A pediatric case of central skull base osteomyelitis caused by Streptococcus milleri group infection and mimicking malignancy.

Central skull base osteomyelitis (CSBO) that has expanded to the middle cranial fossa is a rare complication of nasopharyngeal infection in children. Diagnosing CSBO is challenging in children, because specific symptoms are lacking and imaging findings can mimic skull base malignancy. We report on a 3-year-old girl who complained of pyrexia, headache, and vomiting and in whom a mass around the clivus was detected with magnetic resonance imaging. The patient received a diagnosis of CSBO based on characteristic imaging findings and the detection of a Streptococcus milleri group (SMG) in blood cultures. Clinical symptoms and abnormal imaging findings, including a mass lesion, were improved by prompt antibiotic treatment. The present patient had paranasal sinusitis with bacteremia of SMG, leading to the speculation of hematogeneous dissemination of SMG from the paranasal sinus. Awareness of CSBO, its early diagnosis, and aggressive management are required because CSBO is associated with high morbidity due to a life-threating infection involving multiple cranial nerves.

Pseudomonas aeruginosa Can Inhibit Growth of Streptococcal Species via Siderophore Production.

Cystic fibrosis (CF) is a genetic disease that causes patients to accumulate thick, dehydrated mucus in the lung and develop chronic, polymicrobial infections due to reduced mucociliary clearance. These chronic polymicrobial infections and subsequent decline in lung function are significant factors in the morbidity and mortality of CF. Pseudomonas aeruginosa and Streptococcus spp. are among the most prevalent organisms in the CF lung; the presence of P. aeruginosa correlates with lung function decline, and the Streptococcus milleri group (SMG), a subgroup of the viridans streptococci, is associated with exacerbations in patients with CF. Here we characterized the interspecies interactions that occur between these two genera. We demonstrated that multiple P. aeruginosa laboratory strains and clinical CF isolates promote the growth of multiple SMG strains and oral streptococci in an in vitro coculture system. We investigated the mechanism by which P. aeruginosa enhances growth of streptococci by screening for mutants of P. aeruginosa PA14 that are unable to enhance Streptococcus growth, and we identified the P. aeruginosapqsL::TnM mutant, which failed to promote growth of Streptococcus constellatus and S. sanguinis Characterization of the P. aeruginosa ΔpqsL mutant revealed that this strain cannot promote Streptococcus growth. Our genetic data and growth studies support a model whereby the P. aeruginosa ΔpqsL mutant overproduces siderophores and thus likely outcompetes Streptococcus sanguinis for limited iron. We propose a model whereby competition for iron represents one important means of interaction between P. aeruginosa and Streptococcus spp.IMPORTANCE Cystic fibrosis (CF) lung infections are increasingly recognized for their polymicrobial nature. These polymicrobial infections may alter the biology of the organisms involved in CF-related infections, leading to changes in growth, virulence, and/or antibiotic tolerance, and could thereby affect patient health and response to treatment. In this study, we demonstrate interactions between P. aeruginosa and streptococci using a coculture model and show that one interaction between these microbes is likely competition for iron. Thus, these data indicate that one CF pathogen may influence the growth of another, and they add to our limited knowledge of polymicrobial interactions in the CF airway.

The Yin and Yang of Streptococcus Lung Infections in Cystic Fibrosis: a Model for Studying Polymicrobial Interactions.

The streptococci are increasingly recognized as a core component of the cystic fibrosis (CF) lung microbiome, yet the role that they play in CF lung disease is unclear. The presence of the Streptococcus milleri group (SMG; also known as the anginosus group streptococci [AGS]) correlates with exacerbation when these microbes are the predominant species in the lung. In contrast, microbiome studies have indicated that an increased relative abundance of streptococci in the lung, including members of the oral microflora, correlates with impacts on lung disease less severe than those caused by other CF-associated microflora, indicating a complex role for this genus in the context of CF. Recent findings suggest that streptococci in the CF lung microenvironment may influence the growth and/or virulence of other CF pathogens, as evidenced by increased virulence factor production by Pseudomonas aeruginosa when grown in coculture with oral streptococci. Conversely, the presence of P. aeruginosa can enhance the growth of streptococci, including members of the SMG, a phenomenon that could be exacerbated by the fact that streptococci are not susceptible to some of the frontline antibiotics used to treat P. aeruginosa infections. Collectively, these studies indicate the necessity for further investigation into the role of streptococci in the CF airway to determine how these microbes, alone or via interactions with other CF-associated pathogens, might influence CF lung disease, for better or for worse. We also propose that the interactions of streptococci with other CF pathogens is an ideal model to study clinically relevant microbial interactions.

Clinical characteristics and treatment outcomes in a cohort of patients with pyogenic and amoebic liver abscess.

BACKGROUND: We describe the clinical features of a cohort of patients with liver abscesses and investigate relationships between clinical, radiological and microbiological findings and mortality. METHODS: Retrospective review of pyogenic (PLA) or amoebic liver abscesses (ALA) diagnosed and treated at a major infectious diseases department in London over 9 years. RESULTS: One hundred forty-one patient records were identified; 132 (93.6%) had PLA and 9 (6.4%) ALA. No organism was identified in 38.6% (51/132); a single bacterial species was isolated in 47.0% (62/132) of PLA, ≥ 2 in 14.4% (19/132). There was weak evidence of variation in abscess size by type of microorganism, with streptococcal PLA typically larger (p = 0.03 for Streptococcus milleri group, p = 0.05 for non-milleri streptococci). Patients with ALA were younger (median 41, IQR 37-51 years) than those with PLA (median 68, IQR 50.5-78 years) (p = 0.003) and all were male (9/9, 100%, (p = 0.03)), with a history of recent travel in the majority (6/9, 66.7% (p = 0.003)). C-reactive protein was higher in ALA than in PLA (p = 0.06). In the entire cohort, loculation (HR = 2.51 (95% CI 1.00-6.32), p = 0.04) and baseline ALP (HR = 4.78 (95% CI 1.19-19.2) per log10 increase, p = 0.03) were associated with mortality. 16S ribosomal RNA (rRNA) analysis was used in a subset of culture-negative cases and increased the diagnostic yield by 13%. CONCLUSIONS: Clinical or radiological features cannot be used to distinguish between PLA and ALA, or help identify the bacterial cause of PLA. However, ALA is more common in young, male patients with a history of travel. 16S rRNA analysis of abscess fluid has a role in improving microbiological diagnosis in culture-negative cases.

Polymicrobial Cerebral Abscess in a Child with Uncorrected Tetralogy of Fallot.

Aggregatibacter aphrophilus and Beta haemolytic Streptococci Lancefield group F are part of the normal oral flora and are known to cause endocarditis, sinusitis, empyema, meningitis and septic arthritis. They are now emerging as a cause of brain abscess particularly in patients with congenital heart diseases. We report a case of a 10-year-old boy with Tetralogy of Fallot (TOF), who presented with fever, headache and drowsiness. Culture yielded the growth of Aggregatibacter aphrophilus and Beta hemolytic streptococci Lancefield group F. He became clinically stable after treatment with ceftriaxone.

Cervical necrotizing fasciitis: descriptive, retrospective analysis of 59 cases treated at a single center.

To provide retrospective, descriptive information on patients with cervical necrotizing fasciitis treated at a single center during the years 1998-2014, and to evaluate the outcome of a newly introduced treatment strategy. Retrospective analysis of clinical data obtained from medical records. Mortality, pre-morbidity, severity of illness, primary site of infection, type of bacteria, time parameters. The observed 3-month mortality was 6/59 (10 %). The most common initial foci of the infection were pharyngeal, dental or hypopharyngeal. The most common pathogen was Streptococcus milleri bacteria within the Streptococcus anginosus group (66 % of the cases). Using a combined treatment with early surgical debridement combined with hyperbaric oxygen treatment, it is possible to reduce the mortality rate among patients suffering from cervical necrotizing fasciitis, compared to the expected mortality rate and to previous historical reports. Data indicated that early onset of hyperbaric oxygen treatment may have a positive impact on survival rate, but no identifiable factor was found to prognosticate outcome.

Effects of gatifloxaine content in gatifloxacine-loaded PLGA and ß-tricalcium phosphate composites on efficacy in treating osteomyelitis.

Composites of gatifloxacin (GFLX)-loaded poly (lactic-co-glycolic) acid (PLGA) and ß-tricalcium phosphate (ßTCP) containing 0, 1, and 10 wt % GFLX (0, 1, and 10 wt % GFLX composites), and GFLX-loaded PLGA containing 1, 5, and 10 wt % GFLX (1, 5, and 10wt % GFLX-PLGA) as controls were fabricated and characterized in vitro and in vivo. On in vitro evaluation, the 10 wt % GFLX composite released GFLX over at least 28 days in Hanks' balanced solution and exhibited clinically sufficient bactericidal activities against Streptococcus milleri and Bacteroides fragilis from 1 h to 10 days. The 0, 1, and 10 wt % GFLX composites and 10 wt % GFLX-PLGA were implanted in bone defects created by debridement of osteomyelitis lesions induced by S. milleri and B. fragilis in the mandible of rabbits (n = 5). Four weeks after implantation of the 10 wt % GFLX composite, inflammation in the debrided area disappeared in all the rabbits, while inflammation remained in all the rabbits after implantation of the 0 wt % GFLX composite and 10 wt % GFLX-PLGA, and in three rabbits after implantation of the 1 wt % GFLX composite. Bone formation appears to be less intense for the 10 wt % GFLX composite than for the 1 wt % GFLX composite probably owing to the rapid degradation of the 10 wt % GFLX composite. These findings show that the GFLX composite is effective for the local treatment of osteomyelitis.

A Pathological Fracture of the Mandible due to Osteomyelitis following a Full Dental Clearance.

Orofacial infections following dental extractions are a common referral to an oral and maxillofacial department as an emergency, especially when combined with swelling and limited mouth opening. The case presented demonstrates a rare complication of chronic suppurative osteomyelitis with bilateral pathological fractures of the mandible, which occurred following a staged dental clearance. CPD/Clinical Relevance: Dental extractions are one of the most common treatments carried out by oral surgeons and general dental practitioners. This case highlights a rare but encountered complication of routine oral surgery and demonstrates when it is necessary to make an immediate referral to the local oral and maxillofacial surgery unit.

Parafalcine empyema, a tricky infectious cause of headache: a case report.

Headache caused by subdural empyema is usually associated with fever and symptoms and/or clinical signs of meningeal irritation and increased intracranial pressure. We describe a patient with headache with absence of these signs or symptoms of meningeal irritation or intracranial pressure, who turned out to have a parafalcine subduralempyema. A 28-year-old man had headache for 2 weeks, which had started with visual symptoms with duration of 5 minutes. Two days later, he developed fever. During these 2 weeks, he had recurrence of visual symptoms for 4 times, with duration of several minutes.Neurologic examination at presentation on the emergency department showed no meningeal irritation or papilledema. However, on closer examination, a limited homonymous hemianopsia on the left side and a drift of the left leg were found. Magnetic resonance imaging showed parafalcine subdural empyema on the right side of the falx and a small brain abscess right occipitally. Neuronavigated craniotomy was performed, which confirmed the presence of empyema and allowed culture of the specimens. Streptococcus milleri group was cultured,which allowed narrowing of the antibiotic therapy to Benzylpenicillin12 million entities per 24 hours. Headache and subdural empyema diminished during treatment, and at follow-up 12 weeks after start of treatment, patient had no remaining complaints. Parafalcine-located subdural empyema can present without presence of clear localizing symptoms or signs like meningeal irritation and increased intracranial pressure. When headache is accompanied with fever, one should extensively question neurologic symptoms, and a thorough neurologic examination should be done.

The clinical features of respiratory infections caused by the Streptococcus anginosus group.

BACKGROUND: The Streptococcus anginosus group (SAG) play important roles in respiratory infections. It is ordinarily difficult to distinguish them from contaminations as the causative pathogens of respiratory infections because they are often cultured in respiratory specimens. Therefore, it is important to understand the clinical characteristics and laboratory findings of respiratory infections caused by the SAG members. The aim of this study is to clarify the role of the SAG bacteria in respiratory infections. METHODS: A total of 30 patients who were diagnosed with respiratory infections which were caused by the SAG bacteria between January 2005 and February 2015 were retrospectively evaluated. RESULTS: Respiratory infections caused by the SAG were mostly seen in male patients with comorbid diseases and were typically complicated with pleural effusion. Pleural effusion was observed in 22 (73.3%) patients. Empyema was observed in half of the 22 patients with pleural effusion. S. intermedius, S. constellatus and S. anginosus were detected in 16 (53.3 %), 11 (36.7 %) and 3 (10.0 %) patients, respectively. Six patients had mixed-infections. The duration from the onset of symptoms to the hospital visit was significantly longer in "lung abscess" patients than in "pneumonia" patients among the 24 patients with single infections, but not among the six patients with mixed-infection. The peripheral white blood cell counts of the "pneumonia" patients were higher than those of the "lung abscess" patients and S. intermedius was identified significantly more frequently in patients with pulmonary and pleural infections (pneumonia and lung abscess) than in patients with bacterial pleurisy only. In addition, the patients in whom S. intermedius was cultured were significantly older than those in whom S. constellatus was cultured. CONCLUSIONS: Respiratory infections caused by the SAG bacteria tended to be observed more frequently in male patients with comorbid diseases and to more frequently involve purulent formation. In addition, S. intermedius was mainly identified in elderly patients with having pulmonary infection complicated with pleural effusion, and the aspiration of oral secretions may be a risk factor in the formation of empyema thoracis associated with pneumonia due to S. intermedius.

[Infectious endocarditis complicated with preoperative infectious intracranial aneurysm;report of a case].

A 44-year-old man was admitted with the diagnosis of active infective endocarditis( IE) due to Streptococcus mitis, complicated with infectious intracranial aneurysm. Preoperative echocardiography showed mobile vegetation on the mitral leaflet, size of which was 20 mm. The magnetic resonance imaging( MRI) demonstrated that the size of aneurysm was increasing, and infectious intracranial aneurysm was treated surgically. Twenty one days after the operation, the mitral valve plasty was performed. He was discharged on foot without any neurological findings. The duration between the brain surgery and the cardiac surgery was thought to be important to prevent the new neurological complication.

Host cytokine responses distinguish invasive from airway isolates of the Streptococcus milleri/anginosis group.

BACKGROUND: The Streptococcus Milleri/Anginosus Group (SMG) colonize mucosal surfaces, especially the airways, and are considered to be normal mucosal microbiota; however, they are a major cause of abscesses, pneumonia and pleural empyema. The production of exoenzymes and virulence factors do not correlate with SMG pathogenicity. Since SMG infections are associated with robust inflammatory responses, we hypothesized that host immune responses might distinguish strains associated with asymptomatic carriage and those associated with fulminant disease. METHODS: We measured IL1ß, TNF, IL10, IL12, IL23, IL17, and IL4 production from human peripheral blood mononuclear cells (PBMCs) stimulated with a panel of clinical isolates from the airways and infections and measured the ability of these isolates to stimulate TLR2. RESULTS: Isolates were categorized based on the levels of cytokines they induced from PBMCs (high, intermediate, low). Airway isolates predominantly induced low levels of cytokines and isolates from invasive disease induced higher levels, although about 10% of the strains produced divergent cytokine responses between donors. Interestingly, the donors were most divergent in their production of IL17, IL12 and IL23. CONCLUSIONS: We propose that the ability to inhibit or avoid an inflammatory response is associated with carriage in the airways and variability in responses between isolates and donors might contribute to susceptibility to disease.

A retrospective study on the aetiology, management, and outcome of brain abscess in an 11-year, single-centre study from China.

BACKGROUND: Brain abscesses continue to pose diagnostic and therapeutic challenges in developed and developing countries. Their aetiology and management remain complex and unclear, making improvement of treatments and outcome difficult. METHODS: To determine the demographics, management, and the variables that affect the outcome in subjects with brain abscesses treated at a single centre over an 11-year period, we retrospectively analysed data in 60 patients with brain abscesses surgically treated with stereotactically guided aspiration or open craniotomy excision in Shanghai Changzheng Hospital between January 2001 and December 2011. Such variables as age, gender, Glasgow Coma Scale (GCS) score at admission, clinical presentation, location, number of lesions, predisposing factors, mechanism of infection, aetiological agent, and therapy were analysed independently. RESULTS: Our analysis demonstrated that patient age and gender were factors that influence the occurrence of brain abscess; female patients and patients greater than 40 years of age were most likely to suffer a brain abscess. We also found that a patient's GCS score upon admission did not influence outcome. While frequency of successful culturing of the infectious agent was low, positive cultures were obtained in only 8 of the cases (13.33%), in which the most common isolate was Streptococcus milleri. Outcome was favourable in 78.33% of the subjects, while the mortality rate was 20%. The outcome of one patient was poor due to the abscess in the basal ganglia region. CONCLUSIONS: Stereotactically guided aspiration is an effective treatment for brain abscess with an overall favourable outcome. Mortality due to brain abscess was not directly related to surgery nor surgical technique. Additional studies will continue to reveal patients trends that may improve treatment for brain abscess.

Acute phlegmonous esophagitis as a rare but threatening complication of chemoradiotherapy: report of a case.

Phlegmonous infection involving the digestive tract has been reported to have a poor prognosis. However, the pathogenesis and clinical features of acute phlegmonous esophagitis have remained unclear due to the rarity of the disease. We herein report a case of acute phlegmonous esophagitis that showed a fulminant course during chemoradiotherapy for uterine cancer. The patient developed septic shock 10 h after postprandial nausea and vomiting, and a computed tomographic scan showed diffuse thickening of the esophageal wall. Severe leukopenia that was refractory to the administration of granulocyte colony-stimulating factor persisted during the first few days. The patient fortunately survived after intensive treatment. The acute phlegmonous esophagitis of the present case might have been evoked and worsened by chemoradiotherapy due to its emetic and myelosuppressive adverse effects, respectively. Although its incidence is extremely rare, acute phlegmonous esophagitis may occur as a life-threatening complication of chemoradiotherapy.

Deep neck space abscesses of dental origin: the impact of Streptococcus group Milleri.

In recent years, there has been rising interest in Streptococcus group Milleri (SM) because high mortality rates have been related to it. In case of deep neck infections (DNI), whatever the origin, mortality rates as high as 26% were reported. But there are no data available for DNI with SM of purely dental origin. The aim of our article was to describe and analyse DNI of purely dental origin involving on one hand SM and on the other hand infections without presence of SM. We compared these two groups and statistically investigated if there were differences in clinical presentation (age, mouth opening, length of hospital stay, laboratory parameters) or clinical behaviour (re-operation, re-hospitalisation, secondary osteomyelitis, stay at intensive care, length of antibiotic treatment, presence of resistances against antibiotics, incapacity to work). For this, we retrospectively searched medical records of our institution for all purulent DNI treated from 2004 till 2012. We found 81 patients meeting all inclusion criteria. Thirty-four patients had involvement of SM, 47 did not. The only statistically significant difference between the SM group and the non-SM group was the length of incapacity to work. All other parameters were non-significant. Furthermore, there were no fatalities. In conclusion, the clinical importance of this article is that patients with deep neck abscesses of purely dental origin involving SM do not need more or different care when compared to all other DNI of dental origin.

High-resolution CT findings in Streptococcus milleri pulmonary infection.

AIM: To assess pulmonary high-resolution computed tomography (CT) findings in patients with acute Streptococcus milleri pulmonary infection. MATERIALS AND METHODS: Sixty consecutive patients with acute S. milleri pneumonia who had undergone high-resolution CT chest examinations between January 2004 and March 2010 were retrospectively identified. Twenty-seven patients with concurrent infections were excluded. The final study group comprised 33 patients (25 men, 8 women; aged 20-88 years, mean 63.1 years) with S. milleri infection. The patients' clinical findings were assessed. Parenchymal abnormalities, enlarged lymph nodes, and pleural effusion were evaluated on high-resolution CT. RESULTS: Underlying conditions included malignancy (n = 15), a smoking habit (n = 11), and diabetes mellitus (n = 8). CT images of all patients showed abnormal findings, including ground-glass opacity (n = 24), bronchial wall thickening (n = 23), consolidation (n = 17), and cavities (n = 7). Pleural effusion was found in 18 patients, and complex pleural effusions were found in seven patients. CONCLUSION: Pulmonary infection caused by S. milleri was observed mostly in male patients with underlying conditions such as malignancy or a smoking habit. The CT findings in patients with S. milleri consisted mainly of ground-glass opacity, bronchial wall thickening, pleural effusions, and cavities.

An 11-year-old girl with right-sided weakness secondary to cerebral abscesses: a case report.

A previously healthy 11-year-old girl who presented to the emergency department with 8 days of headache and right-sided weakness was found to have 2 cerebral abscesses. Brain abscess is an uncommon finding for children in the emergency department. With this case, we review the clinical presentation, evaluation, and management of this unusual but potentially life-threatening condition.

Comparative analysis of colony counts of different species of oral streptococci in saliva of dentulous, edentulous and in those wearing partial and complete dentures.

OBJECTIVES: To study and compare the number of colony forming units of Streptococcus mutans, Streptococcus sanguis, Streptococcus salivarius, Streptococcus mitis and Streptococcus milleri in dentulous, edentulous and in those wearing partial and complete dentures by using semi-quantitative culture method of saliva samples with calibrated standard loop. MATERIALS: Sterile specimen collection bottles, Mitis salivarius agar plates, Standard loop, Candle jar, Incubator, Colony counter. METHODOLOGY: Study population consisted of 100 subjects with 25 in each group, with an age range of 40 to 80 years, who were attending the Department of Community Dentistry and Prosthodontics at MNR Dental College, Sangareddy, Hyderabad. Unstimulated saliva samples were collected from patients and inoculated on to Mitis salivarius agar plates using calibrated standard loop. The plates were then incubated anaerobically at 37°C for 24 hours and left at room temperature for further 24 hours. Using a colony counter, the number of colonies of each species was counted. RESULTS: Streptococcus mutans and Streptococcus mitis predominates in the dentulous group, Streptococcus sanguis in complete denture group, Streptococcus salivarius in edentulous group and Streptococcus milleri in removable partial denture group. CONCLUSION: The results of our study are in accordance with the previous studies, which have sought to differentiate different groups of mutans streptococci using a simple calibrated standard loop.

Odontogenic cervico-fascial infections: a continuing threat.

STATEMENT OF THE PROBLEM: Dental abscesses are common and occasionally can progress to life-threatening cervico-fascial infections. Despite medical advances, odontogenic cervico-fascial infections (OCFIs) continue to be a threat. The potential seriousness of odontogenic infections (Ols), or dental abscesses, is frequently underestimated. General dental practitioners (GDPs) in primary care face the challenging decision of whether to refer patients to secondary care or to manage them in the community. PURPOSE OF THE REVIEW: This paper reviews the relevant aspects of Ols that might be helpful to primary care dental practitioners in providing a better understanding of the anatomy and pathology and aims to assist in clinical decision. METHOD: An up-to-date review of literature on OCFIs, highlighting their potential risks with clinical examples. RESULTS AND CONCLUSION: Dental abscesses are common and continue to be a major cause for emergency hospital admission to oral and maxillofacial surgery departments. They occasionally spread to fascial spaces of the neck, potentially posing significant morbidity and mortality. GDPs are usually the first point of contact and face the challenge of recognising those at risk of developing OCFIs, which are potentially life threatening and require urgent referral for hospital treatment. We propose a patient care pathway to be used in primary care.