An unusual skin infection with Achromobacter xylosoxidans.

Achromobacter xylosoxidans is an emerging, multidrug-resistant pathogen capable of forming biofilms on medical products that primarily infects immunocompromised patients. We present the case of a 50-year-old immunocompetent woman who developed an A xylosoxidans granulomatous abscess at the attachment site of her insulin pump. She was successfully treated with surgical excision and oral trimethoprim-sulfamethoxazole (TMP-SMX). This case demonstrates further emergence of A xylosoxidans as a potential pathogen, not only in immunocompromised individuals but in any patient with an indwelling catheter.

Pneumonia due to Pandoraea Apista after evacuation of traumatic intracranial hematomas:a case report and literature review.

BACKGROUND: Pandoraea species is a newly described genus, which is multidrug resistant and difficult to identify. Clinical isolates are mostly cultured from cystic fibrosis (CF) patients. CF is a rare disease in China, which makes Pandoraea a total stranger to Chinese physicians. Pandoraea genus is reported as an emerging pathogen in CF patients in most cases. However, there are few pieces of evidence that confirm Pandoraea can be more virulent in non-CF patients. The pathogenicity of Pandoraea genus is poorly understood, as well as its treatment. The incidence of Pandoraea induced infection in non-CF patients may be underestimated and it's important to identify and understand these organisms. CASE PRESENTATION: We report a 44-years-old man who suffered from pneumonia and died eventually. Before his condition deteriorated, a Gram-negative bacilli was cultured from his sputum and identified as Pandoraea Apista by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS). CONCLUSION: Pandoraea spp. is an emerging opportunistic pathogen. The incidences of Pandoraea related infection in non-CF patients may be underestimated due to the difficulty of identification. All strains of Pandoraea show multi-drug resistance and highly variable susceptibility. To better treatment, species-level identification and antibiotic susceptibility test are necessary.

Severe purulent pericarditis caused by invasive Eikenella corrodens: case report and literature review.

BACKGROUND: Eikenella corrodens is a slowly growing gram-negative bacillus that can cause severe invasive disease in human. Although E. corrodens infections in various sites of human body have been well described, pericarditis caused by invasive E. corrodens has rarely been reported. CASE PRESENTATION: Here we report the case of a 63-year old male with a complaint of left shoulder pain. The patient was diagnosed as purulent pericarditis by chest computed tomography scan and ultrasound-guided pericardiocentesis, and the pathogen of E. corrodens was identified in the pericardial fluid culture. The clinical condition of the patient deteriorated quickly, and he died right after the drainage surgery even though the pathogen was sensitive to antibiotics treatment. CONCLUSION: E. corrodens is a rare pericarditis associated pathogen. Purulent pericarditis caused by E. corrodens presents atypical manifestations and rapid progression of infection in immunosuppressed individuals such as neutropenic patients. Earlier diagnosis and proper drainage surgery with effective antibiotics treatment may improve the prognosis.

5-ALA Fluorescence in Case of Brain Abscess by Aggregatibacter Mimicking Glioblastoma.

BACKGROUND: At present, the differential diagnosis of magnetic resonance imaging enhancing lesions can still be challenging. Preoperative imaging is a valuable tool characterized by high informative value, even if false-positive and false-negative results are possible. In this context, 5-aminolevulenic acid (5-ALA) represents a significant adjunct in glioblastoma (GBM) surgery displaying an assumed specific accumulation only in tumor cells. However, it was anecdotally reported that in some cases it can also be detected in nonneoplastic lesions mimicking GBM, thus potentially leading to misdiagnosis. Moreover, precise identification of involved pathogens from intraoperative brain samples may remain difficult. We report the case of an abscess from Aggregatibacter mimicking a GBM both during preoperative imaging and intraoperatively, since showing 5-ALA fluorescence. CASE DESCRIPTION: A 54-year-old man presented with intense cephalalgia, vomiting, and scotomas in his left eye. Brain magnetic resonance imaging demonstrated a right temporo-occipital rim-enhancing mass, highly suggestive of a GBM, and for this reason the patient underwent 5-ALA-guided complete removal. Histopathologic analysis proved the lesion to be a bacterial abscess from Aggregatibacter as confirmed by polymerase chain reaction on bacterial deoxyribonucleic acid. CONCLUSIONS: 5-ALA fluorescence may not be specifically involved only in malignant tumor cells, thus raising the suspect for alternative diagnoses to GBM and inviting caution into fluorescence-guided surgery.

A 39-Year-Old Man With Diabetes, Pleuritic Chest Pain, and Multiple Cavitary Lung Nodules.

CASE PRESENTATION: A 39-year-old male presented to the ED with a 2-day history of fever (Temperature-Maximum 39°C), nonbloody productive cough, and worsening right-sided pleuritic chest pain. The patient denied shortness of breath, nausea, vomiting, sinus symptoms, and abdominal pain. His medical history included type 2 diabetes mellitus (glycated hemoglobin, 11.1), hyperlipidemia, and depression. He smoked marijuana but denied tobacco or illicit drug use. He reported no recent travels. He reported a 1-week history of left molar pain that began after he siphoned stagnant water with a straw from a refrigerator drip pan. He lived in Ohio all of his life. He denied any sick contacts. His medications include Lantus insulin at night, metformin, glimepiride, pravastatin, and Remeron.

Unusual case of rapid growing intraabdominal abscess caused by Stenotrophomonas maltophilia after laparoscopic appendectomy due to perforated appendicitis: A case report.

INTRODUCTION: An intraabdominal abscess due to Stenotrophomonas maltophilia (S maltophilia) infection is a very rare clinical manifestation. S maltophilia is a glucose nonfermentative, aerobic, gram-negative, mobile, and biofilm-forming bacterium. It is an opportunistic pathogen and uncommon cause of infection. Respiratory tract infections (pneumonia) and bloodstream infections (bacteremia) are the most common clinical manifestations of S maltophilia infection. CONCLUSIONS: This case report describes an unusual case of a rapidly growing, extremely large intraabdominal abscess (within 1 week during antibiotic therapy), which was detected 2 weeks after a laparoscopic appendectomy was performed for perforated appendicitis and was caused by multidrug-resistant S maltophilia infection.

Expression levels of the receptor activator of NF-κB ligand and osteoprotegerin and the number of gram-negative bacteria in symptomatic and asymptomatic periapical lesions.

OBJECTIVE: The study aimed to verify the potential correlation between the detected amount of gram-negative bacteria and the radiographic sizes of the lesions in patients with symptomatic and asymptomatic apical periodontitis. Furthermore, to evaluate whether the expression of receptor activator of NF-κB ligand (RANKL) and osteoprotegerin (OPG) and the RANKL/OPG ratio are differentially regulated in both groups. DESIGN: Twenty patients with periapical lesions were divided into two groups: symptomatic (SYM) n=10 and asymptomatic (ASYM) n=10. After periapical surgery, the lesions were collected and processed for histological examination, and immunohistochemistry. The percentage of RANKL- and OPG-immunopositive areas relative to the total area of the microscopic field was calculated. For gram staining, the number of gram-negative cells per microscopic field was assessed. The radiographs of each patient were processed and measured. The Student's t-test and the Pearson correlation coefficient were performed. RESULTS: The SYM group showed a significantly higher number of gram-negative cells (p=0.007) when compared to the ASYM group. A higher number of gram-negative bacteria occurred more frequently in larger periapical lesions and the SYM group (p=0.03). The expression for RANKL and OPG and the RANKL/OPG ratio were not significantly different between the groups. There was a significant positive correlation between the number of bacteria and OPG levels in the SYM group (p=0.01). CONCLUSION: The number of bacteria seems to influence the symptoms and the radiographic size of a periapical lesion. Gram-negative bacteria may play an important role in OPG activity in the SYM group.

Comparison of gram-negative and gram-positive hematogenous pyogenic spondylodiscitis: clinical characteristics and outcomes of treatment.

BACKGROUND: To the best of our knowledge, no study has compared gram-negative bacillary hematogenous pyogenic spondylodiscitis (GNB-HPS) with gram-positive coccal hematogenous pyogenic spondylodiscitis (GPC-HPS) regarding their clinical characteristics and outcomes. METHODS: From January 2003 to January 2013, 54 patients who underwent combined antibiotic and surgical therapy in the treatment of hematogenous pyogenic spondylodiscitis were included. RESULTS: Compared with 37 GPC-HPS patients, the 17 GNB-HPS patients were more often found to be older individuals, a history of cancer, and a previous history of symptomatic urinary tract infection. They also had a less incidence of epidural abscess formation compared with GPC-HPS patients from findings on magnetic resonance imaging (MRI). Constitutional symptoms were the primary reasons for initial physician visits in GNB-HPS patients whereas pain in the affected spinal region was the most common manifestation in GPC-HPS patients at initial visit. The clinical outcomes of GNB-HPS patients under combined surgical and antibiotic treatment were not different from those of GPC-HPS patients. In multivariate analysis, independent predicting risk factors for GNB-HPS included a malignant history and constitutional symptoms and that for GPC-HPS was epidural abscess. CONCLUSIONS: The clinical manifestations and MRI presentations of GNB-HPS were distinguishable from those of GPC-HPS.

Mesh cage for treatment of hematogenous spondylitis and spondylodiskitis. How safe and successful is its use in acute and chronic complicated cases? A systematic review of literature over a decade.

BACKGROUND: Surgical treatment of hematogenous pyogenic spondylitis and spondylodiskitis includes anterior debridement, stabilization, and fusion. Titanium mesh cage (TMC) has been advocated to immediately correct deformity and eradicate infection with low recurrence rates. There are no comprehensive reviews on TMC. PURPOSE: To evaluate recorded information regarding surgical outcome with the use of TMC for treating patients with pyogenic spinal infection. STUDY DESIGN: Comprehensive review. METHODS: The terms "titanium cage", "spine", "infection" were searched. A total of 486 peer-reviewed papers published from 2002 to 2012 were obtained from PubMed search. Fifteen Level IV articles with 363 patients were enrolled for consideration. Finally, 192 (53 %) patients who received TMC were eligible and included in this review. Age, comorbidities, indications for surgery, abscess formation, time lapsed between symptoms initiation and surgery, microbiology, radiological spine restoration, neurological outcome, and complications following surgery are evaluated. RESULTS: The average age at the index surgery was 57 years, range 15-85 years. The reported time lapsed from symptoms presentation to diagnosis varied significantly from 1 week to 2 years. On admission, there reported paravertebral and/or epidural abscess in 48 % and neurological impairment in 51 % of the patients. One hundred and seventy-seven comorbidities were recorded in 192 patients. Bone biopsy and culture revealed gram (+) bacteria in 71 %, gram (-) in 24 %, and multiple bacteria in 1 %, while it was negative in 3.1 % of the patients. TMC was most commonly (49 %) implanted in the lumbar spine. The follow-up observation following surgery averaged 26 months, range 10-116 months. Most of the studies reported decrease in segmental kyphosis and neurological improvement in incomplete lesions postoperatively. TMC was primarily revised for early dislodgment or cage misplacement in 3.2 % of the patients. Infection recurrence was recorded in two patients (1.3 %), but revision surgery needed in one (0.65 %) patient. Mortality was reported in 5.8 % of the patients. CONCLUSIONS: TMC offers an advantageous and safe technique for spinal debridement and fusion for hematogenous spinal infection. TMC safeguarded medium-term spinal stability with low infection recurrence rates, which were independent form causative pathogen, age, and comorbidities.

Hepatitis From Spiroplasma sp. in an Immunocompromised Patient.

A 70-year-old lung transplant recipient patient was admitted with fever, nausea, abdominal pain, peripheral edema and pronounced weakness. An initial work-up for presumed infection revealed cholestatic hepatitis, leukocytosis and thrombocytopenia, but failed to detect a pathogen. An increased glucose uptake exclusively in the liver was demonstrated by positron emission tomography. Liver biopsy showed basophilic inclusions in the cytoplasm of hepatocytes. Broad- range 16S rRNA gene PCR followed by sequence analysis yielded Spiroplasma sp. in two independent blood samples and the liver biopsy, confirming Spiroplasma sp. as the causative agent. Antibiotic treatment with doxycycline and azithromycin led to complete recovery.

Diffuse descending necrotizing mediastinitis: surgical therapy and outcome in a single-centre series.

OBJECTIVES: Descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical infections. The aim of this article was to give an up-to-date overview on this still underestimated disease, to draw the clinician's attention and particularly to highlight the need for rapid diagnosis and adequate surgical treatment. METHODS: We present a retrospective analysis of 17 patients diagnosed and treated for advanced DNM between 1999 and 2011 in a tertiary referral medical centre. Hence, this is one of the largest single-centre studies in recent years concerning the diffuse form (i.e. extending into the lower mediastinum) of DNM. Subsequently, we analysed and compared the international literature with our data, with the focus on surgical management and outcome. RESULTS: In our series of 17 adult patients, 16 were surgically treated by median sternotomy (n = 8) or the clamshell (n = 8) approach for diffuse DNM. One patient, referred with septic shock, died 2 days after surgery. The median interval from diagnosis of DNM by cervicothoracic computed tomography scan and thoracic surgery was 6 h (range 1-24 h) in all but the one patient with fatal outcome (48 h). Concomitant cervicotomy was performed in 11 patients (65%) and tracheotomy in 9 (53%). The median duration of hospitalization was 16 days (range 4-50 days), including an intensive care unit stay of 4 days (range 1-50 days). CONCLUSIONS: For DNM limited to the upper part of the mediastinum, which applies to the majority of cases, a transcervical approach and drainage may be sufficient. In advanced disease, extending below the tracheal carina, an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients. A timely situational approach via median sternotomy or a clamshell incision allowed us to maintain a very low morbidity, mortality and rate of reoperations, without major complications due to the surgical approach itself.

Cardiobacterium hominis prosthetic valve endocarditis: an infrequent infection.

A case of prosthetic aortic valve endocarditis due to Cardiobacterium hominis in a 67-year-old woman is described. The diagnosis was confirmed by a positive blood culture and echocardiographic detection of aortic valve vegetations. The patient underwent replacement of the valve with a homograft, and received antibiotics postoperatively. She remained well after 12 months.

The role of percutaneous US-guided drainage in the treatment of splenic abscess. Case report and review of the literature.

Splenic abscess is an uncommon but potentially life-threatening disease that generally occurs in patients with neoplasia, immunodeficiency, hemoglobinopathies, trauma, metastatic infection, splenic infarction and diabetes. Splenic abscess should be considered in a patient with fever, left upper abdominal pain, and leukocytosis. Splenectomy has been the gold standard treatment for splenic abscess, however, burdened by high morbidity rate related clinical conditions of the patient. With the recent development of minimally invasive techniques and percutaneous US- or CT-guided procedures, the placement of a drainage has achieved excellent results with resolution of the disease in a high percentage of cases with low morbidity and negligible mortality. Percutaneous drainage is indicated for uniloculated or biloculated abscesses and for high risk surgical patients. It is a reliable technique with a high rate of therapeutical success and low costs compared to surgery. Other advantages include avoiding risks of intra-abdominal spillage and perioperative complications and saving time, along with a better patient compliance and an easier nursing care. The authors describe a case of splenic abscess treated by percutaneous US-guided drainage. Our results suggest that ultrasound-guided percutaneous drainage is a safe and feasible alternative to surgery in the treatment of splenic abscesses. In addition, it allows spleen preservation.

Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection.

BACKGROUND: Septic thrombophlebitis increases patient morbidity and mortality following metastatic infections, pulmonary emboli, and/or septic shock. Central venous catheter (CVC) removal for occult septic thrombophlebitis challenges current strategy in neutropenic patients. PATIENTS AND METHODS: We prospectively evaluated infection-related mortality in 100 acute leukemia patients, with CVC-related bloodstream infection (CRBSI) after chemotherapy, who systematically underwent ultrasonography to identify the need for catheter removal. Their infection-related mortality was compared with that of a historical cohort of 100 acute leukemia patients, with CRBSI after chemotherapy, managed with a clinically driven strategy. Appropriate antimicrobial therapy was administered in all patients analyzed. RESULTS: In the prospective series, 30/100 patients required catheter removal for ultrasonography-detected septic thrombophlebitis after 1 median day from BSI onset; 70/100 patients without septic thrombophlebitis retained their CVC. In the historical cohort, 60/100 patients removed the catheter (persistent fever, 40 patients; persistent BSI, 10 patients; or clinically manifest septic thrombophlebitis, 10 patients) after 8 median days from BSI onset; 40/100 patients retained the CVC because they had not clinical findings of complicated infection. At 30 days median follow-up, one patient died for infection in the ultrasonography-assisted group versus 17 patients in the historical cohort (P<0.01). With the ultrasonography-driven strategy, early septic thrombophlebitis detection and prompt CVC removal decrease infection-related mortality, whereas clinically driven strategy leads to inappropriate number, reasons, and timeliness of CVC removal. CONCLUSION: Ultrasonography is an easy imaging diagnostic tool enabling effective and safe management of patients with acute leukemia and CRBSI.

Delayed Eikenella corrodens orbital infection after fracture repair.

Orbital cellulitis and abscess after fracture repair are rare. Ophthalmic infection with Eikenella species is even more unusual, but can be severe. We report a case of Eikenella corrodens infection in a 28-year-old man who underwent zygomaticomaxillary and orbital floor blowout fracture surgery 4 years before presentation. Eikenella species are often resistant to frequently used empiric antibiotics, and because of specific growth conditions, easily missed on standard cultures. Appropriate efforts should be made to identify and treat E. corrodens in atypical orbital and periocular infections.