Imaging findings of Stenotrophomonas maltophilia pneumonia: emphasis on CT findings between immunocompromised and immunocompetent patients.

BACKGROUND: Stenotrophomonas maltophilia (S. maltophilia) is a globally emerging, rare, waterborne, aerobic, gram-negative, multiple-drug-resistant organism, most commonly associated with respiratory tract infection in humans. Computed tomography (CT) findings in patients with S. maltophilia pneumonia are rarely reported. PURPOSE: To compare CT findings between immunocompromised and immunocompetent patients, and to determine characteristic imaging findings of S. maltophilia pneumonia. MATERIAL AND METHODS: CT findings of eight immunocompromised and 29 immunocompetent patients with proven S. maltophilia pneumonia were reviewed retrospectively. Different patterns of CT abnormalities between immunocompromised and immunocompetent patients were compared by Fisher's exact test. RESULTS: Patchy ground-glass opacities (GGOs) were the most common CT findings, present in 36 (97.3%) of the 37 patients. Among the patients with patchy GGOs, consolidation was seen in 29 (78.4%) patients, and centrilobular nodules were noted in 15 (40.5%) patients. The transaxial distribution of the parenchymal abnormalities was predominantly randomly distributed in 30 (81.1%) cases. Regarding longitudinal plane involvement, the predominant zonal distributions were the diffuse distribution (n=23, 62.2%) and the lower lung zone (n=14, 37.8%). None of the patients showed upper lung zone predominance. The proportion of patients with parenchymal CT findings or associated findings in the immunocompromised patients was not significantly different from that of the immunocompetent patients. However, lower lung zone predominance on the longitudinal plane was significantly more common in immunocompetent patients than in immunocompromised patients (14/29 vs. 0/8, P=0.015). And diffuse distribution of parenchymal abnormalities on a longitudinal plane was significantly more frequent in immunocompromised patients than in immunocompetent patients (8/8 vs. 15/29, P=0.015). CONCLUSION: The most common CT patterns of S. maltophilia pneumonia in immunocompromised and immunocompetent patients were patchy GGOs and consolidation. However, in immunocompetent patients, parenchymal abnormalities were more predominately distributed in lower lung zone than in immunocompromised patients; and in immunocompromised patients, parenchymal abnormalities were more diffusely distributed than in immunocompetent patients.

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.

Capnocytophaga canimorsus peritonitis diagnosed by mass spectrometry in a diabetic patient undergoing peritoneal dialysis: a case report.

BACKGROUND: Bacterial peritonitis is a serious complication of patients undergoing peritoneal dialysis (PD). Although the identification of causative organisms and use of appropriate antibiotics are essential for treatment, rare and fastidious bacteria are sometimes difficult to detect by conventional biochemical assays. Capnocytophaga canimorsus is a fastidious and slow-growing bacterium that forms a part of the normal oral flora of dogs and cats and is extremely rare as a peritonitis-causing organism. This report demonstrates the usefulness of a mass spectrometry-based technique in identifying such a rare organism in PD-related peritonitis and discusses the diagnosis and treatment of C. canimorsus peritonitis. CASE PRESENTATION: A 49-year-old woman with type 2 diabetes mellitus underwent PD for two years. Repeated exit-site infections led to subcutaneous pathway diversion two months ago. She was hospitalized with fever and abdominal pain as well as cloudy dialysis effluent. Laboratory data revealed increased serum C-reactive protein level and white blood cell (WBC) count in the effluent. Her exit site had no sign of infection, leading to the diagnosis of PD-related peritonitis. Initial therapy with intraperitoneal ceftazidime immediately ameliorated her symptoms, and the WBC count in the effluent normalized in five days. Culture test results of the dialysis effluent on admission were negative with no information regarding the infection route. However, mass spectrometry (MALDI Biotyper, Bruker Daltonics) successfully obtained the specific spectral pattern for C. canimorsus. She had four cats in her house and was advised not to allow the cats in the room where the bag exchange took place. CONCLUSIONS: C. canimorsus is a rare cause of peritonitis in PD patients and is usually susceptible to intraperitoneal third-generation cephalosporins. This mass spectrometry-based bacterial identification method could provide more opportunities to identify uncommon causes and promote appropriate antibiotics therapy in PD-related peritonitis.

T2Bacteria magnetic resonance assay for the rapid detection of ESKAPEc pathogens directly in whole blood.

Objectives: To evaluate the magnetic resonance-based T2Bacteria Panel assay for direct detection of ESKAPEc (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Escherichia coli) pathogens in blood samples of patients with suspected bloodstream infection (BSI). Patients and methods: Adult patients admitted to the Emergency Medicine Department, Infectious Diseases Unit and ICU of a large tertiary-care hospital were included if they had a blood culture (BC) ordered concomitantly with a whole-blood sample for T2Bacteria testing. Results were compared with those of BC and other clinically relevant information. Results: A total of 140 samples from 129 BSI patients were studied. Single bacteria were detected in 15.7% (22/140) and 12.1% (17/140), and multiple bacteria in 2.9% (4/140) and 1.4% (2/140), of samples tested by T2Bacteria and BC, respectively. With respect to the six target (ESKAPEc) species, overall sensitivity and specificity of T2Bacteria across all detection channels in comparison with BC were 83.3% and 97.6%, respectively; these values increased to 89.5% and 98.4%, respectively, when a true-infection criterion (i.e. the same microorganism detected only by T2Bacteria was cultured from another sample type reflecting the source of infection) was used as the comparator. There were 808 T2Bacteria detection results across 112 samples, with concordant negative results, yielding a negative predictive value of 99.8%. The mean time to negative result was 6.1 ±âŸ1.5 h, whereas the mean time to detection/species identification was 5.5 ±âŸ1.4 h. Conclusions: The T2Bacteria Panel assay has the potential to provide accurate and timely diagnosis of ESKAPEc bacteraemia, which might support the direct therapeutic management of BSI patients.

First isolation and characterization of the pathogenic Aeromonas veronii bv. veronii associated with ulcerative syndrome in the indigenous Pelophylax ridibundus of Al-Ahsaa, Saudi Arabia.

Virulent microbial pathogen infections are the main cause for amphibian decline worldwide. In the present study, a bacterial strain named RDL-2, which was isolated from the skin of infected Pelophylax ridibundus larvae, was cultured and then phenotypically and biochemically characterized using scanning electron microscopic observations and the API20E strip and Biolog Gen III MicroPlate system. The 16S rRNA gene sequence of this strain was also obtained and used in strain identification and phylogenetic analysis. Healthy P. ridibundus larvae were challenged with RDL-2 and monitored to determine clinical signs consistent with the disease. Strain RDL-2 was identified as Aeromonas veronii based on its phenotypic and biochemical characteristics and on 16S rRNA gene sequence and phylogenetic analysis: RDL-2 was gram-negative, rod-shaped, and reacted positively for 69 (73%) of the 94 traits analysed; its 16S rRNA gene sequence displayed the highest homology to that of A. veronii bv. veronii (99.9%). Koch's postulates were fulfilled confirming that A. veronii is the causal agent of ulcerative syndrome. Thus, this study is the first to report A. veronii as a marsh frog pathogen in the Al-Ahsaa region. The aetiology of A. veronii as a potential poikilothermic pathogen shown here will expedite the development of diagnostic tests and methods for eradicating ulcerative syndrome.

Recurrent Urinary Tract Infections Due to Bacterial Persistence or Reinfection in Women-Does This Factor Impact Upper Tract Imaging Findings?

PURPOSE: We compared the rates of upper tract imaging abnormalities of recurrent urinary tract infections due to bacterial persistence or reinfection. MATERIALS AND METHODS: Following institutional review board approval we reviewed a prospectively maintained database of women with documented recurrent urinary tract infections (3 or more per year) and trigonitis. We searched for demographic data, urine culture findings and findings on radiology interpreted upper tract imaging, including renal ultrasound, computerized tomography or excretory urogram. Patients with irretrievable images, absent or incomplete urine culture results for review, no imaging performed, an obvious source of recurrent urinary tract infections or a history of pyelonephritis were excluded from analysis. RESULTS: Of 289 women from 2006 to 2014 with symptomatic recurrent urinary tract infections 116 met study inclusion criteria. Mean ± SD age was 65.0 ± 14.4 years. Of the women 95% were white and 81% were postmenopausal. Almost a third were sexually active and none had prolapse stage 2 or greater. Of the 116 women 48 (41%) had persistent and 68 (59%) had reinfection recurrent urinary tract infection. Imaging included ultrasound in 52 patients, computerized tomography in 26, ultrasound and computerized tomography in 31, and excretory urogram with ultrasound/computerized tomography in 7. Of the total of 58 imaging findings in 55 women 57 (98%) were noncontributory. One case (0.9%) of mild hydronephrosis was noted in the persistent recurrent urinary tract infection group but it was not related to any clinical parameters. Escherichia coli was the dominant bacteria in 71% of persistent and 47% of reinfection recurrent urinary tract infections in the most recently reported urine culture. CONCLUSIONS: This study reaffirms that upper tract imaging is not indicated for bacterial reinfection, recurrent urinary tract infections. However, the same conclusion can be extended to recurrent urinary tract infections secondary to bacterial persistence, thus, questioning the routine practice of upper tract studies in white postmenopausal women with recurrent urinary tract infections and trigonitis.

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.

[CHANGES IN THE AREA OF THE WOUND SURFACE ON EXPOSURE LOW­DOSE VACUUM].

Results of treatment of were analysed 30 patients over a long non­healing wounds and trophic ulcers, in which as a topical treatment, the method of vacuum therapy was applied. To study the activity of reparative regeneration in the wound using a dynamic method of determining the area of wounds using lqSquare computer program and immunohistochemical method for determining the Ki 67 positive cells in tissues of near wound area. It was found that low­dose exposure to vacuum at the wound contributed to increase the proliferative activity of tissues of near wound area and reduce the area of wound defect. Assessment of changes in the area of the wound surface is an important predictor of treatment efficacy, prevention of complications.

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.

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.

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.

In Vitro and In Vivo Evaluation of 99mTc-Polymyxin B for Specific Targeting of Gram-Bacteria.

BACKGROUND: Infectious diseases are one of the main causes of morbidity and mortality worldwide. Nuclear molecular imaging would be of great help to non-invasively discriminate between septic and sterile inflammation through available radiopharmaceuticals, as none is currently available for clinical practice. Here, we describe the radiolabeling procedure and in vitro and in vivo studies of 99mTc-polymyxin B sulfate (PMB) as a new single photon emission imaging agent for the characterization of infections due to Gram-negative bacteria. RESULTS: Labeling efficiency was 97 ± 2% with an average molar activity of 29.5 ± 0.6 MBq/nmol. The product was highly stable in saline and serum up to 6 h. In vitro binding assay showed significant displaceable binding to Gram-negative bacteria but not to Gram-positive controls. In mice, 99mTc-HYNIC-PMB was mainly taken up by liver and kidneys. Targeting studies confirmed the specificity of 99mTc-HYNIC-PMB obtained in vitro, showing significantly higher T/B ratios for Gram-negative bacteria than Gram-positive controls. CONCLUSIONS: In vitro and in vivo results suggest that 99mTc-HYNIC-PMB has a potential for in vivo identification of Gram-negative bacteria in patients with infections of unknown etiology. However, further investigations are needed to deeply understand the mechanism of action and behavior of 99mTc-HYNIC-PMB in other animal models and in humans.

Myocardial dysfunction in fetuses exposed to intraamniotic infection: new insights from tissue Doppler and strain imaging.

OBJECTIVE: The purpose of this study was to assess myocardial function of fetuses who were exposed to intraamniotic infection compared with fetuses of uncomplicated pregnancies by the application of tissue Doppler and strain rate (SR) imaging. STUDY DESIGN: We evaluated the right ventricular function of fetuses with preterm premature rupture of membranes and proven intraamniotic infection (n = 12 fetuses) and healthy fetuses (n = 27). Tissue Doppler velocities during early diastolic relaxation (E(m)) and atrial contraction (A(m)) and early diastolic SR were measured as indices of diastolic function, whereas the peak systolic strain and SR were used as parameters of systolic function. RESULTS: Fetuses with intraamniotic infection exhibit impairment in both diastolic and systolic performance, which was characterized by increased diastolic compliance (increased E(m)/A(m) ratio, increased early diastolic SR compared with the control fetuses), decreased systolic contractile function (reduced systolic strain and SR), and longitudinal myocardial dyskinesia. CONCLUSION: New echocardiographic tools suggest that fetal heart is a target organ in the context of intraamniotic infection.

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.

Plesiomonas shigelloides pneumonia.

Plesiomonas shigelloides is known to cause mild to cholera-like diarrhea in most infected persons. In immunocompromised patients extra-intestinal manifestations have been described. We report the first case of pneumonia caused by P. shigelloides in a 76-year-old woman who had undergone a curative gastrectomy and esophageal-jejunostomy due to a low differentiated adenocarcinoma of the stomach (pT2, pN1 pMx, G3, R0, Lauren: intestinal type). The patient was admitted in hospital with clinical signs of pulmonary infection. CT-scan revealed a cavernous lesion in the right upper pulmonary lobe. Bronchial lavage showed a granulocytic inflammation 105CFU/ml P. shigelloides. Although antibiotic treatment led to a decrease of inflammation parameters and decrease of the pulmonary infiltrate the patient died due to development of torsades de pointes tachycardia leading to ventricular fibrillation and hypoxic brain damage.

Thyroid abscess due to Eikenella corrodens in a pediatric patient.

Eikenella corrodens is one of the HACEK bacteria that is commensal microorganism of the oropharngeal flora. E. corrodens has been increasingly reported to cause pyogenic abscesses, especially in diabetic or immunocompromised adults. It is less frequently reported in immunocompotent children. Here, we report a deep neck infection, including the thyroid gland, in a previously healthy girl. E. corrodens was the only microorganism isolated in two different cultures. Antibiotic susceptibility is variable, in contrast to other oropharyngeal pathogens. Thus, to avoid delayed treatment, E. corrodens should always be considered in infections of the head and neck area.