Hepatic Cyst Infection Following Recurrent Biliary Obstruction in Polycystic Liver Disease.

An 89-year-old man with polycystic liver disease (PCLD) received uncovered self-expandable metallic stent (SEMS) placement above the papilla for malignant biliary obstruction caused by cholangiocarcinoma. He developed cholangitis ten months later due to SEMS occlusion caused by tumor ingrowth, and 2 plastic biliary stents were placed inside the SEMS across the papilla. Fever and right costal pain appeared two weeks after reintervention. Suspecting hepatic cyst infection based on imaging studies, percutaneous transhepatic cyst drainage was performed. Increased inflammatory cells and the presence of pathogens in the cyst fluid led to a definitive diagnosis of hepatic cyst infection. Following drainage, the hepatic cyst shrank with resolution of the symptoms. SEMS occlusive-related cholangitis or retrograde infection due to duodenal-biliary reflux after reintervention was considered as the cause of the hepatic cyst infection. Careful clinical and imaging evaluation should be performed in patients with PCLD undergone biliary stenting, because cyst infection may occur following stent occlusion or subsequent biliary reintervention.

Association of Bartholin cysts and abscesses and sexually transmitted infections.

INTRODUCTION: Bartholin gland cysts or abscesses account for many gynecologic visits in the emergency department (ED). Previous smaller studies have suggested a link between Bartholin cysts/abscesses and sexually transmitted infections (STIs), but few studies have involved the ED. METHODS: We retrospectively identified patients aged 18 years or older seen in 1 ED between January 2012 and March 2017 who had urinalysis and urine culture and/or were tested for gonorrhea, chlamydia, or trichomonas by nucleic acid amplification testing. Univariate and multivariate analyses were used to evaluate associations between Bartholin cysts/abscess and demographics, laboratory findings, and ED diagnoses. RESULTS: Data were collected for 75,000 ED patients; 64 patients had a diagnosis of Bartholin cyst or abscess, 40 of whom were also tested for Neisseria gonorrhoeae or Chlamydia trachomatis. Ten percent of patients with a Bartholin cyst/abscess were infected with N gonorrhoeae, compared with 3% of those without a Bartholin cyst/abscess (P = .008). The rates of C trachomatis and Trichomonas vaginalis infections were 13% and 26%, respectively, among patients with a Bartholin cyst/abscess, compared with 8% and 30%, respectively, among those without a Bartholin cyst/abscess (P > .05 for both). On regression analysis, only increased urobilinogen level (ß, 0.31; odds ratio, 1.36; 95% CI, 1.11-1.66; P = .003) and infection with N gonorrhoeae (ß, 1.69; odds ratio, 5.40; 95% CI, 1.43-20.35; P = .01) were associated with a Bartholin cyst/abscess. CONCLUSIONS: Clinicians in the ED should consider testing patients with a Bartholin cyst/abscess for gonorrhea.

Campylobacter upsaliensis isolated from a giant hepatic cyst.

Campylobacter upsaliensis is an enteropathogenic bacterium in animals, and is also rarely isolated from humans, where it can cause enteritis and bacteremia. This report describes the first case of isolation of C. upsaliensis from an infected giant hepatic cyst. This bacterium could not be cultured from abscess punctuate in a usual Campylobacter-selection medium (charcoal cefoperazone deoxycholate agar medium), because of high concentration of cefoperazone as a selection agent. It could not identified by matrix-assisted laser desorption ionization-time of flight mass spectrum. Rather, it was identified as C. upsaliensis by whole genome sequencing, including by multilocus sequence typing.

Subcutaneous phaeohyphomycosis caused by a black pigmented mould (Rhytidhysteron species) in rural north-western New South Wales, Australia.

Invasive fungal infections are becoming increasingly more prevalent in clinical practice. This corresponds with more patients living with immunosuppression and improved techniques to identify fungal infections. Subcutaneous fungal masses can often masquerade and imitate common dermatological lesions such as cysts. Querying a fungal aetiology of a mass is important, as fungal elements can be missed on histological examination, and special stains may be needed to identify spores and hyphae to make the diagnosis. Skin trauma with inoculation of fungal elements contained in soil and vegetable matter is the most common source of subcutaneous fungal masses. While traditionally considered a disease of the tropics, subcutaneous fungal masses can present worldwide in both immunosuppressed and immunocompetent patients. This case study describes a subcutaneous knee mass in a 53-year-old immunosuppressed farmer in Australia. A subcutaneous phaeohyphomycosis was diagnosed with a black pigmented mould, Rhytidhysteron species. A latent period of 12 years was observed between traumatic inoculation with farm soil and wheat dust in north-western New South Wales and development of the knee mass. Rhytidhysteron is considered a disease of the tropics, most commonly reported in India. This case, to the author's knowledge, is the first case report of pathogenic Rhytidhysteron from Australia. Surgery and antifungal therapy are recommended to treat Rhytidhysteron infection. This patient's recommended antifungal treatment was shortened due to severe hepatic disease. The clinical course was complicated by three localised recurrences in the patient's knee over 14 months. At the time of the third localised recurrence, this patient could tolerate posaconazole therapy for a month only. Surgical excision using general anaesthesia, use of diathermy for excision and wound lavage with iodine, hydrogen peroxide and saline has coincided in remission of clinical disease for 3 years at the time of writing.

Helicobacter cinaedi Hepatic Cyst Infection with Bacteremia.

Helicobacter cinaedi is an enterohepatic bacillus that causes infections of various manifestations. We report a novel case of hepatic cyst infection with bacteremia caused by H. cinaedi in an immunocompetent woman in Japan. Further research is warranted to identify the epidemiologic and clinical features of H. cinaedi infection.

Two cases of fungal cyst infection in ADPKD: is this really a rare complication?

BACKGROUND: Cyst infection is a prevalent complication in autosomal dominant polycystic kidney disease (ADPKD) patients, however therapeutic and diagnostic approaches towards this condition remain unclear. The confirmation of a likely episode of cyst infection by isolating the pathogenic microorganism in a clinical scenario is possible only in the minority of cases. The available antimicrobial treatment guidelines, therefore, might not be appropriate to some patients. CASE PRESENTATION: We describe two unique cases of kidney cyst infection by Candida albicans, a condition that has not been previously described in literature. Both cases presented clear risk factors for Candida spp. infection. However, since there was no initial indication of cyst aspiration and culture, antifungal therapy was not immediately started and empirical treatment was initiated as recommended by the current guidelines. Antifungal treatment was instituted in both cases along the clinical course, according to their specificities. CONCLUSION: Our report highlights the possibility of Candida spp. cyst infection. Failure of clinical improvement with antibiotics should raise the suspicion of a fungal infection. Identification of infected cysts should be pursued in such cases, particularly with PET-CT, and when technically possible followed by cyst aspiration and culture to guide treatment. Risk factors for this condition, such as Candida spp. colonization, previous antimicrobial therapy, hemodialysis, necrotizing pancreatitis, gastrointestinal/hepatobiliary surgical procedure, central venous catheter, total parenteral nutrition, diabetes mellitus and immunodeficiency (neutropenia < 500 neutrophils/mL, hematologic malignancy, chemotherapy, immunosuppressant drugs), should be also considered accepted criteria for empirical antifungal therapy.

Paracoccus yeei: a Rare Opportunistic Bacterium in a Patient with Parotid Cyst.

BACKGROUND: Parotid cyst is a common problem in patients treated by surgeons. However, Paracoccus yeei was isolated from an aerobic blood culture in a patient with parotid cyst as an unusual etiologic opportunistic agent. METHODS: Since old biochemical identification kits are not able to identify this species, MALDI-TOF MS correctly was recommended to identify this isolate. Its identity was confirmed by sequencing of the 16S rRNA gene. RESULTS: The aligned sequences (16S rRNA gene) were used for a phylogenetic analysis (phylogenetic tree), which was produced using the BLAST pair-wise alignments. The sequence analysis determined that the best matches were with Paracoccus yeei. CONCLUSIONS: Paracoccus yeei has been reported as a rare opportunistic human pathogen, we should actively com-municate to the clinic to improve the real positive rate.

Streptococcus chosunense sp. nov., Isolated from Human Postoperative Maxillary Cyst.

A novel facultative anaerobic, non-spore forming, non-motile, and Gram-stain-positive coccus, designated strain ChDC B353T, was isolated from human postoperative maxillary cyst. The 16S ribosomal RNA gene (16S rDNA) sequence of the strain was most closely related to those of Streptococcus pseudopneumoniae ATCC BAA-960T (99.4%), Streptococcus mitis NCTC 12261T (99.3%), and Streptococcus pneumoniae NCTC 7465T (99.2%). The major fatty acids of the strain were C16:0 (43.2%) and C18:1 ω6c/C18:1 ω7c (20.2%). The genome of strain ChDC B353T was composed of 1,902,053 bps. The DNA G+C content of the strain was 40.2 mol%. Average nucleotide identity (ANI) values between strain ChDC B353T and S. pseudopneumoniae ATCC BAA-960T, S. mitis NCTC 12261T, and S. pneumoniae NCTC 7465T were 91.9%, 93.5%, and 91.3%, respectively. Genome-to-genome distance (GGD) values between strain ChDC B353T and S. pseudopneumoniae ATCC BAA-960T, S. mitis NCTC 12261T, or S. pneumoniae NCTC 7465T were 46.6% (44.0-49.2%), 53.2% (50.5-55.9%), and 46.0% (43.5-48.7%), respectively. The threshold values of ANI and GGD for species discrimination are 95-96% and 70%, respectively. These results reveal that strain ChDC B353T (= KCOM 1699T = JCM 33453T) is a novel species belonging to genus Streptococcus, for which a name of Streptococcus chosunense sp. nov. is proposed.

Dacryoadenitis Caused by Blastomycosis: A Case Report.

This is the first case of histopathologically proven blastomycosis involving the lacrimal gland. A 51-year-old woman with a history of disseminated blastomycosis involving her lungs and skin, on oral itraconazole, presented with 3 days of right upper eyelid swelling, erythema, and pain concerning for recurrent dacryoadenitis. MRI showed enlargement of the right lacrimal gland with a cystic lesion at the anterior aspect of the gland with a radiographic differential diagnosis of abscess versus cyst. After no improvement with intravenous antibiotics, orbitotomy with lacrimal gland biopsy and incision and drainage of the cystic lesion were performed. Culture and pathology of the drained fluid demonstrated an abscess with both viable and nonviable broad-based budding yeast consistent with partially treated blastomycosis. The patient's symptoms improved after the surgery and continued itraconazole therapy.

Undiagnosed Cryptococcus gattii meningitis leading to subsequent ventriculoperitoneal shunt infection in a patient with symptoms of normal pressure hydrocephalus: case report and literature review.

BACKGROUND: Cryptococcus gattii is known to be an etiologic agent of human cryptococcosis, particularly in immunocompetent persons. C. gattii infection usually involves the central nervous system, the respiratory tract, or may be disseminated. Here we report an atypical manifestation of C. gattii infection in a patient who had C. gattii meningitis complicating the ventriculoperitoneal (VP) shunt infection and concurrent infected intraabdominal VP shunt pseudocyst. CASE PRESENTATION: A 66-year-old Thai female was initially diagnosed with normal pressure hydrocephalus (NPH) and underwent programmable VP shunt placement. However, she still suffered from recurrent communicating hydrocephalus with in-place VP shunt, and later developed recurrent gait impairment, chronic abdominal pain and abdominal mass. Radiological studies demonstrated recurrent hydrocephalus and a very large intraabdominal VP shunt pseudocyst. C. gattii was isolated from both the cerebrospinal fluid and the pseudocyst aspiration. C. gattii meningitis complicating the VP shunt infection and concurrent infected intraabdominal VP shunt pseudocyst was diagnosed. Prolonged antifungal therapy, removal of the infected VP shunt with subsequent implant of a new shunt provided a good outcome. CONCLUSION: Chronic C. gattii meningitis should be aware in a patient presenting with normal pressure hydrocephalus. Under-diagnosed cryptococcal meningitis following VP shunt insertion for treating the hydrocephalus can render a complicated VP shunt infection including infected VP shunt pseudocyst.

Solving the mystery: Hyalinized cyst wall containing organism-like structures in a lung transplant donor.

A 59-year-old man with non-ischemic cardiomyopathy underwent orthotopic heart transplantation. The donor, a 31-year-old male declared brain dead after a gunshot wound to the head, was considered high risk due to history of incarceration, illicit drug use, and sex with a HIV-positive partner. At organ procurement, the heart, kidneys, pancreas, and liver looked grossly normal. A small right lower lobe nodule was noticed, and lung biopsy was performed. Bronchoscopy showed purulent secretions in the right lower lobe. Images from pathology are presented. Lung biopsy confirmed the presence of hyalinized cyst wall containing organism-like structures. A combination of culture, microscopic morphology, and gene sequencing was used to identify the causative organism. The patient and all other organ recipients received appropriate antifungal prophylaxis and remain asymptomatic 6 months post-transplant.

Primary cutaneous non-pigmented mycotic cyst contained in an epidermal inclusion cyst: Case report and review of the literature.

Primary cutaneous mycotic cysts are uncommon dermal or subcutaneous fungal lesions. The most commonly implicated organisms are species within a heterogeneous group of pigmented fungi called dematiaceous fungi. Mycotic cysts usually present as solitary lesions and can be caused by traumatic introduction of fungal elements by foreign bodies or present as a cutaneous manifestation of systemic fungal infections, especially in immunocompromised patients. We present a case of a 63-year-old immunocompetent male who developed a non-erythematous solitary nodule after doing yardwork. Histopathologically, a benign-appearing epidermal inclusion cyst was apparent containing a splinter with keratinous granular debris and no indication of inflammatory host reaction. However, abundant non-pigmented hyphae were visualized after a periodic acid-Schiff stain was performed. This case offers an interesting histopathological view of a non-pigmented mycotic cyst contained within an epidermal inclusion cyst with a true epithelial lining. It also raises the question of whether mycotic cysts caused by non-pigmented fungi are rare or simply under-diagnosed because of their deceptively benign initial appearance. Even in the absence of an inflammatory or granulomatous host response, we recommend investigating for fungal elements in lesions where a splinter or other foreign body material is present in order to avoid misdiagnosis.

Cystic neutrophilic granulomatous mastitis: A clinicopathologic study of a distinct entity with supporting evidence of a role for Corynebacterium-targeted therapy.

Cystic neutrophilic granulomatous mastitis (CNGM) is a distinct histopathologic entity characterized by neutrophilic and granulomatous inflammation surrounding clear cystic spaces. Rare gram-positive bacilli are sometimes identified within these cystic spaces. Studies in the literature have identified these gram-positive bacilli to be Corynebacterium species. We describe the clinicopathologic features of 7 cases of CNGM, including a case with evidence of Corynebacterium amycolatum. Patients were young to middle aged parous women ranging in age from 28 to 53 years (median age: 41 years). Gram-positive bacilli were identified in 4 cases, all within cystic spaces. Microbial culture from a 41-year old Hispanic woman grew Corynebacterium species on multiple occasions and Corynebacterium amycolatum was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) on two separate occasions. Antibiotic susceptibility testing performed both times showed resistance to multiple antibiotics and susceptibility to vancomycin. Follow-up of all patients (range 3-12 months, median 6 months) showed a widely variable clinical course and varying response to a variety of treatment modalities. Five of the seven CNGM patients were parous, reproductive-aged Hispanic women who were born outside of the United States. Our findings further support the association of CNGM with corynebacteria and gram-positive bacilli. Furthermore, this study shows that Corynebacterium amycolatum, a nonlipophilic and multidrug-resistant corynebacterium can be associated with CNGM, hence the need for targeted antibiotic therapy. We propose identifying corynebacteria to the species level and performing antibiotic susceptibility testing in patients with CNGM because of the varied susceptibility testing profile that has been reported among different species of corynebacteria.

Subcutaneous Mycotic Cyst Caused by Roussoella percutanea in a UK Renal Transplant Patient.

Fungi from more than 100 genera have been implicated in subcutaneous fungal infections, usually following traumatic inoculation of the etiologic agent. With the advent of molecular approaches to fungal identification and taxonomy, novel agents of subcutaneous mycoses are increasingly reported. In this manner, Roussoella percutanea, a novel species in Pleosporales, was described in 2014 from a subcutaneous mass in an immunocompetent male adult. Two additional cases involving renal transplant recipients were recently reported from patients resident in France and Germany, with several further cases discovered after analyses of historical culture collection isolates. Here, we describe a new case of subcutaneous R. percutanea infection, causing a mycotic cyst in a renal transplant patient resident in the UK. Although fungal infection was confirmed histologically, viable fungal isolates could not be recovered in culture from biopsy material and identification of the causative agent relied upon PCR amplification and sequencing of fungal rDNA genes. This is the fourth well-documented case of infection with R. percutanea in renal transplant patients, and the first reported from a patient resident in the UK. The current case illustrates the importance of molecular approaches for the identification of emerging fungal pathogens in culture-negative subcutaneous fungal infections.

Population Genetics of Hirsutella rhossiliensis, a Dominant Parasite of Cyst Nematode Juveniles on a Continental Scale.

Hirsutella rhossiliensis is a parasite of juvenile nematodes, effective against a diversity of plant-parasitic nematodes. Its global distribution on various nematode hosts and its genetic variation for several geographic regions have been reported, while the global population genetic structure and factors underlying patterns of genetic variation of H. rhossiliensis are unclear. In this study, 87 H. rhossiliensis strains from five nematode species (Globodera sp., Criconemella xenoplax, Rotylenchus robustus, Heterodera schachtii, and Heterodera glycines) in Europe, the United States, and China were investigated by multilocus sequence analyses. A total of 280 variable sites (frequency, 0.6%) at eight loci and six clustering in high accordance with geographic populations or host nematode-associated populations were identified. Although H. rhossiliensis is currently recognized as an asexual fungus, recombination events were frequently detected. In addition, significant genetic isolation by geography and nematode hosts was revealed. Overall, our analyses showed that recombination, geographic isolation, and nematode host adaptation have played significant roles in the evolutionary history of H. rhossiliensis IMPORTANCE: H. rhossiliensis has great potential for use as a biocontrol agent to control nematodes in a sustainable manner as an endoparasitic fungus. Therefore, this study has important implications for the use of H. rhossiliensis as a biocontrol agent and provides interesting insights into the biology of this species.

Intracystic magnetic resonance imaging in patients with autosomal dominant polycystic kidney disease: features of severe cyst infection in a case-control study.

BACKGROUND: The purpose of this study was to investigate the usefulness of intracystic MRI features for detection of severe cyst infection that is usually refractory to antibiotic therapy alone in patients with autosomal dominant polycystic kidney disease. METHODS: Seventy-six patients (88 episodes) with positive cyst cultures treated from January 2006 to December 2013 were enrolled as the cases for this case-control study, while 147 patients who continued to attend our hospital from January 2011 to December 2013 and did not have cyst infection diagnosed during that period were enrolled as the controls. Intracystic MRI findings were investigated. RESULTS: At least one of four intracystic MRI features (high signal intensity (SI) on diffusion-weighted images (DWI), fluid-fluid level, wall thickening, or gas) was found in all of the cases, but such findings were also detected in some controls. Intracystic gas was specific for cyst infection, but its sensitivity was only 1.1 %. A high intracystic SI on DWI showed a sensitivity of 86.4 %, but its specificity was lower at 33.3 %. Both the specificity and sensitivity of a fluid-fluid level or wall thickening were about 80 %. However, the specificity of these MRI features decreased as total liver and kidney volume (TLKV) increased, falling to 65.8 % in patients with organomegaly (TLKV > 8500 cm3). A cyst diameter > 5 cm was useful for detecting severely infected cysts that needed drainage, and specificity was increased by combining the other four MRI findings with a cyst diameter > 5 cm. CONCLUSIONS: MRI with DWI was useful for detecting severe cyst infection in ADPKD. While the specificity of MRI alone was not high enough in patients with organomegaly, combining the four MRI features with abdominal pain, sequential MRI changes, or cyst diameter > 5 cm improved detection of severely infected cysts in these patients.

Subcutaneous Phaeohyphomycosis Cyst Associated with Medicopsis romeroi in an Immunocompromised Host.

An 88-year-old man, receiving prednisolone for sarcoidosis, presented with a discrete keratotic lesion on the dorsum of his right hand following the placement of an intravenous cannula a month prior to its appearance. Medicopsis romeroi was isolated from the tissue and identified by sequencing the internal transcribed spacer region ITS-1 and the D1-2 fragment of the 28S rDNA gene. Histopathological examination showed fungal hyphae in the internal inflammatory cells layer and within the histocyte-macrophage layer, highly suggestive of deep mycosis. The patient was successfully treated with surgical excision of the cyst. M. romeroi exhibited high MIC values for echinocandin drugs in vitro, but appeared susceptible to newer triazole agents, amphotericin B and terbinafine. This is the first report of a subcutaneous phaeohyphomycotic cyst occurring following the placement of an intravenous cannula. This report highlights the potential role of M. romeroi as an emerging cause of deep, non-mycetomatous infection in immunocompromised patients.

Characterization of dacryops infections.

PURPOSE: The purpose of this study was to characterize the clinical entity of dacryops infections through imaging with or without histopathology in the differential of ocular adnexal masses in the setting of infection. METHODS: A retrospective chart review was performed on 5 patients seen at 1 clinical practice in which a complete ophthalmologic examination and imaging of the lesion had been obtained. Two of these patients additionally obtained surgical intervention with histopathologic examination. RESULTS: The main lacrimal gland was involved in all 5 patients with dacryops infection presenting unilaterally. The average age of the patients was 44.6 years. Predisposing factors of eyelid margin disease, conjunctivitis, and contact lens usage were highlighted. CT provided useful information on the location and size of the lesion. Excision with or without marsupialization appears to prevent recurrence and provides a histopathologic diagnosis although spontaneous (or self-induced) drainage of the cyst in addition to antibiotic therapy can successfully manage the infection and cyst size, wherein affected individuals may not pursue further surgical management. CONCLUSIONS: Dacryops infection is a rare but important consideration in the differential of a mass lesion in the upper fornix associated with inflammation that may be confused with orbital cellulitis or abscess. Orbital imaging is helpful in delineating the extent of the lesion, whereas surgical excision with histopathology can confirm the diagnosis. The authors described 5 cases with this acute presentation and highlighted concomitant factors that may predispose certain patients to the development of infection.