INAA) are rare but life-threatening infections. Early microbiological identification is crucial to initiate adequate therapy and decrease the peri-operative risk, but can be challenging when blood cultures remain negative. We describe two cases of pneumococcal INAA with negative blood cultures, diagnosed in the with the pneumococcal urinary antigen test.

Eckardt keratoprosthesis for combined pars plana vitrectomy and therapeutic keratoplasty in a patient with endophthalmitis and suppurative keratitis.

This is a case report on the use of Eckardt keratoprosthesis for pars plana vitrectomy in a patient with endophthalmitis and suppurative keratitis that developed after cataract surgery. A 79-year-old woman developed acute-onset infectious endophthalmitis and suppurative keratitis after cataract surgery that failed to respond to treatment with antibiotic eyedrops and intravitreal antibiotic injection. Using a temporary keratoprosthesis that enabled sufficient visualization, vitrectomy was performed, followed by therapeutic keratoplasty using a cryopreserved donor cornea. The patient's vision was improved from light perception to counting fingers at 30 cm, 3 months postoperatively. There was no recurrence of infection or other significant complications.

Bartholin's gland abscess caused by Streptococcus pneumoniae in a sexually active young woman.

Gynaecological infections are frequent in women, particularly in young women during their reproductive time. Anatomophysiologically, Bartholin's gland is greatly susceptible to infections and is characterised by an inherent polymicrobial population. In fact, gynaecological microbiota has a set of agents coming from the perianal region that colonise the vagina and, in particular, Bartholin's gland. Taking this into account, infections caused by agents that do not belong to the genital microbiota are less frequent. Here, we describe a case of a 23-year-old young woman with an abscess in Bartholin's gland caused by Streptococcus pneumoniae.

Mowat-Wilson Syndrome Presenting With Purpura Fulminans.

Purpura fulminans is a rapidly progressive syndrome of intravascular thrombosis and hemorrhagic infarction of the skin. The most common infectious etiology is Neisseria meningitidis sepsis, and less commonly it has been documented as a complication of invasive Streptococcus pneumoniae In children who are otherwise healthy, splenic dysfunction is a significant predisposing factor for invasive pneumococcal infection. We present the case of a 10-month-old girl with a history of developmental delay, who developed an overwhelming infection complicated by purpura fulminans and was found to have previously undiagnosed Mowat-Wilson syndrome with anatomic asplenia. We propose screening patients with clinical features suggestive of Mowat-Wilson syndrome for asplenia to evaluate the need for additional preventive care.

Absceso de tubo-ovárico causado por neumococo / Pneumococcal tube-ovarian abscess

Streptococcus pneumoniae es un patógeno habitual en infecciones del tracto respiratorio y representa la causa más frecuente de neumonía, otitis media y sinusitis. Excepcionalmente, y de forma transitoria, puede colonizar el tracto genital inferior y ser causa de enfermedad pélvica inflamatoria y peritonitis secundaria. El objetivo es presentar un caso con el diagnóstico de absceso tubo-ovárico izquierdo con un germen poco común en esta localización. Se presenta el caso de una paciente de 52 años, histerectomizada desde hace 12 años con una inmunodepresión secundaria como factor predisponente para el desarrollo de esta complicación. Se realizó laparotomía y se realizó exéresis de la tumoración y el cultivo microbiológico del contenido de ella. Se diagnosticó una infección por Streptococcus pneumoniae. La evolución posoperatoria fue satisfactoria(AU)

Streptococcus pneumoniae is a common pathogen in respiratory tract infections and the most common cause of pneumonia, otitis media, and sinusitis. Exceptionally, and transiently, it can colonize the lower genital tract causing pelvic inflammatory disease and secondary peritonitis. The objective is to present a case with left tube-ovarian abscess diagnosis, with a rare germ at this location. The case of a 52-year-old patient is reported here. She was hysterectomized 12 years before with secondary immunosuppression as a predisposing factor for developing this complication. A laparotomy was performed and excision of the tumor and microbiological culture of the contents of the tumor were completed. Streptococcus pneumoniae was diagnosed. Postoperative evolution was satisfactory(AU)

A Community-acquired Lung Abscess Attributable to Streptococcus pneumoniae which Extended Directly into the Chest Wall.

We herein report the case of 75-year-old Japanese female with a community-acquired lung abscess attributable to Streptococcus pneumoniae (S. penumoniae) which extended into the chest wall. The patient was admitted to our hospital with a painful mass on the left anterior chest wall. A contrast-enhanced chest computed tomography scan showed a lung abscess in the left upper lobe which extended into the chest wall. Surgical debridement of the chest wall abscess and percutaneous transthoracic tube drainage of the lung abscess were performed. A culture of the drainage specimen yielded S. pneumoniae. The patient showed a remarkable improvement after the initiation of intravenous antibiotic therapy.

Frozen elephant trunk procedure for extensive pneumococcal thoracic aortitis.

Infectious arteritis is an insidious condition commonly associated with a long diagnostic delay. We report the management of extensive pneumococcal thoracic aortitis in a 64-year-old woman. The frozen elephant trunk procedure was performed to repair the aortic arch. Prolonged aortic wall cultures were positive for Streptococcus pneumoniae. Late follow-up imaging at 36 months demonstrated no sign of recurrence around the hybrid vascular graft in the thoracic aorta.

Characteristics and prognosis of pneumococcal endocarditis: a case-control study.

Case series have suggested that pneumococcal endocarditis is a rare disease, mostly reported in patients with co-morbidities but no underlying valve disease, with a rapid progression to heart failure, and high mortality. We performed a case-control study of 28 patients with pneumococcal endocarditis (cases), and 56 patients with non-pneumococcal endocarditis (controls), not matched for sex and age, during the years 1991-2013, in one referral centre. Alcoholism (39.3% versus 10.7%; p <0.01), smoking (60.7% versus 21.4%; p <0.01), the absence of previously known valve disease (82.1% versus 60.7%; p 0.047), heart failure (64.3% versus 23.2%; p <0.01) and shock (53.6% versus 23.2%; p <0.01) were more common in pneumococcal than in non-pneumococcal endocarditis. Cardiac surgery was required in 64.3% of patients with pneumococcal endocarditis, much earlier than in patients with non-pneumococcal endocarditis (mean time from symptom onset, 14.1 ± 18.2 versus 69.0 ± 61.1 days). In-hospital mortality rates were similar (7.1% versus 12.5%). Streptococcus pneumoniae causes rapidly progressive endocarditis requiring life-saving early cardiac surgery in most cases.

[Infectious aortitis caused by Streptococcus pneumoniae]. / Aortite infectieuse à Streptococcus pneumoniae.

Infectious aortitis is a rare clinical entity that most often manifests itself by an aortic aneurysm. The syphilitic or tubercular forms can be subacute. When it is caused by Salmonella sp., Staphylococcus sp. or Streptococcus pneumoniae, the aortitis is acute with alarming symptoms. Germs found in most cases are Salmonella and Staphylococcus aureus. S. pneumoniae rarely causes infectious aortitis. We report the case of a 75-year-old patient seen in an emergency setting for sudden-onset abdominal pain with fever. An abdominal angio-computed tomography (CT) scan showed a sacciform infrarenal abdominal aortic aneurysm, with an inflammatory aspect and periaortic hematoma. Surgical cure was undertaken because of the impending rupture. An interposition aortic replacement graft was implanted. Blood cultures and bacteriological study of the aortic wall isolated a S. pneumoniae. The anatomical pathology study reported fibrin clot leukocyte remodeling of the aortic wall. An intravenous antibiotic regimen was started. Several organisms, including Streptococcus, can cause infectious aortitis. We found 36 cases described in the literature in addition to our patient.

Management of a Mycotic Thoracoabdominal Aortic Aneurysm Involving the Celiac Artery.

A mycotic aneurysm that also involves the visceral arteries is a life-threatening condition. Surgical management typically consists of débridement and in situ repair with a Dacron graft and reimplantation of the involved visceral branches. We report a rare case of a mycotic saccular thoracoabdominal aortic aneurysm involving the celiac artery, with Streptococcus pneumoniae as the responsible organism. Successful repair of the aneurysm and concomitant revascularization of the celiac artery were achieved.

Video assisted thoracic surgery in a second trimester pregnant woman with thoracic empyema: a case report.

BACKGROUND: An empyema is an infection of the pleural space that occurs most frequently secondary to the progression of pneumonia. The stages of empyema are based on pleural characteristics and reflect the risks of the condition for morbidity and mortality. Pregnancy is a risk factor for major complications of pneumonia, including empyema. CASE: A pregnant woman at 25 weeks' gestation with a community-acquired Streptococcus pneumoniae pneumonia underwent video-assisted thoracotomy decortication and debridement of a large loculated, gelatinous empyema after conservative medical therapy failed. CONCLUSION: Conservative medical therapy with antibiotics alone may not be adequate for advanced bacterial empyema in pregnancy.

Impact of the 13-valent pneumococcal conjugate vaccine on chronic sinusitis associated with Streptococcus pneumoniae in children.

BACKGROUND: The widespread use of the 7-valent pneumococcal conjugate vaccine has been associated with epidemiologic changes of mucosal and invasive pneumococcal disease. No study describes the impact of 13-valent pneumococcal conjugate vaccine (PCV13) on chronic sinusitis in children. We describe changes in epidemiology of Streptococcus pneumoniae chronic sinusitis after the introduction of PCV13 at Texas Children's Hospital. METHODS: We identified patients <18 years with positive sinus culture for S. pneumoniae who underwent endoscopic sinus surgery because of chronic sinusitis from August 2008 to December 2013 at Texas Children's Hospital. Isolates were serotyped by the capsular swelling method. Demographic and clinical information was collected retrospectively. The χ test and Fisher's exact test were used to analyze dichotomous variables. RESULTS: We identified 91 cases of chronic sinusitis with positive sinus culture for S. pneumoniae. Sixty-one (67%) isolates were non-PCV13 serotypes. PCV13 cases decreased 31% in the post-PCV13 period (P = 0.003). Serotype 19A decreased 27% in the post-PCV13 period (P = 0.007), but accounted for all the isolates with penicillin minimal inhibitory concentration ≥ 4 µg/mL and ceftriaxone minimal inhibitory concentration ≥ 2 µg/mL. Serotypes 19A (38%) and 15C (17%) were the most common in the pre- and post-PCV13 periods, respectively. The most common organism co-isolated was Haemophilus influenzae (52%). Isolation of Prevotella spp. increased in the post-PCV13 period (P = 0.02). CONCLUSIONS: S. pneumoniae continues to represent an important pathogen in chronic sinusitis in children <5 years of age. After the introduction of PCV13, S. pneumoniae isolation declined in children with chronic sinusitis at Texas Children's Hospital. We also observed a substantial reduction of PCV13 serotypes, predominantly serotype 19A.

Staged open, endovascular, and hybrid repair of concomitant mycotic aneurysms.

Primary mycotic aneurysms of the aorta are a rare but life-threatening condition. A 59-year-old woman developed a back abscess secondary to an insect bite. A computed tomography scan revealed 3 concomitant mycotic aneurysms, including a rupture. Staged repair was undertaken: immediate open repair for contained rupture of a type IV thoracoabdominal aortic aneurysm, followed by endovascular repair of a descending thoracic aneurysm 3 weeks later and finally an aortic arch hybrid repair of a left subclavian artery aneurysm 16 months later. She remains well postoperatively. There is currently no consensus on the timing of repair or modality of treatment of mycotic aneurysms. Each patient should be treated individually based on aneurysm location, rupture, and comorbidities, as shown by this case.

[V. A. C. INSTILL® therapy - new option in septic thoracic surgery]. / V. A. C.-INSTILL®-Therapie - neue Wege in der septischen Thoraxchirurgie.

BACKGROUND: The V. A. C. INSTILL® therapy is an innovative process for treating chronic wounds that are not optimally accessible to a systemic antibiotic therapy or infected with multi-resistant pathogens. We report on our first experience and applications of V. A. C. INSTILL® therapy in the field of septic thoracic surgery. MATERIALS AND METHODS: V. A. C. INSTILL therapy was used in 11 cases between 11/2009 and 01/2012. Three patients had sternum osteomyelitis (2 MRSA, 1 Finegoldia magna). In 3 patients chronic pleural empyema after lobectomy (1 Streptococcus viridans, 1 mixed infection with MRSA among others) and after pneumectomy (1 MRSA) were detected. In 2 cases there was an acute pleural empyema with extensive phlegmona in the region of the thoracic soft tissues (2 streptococci). In 1 patient a chronic pleural empyema with MRSA infection was treated. Septic arthritis of the sternoclavicular joint with joint destruction and extensive phlegmona in the region of the cervical soft tissues (1 Streptococcus pneumoniae, 1 Staphylococcus aureus) was treated in 2 patients. In all cases instillation of the wound was performed with Lavasept 0.2 %. Swabs of the wound were taken before starting and after ending V. A. C. INSTILL® therapy as well as before wound closure. RESULTS: Mean patient age was 48.8 ± 18.9 years. V. A. C. INSTILL® therapy was performed for 6.5 ± 1.7 days. Instillation time amounted to 21.7 ± 5.7 s. The duration of action was standardised at 18 min in all cases. In 2 cases (1 MESA, 1 finegoldia) the V. A. C. INSTILL® therapy was repeated. In 10 patients a sterile wound status was achieved before secondary wound closure. All wounds underwent secondary closure without recurrence. CONCLUSIONS: Chronic osteomyelitis with MRSA infections as well as chronically infected residual cavities after empyema surgery and extensive phlegmona are possible indications for V. A. C. INSTILL® therapy in order to help eradicating the infection as quickly and as completely as possible.