Recurrent, ICD-associated L. monocytogenes bacteraemia with multiple septic pulmonary embolisms over a 2-year period.

BACKGROUND: Listeria monocytogenes is a bacterial pathogen known for causing listeriosis, a foodborne illness with a wide spectrum of clinical presentations ranging from mild gastroenteritis to severe invasive disease, particularly affecting immunocompromised individuals, pregnant women, newborns, and the elderly. Successful treatment of patients with recurring listeria episodes due to colonised foreign material is often challenging, typically requiring a combination of antimicrobial treatment and surgical removal. CASE PRESENTATION: Here, we present a particularly complex case of chronic invasive listeriosis with a total of six relapses. After extensive investigations, the patient's ICD device was identified as the focus of infection. CONCLUSION: The confirmation of relapses through cgMLST analysis highlights the persistence of Listeria monocytogenes and the potential for recurrence even after apparent resolution of symptoms in patients with foreign material. It emphasises the necessity for a comprehensive assessment to identify and mitigate the risk of relapses, thereby ensuring optimal management and outcomes.

Septic pulmonary embolism associated with periodontal disease: a case report and literature review.

BACKGROUND: Periodontal disease, including periodontitis, has been reported to be a rare cause of septic pulmonary embolism (SPE). It is however extremely difficult to isolate the causative pathogen of periodontal disease-associated SPE from blood cultures of these patients. CASE PRESENTATION: In this study, an 85-year-old Japanese man was admitted with fever and worsening malaise. He was later noted to have multiple bilateral subpleural pulmonary nodules on chest computed tomography scan. After admission, Parvimonas micra (P. micra) was isolated from his blood culture. This was followed by a meticulous search for the primary source of SPE, focusing on the head and neck areas. Consequently, apical periodontitis and infratemporal fossa abscess were identified as the primary sources of SPE. Although P. micra is one of the most frequently detected bacteria in the infected root canals of teeth with chronic apical periodontitis, it has rarely been proven as a causative pathogen of periodontal disease-associated SPE. CONCLUSIONS: This case study demonstrated that periodontal disease is an important primary source of SPE and P. micra could be a causative pathogen of SPE.

Septic pulmonary embolism in China: clinical features and analysis of prognostic factors for mortality in 98 cases.

BACKGROUND: To investigate the clinical features of septic pulmonary embolism (SPE) cases and prognostic factors for in-hospital mortality in China. METHODS: A retrospective analysis was conducted of SPE patients hospitalized between January 2007 and June 2018 in the Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Guangxi Medical University. RESULTS: A total of 98 patients with SPE were identified. All patients had bilateral multiple peripheral nodules on chest computed tomography. The most common pathogen found in blood culture was Staphylococcus aureus (10/33, 30.3%). Transthoracic echocardiography was performed in 39 patients and 20 showed vegetations. Bronchoscopy was performed in 24 patients. Bronchoalveolar lavage fluid (BALF) was obtained from 15 patients (62.5%) and showed predominantly polymorphonuclear cell infiltration (52%, range of 48%~ 63%). Four patients received transbronchial lung biopsy, and histopathological examinations revealed suppurative pneumonia and organizing pneumonia. The in-hospital mortality rate was 19.4%. Age (odds ratio [OR] 1.100; 95% confidence interval [CI] 1.035-1.169), hypotension (OR 7.260; 95% CI 1.126-46.804) and ineffective or delay of empirical antimicrobial therapy (OR 7.341; 95% CI 1.145-47.045) were found to be independent risk factors for in-hospital mortality, whereas drainage treatment was found to be a protective factor (OR 0.33; 95% CI 0.002-0.677). CONCLUSIONS: SPE cases presented with nonspecific clinical manifestations and radiologic features. Blood cultures and bronchoscopy are important measures for early diagnosis and differential diagnosis. There is relationship between primary infection sites and the type of pathogen. Maintaining normal blood pressure and providing timely and appropriate initial antimicrobial therapy for effective control of the infection could improve prognosis.

Embolizing pulmonary aspergillosis, mycobacterial & aspergillous splenic abscess and cytomegalovirus co-infection following steroid induced immunosuppression: a case report.

BACKGROUND: Aspergillosis is a serious infection particularly affecting the immunodeficient host. Its co-infection with tuberculosis and cytomegalovirus has not been reported before. Embolic events are well recognized with aspergillous endocarditis and aortitis. Splenic abscess is a rare serious complication of disseminated aspergillosis and is difficult to treat. We report the first case of multiple embolic events and splenic abscess in a patient with pulmonary aspergillosis and cytomegaloviral and tuberculous co-infection, without endocarditis or aortitis. CASE PRESENTATION: Thirty-year-old male presented with fever and non-productive cough while on glucocorticoids for glomerulonephritis. He was found to have pulmonary aspergillosis and subsequently developed bilateral lower limb and cerebral fungal emboli and fungal abscess in the spleen. He had IgM and B cell deficiency and cytomegalovirus (CMV) and tuberculous co-infections. He recovered after prolonged course of antimicrobials, splenectomy and cessation of glucocorticoid therapy which also lead to the resolution of immune deficiencies. CONCLUSION: This report illustrates rare combination of B and T cell suppressive effects of glucocorticoids leading to co-infections with CMV, Mycobacterium tuberculosis and Aspergillus and systemic fungal embolization from pulmonary aspergillosis.

Right-sided infective endocarditis with coronary sinus vegetation.

BACKGROUND: Infective endocarditis (IE) is a rare disease with high mortality. Right-sided IE accounts for 5-10% of cases of IE. The tricuspid valve is most commonly affected, oppositely in coronary sinus (CS). The diagnoses, treatments and outcomes of CS vegetation has not been summarized yet. CASE PRESENTATION: We present a 71-year-old man complained of cough and fever. Transthoracic echocardiography revealed the aneurysmal dilated CS with the band medium-echo mobile structure. A sinus venosus atrial septal defect has been detected. He had a persistent left superior vena cava which drained the right atrium via the aneurysmal dilated CS. Blood cultures were positive for Staphylococcus aureus. After intravenous antibiotic therapy, he had the symptom of dyspnea. The suspicious diagnosis is recurrent septic lung emboli which was confirmed by thoracic contrast enhanced computed tomography. The thoracotomy was performed to repair the atrial septum and remove the CS vegetation. Ten days later, the patient was discharged with only mild cough. CONCLUSION: Both positive blood cultures and echocardiography are major criteria in right-sided IE with CS vegetation. Current treatment options of CS vegetation include medical therapy and surgery. The surgical strategy for CS vegetation should be individualized, due to the controversial indications and optimum time of surgery. Most people have a good prognosis after proper treatment.

Necrotizing fasciitis with pulmonary septic emboli following an infected insect bite.

Although systemic infections originating from skin infections caused by insect bites are uncommon, it is imperative to maintain a broad differential diagnosis should patients develop systemic symptoms. Necrotizing fasciitis is a rare diagnosis, and progression to septic pulmonary emboli is even less common. Emergent identification and aggressive treatment of these two disease processes are imperative as both carry high rates of morbidity and mortality.

Managing pulmonary embolism secondary to suppurative deep vein thrombophlebitis due to community-acquired Staphylococcus aureus in a resource-poor setting.

Deep vein thrombosis and pulmonary thromboembolism are rare and life threatening emergencies in children. We report an 11-year old female who presented with acute complaints of high grade fever, pain in the left thigh and inability to walk and breathlessness since 6 days. On physical examination, there was a diffuse tender swelling of the left thigh, tachypnea, tachycardia with hyperdynamic precordium and bilateral basal crepitations. Ultrasonography and venous doppler of lower limbs showed mild effusion of left hip joint and thrombus in the left common femoral vein and left external iliac vein suggesting a diagnosis of septic arthritis with thrombophlebitis. The tachypnea and tachycardia which was out of proportion to fever and crepitations on auscultation prompted suspicion of an embolic phenomenon. Radiograph of the chest revealed multiple wedge shaped opacities in the right middle zone and lower zone suggestive of pulmonary embolism and left lower zone consolidation. For corroboration, computed tomography pulmonary angiography and computed tomography of abdomen was performed which showed pulmonary thromboembolism and deep venous thrombosis extending up to infrarenal inferior vena cava. On further workup, magnetic resonance imaging of hips showed left femoral osteomyelitis and multiple intramuscular abscesses in the muscles around the hip joint. Blood culture grew methicillin resistant Staphylococcus aureus. Antibiotics were changed according to culture sensitivity and there was a dramatic response. After four weeks of anticoagulation and antibiotics the child became asymptomatic and thrombus resolved. Thus, it is crucial to consider methicillin resistant Staphylococcus aureus infection as an important infection when we encounter such a clinical scenario. This case report highlights an unusual and potentially life threatening presentation of a virulent strain of a common pathogen, which when diagnosed was completely amenable to treatment.

Emergency Department Diagnosis of Septic Pulmonary Embolism due to Infectious Endocarditis Using Bedside Ultrasound.

BACKGROUND: Septic pulmonary embolism (SPE) is a rare disorder caused by metastasis of infectious thrombi to the lungs. Most commonly, this occurs as a result of infectious endocarditis. This clinical entity may easily be confused for more common and less mortal diagnoses such as pneumonia, bronchitis, or pulmonary embolism. CASE REPORT: A 47-year-old woman presented in respiratory distress with a complaint of cough productive of rusty sputum, shortness of breath, and pleuritic chest pain. A bedside ultrasound suggested endocarditis and SPE. She was resuscitated and admitted to the hospital for surgical source control and continued i.v. antibiotics. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SPE is a rare disorder that may be easily missed but carries a high mortality rate. Additionally, the presence of the embolic phenomena makes the diagnosis of infectious endocarditis more attainable in the emergency department (ED). To our knowledge, this case is the first in which ED bedside ultrasound was used to make the diagnosis of SPE due to infectious endocarditis.

Septic pulmonary emboli detected by 18F-FDG PET/CT in children with S. aureus catheter-related bacteremia.

PURPOSE: The role of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) in the diagnosis of metastatic infectious foci in children with catheter-related blood stream infection has been hardly studied, although some authors have reported it benefit in the screening of metastatic foci in adult population. Septic pulmonary emboli are among the most difficult to identify, because many cases do not present pulmonary complaints or abnormal chest radiography. However, diagnosis of these foci has important therapeutic consequences. The purpose of this article is to describe the role of 18F-FDG PET/CT in the diagnosis of septic pulmonary embolism in children with S. aureus catheter-related bacteremia. METHODS: We report 3 children with S. aureus catheter-related bacteremia and normal chest X-ray at admission, in whom 18F-FDG PET/CT led to the diagnosis of unsuspected septic pulmonary emboli, with an impact on clinical management. RESULTS: All patients had hemophilia and implantable venous access ports and presented with fever and normal lung auscultation. Only 1 reported non-specific symptoms (undifferentiated left chest pain). All patients had normal chest X-ray on admission. Catheters were removed within 48 h after admission in 2 cases, and 5 days after admission in the last case, subsiding fever. In 2 children, paired blood cultures were not able to identify bacteremia. However, in all cases catheter tip and subcutaneous port cultures yielded S. aureus and PET/CT detected unsuspected pulmonary metastatic emboli. CONCLUSIONS: 18F-FDG PET/CT should be considered as a useful tool to diagnose septic pulmonary embolism in S. aureus catheter-related bacteremia, especially if conventional diagnostic imaging techniques have failed to reveal possible metastatic foci. Further studies are needed to clarify the usefulness of PET/CT performance in children with CRBSI.

1918 pandemic influenza virus and Streptococcus pneumoniae co-infection results in activation of coagulation and widespread pulmonary thrombosis in mice and humans.

To study bacterial co-infection following 1918 H1N1 influenza virus infection, mice were inoculated with the 1918 influenza virus, followed by Streptococcus pneumoniae (SP) 72 h later. Co-infected mice exhibited markedly more severe disease, shortened survival time and more severe lung pathology, including widespread thrombi. Transcriptional profiling revealed activation of coagulation only in co-infected mice, consistent with the extensive thrombogenesis observed. Immunohistochemistry showed extensive expression of tissue factor (F3) and prominent deposition of neutrophil elastase on endothelial and epithelial cells in co-infected mice. Lung sections of SP-positive 1918 autopsy cases showed extensive thrombi and prominent staining for F3 in alveolar macrophages, monocytes, neutrophils, endothelial and epithelial cells, in contrast to co-infection-positive 2009 pandemic H1N1 autopsy cases. This study reveals that a distinctive feature of 1918 influenza virus and SP co-infection in mice and humans is extensive expression of tissue factor and activation of the extrinsic coagulation pathway leading to widespread pulmonary thrombosis.

Evaluation of vegetation size and its relationship with septic pulmonary embolism in tricuspid valve infective endocarditis: A real time 3DTEE study.

BACKGROUND: Tricuspid valve infective endocarditis (TVIE) causes septic pulmonary embolism (PE). However, the impact of vegetation size on PE is not fully elucidated. METHODS: In 26 consecutive patients with definite TVIE according to Duke criteria, we tested clinical, microbiological, and echocardiographic data including real time three-dimensional transesophageal echocardiography (3DTEE) as potential predictors of PE. 3DTEE measurement of maximum length of vegetation (MLV) was obtained with Advanced QLAB Quantification Software by cropping the 3D volume with the appropriate 2D plane to obtain the largest value. The standard two-dimensional transesophageal echocardiography (2DTEE) images were also evaluated to determine the MLV. RESULTS: Pulmonary embolism occurred after TVIE diagnosis with 3DTEE assessment and initiation of antibiotic therapy in 12 patients (46.2%). The 3DTEE MLV was larger than the 2DTEE value with a mean difference of 3.6 mm (95% CI, 2.5-4.6 mm). The best cutoff value for prediction of PE was MLV ≥16.4 mm with 3DTEE and MLV ≥9.5 mm with 2DTEE. The positive predictive value increased from 76.9% to 90% when 3DTEE was used. The accuracy of classification of patients with PE increased from 80.6% to 84.9% with 3DTEE. On multivariate analysis, 3DTEE MLV ≥16.4 mm (odds ratio 20.5; 95% confidence interval 1.31-322; P=.031) was independently associated with the occurrence of PE after adjustment for age, sex, complex vegetation, and the number of vegetation-attached leaflets. CONCLUSIONS: In TVIE, vegetation length is a strong predictor of the occurrence of PE. In combination with 2DTEE, 3DTEE may identify high-risk patients who will need a more aggressive therapeutic strategy.

[Extensive burns complicated with infective endocarditis and septic pulmonary embolism: case report and literature review].

Objective: To improve the clinical recognition of infective endocarditis (IE) and septic pulmonary embolism (SPE) in patients with extensive burns. Methods: A case of large area burn complicated with IE and SPE confirmed by blood cultures and echocardiography was described. A literature review was performed with "burn" and "infective endocarditis" as the Chinese key words in Wanfang database; with "burn" and "infective endocarditis" as Mesh terms in PubMed. Results: The patient was a 37-year-old male with large area burn, who presented with fever and hemoptysis. Blood cultures were positive for methicillin resistant Staphylococcus aureus (MRSA). Echocardiography disclosed vegetations located in the tricuspid valve. Multiple wedge-shaped lesions were found on chest CT. From January 1978 to December 2015, 26 related articles were retrieved and 134 burned patients complicated with endocarditis were reported, of which, 97 cases were IE and 1 case with SPE. Of the 134 cases, 120 cases were dead, 12 cases cured and 2 cases unknown. The mortality was 89.6%. Conclusions: There was a high mortality of burned patients complicated with IE. SPE should be considered for patients with multiple peripheral nodules in both lungs and a positive blood culture. Combination and prolonged anti-infective therapy may increase the treatment success and reduce the risk of recurrence.

Periodontitis-associated septic pulmonary embolism caused by Actinomyces species identified by anaerobic culture of bronchoalveolar lavage fluid: a case report.

BACKGROUND: Periodontal disease is a less common but important cause of septic pulmonary embolism (SPE). However, the pathogens causing periodontal disease-associated SPE (PD-SPE) have been poorly understood. Actinomyces species are resident microbiota in the oral cavity. Here we report a case of PD-SPE caused by Actinomyces species, which was identified by anaerobic culture of bronchoalveolar lavage fluid (BAL). CASE PRESENTATION: A 64-year-old Asian man, complicated with severe chronic periodontitis, was admitted with chest pain and fever. Chest CT revealed multiple bilateral pulmonary nodules located subpleurally. We diagnosed the case as SPE associated with periodontitis. Although blood cultures were negative for the usual 5-day incubation, anaerobic culture of the BAL fluid sample yielded Actinomyces species. Antibacterial therapy alone did not ameliorate the symptoms; however, additional dental treatment, including tooth extraction, promptly did. The patient was discharged 23 days after admission. The 3-month follow-up revealed no recurrence of the symptoms and complete resolution of the lung lesions. CONCLUSION: This case demonstrated that Actinomyces species can cause PD-SPE. Additionally, clinicians should consider performing appropriate anaerobic culture of BAL fluid to identify the pathogen of SPE, and to ordering dental treatment, if necessary, in addition to antibiotics for the initial management of PD-SPE.

Linezolid is a novel and effective treatment for septic pulmonary embolism.

Septic pulmonary embolism (SPE) is an uncommon and severe infectious disease that requires early diagnosis and proper antibiotic therapy. We present the case of a healthy 14-year-old girl with a history of atopic dermatitis, who developed SPE caused by Staphylococcus aureus bacteremia. We initially administered intravenous doripenem and vancomycin. Four days after her admission, blood and urine cultures yielded penicillinase nonproducing, methicillin-sensitive S aureus, with a minimum inhibitory concentration less than 0.06 µg/mL. However,the administration of penicillin G aggravated her condition; therefore, treatment was switched to linezolid on day 8. Her condition subsequently resolved, and she was discharged 40 days after admission without any complications. To our knowledge, this is the first report regarding the efficacy of linezolid for SPE that is related to community-acquired methicillin-sensitive S aureus bacteremia. The favorable lung tissue transfer of linezolid may have contributed to its efficacy against the SPE.

Pediatric acute osteomyelitis in the postvaccine, methicillin-resistant Staphylococcus aureus era.

OBJECTIVE: We sought to describe the causative organisms, bones involved, and complications in cases of pediatric osteomyelitis in the postvaccine age and in the era of increasing infection with community-associated methicillin-resistant Staphylococcus aureus (MRSA). METHODS: We reviewed the medical records of children 12 years and younger presenting to our pediatric emergency department between January 1, 2003, and December 31, 2012, with the diagnosis of osteomyelitis. We reviewed operative cultures, blood cultures, and imaging studies. We identified causative organisms, bone(s) involved, time to therapeutic antibiotic treatment, and local and hematogenous complications. RESULTS: The most common organism identified was methicillin-sensitive S aureus (26/55), followed by MRSA (21/55). Seventy-three bone areas were affected in 67 subjects. The most common bone area was the femur (24/73). Forty-six subjects had 75 local complications. The most common organism in cases with local complications was MRSA (49%). Three subjects had hematogenous complications of deep venous thrombosis, septic pulmonary embolus, and endophthalmitis. Subjects with complications had shorter time to therapeutic antibiotic treatment. When an operative culture was done after therapeutic antibiotics were given, an organism was identified from the operative culture in 84% of cases. CONCLUSION: Treatment of pediatric osteomyelitis should include antibiotic coverage for MRSA. Most cases of pediatric osteomyelitis occur in the long bones. Hematogenous complications may include deep venous thrombosis and may be related to treatment with a central venous catheter. Operative culture yield when antibiotics have already been given is high, and antibiotic treatment should not be delayed until operative cultures are obtained.

Septic Pulmonary Embolism Following Appendectomy Surgery.

Septic Pulmonary embolism is a rare condition where there were numerous pulmonary infarcts resulting from blood clot emboli that also contains microorganism. This disorder is insidious onset, Its clinical features usually unspecific and the diagnosis usually difficult to establish. A 43 old woman who underwent an appendicitis surgery, reentered the hospital at the sixth day after surgery presented with fever, pain at the surgical site, progressive severe dyspnea and chest tightness. From the physical examination finding there were tachycardia, tachypneu, wet rough basal rhonki on the right rear and tenderness at right lower region of the abdomen. The thorax-abdomen CT scan result was pleuropneumonial with minimal effusion in the right side. A CT angiography scan of the chest and abdomen showed intralumen emboli in medial lobe segmen of right pulmonary artery, right pleuropneumonia with segmental lession in segmen 10 right lobe and inflammation process along right lateral wall of the abdomen. Laboratory results that also supported diagnosis were D dimer 3442 ng/mL and culture result from surgical site pus showed E. Coli ESBL (+). Base on these findings, this case was established as a septic pulmonary embolism.

Infections with the tick-borne bacterium "Candidatus Neoehrlichia mikurensis" mimic noninfectious conditions in patients with B cell malignancies or autoimmune diseases.

BACKGROUND: Candidatus Neoehrlichia mikurensis is a newly discovered noncultivatable bacterium spread among ticks and rodents in Europe and Asia that can infect humans, particularly immunocompromised patients. METHODS: We compiled clinical and laboratory data from 11 patients with hematological malignances or autoimmune diseases who were diagnosed with Candidatus N. mikurensis infection in Europe 2010-2013. Both published (6) and unpublished cases (5) were included. RESULTS: The patients had a median age of 67, were mostly male (8/11), and resided in Sweden, Switzerland, Germany, and the Czech Republic. All but one had ongoing or recent immune suppressive treatment and a majority were splenectomized (8/11). Less than half of them recalled tick exposure. The most frequent symptoms were fever (11/11), localized pain afflicting muscles and/or joints (8/11), vascular and thromboembolic events (6/11), that is, deep vein thrombosis (4), transitory ischemic attacks (2), pulmonary embolism (1), and arterial aneurysm (1). Typical laboratory findings were elevated C-reactive protein, leukocytosis with neutrophilia, and anemia. Median time from onset of symptoms to correct diagnosis was 2 months. In at least 4 cases, the condition was interpreted to be due to the underlying disease, and immunosuppressive therapy was scheduled. All patients recovered completely when doxycycline was administered. CONCLUSIONS: Candidatus N. mikurensis is an emerging tick-borne pathogen that may give rise to a systemic inflammatory syndrome in persons with hematologic or autoimmune diseases that could be mistaken for recurrence of the underlying disease and/or unrelated arteriosclerotic vascular events. Awareness of this new pathogen is warranted among rheumatologists, hematologists, oncologists, and infectious disease specialists.

Disseminated Cunninghamella bertholletiae infection with septic pulmonary embolism after allogeneic bone marrow transplantation.

Mucormycosis in immunocompromised patients is often reported. We report a patient who developed non-thrombotic pulmonary embolism due to Cunninghamella bertholletiae after allogeneic stem cell transplantation.