A simple scoring algorithm predicting paravertebral and/or iliopsoas abscess among adults with community-onset bloodstream infections: matters of PVL-producing Staphylococcus aureus.

PURPOSE: Misdiagnosis or delayed diagnosis of paravertebral and/or iliopsoas abscess (PVIPA) has been frequently reported to be associated with unfavorable prognosis. We aimed to develop a scoring algorithm that can easily and accurately identify patients at greater risk for PVIPA among individuals with community-onset bloodstream infections. METHODS: In a multicenter, retrospective cohort study, the score was developed with the first four study years and validated with the remaining two years. Applying logistic regression, the score values of prediction determinants were derived from the adjusted odds ratios (AOR). The performance of the scoring algorithm was assessed with the receiver operating characteristic (ROC) curve. RESULTS: In the derivation (3869 patients) and validation (1608) cohorts, patients with PVIPA accounted for 1.7% and 1.4%, respectively. In the derivation cohort, five independent predictors of PVIPA were recognized using multivariable analyses: time-to-defervescence > 5 days (AOR, 7.00; 2 points), Panton-Valentine Leukocidin (PVL)-producing Staphylococcus aureus (AOR, 5.98; 2 points), intravenous drug users (AOR, 2.60; 1 points), and comorbid hemato-oncology (AOR, 0.41; -1 point) or liver cirrhosis (AOR, 2.56; 1 points). In the derivation and validation cohorts, areas under ROC curves (95% confidence intervals) of the prediction algorithm are 0.83 (0.77-0.88) and 0.85 (0.80-0.90), and a cutoff score of + 2 represents sensitivity of 83.3% and 95.7%, specificity of 68.6% and 67.7%, positive predictive values of 4.4% and 4.1%, and negative predictive values of 99.6% and 99.9%, respectively. CONCLUSIONS: Of a scoring algorithm with substantial sensitivity and specificity in predicting PVIPA, PVL-producing S. aureus and Time-to-defervescence > 5 days were crucial determinants.

Spinal subdural abscess following chronic meningitis - A rare manifestation of Mucormycosis.

A 57-year old man with uncontrolled diabetes presented with features suggestive of chronic meningitis. Cerebrospinal fluid (CSF) analysis revealed a polymorphonuclear pleocytosis with low glucose and high protein levels in the CSF. Bacterial and fungal cultures and tests for M. tuberculosis were negative. MRI spine showed leptomeningeal enhancement. On ruling out other causes, fungal meningitis was considered. The patient developed paraparesis in the hospital. MRI showed peripherally enhancing subdural lesion with dorsal cord involvement at the level of D4 and D5 vertebrae. On laminectomy and exploration, an intradural extramedullary abscess and a granuloma were noticed at T4--T5 spinal levels causing compression of the cord below. Histopathological examination of the lesions revealed acute on chronic inflammatory infiltrates interspersed by broad, aseptate, ribbon-like fungal elements highlighted by PAS stain, diagnostic of mucormycosis. Intravenous amphotericin B and oral posaconazole were administered for more than 8 weeks. On follow-up, he had complete neurological recovery without sequelae.

Chest wall subcutaneous mass leading to the diagnosis of pericostal tuberculosis.

When diagnosing a chest wall mass, even in the absence of pulmonary lesions, it is crucial to consider pericostal tuberculosis as a differential diagnosis. Attention must be paid to the characteristic findings on contrast-enhanced computed tomography, such as central low attenuation, peripheral rim enhancement of soft tissue, and pleural involvement.

Successful Endoscopic Drainage of Acute Duodenal Diverticulitis Complicated by Abscess.

Duodenal diverticulitis complicated by abscess formation is a rare clinical entity, albeit may, in some cases, be associated with significant morbidity and mortality. We present a unique case that elucidates the success of endoscopic management of duodenal diverticulitis complicated by an abscess in the third part of the duodenum, through forward-viewing endoscopic maneuvers. Although surgery has been the primary interventional strategy for complicated duodenal diverticulitis beyond medical management, endoscopy is shown to be a safe and effective alternative in the clinically stable patient and/or poor surgical candidate, for this uncommon sequela of duodenal diverticulosis.

Felty Syndrome Presented With Candida albicans Lung Abscess Without Arthritis: A Case Report.

Felty syndrome (FS) is a late manifestation of severe active rheumatoid arthritis (RA). A high index of suspicion or FS is needed in patients who present with neutropaenia and splenomegaly with no initial or obvious identifiable cause. We present the case of a 52-year-old who presented with a one-week history of haemoptysis, fever, and night sweats. The patient was hypotensive, tachycardia, and febrile (38 °C). On examination, bilateral crackles and reduced air entry were identified on the right basal and middle zones. The patient was diagnosed with RA two years prior to this presentation and was not on a disease-modifying antirheumatic drug (DMARD). Haematology showed high inflammatory markers and pancytopenia. Chest X-ray showed a right upper lobe abscess. CT-thorax, abdomen, and pelvis confirmed lung abscesses and hepatosplenomegaly. Candida albicans was detected on the broncho-alveolar lavage. He responded well to antifungal medication and corticosteroids with normalisation of the pancytopenia and inflammatory markers and reduction of the spleen size. This case report details the unusual and early presentation of FS in a patient newly diagnosed with RA and who had no active arthritis. We wish to emphasize the importance of a high index of suspicion in patients with RA regardless of the length of their illness.

Unraveling the Puzzle: The Secret Hideout of Methicillin-Resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) is a prevalent nosocomial pathogen known for causing severe disseminated infections. Recently, there has been an increase in community-acquired MRSA infections. We present a case of MRSA bacteremia complicated by a cervical epidural abscess. A 63-year-old female with no significant past medical history presented with altered mental status lasting two days. She had recently experienced neck stiffness after lifting a heavy object, initially diagnosed as torticollis, at an outside facility. On examination, she appeared ill and met the criteria for sepsis. Blood cultures confirmed MRSA. She developed hypotension, and an MRI of the brain and cervical spine revealed leptomeningeal enhancement and an epidural abscess. MRSA bacteremia, although common, can manifest in various forms. While it typically occurs in patients with identifiable risk factors, our patient had none. Identifying the source of bacteremia is crucial, as effective treatment requires both source control and antibiotic therapy. Given MRSA's high morbidity and mortality, a thorough and rigorous approach to assessment and management is essential.

Emergency department referrals for CT imaging of extremity soft tissue infection: before and during the COVID-19 pandemic.

Objectives: To evaluate the incidence and spectrum of findings in patients referred for CT imaging of extremity soft tissue infection in the adult emergency department (ED) setting before and during the COVID-19 pandemic. Methods: Two hundred thirteen CT exams in the pre-COVID cohort (February 1, 2018-January 31, 2020) and 383 CT exams in the COVID cohort (February 1, 2020-January 31, 2022) were evaluated in this multicentre, retrospective study. Demographic information and clinical histories were collected, along with regional data on COVID-19 hospitalizations and deaths. Results: Comparable age and sex distribution was found in the pre-COVID (average age of 53.5 years; male: female ratio of 71:29) and COVID (average age of 54.6 years; male: female ratio of 69:31) cohorts. The frequency of reported clinical risk factors (diabetes mellitus, injected drug use, prior surgery, animal bite) was not significantly different between the two cohorts. Findings of simultaneous involvement of both superficial and deep soft tissue infection on CT imaging were significantly higher in the COVID cohort (53.4%) than in the pre-COVID cohort (33.7%). CT findings of phlegmon (49.1% vs 22.1%), ulcers (48.8% vs 30%), osteomyelitis (21.7% vs 13.1%), as well as localized (18.8% vs 11.7%) and extensive (3.7% vs 2.3%) soft tissue gas were significantly more common in the COVID cohort than in the pre-COVID cohort. Conclusions: During the COVID-19 pandemic, the number of ED CT exams for the evaluation of extremity soft tissue infection increased, with this imaging also showing more advanced disease. Pandemic-related modifications to human behaviour and re-distribution of healthcare resources may underlie these observed changes. Advances in knowledge: This multi-centre study shows an increase in extremity soft tissue infection presenting to the ED during the pandemic. This finding is important for future pandemic preparations, as it can aid in the decision-making process around resource allocation.

Diagnostic Value of SAA Levels and Perianal Symptoms in the Complicated Perianal Abscesses Among Mpox-Infected Patients.

Objective: Precise prediction of the occurrence of complicated perianal abscesses (PAs) in monkeypox (mpox)-infected patients is important for therapeutic optimization. This study sought to identify risk factors of complicated PA. Methods: A total of 48 patients with mpox infection (PA group, n = 10; non-PA (NPA) group, n = 38) were enrolled in our study, who were hospitalized in Hangzhou Xixi Hospital, China from 29 June to 3 September 2023. The data of demographic characteristics, and clinical symptoms, serum SAA, PCT, CRP, and IL-6 levels were collected by the Electronic Medical Record. The diagnostic values of these biomarkers were assessed using multivariate logistic regression and ROC curve analyses. Results: A decrease in serum IL-6, SAA, and CRP levels (all p-value < 0.05), but not PCT, was observed in all mpox-infected patients. A significant positive correlation was also noted between IL-6, SAA, CRP, and PCT levels (all p-value < 0.05). There was a significant increase in IL-6 and SAA levels and the SAA/CRP ratio in serum samples from patients in the PA group. Multivariate logistic regression and ROC curve analyses identified that the combined use of perianal symptoms and SAA was more sensitive than perianal symptoms or SAA alone as predictors of complicated PA. This combination had the highest predictive value for disease progression, with an AUC of 0.920 (p-value < 0.001). Conclusion: The combination of perianal symptoms and SAA levels was strongly linked to the occurrence of complicated PA in mpox-infected patients. These findings may inform the early diagnosis of this patient population.

A rare case of spontaneous carotid sheath abscess presenting as a painful neck mass.

Infections of the carotid arteries and sheath without any underlying etiology are extremely uncommon. In this article, we report the successful open repair of a right carotid sheath abscess in a 71-year-old woman with multiple comorbidities. The repair consisted of excision of the affected carotid segment and reconstruction by interposition of a reversed great saphenous vein graft. Postoperative Doppler ultrasound examination showed patent right carotid artery, and the patient demonstrated no recurrence postoperatively. This case suggests that, although rare, spontaneous carotid sheath remains a possible cause of neck mass, warranting high suspicion index for optimal treatment in a timely manner to avoid further complications.

Catheter embolization for pulmonary arteriovenous malformations during chemotherapy for appendiceal adenocarcinoma: A case report of associated brain abscess.

Pulmonary arteriovenous malformations are rare, abnormal, low-resistance vascular structures that connect a pulmonary artery to a vein. They are common in patients with hereditary hemorrhagic telangiectasia; however, acquired malformations can occur in patients with underlying diseases such as chest trauma, hepatic cirrhosis, and mitral stenosis. Pulmonary arteriovenous malformations bypass the normal pulmonary capillary bed and result in intrapulmonary right-to-left shunts, which may cause central nervous system complications such as brain abscesses or ischemic stroke. Brain abscesses related to pulmonary arteriovenous malformations are not uncommon; however, reports of their occurrence during chemotherapy are limited. Here, we report the case of a 68-year-old woman with bilateral pulmonary arteriovenous malformations and appendiceal adenocarcinoma who developed a bacterial brain abscess during chemotherapy. The infection was treated using abscess drainage and antibiotic therapy. After the brain abscess healed, catheter embolization was performed on the pulmonary arteriovenous malformations and chemotherapy was resumed. The present case suggests that if a patient with a malignancy has a pulmonary arteriovenous malformation, clinicians should pay special attention to complications such as brain abscesses during chemotherapy. For patients who do not urgently need chemotherapy, embolization of the pulmonary arteriovenous malformation before chemotherapy may be a better treatment option.

A Unilateral Intratonsillar Abscess in an Adult Treated by Antibiotic Therapy and Needle Aspiration.

Intratonsillar abscess (ITA) is a rare clinical phenomenon in pediatric and adult populations. Even though it is rather uncommon, ITA should be included in the differential diagnosis of tonsillitis, peritonsillitis, and peritonsillar abscess. A computed tomography (CT) scan serves as a diagnostic tool for confirming the presence of an ITA. Needle aspiration of the tonsil not only further confirms the diagnosis but as part of the treatment of ITA in this case. Here, we report a case of a 34-year-old gentleman who presented with acute painful right neck swelling associated with odynophagia, voice changes, and reduced oral intake with examination revealed muffled voice, trismus, right cervical lymphadenopathy, bulging of the right peritonsillar region and deviation of the uvula to the left. Intravenous antibiotic therapy started and proceeded with aspiration then incision and drainage of the right peritonsillar region done as the initial provisional diagnosis was a right peritonsillar abscess. However, no pus drained. Thus, contrast-enhanced computed tomography (CECT) of the neck was done to assess the abscess collection and confirm the diagnosis. Therefore, the diagnosis was revised to the right ITA as the CECT neck showed a hypodense collection in the right palatine tonsil. In our case, the patient was treated by aspiration of the right tonsil to drain the pus with the continuation of antibiotics. Subsequently, the symptoms improved and resolved. In this case, the ITA can be treated with antibiotics and needle aspiration without surgical intervention.

Something Seems Fishy: Hepatic Abscess Due to Foreign Body Ingestion in a Pediatric Patient.

Pediatric hepatic abscesses are uncommon in children. They are usually preceded by intra-abdominal infections or caused by acute or chronic biliary disease. Cases of hepatic abscesses secondary to foreign body ingestion are even rarer but are most reported in countries such as China, where ingestion of fish and chicken bones is common. We report a rare case of an adolescent patient who developed a hepatic abscess after ingestion of a fishbone foreign body. He presented to the emergency department with emesis, abdominal pain, and subjective fevers of unknown etiology. Initial imaging of the abdomen was pertinent for a heterogeneous hepatic mass with evidence of fluid collection, concerning for malignancy. Subsequent incision and drainage then confirmed fluid collection to be pus. However, his cryptogenic hepatic abscess was not responsive to broad-spectrum intravenous antibiotics. After imaging was re-reviewed and repeated, a 4.3 cm thin curvilinear hyperdensity was identified embedded in the liver parenchyma. Eventually, the patient underwent exploratory laparoscopy where a fishbone foreign body was removed. To our knowledge, this is one of the few reported pediatric cases of hepatic abscess formation caused by a foreign body ingestion. Hepatic abscesses that do not resolve with antibiotics and ultrasound-guided drainage via catheter should prompt reassessment of other uncommon etiologies, specifically migrated foreign bodies as a rare but important differential diagnosis. Compared to pyogenic hepatic abscesses, hepatic abscesses secondary to foreign bodies require expedited surgical intervention for source control; thus, timely recognition and prompt intervention are crucial to minimize morbidity and mortality.

A Rare Case of Granulicatella adiacens Gallbladder Abscess Associated With Gallbladder Adenocarcinoma: Diagnostic and Therapeutic Challenges.

Granulicatella adiacens, a nutritionally variant streptococcus, is part of the normal oral, gastrointestinal, and urogenital flora. It is associated with bacteremia, infectious endocarditis, and, rarely, bone and joint infections. G. adiacens infections also tend to have high mortality due to diagnostic challenges and antibiotic resistance. Few case reports have documented its role in abscess formation. Here, we report the first known case of G. adiacens causing a gallbladder abscess in a patient with gallbladder carcinoma (GBC), a rare but aggressive cancer. Enhanced awareness and improved diagnostic methods are needed to manage such infections and understand their underlying mechanisms, particularly in immunocompromised patients with malignancies.

Pediatric head and neck emergencies.

PURPOSE: Head and neck emergencies in children are frequent cause of visits to the hospital. Imaging plays a critical role in the management of these patients. This review article aims to familiarize radiologists with the common clinical presentations encountered, imaging characteristics of nontraumatic pediatric head and neck emergencies, and improve their ability to recognize associated complications as well as be aware of common mimics. METHODS: We researched our database for commonly encountered nontraumatic head and neck emergencies in children. A literature search was done to compare and complete the list of conditions to be discussed in this review. RESULTS: The review was organized according to anatomical location of the emergent condition. Relevant anatomy has been discussed along with clinical presentation, imaging characteristics and complications. We have presented common mimics with each set of disorders. Key imaging characteristics have been delineated using radiology images. CONCLUSION: Familiarity with the known complications of head and neck emergencies allows the radiologist to actively search for such findings, encourage early institution of appropriate therapy, and improve outcomes.

Intra-abdominal Abscess Caused by Mycobacteroides abscessus in a Peritoneal Dialysis Patient: A Case Report.

A 57-year-old man was diagnosed with peritoneal dialysis (PD)-associated peritonitis 2 months after surgery for tunnel infection (TI) caused by Mycobacteroides abscessus (M. abscessus). The patient was treated with multiple antibiotics, and the cell count in the PD effluent decreased. However, the patient experienced abdominal pain and developed hiccups. Computed tomography revealed an encapsulated fluid collection, indicating intra-abdominal abscess (IAA) formation. Percutaneous drainage was performed to treat IAA, and the catheter was removed. This case suggests that PD-associated peritonitis caused by M. abscessus can lead to IAA formation. If symptoms persist even after a favorable course of peritonitis, IAA should be suspected.

Cervical Spine Spondylodiscitis Due To Neglected Esophageal Perforation after a dilation procedure 30 years after a Laringectomy and Radiotherapy. Report of a case and review of literature.

Current treatment of cervical spine spondylodiscitis generally involves a radical surgical debridement and stable reconstruction together with antibiotic therapy until complete healing. But this classical approach could be difficult for patients who have been treated previously for an esophageal carcinoma and received radiotherapy. We present a case of a 75-year-old male who underwent an esophageal dilation procedure and developed afterward a spondylodiscitis with epidural abscess due to a neglected esophageal perforation. Blood cultures were positive for Peptostreptococcus. Cervical spondylodiscitis and epidural abscess are extremely rare complications of esophageal dilations. Successful treatment without debridement was achieved by performing a posterior fixation without decompression associated with antibiotic therapy for 8 weeks. The present case highlights that spondylodiscitis and epidural abscess may be treated in selected cases where the anterior neck is unapproachable and with a recognized pathogen by a posterior approach fixation without debridement, in association to specific antibiotic therapy.

Cervical Intradural Fungal Infection Masquerading as a Meningioma in an Immunocompetent Patient: A Case report and Systematic Review.

BACKGROUND: Intradural spinal fungal infection is a rare phenomenon that can carry a significant increase in morbidity and mortality. In this systematic review and case report presentation of a 75-year-old male with an intradural cervical mass that was diagnosed as a fungal infection intraoperatively. The objective of this paper is to analyze and report on intradural spinal fungal infections in immunocompetent patients. METHOD: We performed a systematic literature review following the PRISMA protocol for studies of intradural fungal infections published in the past 25 years. Original articles with a description of treatment outcomes of such patients were included. RESULTS: 8 studies were included in this review with the addition of the present case. There were 5 males and 4 females with the average age of patients was 45.6-year-old (range 24-75). Aspergillus and Candida species being the most isolated fungal organism. The origin of the lesions was identified and iatrogenic in four cases. Most patients underwent decompressive laminectomy with biopsy, abscess drainage, or resection of the identified lesion. There were two instances of cervical lesions, but most of the lesions were in the thoracic and lumbar spine. Half of the cases reported symptoms improvement, but two patients died from the infection or complications from the infections. CONCLUSION: Intradural fungal infections are rare with only ten total cases reported in the past 25 years. Nonetheless, they can be associated with significant mortality and morbidity. Thus, the timeline from presentation to intervention should be evaluated and determined carefully.

An underdog under the mandible: Pantoea agglomerans abscess of the submandibular region- a case report.

BACKGROUND: Pantoea agglomerans is a gram negative, aerobic/facultative anaerobic, rod shaped bacilli commonly isolated from plants, soil, food and faeces.(1) It is a rare cause of opportunistic infections in humans acquired mainly via two major routes being, wound infection or hospital acquired. CASE REPORT: Here, we encountered a landmark, first of its kind, head and neck manifestation of a cervical soft tissue abscess with Pantoea agglomerans being the miscreant. The patient presented with complaints of a left sided neck swelling, which was radiologically suggestive of a cold abscess, however clinical suscpicion encouraged us to perform an incision and drainage, culture of which revealed this notorious phytogenic bacterium. DISCUSSION: Commonly encountered Pantoea infected cases documented in literature have shown a clinical picture of endophthalmitis, acute unilateral dacryocystitis, periostitis, endocarditis, osteomyelitis and a tumour like muscle cyst of the thigh with many of them eventually leading to septicemia while a few also resolved with targeted antibiotics.(2) Remarkably, no ENT or head and neck presentations have been reported in literature till date. History of trauma by brushing against a mango tree was confirmed retrospectively, which was found to be the missing piece of the puzzle.