Blastocystis hominis -Associated Acute Appendicular Peritonitis in a 9-Year-Old Boy: A Case Report and a Comprehensive Review of the Literature.

Although Blastocystis sp. has been classically considered a commensal parasite with limited pathogenicity, recent studies suggest that its pathogenic potential is high. We report the case of a 9-year-old Spanish male who presented with peritonitis secondary to acute appendicitis with abundant intra-abdominal turbid-free fluid. A standard appendectomy was performed, and a sample of the fluid was taken for microbiological culture. Multimicrobial flora was isolated in peritoneal fluid culture. The antibiotic resistance study showed that all the microorganisms were sensitive to meropenem. On the 5th postoperative day, a control blood test showed relative eosinophilia and a persistently elevated C-reactive protein. A stool parasitological study showed abundant cysts morphologically compatible with Blastocystis hominis . The hematoxylin & eosin and Giemsa study identified abundant parasitic cysts in the appendix. The patient evolved favorably and is currently asymptomatic and under follow-up. Regarding acute appendicitis, there is only one report in the literature of peritonitis of appendiceal origin associated with Blastocystis sp. In conclusion, although infrequent, parasitosis should be considered as a potential etiological agent of acute appendicitis, even in nonendemic areas. Relative eosinophilia or persistently elevated acute phase reactants despite adequate antibiotic coverage should help to establish diagnostic suspicion.

Nontuberculous Mycobacteria, Mucociliary Clearance, and Bronchiectasis.

Nontuberculous mycobacteria (NTM) are environmental and ubiquitous, but only a few species are associated with disease, often presented as nodular/bronchiectatic or cavitary pulmonary forms. Bronchiectasis, airways dilatations characterized by chronic productive cough, is the main presentation of NTM pulmonary disease. The current Cole's vicious circle model for bronchiectasis proposes that it progresses from a damaging insult, such as pneumonia, that affects the respiratory epithelium and compromises mucociliary clearance mechanisms, allowing microorganisms to colonize the airways. An important bronchiectasis risk factor is primary ciliary dyskinesia, but other ciliopathies, such as those associated with connective tissue diseases, also seem to facilitate bronchiectasis, as may occur in Lady Windermere syndrome, caused by M. avium infection. Inhaled NTM may become part of the lung microbiome. If the dose is too large, they may grow excessively as a biofilm and lead to disease. The incidence of NTM pulmonary disease has increased in the last two decades, which may have influenced the parallel increase in bronchiectasis incidence. We propose that ciliary dyskinesia is the main promoter of bronchiectasis, and that the bacteria most frequently involved are NTM. Restoration of ciliary function and impairment of mycobacterial biofilm formation may provide effective therapeutic alternatives to antibiotics.

Formation of Mycobacterium abscessus colonies in cellular culture in an in vitro infection model.

Mycobacterium abscessus is one of the most important nontuberculous mycobacteria that cause lung diseases. In vitro infection models developed to analyze the immune response are frequently based on the addition of mycobacteria to mononuclear cells or neutrophils from peripheral blood. An important requirement of these assays is that most cells phagocytose mycobacteria, only accomplished by using large multiplicities of infection (1 or more bacteria per cell) which may not adequately reflect the inhalation of a few mycobacteria by the host. We propose modifications that try to mimic some of the conditions in which immune cells deal with mycobacteria. For the preparation of the inoculum mycobacteria are grown in solid media followed by preparation to a single cell suspension. Multiplicities of infection (number of bacteria per cell) are below 0.01. Serum-free cellular media is used to allow the growth of M. abscessus. After several days of incubation Bacterial Colonies in Cellular Culture (BCCC) develop, which are enumerated directly under an inverted microscope. These colonies may represent biofilm formation during chronic infections. •Low multiplicity of infection (below 0.01 bacteria per cell) reflects more realistically conditions encountered by immune cells in the lungs.•The surface of mycobacteria prepared for infection assays that are grown in solid media are less affected than that of mycobacteria grown in liquid media with detergents.•Colony formation in the infected cells may reflect the aggregation and biofilm formation in the lungs during chronic infection.

A rapid proteomic system (MALDI-TOF) for nontuberculous-mycobacteria identification.

Proteomic techniques relaying upon mass spectrometry (MALDI_TOF) applied to nontuberculous mycobacteria (NTM) identification, constitute a difficult goal. Cell wall structure features complicates the protein extraction procedure. A total of 106 isolates belonging to a variety of MNTs species isolated from clinical samples taken at the Complejo Asistencial Universitario de León for a two years period (2019-20) were identified following a simplified method (MALDI-TOF Biotyper Bruker®) developped in our laboratory. The resultant identification was compared to a parallel one ruled on the Centro de Referencia de Majadahonda. A total of 22different MNTs species were tested, obtaining an agreement of 92,45%. Only 8 minor discrepancies between species belonging to same taxonomic group of MNTs were detected. The score obtained in the 67.92% of the cases was higher than 1.8. A time-saving of 24min compared to the manufacturer's proceeding was achieved.

Mycobacterium avium complex infected cells promote growth of the pathogen Pseudomonas aeruginosa.

Bronchiectasis is considered a consequence of the neutrophilic inflammatory response to infection. Mycobacterial infections, mainly from the Mycobacterium avium complex and M. abscessus, have been inextricably linked to bronchiectasis development. The most important pathogen that infect patients with bronchiectasis is Pseudomonas aeruginosa, associated with an increased risk of death. Patients with bronchiectasis are often co-infected with P. aeruginosa and M. avium complex, and it was studied whether they interacted in immune cell cultures. Peripheral blood mononuclear cells from healthy volunteers were infected overnight with clinical isolates of mycobacteria, 18 h later co-infected with P. aeruginosa and Pseudomonas multiplication was quantified. Inoculated P. aeruginosa multiply faster when cells were previously infected in vitro with M. avium complex or M. tuberculosis, but not with M. kansasii or M. gordonae, mycobacteria not regularly isolated from patients with bronchiectasis. The interaction between mycobacteria and P. aeruginosa also takes place in the absence of cells, but to a lower degree. Growth of Staphylococcus aureus, less frequently co-isolated with mycobacteria, was not affected by previous infection with mycobacteria. Surprisingly, multiplication of P. aeruginosa in neutrophil cultures did not vary in the presence of mycobacteria. Nevertheless, co-infection of mycobacteria and P. aeruginosa induced the production of IL-1ß, a mediator of neutrophilic inflammation. P. aeruginosa stimulation by mycobacteria provides evidence for explaining their common clinical association. Strategies to control mycobacteria may be useful to impair P. aeruginosa colonization.

A rapid proteomic system (MALDI-TOF) for nontuberculous-mycobacteria identification. / Identificación rápida de micobacterias no tuberculosas mediante técnicas proteómicas (MALDI-TOF).

Proteomic techniques relaying upon mass spectrometry (MALDI_TOF) applied to nontuberculous mycobacteria (NTM) identification, constitute a difficult goal. Cell wall structure features complicates the protein extraction procedure. A total of 106 isolates belonging to a variety of MNTs species isolated from clinical samples taken at the Complejo Asistencial Universitario de León for a two years period (2019-20) were identified following a simplified method (MALDI-TOF Biotyper Bruker®) developped in our laboratory. The resultant identification was compared to a parallel one ruled on the Centro de Referencia de Majadahonda. A total of 22 different MNTs species were tested, obtaining an agreement of 91,5%. Only 9 minor discrepancies between species belonging to the same taxonomic group of MNTs were detected. The score obtained in the 67.92% of the cases was higher than 1.8. A time-saving of 24 minutes compared to the manufacturer's proceeding was achieved.

A strategy based on Amplified Fragment Length Polymorphism (AFLP) for routine genotyping of nontuberculous mycobacteria at the clinical laboratory.

The increasing worldwide incidence of mycobacteriosis and the need to achieve improved clinical management makes nontuberculous mycobacteria (NTM) genotyping a useful tool. However, because of technical difficulties, medium size microbiology laboratories do not attempt to compare the genetic patterns that each of their isolates present. We have aimed to optimize a genotyping method with a reduced hands-on experimental time and that requires few technical resources. A strategy based on the Amplified Fragment Length Polymorphism (AFLP) methodology was developed using two rare-cutters enzymes (SacI and BglII). One out of seven primers was sequentially used in each amplification reaction that was analyzed by agarose gel electrophoresis. This approach makes it possible the timely genotyping of a moderate number of strains and its characterization without the need of image analysis software. We have genotyped 28 Mycobacterium intracellulare and 4 M. abscessus. Clinical researchers are encouraged to routinely genotype their NTM isolates.

Human Mycobacterium bovis infection in Castile and León (Spain), 2006-2015. / Tuberculosis por Mycobacterium bovis en la población de Castilla y León (España), 2006-2015.

INTRODUCTION: The annual incidence of tuberculosis (TB) from Mycobacterium bovis in humans has considerably declined in industrialised countries since the early twentieth century. The objective of this study was to determine the epidemiological, clinical and microbiological characteristics of patients with this illness in Castile and León (CyL). METHODS: Retrospective study of all M. bovis TB cases in CyL over a 10-year period, comparing the risk factors, the epidemiology and the clinical course between pulmonary (PTB) and extrapulmonary TB (EPTB). RESULTS: 75 cases of TB were due to M. bovis: 45 PTB and 31 EPTB. The annual incidence of TB due to M. bovis was 0.3 cases per 100,000. It remained stable between the first and second five-year period (0.27 vs. 0.33, p=0.656). However, the overall incidence of TB fell in both five-year periods (13.58 vs. 10.71, p<0.0001). The mean age was 66.2+21.3 years, mainly men (63%) and Spanish patients (92%). PTB was significantly more frequent in men, aged over 66 years, with immunosuppressive conditions or who were smokers. Mortality was 9%, associated with higher age, immunosuppression or treatment different from that recommended by the WHO. CONCLUSIONS: The incidence of M. bovis TB in CyL was higher than that for Spain and for other European countries, and remained stable despite the decreased the TB due to MTC. It affected mostly Spanish-born patients who lived in rural areas and with a high mean age.

Lady Windermere syndrome in Castile and León. / Síndrome de Lady Windermere en Castilla y León.

INTRODUCTION: Lady Windermere syndrome (LWS) is a pulmonary disease caused by Mycobacterium avium complex (MAC). The objective of this study is to ascertain its frequency and characteristics in the northern area of the autonomous community of Castile and León. METHODS: A retrospective study of patients with MAC isolates in respiratory samples from five public hospitals in the autonomous community over a six-year period, following the ATS/IDSA criteria. The MAC strains were identified by GenoType Mycobacterium reverse hybridisation probes or PCR-RFLP analysis of the hsp65 gene. RESULTS: Of 183 cases of MAC identified, only five women (2.7%) aged 68.8±10.7years met LWS criteria. In three cases, MAC was isolated jointly and intermittently with other pathogens. Only one patient was treated according to ATS/IDSA criteria. DISCUSSION: LWS remains underestimated, with affected patients representing a significant burden on healthcare resources over long periods of time. As a result, greater microbiological and therapeutic knowledge of the syndrome is needed.

Contribution of microbiology in the diagnosis of tuberculosis in Castile and León (Spain): Findings of the GRUMICALE 2013 study. / Contribución de la microbiología al diagnóstico de la tuberculosis en Castilla y León: conclusiones del estudio GRUMICALE 2013.

INTRODUCTION AND OBJECTIVES: A retrospective study was conducted by collecting microbiological tuberculosis (TB) data in Castile and León during the year 2013 in order to determine the incidence and distribution of TB, and resistance to the tuberculostatic drug, and compare them with the epidemiological data provided by the Department of Epidemiological Surveillance (SIVE). MATERIAL AND METHODS: Microbiologists of the 14 hospitals of the Castile and León public health network (GRUMICALE) collected epidemiological, microbiological, and management data from the Microbiology laboratories in the community during the year 2013. A single isolate of Mycobacterium tuberculosis complex (MTC) per patient was considered. RESULTS: The study included a total of 270 MTC isolates (an incidence rate of 11.63 cases/100,000 inhab./year). A total of 288 cases of TB (11.43 cases/100,000 inhab. year) were recovered using epidemiological data, which included 243 confirmed, 29 suspected, and 16 as probable cases. Pulmonary TB was predominant, followed a long way off by the pleural TB and the remaining locations. A total of 27,620 samples were processed for mycobacterial detection. Mycobacterial growth was observed in 3.46% of automated fluid cultures, and 50.37% were positive by direct staining of the smear. Resistance to one tuberculostatic drug, mostly to isoniazid, was observed in 16 (5.92%) isolates of Mycobacterium tuberculosis (MT). The province with greater incidence and number of isolates was León (24.23 cases/100,000 inhab./year), with the highest being observed in El Bierzo health area (30.46 cases/100,000 inhab./year). CONCLUSIONS: An adequate collection of microbiological information is essential to determine the epidemiology of TB in our region.

In vitro infection with Mycobacterium tuberculosis induces a distinct immunological pattern in blood from healthy relatives of tuberculosis patients.

Part of the susceptibility to tuberculosis has a genetic basis, which is clear in primary immunodeficiencies, but is less evident in apparently immunocompetent subjects. Immune responses were analysed in blood samples from tuberculosis patients and their healthy first-degree relatives who were infected in vitro with mycobacteria (either Mycobacterium tuberculosis or M. bovis BCG). The antimicrobial activity against M. tuberculosis in blood from relatives was significantly lower than that observed in healthy controls. Tuberculosis patients exhibited a higher number of neutrophils, and monocyte phagocytosis was inhibited in both relatives and tuberculosis patients. A remarkable finding was that the production of reactive oxygen species by infected neutrophils was higher in relatives than in healthy controls. A higher production of TNFα in infected blood from relatives was also observed. These results may indicate that relatives display a stronger inflammatory response and that their immune response to M. tuberculosis is different from those of unrelated controls. First-degree relatives may represent a highly informative group for the analysis of tuberculosis susceptibility.

Blood antimicrobial activity varies against different Mycobacterium spp.

In vitro analysis of mycobacterial pathogenicity or host susceptibility has traditionally relied on the infection of macrophages, the target cell of mycobacteria, despite difficulties reproducing their antimycobacterial activity. We have employed alternative models, namely whole blood and leukocytes in plasma, from QuantiFERON negative individuals, and performed infections with the pathogenic M. tuberculosis, the less pathogenic M. avium, M. kansasii and M. chelonae and the occasionally pathogenic M. gordonae and M. bovis. The anticoagulant used in blood extraction, heparin or EDTA, had a major influence in the outcome of the infection. Thus, while in the heparinized models a similar number of bacteria were enumerated in the inoculum and after seven days, in the presence of EDTA a killing effect was observed, despite the inhibitory effect of EDTA on cellular functions like the production of cytokines or reactive oxygen species (ROS). A special case was the rapidly growing mycobacteria M. chelonae, that multiplied in heparinized models but was eliminated in models with EDTA. We verified that EDTA is not responsible for the bactericidal effect, but acts as a bacteriostatic agent. Further work will determine whether blood derived models are a better alternative to the classical macrophage.

Immunological response to Mycobacterium tuberculosis infection in blood from type 2 diabetes patients.

The convergence of tuberculosis and diabetes represents a co-epidemic that threatens progress against tuberculosis. We have investigated type 2 diabetes as a risk factor for tuberculosis susceptibility, and have used as experimental model whole blood infected in vitro with Mycobacterium tuberculosis. Blood samples from diabetic patients were found to have a higher absolute neutrophil count that non-diabetic controls, but their immune functionality seemed impaired because they displayed a lower capacity to phagocytose M. tuberculosis, a finding that had been previously reported only for monocytes. In contrast, an increased production of TNFα was detected in infected blood from diabetic patients. Despite the altered phagocytic capacity showed by cells from these patients, the antimicrobial activity measured in both whole blood and monocyte derived macrophages was similar to that of controls. This unexpected result prompts further improvements in the whole blood model to analyze the immune response of diabetes patients to tuberculosis.

Plasma contributes to the antimicrobial activity of whole blood against Mycobacterium tuberculosis.

The whole blood model for infection has proven useful to analyze the immunological response to Mycobacterium tuberculosis, because it exerts a significant antimicrobial activity. Although this activity has been generally assumed to be cellular, we have found that the leukocyte fraction of blood from healthy volunteers did not kill the bacilli. We have discovered that plasma was responsible for a large proportion, but not all, of the antimicrobial activity. Furthermore, infected monocytes controlled the mycobacterial multiplication when cultivated in the presence of plasma. Intriguingly, serum from the same donors did not share this activity, although it was able to eliminate the non-pathogenic Mycobacterium gordonae To identify the remaining components that participate in the antimycobacterial activity we fractionated blood in leukocytes, plasma, erythrocytes and platelets, and analyzed the bactericidal power of each fraction and their combinations using a factorial design. We found that erythrocytes, but not platelets, participated and showed by flow cytometry that mycobacteria physically associated with erythrocytes. We propose that in exposed healthy individuals that show 'early clearance' of the mycobacteria, the innate response is predominantly humoral, probably through the effect of antimicrobial peptides and proteins.

Histopathological clues in the diagnosis of fungal infection by Scedosporium in a case of endophthalmitis starting as conjunctivitis.

Cutaneous fungal infections can result in disastrous episodes if improperly diagnosed and treated, especially in immunosuppressed patients. Although dermatopathologists are highly familiar with some filamentous fungi - such as Aspergillus and Zygomycetes - they are not so aware of other less common species. We report a case of ocular infection by Scedosporium apiospermum that started as conjunctivitis and resulted in Phthisis bulbi and subsequent exeresis of the left eye. We describe some of the main morphological features of the fungus as well as the important morphological clues for the differential diagnosis with some similar species, such as Aspergillus, Scopulariopsis, Fusarium, Paecilomyces and Zygomycetes.

[Eye infections caused by Purpureocillium lilacinum: A case report and literature review]. / Infecciones oculares por Purpureocillium lilacinum: presentación de un caso y revisión de la literatura.

BACKGROUND: Purpureocillium lilacinum eye infections (previously called Paecilomyces lilacinus) make up a significant percentage of the recorded cases of infection by this fungus, and is considered as an emerging pathogen. AIMS: To report a case of ocular mycosis in a patient aged 70, with a double corneal transplantation in the right eye, and exhibiting a poor response to antifungal and surgical treatment. METHODS: Corneal ring and ocular tissues obtained by surgical procedures were cultured in common mycological media. Molecular identification of the isolated fungus was obtained. RESULTS: Colonies of a filamentous fungus were obtained, and according to the macroscopic and microscopic morphology it was identified as P. lilacinum. The identification was confirmed by molecular methods in a reference laboratory. CONCLUSIONS: Eye infections due to P. lilacinum are rare but serious diseases that requires rapid diagnostic and therapeutic measures to enable visual function to recover.