Severe necrotizing tracheobronchitis caused by influenza B and methicillin-resistant Staphylococcus aureus co-infection in an immunocompetent patient.

PURPOSE AND METHOD: Necrotizing tracheobronchitis is a rare clinical entity presented as a necrotic inflammation involving the mainstem trachea and distal bronchi. We reported a case of severe necrotizing tracheobronchitis caused by influenza B and methicillin-resistant Staphylococcus aureus (MRSA) co-infection in an immunocompetent patient. CASE PRESENTATION: We described a 36-year-old man with initial symptoms of cough, rigors, muscle soreness and fever. His status rapidly deteriorated two days later and he was intubated. Bronchoscopy demonstrated severe necrotizing tracheobronchitis, and CT imaging demonstrated multiple patchy and cavitation formation in both lungs. Next-generation sequencing (NGS) and bronchoalveolar lavage fluid (BALF) culture supported the co-infection of influenza B and MRSA. We also found T lymphocyte and NK lymphocyte functions were extremely suppressed during illness exacerbation. The patient was treated with antivirals and antibiotics including vancomycin. Subsequent bronchoscopy and CT scans revealed significant improvement of the airway and pulmonary lesions, and the lymphocyte functions were restored. Finally, this patient was discharged successfully. CONCLUSION: Necrotizing tracheobronchitis should be suspected in patients with rapid deterioration after influenza B infection. The timely diagnosis of co-infection and accurate antibiotics are important to effective treatment.

Invasive Aspergillus tracheobronchitis in a patient with hairy cell leukemia and previous Plasmodium falciparum infection.

Invasive Aspergillus tracheobronchitis is a relatively rare form of invasive pulmonary aspergillosis characterized by invasion of the tracheobronchial tree by Aspergillus spp. Invasive pulmonary aspergillosis is predominantly detected in severely immunocompromised patients. Notably however, pulmonary and tracheobronchial cases of invasive aspergillosis have also been reported, particularly in the context of severe malaria caused by Plasmodium falciparum. Herein, we present a case of invasive Aspergillus tracheobronchitis in a patient with hairy cell leukemia and previous Plasmodium falciparum infection.

Occlusive mycotic tracheobronchitis and systemic Alphaherpesvirus coinfection in a free-living striped dolphin Stenella coeruleoalba in Italy.

A juvenile female striped dolphin Stenella coeruleoalba live stranded on 4 March 2016 at Alassio, western Ligurian Sea coast, Italy. The dolphin died shortly after stranding, and a complete postmortem examination was performed. Necropsy revealed severe tracheal occlusion and unilateral bronchial stenosis with luminal accumulation of abundant green-yellow mucous-gelatinous material. Histological features suggestive of tracheobronchial aspergillosis were observed. Cultures of lung tissue and tracheo-bronchial exudate isolated Aspergillus fumigatus, identified by a Microseq D2 LSUrDNA fungal sequencing kit. A pan-Herpesvirus nested-PCR assay on frozen samples obtained from multiple organs was positive. Phylogenetic analysis on the partial DNA polymerase gene revealed that the striped dolphin isolate was closely related to known cetacean Alphaherpesvirus sequences from the same host species. Attempted virus isolation was unsuccessful. The tissue levels of different persistent organic pollutants and the toxicological stress, evaluated using a theoretical model, showed a severely impaired immune response. This study reports the first case of occlusive mycotic tracheobronchitis in a free-living cetacean and the first molecular identification of an Alphaherpesvirus in a free-ranging striped dolphin stranded on the coast of Italy.

Invasive Aspergillus Pseudomembranous and Obstructive Tracheo-bronchitis in an Immuno-competent Patient.

A 19 year female, presented with life threatening haemoptysis and cough with minimum expectoration for 3 months. Bronchoscopy showed multiple nodules in airway. The direct microscopy and culture of sputum revealed fungal elements and Aspergillus flavus respectively. Serum Galactomannan was positive. Thus diagnosis of invasive aspergillus tracheo-bronchitis made. She responded to voriconazole. Aspergillus tracheo-bronchitis is a rare form of invasive pulmonary aspergillosis in immuno-competent host. Aspergillus spp in respiratory samples should not be routinely discarded as colonization.

Unique Case of Pseudomembranous Aspergillus Tracheobronchitis: Tracheal Perforation and Horner's Syndrome.

Pseudomembranous aspergillus tracheobronchitis is an uncommon form of invasive pulmonary aspergillosis, and it is generally seen in immunocompromised patients. We report about a mildly immunocompromised case with pseudomembranous aspergillus tracheobronchitis, which caused tracheal perforation, and Horner's syndrome. A 44-year-old female with uncontrolled diabetes mellitus, complaining of fever and dyspnea, was admitted to the hospital. She was hospitalized with community-acquired pneumonia and diabetic ketoacidosis. Insulin infusion and empirical antibiotics were firstly commenced. Bronchoscopy showed left vocal cord paralysis with extensive whitish exudative membranes covering the trachea and the main bronchi. Liposomal amphotericin B was added due to the probability of fungal etiology. Mucosal biopsy revealed aspergillus species. Second bronchoscopic examination demonstrated a large perforation in the tracheobronchial system. Despite all treatments, respiratory failure developed on the 25th day and the patient died within 2 days. Pseudomembranous aspergillus tracheobronchitis is fatal in about 78 % of all cases despite appropriate therapy. Early diagnosis and efficient antifungal therapy may improve the prognosis.

Endotracheal tube biofilm translocation in the lateral Trendelenburg position.

INTRODUCTION: Laboratory studies demonstrated that the lateral Trendelenburg position (LTP) is superior to the semirecumbent position (SRP) in the prevention of ventilator-associated pulmonary infections. We assessed whether the LTP could also prevent pulmonary colonization and infections caused by an endotracheal tube (ETT) biofilm. METHODS: Eighteen pigs were intubated with ETTs colonized by Pseudomonas aeruginosa biofilm. Pigs were positioned in LTP and randomized to be on mechanical ventilatin (MV) up to 24 hour, 48 hour, 48 hour with acute lung injury (ALI) by oleic acid and 72 hour. Bacteriologic and microscopy studies confirmed presence of biofilm within the ETT. Upon autopsy, samples from the proximal and distal airways were excised for P.aeruginosa quantification. Ventilator-associated tracheobronchitis (VAT) was confirmed by bronchial tissue culture ≥3 log colony forming units per gram (cfu/g). In pulmonary lobes with gross findings of pneumonia, ventilator-associated pneumonia (VAP) was confirmed by lung tissue culture ≥3 log cfu/g. RESULTS: P.aeruginosa colonized the internal lumen of 16 out of 18 ETTs (88.89%), and a mature biofilm was consistently present. P.aeruginosa colonization did not differ among groups, and was found in 23.6% of samples from the proximal airways, and in 7.1% from the distal bronchi (P = 0.001). Animals of the 24 hour group never developed respiratory infections, whereas 20%, 60% and 25% of the animals in group 48 hour, 48 hour-ALI and 72 hour developed P.aeruginosa VAT, respectively (P = 0.327). Nevertheless, VAP never developed. CONCLUSIONS: Our findings imply that during the course of invasive MV up to 72 hour, an ETT P.aeruginosa biofilm hastily colonizes the respiratory tract. Yet, the LTP compartmentalizes colonization and infection within the proximal airways and VAP never develops.

Bacterial Laryngotracheitis and Associated Upper Airway Obstruction: A Case Series.

BACKGROUND: Iatrogenic laryngotracheal stenosis (LTS) continues to be a known complication of indwelling endotracheal tubes (ETTs). It is well established that secondary scar formation caused by inflammation and mucosal injury are the main mechanisms by which stenosis occurs. Additionally, there are reports of bacterial colonization of ETTs and its potential association with tracheal scar formation. We describe 4 cases of patients with history of intubation and/or tracheostomy and presumed LTS that improved with the management of concurrent bacterial laryngotracheitis. METHODS: A retrospective case series of 4 subjects initially diagnosed at a tertiary care center with posterior glottic or subglottic stenosis and positive bacterial laryngotracheal cultures was performed. RESULTS: All 4 patients with presumed LTS had culture-proven bacterial growth isolated from the laryngotrachea and were treated with adjunct antibiotics. In the first 3 cases, complete resolution of upper airway obstruction was achieved. The fourth patient had notable improvement in her airway status without the need for additional surgical intervention. CONCLUSION: This case series suggests that bacterial growth within the airway may play a larger role in adult postintubation airway injury. Those patients presenting with concern for LTS and symptoms suspicious for an ongoing bacterial infection may benefit from adjunct antibiotic therapy.

[Necrotizing tracheobronchial aspergillosis in an immunosuppressed patient. Report of one case]. / Aspergilosis traqueobronquial necrotizante en paciente crítico.

Necrotizing tracheobronchitis due to Aspergillus spp is a rare form of invasive aspergillosis. This infection is limited to or predominant in the bronchial tree. The clinical evolution is gradual: from mild non-specific manifestations of acute tracheobronchitis to severe acute respiratory insufficiency determined by a bronchial obstruction syndrome. We report a 38 years old female with systemic lupus erythematosus treated with methylprednisolone and cyclophosphamide. She developed an invasive aspergillosis, severe respiratory failure with predominant tracheobronchial damage and upper respiratory complications.

First isolation of Mycoplasma iowae in grey partridge flocks.

Mycoplasma iowae, an occasional pathogen of turkeys, was isolated for the first time from captive grey partridges (Perdix perdix). Clinical signs including respiratory and intestinal disorder were seen in birds of all ages but mainly in those kept housed during rearing. Mortality rates averaged over 20% during the year. Treatment with antibiotics and antiparasitic drugs produced only a transient improvement in condition. The gross pathology findings included poor body growth, lack of development of the breast muscles, abnormalities in the keel development, and bone fragility. Some birds showed infraorbital sinusitis with serous or fibrinous exudates and catarrhal tracheitis, while others presented serofibrinous airsacculitis and splenomegaly. Laboratory investigations revealed pure cultures of M. iowae in the gut as well as sinus and air sacs. While other organisms such as coccidia, Trichomonas, Escherichia coli, Clostridium perfringens, and Aspergillus spp. were detected, the similarity of the disease with that seen in turkeys infected with M. iowae strongly suggests that this mycoplasma may be the primary pathogen here. The presence of M. iowae in game birds commonly released into the wild could have serious implications particularly in areas where industrial poultry farms are concentrated.

Clinical presentations and diagnostic approaches of pediatric necrotizing tracheobronchitis with influenza A virus and Staphylococcus aureus co-infections.

In March 2023, our pediatric intensive care unit (PICU) retrospectively examined six cases of pediatric necrotizing tracheobronchitis (NTB), focusing on co-infections with influenza A virus (IAV) and Staphylococcus aureus (S. aureus). This study aimed to elucidate NTB's clinical characteristics, diagnostics, and therapeutic approaches. Diagnostics included symptom assessment, microbiological testing that confirmed all patients were positive for IAV H1N1 with a predominant S. aureus co-infection, and bronchoscopy. The patients predominantly exhibited fever, cough, and dyspnea. Laboratory analysis revealed decreased lymphocyte counts and elevated infection markers like C-reactive protein and procalcitonin. Chest computed tomography (CT) scans detected tracheobronchial obstructions in half of the cases, while bronchoscopy showed severe mucosal congestion, edema, necrosis, and purulent-hemorrhagic exudates. Treatments encompassed comprehensive strategies like oxygen therapy, intubation, bronchoscopic interventions, thoracentesis, oseltamivir, and a regimen of antibiotics. Our findings suggested potential correlations between clinical markers, notably lymphocyte count and procalcitonin, and clinical interventions such as the number of rescues and intensive care unit (ICU) duration. This research highlights the importance of early detection and the role of bronchoscopy and specific markers in assessing NTB, advocating for continued research in larger cohorts to better understand its clinical trajectory and refine treatment approaches for this challenging pediatric disease.

Tracheobronchial mycosis in a retrospective case-series study of five status asthmaticus patients.

The etiology of status asthmaticus (SA), a complication of severe asthma, is unknown. Fungal exposure, as measured by fungal atopy, is a major risk factor for developing asthma, but the relationship of fungi in SA per se has not previously been reported. In this five patient retrospective case series study, lower respiratory tract cultures were performed on bronchoalveolar lavage or tracheal aspirate fluid, comparing standard clinical laboratory cultures with a specialized technique in which respiratory mucus was removed prior to culture. We show that mucolytic treatment allows an increased detection of fungal growth, especially yeast, from the lower airways of all SA patients. We also demonstrate that inhalation of the yeast Candida albicans readily induces asthma-like disease in mice. Our observations suggest that SA may represent a fungal infectious process, and support additional prospective studies utilizing anti-fungal therapy to supplement conventional therapy, broad-spectrum antibiotics and high-dose glucocorticoids, which can promote fungal overgrowth.

Comparison of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia and tracheobronchitis caused by Pseudomonas aeruginosa or Acinetobacter baumannii.

PURPOSE: This study was designed to compare the efficacy of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT) by Pseudomonas aeruginosa or Acinetobacter baumannii. METHODS: A prospective cohort study was performed. Patients >18 years of age with the diagnosis of VAP or VAT who received appropriate therapy for >48 h were analyzed. The primary outcome was 30-day mortality. Clinical covariates were assessed and compared between the groups. RESULTS: A total of 67 episodes were analyzed: 45 (67 %) treated with polymyxin B and 22 (33 %) with comparators. The crude 30-day mortality was 53 % (24 of 45) in the polymyxin B group and 27 % (6 of 22) in the comparator group (P = 0.08). Multivariable analysis using Cox regression models indicated that polymyxin B treatment was independently associated with increased mortality. CONCLUSIONS: Polymyxin B treatment in the currently recommended dosage may be inferior to other drugs in the treatment of VAP and VAT caused by organisms tested as susceptible in vitro to this agent.

Occlusive fungal tracheitis in 4 captive bottlenose dolphins (Tursiops truncatus).

Respiratory disease is common in dolphins, primarily affecting pulmonary parenchyma and sparing large airways. Over a 10-year period, 4 captive adult bottlenose dolphins succumbed to chronic, progressive respiratory disease with atypical recurrent upper respiratory signs. All dolphins had severe, segmental to circumferential fibrosing tracheitis that decreased luminal diameter. Histologically, tracheal cartilage, submucosa, and mucosa were distorted and replaced by extensive fibrosis and pyogranulomatous inflammation centered on fungal hyphae. In 3 of 4 cases, hyphae were morphologically compatible with Aspergillus spp and confirmed by culture in 2 cases. Amplification of fungal DNA from tracheal tissue was successful in one case, and sequences had approximately 98% homology to Aspergillus fumigatus. The remaining case had fungi compatible with zygomycetes; however, culture and polymerase chain reaction were unsuccessful. Lesions were evaluated immunohistochemically using antibodies specific to Aspergillus spp. Aspergillus-like hyphae labeled positively, while presumed zygomycetes did not. These cases represent a novel manifestation of respiratory mycoses in bottlenose dolphins.

Pathologic lesions caused by coinfection of Mycoplasma gallisepticum and H3N8 low pathogenic avian influenza virus in chickens.

Chickens were infected under experimental conditions with Mycoplasma gallisepticum and low pathogenic avian influenza (LPAI) strain A/mallard/Hungary/19616/07 (H3N8). Two groups of chickens were aerosol challenged with M. gallisepticum strain 1226. Seven days later, one of these groups and one mycoplasma-free group was challenged with LPAI H3N8 virus; one group without challenge remained as negative control. Eight days later, the birds were euthanized and examined for gross pathologic and histologic lesions. The body weight was measured, and the presence of antimycoplasma and antiviral antibodies was tested before the mycoplasma challenge, before the virus challenge, and at the end of the study to confirm both infections. Chickens in the mycoplasma-infected group developed antibodies against M. gallisepticum but not against the influenza virus. Chickens of the group infected with the influenza virus became serologically positive only against the virus, while the birds in the coinfected group developed antibodies against both agents. The LPAI H3N8 virus strain did not cause decrease in body weight and clinical signs, and macroscopic pathological lesions were not present in the chickens. The M. gallisepticum infection caused respiratory signs, airsacculitis, and peritonitis characteristic of mycoplasma infection. However, the clinical signs and pathologic lesions and the reduction in weight gain were much more significant in the group challenged with both M. gallisepticum and LPAI H3N8 virus than in the group challenged with M. gallisepticum alone.

The chance identification of unusual-appearing bacteria in bronchoalveolar lavage fluid.

BACKGROUND: A well-known indication for the cytologic examination of bronchoalveolar lavage (BAL) fluid is the identification of infectious organisms. However, an important distinction must be made as to whether the organisms seen represent a true opportunistic lower respiratory tract infection or a non-pathologic contamination. CASE: We describe herein the case of a 13-month-old male infant who presented with persistent chest congestion and tracheobronchitis and who underwent BAL as part of his clinical work-up. On cytological examination of the BAL fluid, the Romanowsky-stained cytospin slides contained numerous squamous epithelial cells with some showing rare striated rod-like structures on their surfaces. The peculiar structures also had rounded ends and were very large when compared to adjacent known bacterial cocci. CONCLUSION: We have determined that the striated rod-like structures in the infant's BAL fluid were indeed bacteria, Simonsiella sp. Simonsiella has reportedly been found in up to 32% of oral swabs in normal humans and it is considered a commensal and non-pathogenic organism. The characteristically large size, the association with normal oral-derived squamous cells and the striated appearance is diagnostic and will hopefully eliminate any possibility of confusion with a truly pathogenic organism.

Intubated patients developing tracheobronchitis or pneumonia have distinctive complement system gene expression signatures in the pre-infection period: a pilot study.

INTRODUCTION: It remains unknown why some intubated patients remain infection-free while others develop tracheobronchitis (VAT) or pneumonia (VAP). OBJECTIVE: To identify and compare VAP/VAT gene expression "signatures" using genome-wide oligonucleotide microarrays. MATERIAL AND METHODS: A prospective translational study of gene expression profiles of VAP and VAT groups was carried out, establishing comparisons in both pre-infection and infection phases. Pathway and functional analyses were performed with Ingenuity Pathway Analysis (IPA). Data analysis and hierarchical clustering of the genes involved in the signalling pathways expressed differentially in the two groups were performed with GeneSpring GX 11.0. RESULTS: Eight patients developing respiratory infections (3 VAP and 5 VAT) after 4 days of mechanical ventilation were assessed. Comparison of gene expression profiles in the pre-infection period revealed 5595 genes expressed differentially between VAP and VAT (p<0.01, fold change >2). Comparative IPA analysis identified a significant depression of the complement system signalling pathway in the VAP group, affecting the classical pathway along with the final common pathway (p<0.05). In addition, the cAMP and calcium signalling pathways were also significantly depressed in the VAP group during the pre-infection phase also. CONCLUSION: Intubated patients complicated with pneumonia developed immune impairment in the pre-infection period, manifesting as a relatively lower expression of genes involved in the complement system that differed from patients developing tracheobronchitis. These findings suggest that a significant proportion of VAP episodes cannot be prevented, but might be treatable through pre-emptive therapy.

Acute intratracheal Pseudomonas aeruginosa infection in cystic fibrosis mice is age-independent.

BACKGROUND: Since the discovery of the human CFTR gene in 1989 various mouse models for cystic fibrosis (CF) have been generated and used as a very suitable and popular tool to approach research on this life-threatening disease. Age related changes regarding the course of disease and susceptibility towards pulmonary infections have been discussed in numerous studies. METHODS: Here, we investigated CftrTgH(neoim)Hgu and Cftrtm1Unc-Tg(FABPCFTR)1Jaw/J CF mice and their non-CF littermates during an acute lung infection with Pseudomonas aeruginosa for age dependent effects of their lung function and immune response.Mice younger than three or older than six months were intratracheally infected with P. aeruginosa TBCF10839. The infection was monitored by lung function of the animals using non-invasive head-out spirometry and the time course of physiological parameters over 192 hours. Quantitative bacteriology and lung histopathology of a subgroup of animals were used as endpoint parameters. RESULTS: Age-dependent changes in lung function and characteristic features for CF like a shallower, faster breathing pattern were observed in both CF mouse models in uninfected state. In contrast infected CF mice did not significantly differ from their non-CF littermates in susceptibility and severity of lung infection in both mouse models and age groups. The transgenic Cftrtm1Unc-Tg(FABPCFTR)1Jaw/J and their non-CF littermates showed a milder course of infection than the CftrTgH(neoim)Hgu CF and their congenic C57Bl/6J non-CF mice suggesting that the genetic background was more important for outcome than Cftr dysfunction. CONCLUSIONS: Previous investigations of the same mouse lines have shown a higher airway susceptibility of older CF mice to intranasally applied P. aeruginosa. The different outcome of intranasal and intratracheal instillation of bacteria implies that infected CF epithelium is impaired during the initial colonization of upper airways, but not in the subsequent response of host defense.

Bacterial tracheitis: a varied entity.

OBJECTIVE: The objective of the study was to highlight the different presentations of bacterial tracheitis (BT), a potential life-threatening cause of airway obstruction in children. DESIGN: Case series. METHODS: A review of medical records of 4 cases of BT who presented with differing signs and symptoms was performed. RESULTS: Clinical manifestations of 4 patients with BT are presented with corresponding endoscopic appearances of the airway. Two patients were afebrile and nontoxic, and 2 had an elevated white cell count. Three had different degrees of stridor. One had a respiratory arrest. Cultures grew Staphylococcus aureus in 2 and Moraxella catarrhalis in 1 and were mixed in 1 patient. None required intubation. All were successfully treated with antibiotics and bronchoscopic debridement of the membranes. CONCLUSIONS: Bacterial tracheitis needs a high index of suspicion because of its varied presentations. Certain forms have less severe clinical manifestations. These forms also require aggressive management as they can result in airway obstruction from membranes and edema.

[Nebulized colistin treatment of multi-resistant Acinetobacter baumannii pulmonary infection in critical ill patients]. / Utilización de la colistina nebulizada en la colonización e infección respiratoria por Acinetobacter baumannii en pacientes críticos.

OBJECTIVE: To analyze the efficacy of nebulized colistin in the microbiological eradication and clinical improvement of patients with pulmonary infection by multi-resistant Acinetobacter baumannii (MAB). DESIGN: A retrospective study. SETTING: Intensive Care Unit of a Tertiary hospital. PATIENTS: Hospitalized patients on invasive mechanical ventilation with positive MAB cultures of the airway. INTERVENTIONS: All received treatment with colistin (CL). Nosocomial pneumonia (NP) or Tracheobronchitis (TB) was determined according to routine criteria and colonization (CO) was determined in the case of a positive culture in the absence of infection criteria. Three groups of patients were defined: those treated with nebulized CL, those treated with IV CL and those treated with IV CL plus nebulized CL. MAIN MEASUREMENTS: Baseline characteristics. Microbiological eradication and clinical recovery were evaluated according to routine criteria. RESULTS: 83 patients were studied, 54 of whom were treated, with the following diagnoses: 15 (27.8%) with NP, 16 (29.6%) with TB and 23 patients (42.6%) with CO. Nebulized CL was used in 36 patients (66.7%): 66.7% of which for CO, 33.3% in treatment for TB and in no case of NP. In 61.1% of the patients, IV CL was used: 22.2% of which for CO, 38.9% for TB and 38.9% in NP. The combination of IV CL and nebulized CL was used in 15 patients (27.8%): 5 patients (33.3%) CO, 2 patients (13.3%) TB and 8 patients (53.3%) NP. Microbiological eradication was achieved in 32 patients (59.3%), with the following distribution: 8 (47.1%) with IV CL, 15 (83.3%) with nebulized CL and 9 patients (69.2%) with a combination of IV CL and nebulized CL. Clinical recovery was achieved in 42 patients (77.8%): 12 (80%) with IV CL, 18 (94.7%) with nebulized CL and 12 (85.7%) with a combination of nebulized and IV CL. These differences were not significant. In the group of patients with infection due to TB and NP (31 patients, 57.4%), microbiological eradication was achieved in 5 patients (100%) treated with nebulized CL and in 6 of the 9 patients (42.9%) treated with IV CL, the difference being significant (P<.05). Clinical recovery in this group was 100% (6 patients) treated with nebulized CL and 75% (9 of the 12 patients) in the IV CL group. This difference was not significant. CONCLUSIONS: Our study suggests that treatment with colistin in patients with pulmonary infection with multi-resistant Acinetobacter baumannii could be more efficient if it were to be administrated solely nebulized or in combination with IV colistin rather than administered solely intravenously.