Sepsis Caused by Bacterial Colonization of Migrated Distal Ventriculoperitoneal Shunt Catheter into the Pulmonary Artery: A First Case Report and Literature Review.

BACKGROUND: Migration of distal ventriculoperitoneal (VP) shunt catheter into another body part has been described as a potentially serious surgical complication. We present the first case of sepsis caused by transcardial and pulmonary migration of a distal catheter into the heart and pulmonary artery, which was subsequently colonized by Klebsiella pneumoniae. CASE REPORT: A 56-year-old man underwent VP shunt insertion for hydrocephalus that developed after the surgery for intracranial meningioma. Three years later, he was admitted to department for infectious diseases because of persistent fever. Klebsiella pneumoniae was isolated from the blood cultures. Computed tomography (CT) of the thorax showed migration of the distal catheter into the heart and pulmonary artery. The migrated shunt catheter was retrieved without any complication with the assistance of a cardiovascular surgeon; microbiologic analysis confirmed that the catheter was colonized with K. pneumoniae. We decided to delay new VP shunt placement because of the positive blood cultures, and 3 weeks after the surgery, the patient was without signs of increased intracranial pressure and without any heart problems. CONCLUSION: Migration of a distal VP shunt catheter into the heart should be considered in patients with a previously placed VP shunt presenting with cardiopulmonary problems, arrhythmia, and/or fever. Neurosurgeons should be involved as soon as possible, and a multidisciplinary approach is warranted.

Enhanced Permeability and Retention-like Extravasation of Nanoparticles from the Vasculature into Tuberculosis Granulomas in Zebrafish and Mouse Models.

The enhanced permeability and retention (EPR) effect is the only described mechanism enabling nanoparticles (NPs) flowing in blood to reach tumors by a passive targeting mechanism. Here, using the transparent zebrafish model infected with Mycobacterium marinum we show that an EPR-like process also occurs allowing different types of NPs to extravasate from the vasculature to reach granulomas that assemble during tuberculosis (TB) infection. PEGylated liposomes and other NP types cross endothelial barriers near infection sites within minutes after injection and accumulate close to granulomas. Although ∼100 and 190 nm NPs concentrated most in granulomas, even ∼700 nm liposomes reached these infection sites in significant numbers. We show by confocal microscopy that NPs can concentrate in small aggregates in foci on the luminal side of the endothelium adjacent to the granulomas. These spots are connected to larger foci of NPs on the ablumenal side of these blood vessels. EM analysis suggests that NPs cross the endothelium via the paracellular route. PEGylated NPs also accumulated efficiently in granulomas in a mouse model of TB infection with Mycobacterium tuberculosis, arguing that the zebrafish embryo model can be used to predict NP behavior in mammalian hosts. In earlier studies we and others showed that uptake of NPs by macrophages that are attracted to infection foci is one pathway for NPs to reach TB granulomas. This study reveals that when NPs are designed to avoid macrophage uptake, they can also efficiently target granulomas via an alternative mechanism that resembles EPR.

Infected pulmonary aneurysm following pulmonary artery banding.

A 1-month-old girl, diagnosed with a common atrioventricular canal, moderate atrioventricular valvular regurgitation, and pulmonary hypertension, underwent pulmonary artery banding. Postoperatively, methicillin-resistant Staphylococcus aureus wound infection was treated with antibiotics. One month later, emergency surgery was performed for oozing rupture of an infected pulmonary aneurysm. The pulmonary aneurysm was completely resected, the banding tape was removed, and pulmonary angioplasty was performed to create pulmonary stenosis without using foreign material. Methicillin-resistant Staphylococcus aureus was cultured from the resected tissues and banding tape. The patient was discharged after antibiotic administration. Correction was performed at 1 year of age, and she remains well.

A case of pulmonary infective endarteritis associated with patent ductus arteriosus: surgical closure under circulatory arrest.

A 35-year-old man was admitted to the hospital with prolonged high-grade fever. Chest computed tomography revealed multiple pulmonary infiltrations in both lungs, suggesting septic emboli. Echocardiography revealed patent ductus arteriosus and mobile large vegetations in the pulmonary artery. Because of uncontrollable infection and the imminent possibility of massive pulmonary embolism, he underwent transpulmonary surgical closure of the ductus and resection of the vegetations under hypothermic circulatory arrest using cardiopulmonary bypass. We report a rare case of open heart surgery in a patient with pulmonary infective endarteritis associated with patent ductus arteriosus.

The lectin-like domain of TNF protects from listeriolysin-induced hyperpermeability in human pulmonary microvascular endothelial cells - a crucial role for protein kinase C-alpha inhibition.

Listeriosis can lead to potentially lethal pulmonary complications in newborns and immune compromised patients, characterized by extensive permeability edema. Listeriolysin (LLO), the main virulence factor of Listeria monocytogenes, induces a dose-dependent hyperpermeability in monolayers of human lung microvascular endothelial cells in vitro. The permeability increasing activity of LLO, which is accompanied by an increased reactive oxygen species (ROS) generation, RhoA activation and myosin light chain (MLC) phosphorylation, can be completely inhibited by the protein kinase C (PKC) alpha/beta inhibitor GO6976, indicating a crucial role for PKC in the induction of barrier dysfunction. The TNF-derived TIP peptide, which mimics the lectin-like domain of the cytokine, blunts LLO-induced hyperpermeability in vitro, upon inhibiting LLO-induced protein kinase C-alpha activation, ROS generation and MLC phosphorylation and upon restoring the RhoA/Rac 1 balance. These results indicate that the lectin-like domain of TNF has a potential therapeutic value in protecting from LLO-induced pulmonary endothelial hyperpermeability.

Significance of infection markers and microbiological findings during tissue processing of cryopreserved arterial homografts for the early postoperative course.

BACKGROUND: To evaluate homograft implantation for the urgent treatment of vascular infections on the basis of the course of infection using microbiological findings in perioperatively obtained specimens and during homograft processing. PATIENTS AND METHODS: 85 patients were treated with cryopreserved homografts from 2004-2007. The microbiological findings of the decontamination process of homografts in the tissue bank were evaluated. The perioperative infection profile (microorganisms, CRP, leukocytes, body temperature) of the patients was analysed. RESULTS: Complete microbiological and clinical follow-up for the postoperative course was available for 35 patients, who were treated with homografts from the same tissue bank and finally included into this study. 55 cryopreserved homografts were implanted. 35/55 (64%) homografts were positive for microorganisms before decontamination. 3/35 (9%) homografts remained positive after the decontamination. 33 patients were operated for prosthetic graft infection and 2 for an infiltration of a large vessel from neighbouring malignant disease. The most common infection agent was Staphylococcus aureus. Thirty-day mortality was 20% (7/35). Only in 4/35 (11%) patients were the microorganisms of the intraoperative swabs also detected during the postoperative course. The microorganisms were ORSA, Enterococcus faecium, Enterobacter aerogenes and Burkholderia cepacia. The patient with ORSA infection died on POD 11 from multiple organ failure and all other patients recovered. None of the postoperative swabs showed the homograft predecontamination microorganisms. Interestingly, a significant association (P = 0.003) between C-reactive protein increase two weeks after surgery and donor-recipient ABO mismatch was found. CONCLUSIONS: The implantation of homografts following the established decontamination is an alternative urgent therapeutic option in vascular infections with encouraging outcomes. The absence of the predecontamination focus in the postoperative specimens of patients, suggests that the postoperative course and outcomes show no strong relation to potential homograft contamination prior to the decontamination process.

Infected aortic aneurysm, purulent pericarditis, and pulmonary trunk rupture caused by methicillin-resistant Staphylococcus aureus.

A 66-year-old woman presented with cardiac tamponade. Pericardiocentesis revealed purulent pericarditis. Enhanced computed tomography showed a saccular aneurysm of the aortic arch. An irregularly shaped and partially enhanced mass was seen adjacent to the aneurysm, which suggested development of a mycotic pseudoaneurysm. Surgical drainage was performed through a subxiphoid incision, and continuous irrigation was commenced. On the following day, however, massive bleeding was recognized through the drains. The patient was immediately transferred to the operating theater, and extracorporeal circulation was established. A perforation 1 cm in diameter was found on the anterior surface of the pulmonary trunk, and a large amount of pus came out from the tear. The ascending aorta and the arch were found to be infected. Surgical repair was impossible due to extensive infection, and the patient died. Methicillin-resistant Staphylococcus aureus was isolated from the pericardial effusion, blood, and intraluminal thrombus of the aortic aneurysm.

Successful surgical management of invasive aspergillosis of the pulmonary arteries.

We describe an 11-year-old girl with severe obstruction of the main pulmonary arteries caused by invasive aspergillosis and managed with combined pulmonary endarterectomy and antimycotic treatment.

Mycotic pulmonary artery aneurysm as a late complication of infective endocarditis after pacemaker implantation.

A 49-year-old-woman who had had a pacemaker implanted 15 years earlier became acutely ill with a continuous high fever and general fatigue. A pulmonary artery aneurysm had been rapidly developing and had arrived at the acute phase within 2 weeks. After removal of the pacemaker and with antibiotic therapy the aneurysm gradually decreased in size and has been without rupture for 3 years. Conservative treatment seemed to be sufficient for the management of a mycotic aneurysm in this case.

Bartonella endocarditis in complex congenital heart disease.

Bartonella species are an important cause of culture-negative endocarditis, with recognized risk factors of alcoholism, homelessness, cat exposure, and pre-existing valvular disease. We report a case of Bartonella henselae endocarditis in a 36-year-old woman with complex congenital heart disease who presented with a 7-month history of hemolytic anemia, leukocytoclastic vasculitis, and recurrent fevers. Transesophageal echocardiogram revealed vegetations on the patient's native aortic valve and in the right ventricular to pulmonary artery conduit and associated bioprosthetic valve. Diagnosis of B. henselae was confirmed with serum antibody and polymerase chain reaction (PCR) testing and tissue stains. The patient was treated successfully with surgical resection and prolonged antimicrobial therapy with ceftriaxone, gentamicin, and doxycycline. A review of the literature suggests prosthetic valves and complex congenital heart disease are risk factors for Bartonella endocarditis, and a high index of suspicion with antibody and PCR testing can expedite diagnosis and improve outcomes.

Successful treatment of mucormycosis in the pulmonary artery after cardiac surgery.

Mucormycosis endocarditis after cardiovascular surgery is a rare and usually fatal complication. Here, we report one case of mucormycosis occurring in the pulmonary artery and the residual patent ductus arteriosus (PDA) in a 9-year-old girl, who had been successfully cured with the combination of the emergent surgical removal of infected tissues and the subsequent antifungal drug therapy.

Non-valvular isolated pulmonary artery vegetations.

BACKGROUND: One of the serious potential complications of complex congenital heart defect (CHD) is bacterial endocarditis. Right sided endocarditis accounts for 5-10% of all cases of infective endocarditis, with the tricuspid valve more frequently affected than the pulmonary valve. Pulmonary artery involvement in bacterial endocarditis is very rare, but when it exists it is almost always associated with endocarditis of the pulmonary valve: isolated pulmonary artery vegetations have not previously been reported before. CASE REPORT: A 6-year-old boy with atrial septal defect (ASD), ventricular septal defect (VSD), coarctation of the aorta (CA), persistent ductus arteriosus (PDA) and pulmonary hypertension, who had been operated for closure of PDA, correction of CA and pulmonary artery banding, was readmitted with bacterial endocarditis. In surgery, the VSD was closed with a Dacron patch using interrupted pledget buttressed sutures, and the ASD was closed using primary sutures. After debanding, while pulmonary arteriotomy was performed for patch angioplasty, we observed that the entire pulmonary artery trunk, right and left pulmonary artery branches, were filled with a solid mass, which was successfully treated by surgical excision. CONCLUSIONS: With ongoing improvements in diagnostic tools, especially in echocardiography, antibiotic therapy and surgery, CHD can now be treated successfully in early infancy or childhood.

Surgical treatment of an aortopulmonary artery fistula complicating a syphilitic aortic aneurysm.

Spontaneous rupture of an aortic aneurysm into the pulmonary artery is unusual and is rarely reported in the literature. The case of a patient with a syphilitic aneurysm of the ascending aorta perforated into the pulmonary artery is presented. In an attempt to define the best surgical treatment for this complication the literature has been comprehensively reviewed.

Morphologic and microbiologic features of Pseudomonas aeruginosa pneumonia in normal hamsters.

A model of pneumonia due to Pseudomonas aeruginosa was produced in hamsters by an intratracheal bolus instillation of microorganisms. Sequential lung changes from 4 hr through 11 days were studied by morphologic and microbiologic methods. Hamsters inoculated with greater than 10(6) pseudomonads survived but consistently had histologic evidence of mild bronchopneumonia 24 hr postinoculation, whereas a severe bronchopneumonia and a 100% mortality were elicited with a 10(8) inoculum of organisms in 0.5 ml phosphate-buffered saline (PBS). An inoculum of 10(7) pseudomonads/0.5 ml PBS was then used to define the changes in the bacterial population in Pseudomonas pneumonia and to obtain serial histopathologic observations. Quantitative lung cultures obtained within 1 hr postinoculation demonstrated a mean of 10(6) colony forming units per lung, and none of the hamsters were bacteremic. However, by 24 hr bacterial counts had increased and all animals were bacteremic. Bacterial proliferation continued through 48 hr; however, the number of bacteremic animals had decreased. By 72 hr, bacterial counts had decreased with total Pseudomonas clearance noted by 120 hr. A striking polymorphonuclear leukocyte-rich alveolar exudate was present by 12 hr. Pseudomonas "vasculitis" was evident by 24 hr. The evolution of this vascular lesion correlated with the bacteremic state of the hamsters. By 11 days, resolution of the pneumonic process was seen. The macroscopic and microscopic features of this hamster model of Pseudomonas pneumonia are very similar to those reported in infected patients.