CLINICAL CHARACTERISTICS AND VISUAL OUTCOMES IN ENDOPHTHALMITIS AFTER KERATOPROSTHESIS IMPLANTATION.

PURPOSE: To describe the presentation, microbiology, management, and prognosis of eyes with endophthalmitis after Boston keratoprosthesis implantation. METHODS: Retrospective case series with history, diagnostics, management, and outcomes data in endophthalmitis after keratoprosthesis implantation presenting to a tertiary center between 2009 and 2020. RESULTS: Of 137 keratoprosthesis-implanted eyes, 7 eyes of 7 patients (5%) developed endophthalmitis. On presentation, 6 (86%) reported decreased visual acuity, and only 1 (14%) reported pain. Peripheral corneal ulcers were present in 2 eyes (29%). Seidel testing was negative in all cases. Six eyes (86%) had retroprosthetic membranes. One (14%) underwent initial pars plana vitrectomy with mechanical vitreous biopsy, whereas 6 (86%) received a needle vitreous tap-half of which were dry. Organisms were isolated after vitreous tap in two eyes: Streptococcus intermedius and Mycobacterium abscessus. The mean visual acuity preendophthalmitis, at presentation, and at 6 months were 20/267, 20/5,944, and 20/734, respectively. The visual acuity improved 9.08 ± 11.78 Early Treatment Diabetic Retinopathy Study lines from presentation to 6 months. Six-month visual acuity was correlated with preendophthalmitis visual acuity (r = 0.92, P = 0.003) but not presenting visual acuity (P = 0.838). CONCLUSION: Visual acuity at 6 months is correlated with preendophthalmitis visual acuity, not presenting visual acuity. Endophthalmitis should be considered in the differential diagnosis of painless intraocular inflammation any time after keratoprosthesis implantation, even if Seidel negative.

Measuring the subgingival microbiota in periodontitis patients: Comparison of the surface layer and the underlying layers.

Periodontitis is a major cause of tooth loss in adults that initially results from dental plaque. Subgingival plaque pathogenesis is affected by both community composition and plaque structures, although limited data are available concerning the latter. To bridge this knowledge gap, subgingival plaques were obtained using filter paper (the fourth layer) and curette (the first-third layers) sequentially and the phylogenetic differences between the first-third layers and the fourth layer were characterized by sequencing the V3-V4 regions of 16S rRNA. A total of 11 phyla, 148 genera, and 308 species were obtained by bioinformatic analysis, and no significant differences between the operational taxonomic unit numbers were observed for these groups. In both groups, the most abundant species were Porphyromonas gingivalis and Fusobacterium nucleatum. Actinomyces naeslundii, Streptococcus intermedius, and Prevotella intermedia possessed relatively high proportions in the first-third layers; while in the fourth layer, both traditional pathogens (Treponema denticola and Campylobacter rectus) and novel pathobionts (Eubacterium saphenum, Filifactor alocis, Treponema sp. HOT238) were prominent. Network analysis showed that either of them exhibited a scale-free property and was constructed by two negatively correlated components (the pathogen component and the nonpathogen component), while the synergy in the nonpathogen component was lower in the first-third layers than that in the fourth layer. After merging these two parts into a whole plaque group, the negative/positive correlation ratio increased. With potential connections, the first-third layers and the fourth layer showed characteristic key nodes in bacterial networks.

Differential diagnosis of atypical encephalopathy in critical care: a case report.

BACKGROUND: A lower level of consciousness is a common presentation in critical care, with many different causes and contributory factors, of which more than one may be present concurrently. CASE PRESENTATION: We described a woman with poorly controlled diabetes and steroid-dependent asthma who presented in a deep coma. She was found to have Streptococcus intermedius bacteremia and pyogenic ventriculitis that originated from right middle lobe pneumonia. Also, multiple small parenchymal lesions were observed on brain magnetic resonance imaging and increased protein concentration was noted in cerebral spinal fluid. Initially, her coma was thought to be due to diabetic ketoacidosis and septic encephalopathy. However, her lowered level of consciousness was disproportionate to either diabetic ketoacidosis or septic encephalopathy, and her clinical course was not as expected for these two conditions. Treatment with antibiotic, corticosteroid and antihelminthic drugs was administered resulting in improving consciousness. The Streptococcus intermedius pneumonia progressed to form a large cavity that needed an early surgical lobectomy and resulted in the unexpected diagnosis of chronic cavitary pulmonary aspergillosus. CONCLUSIONS: In critical care, a lowered level of consciousness may have many etiologies, and critical care clinicians should be familiar with the signs and symptoms of all possible causes to enable prompt diagnosis and appropriate treatment.

Precision diagnosis and therapy of a case of brain abscesses associated with asymptomatic pulmonary arteriovenous fistulas.

BACKGROUND: Brain abscesses, a severe infectious disease of the CNS, are usually caused by a variety of different pathogens, which include Streptococcus intermedius (S. intermedius). Pulmonary arteriovenous fistulas (PAVFs), characterized by abnormal direct communication between pulmonary artery and vein, are a rare underlying cause of brain abscesses. CASE PRESENTATION: The patient was a previous healthy 55-year-old man who presented with 5 days of headache and fever. Cerebral magnetic resonance imaging (MRI) suggested a brain abscess. Thoracic CT scan and angiography demonstrated PAVFs. Aiding by metagenomic next-generation sequencing (mNGS) of the cerebrospinal fluid (CSF) sample which identified S. intermedius as the causative pathogen, the patient was switched to the single therapy of large dose of penicillin G and was cured precisely and economically. CONCLUSIONS: It is an alternative way to perform mNGS to identify causative pathogens in patients with brain abscesses especially when the results of traditional bacterial culture were negative. Further thoracic CT or pulmonary angiography should also be undertaken to rule out PAVFs as the potential cause of brain abscess if the patient without any known premorbid history.

Dermacoccus sp. isolated from a brain abscess in a 4-year-old child.

Dermacoccus spp. have rarely been reported as human pathogens. We describe a case of a 4-year-old boy with congenital heart disease who was diagnosed with a brain abscess. The abscess was drained and the sample grew Streptococcus intermedius, Aggregatibacter aphrophilus and Dermacoccus sp.. Dermacoccus grew after 5 days of incubation and the patient was treated with meropenem.

Sites of infection associated with Streptococcus anginosus group among children.

Streptococcus anginosus group (SAG) are parts of normal flora of the oral cavity and associated with abscess forming in various sites on the body. Although the clinical features of infections caused by each member of the SAG in adults has been reported, it has not well been known in children. The aim of this study was to clarify the site of infections associated with individual SAG species among children. Medical records from March 2010 to July 2016 were reviewed at Tokyo Metropolitan Children's Medical Center. Any SAG species (S. anginosus, S. constellatus, or S. intermedius) isolated from clinical samples and recorded in the microbiological database were included for analysis. Analysis of 52 infectious episodes found that S. anginosus was most frequently isolated from the genitourinary tract, and 73% of genitourinary tract infection was balanoposthitis. All genitourinary tract infections were associated with S. anginosus. These findings were different from those of a previous study of adults. Of all the patients, 45 patients (87%) had polymicrobial infections. More than 70% of patients infected by S. anginosus and S. constellatus were co-infected by obligate anaerobes, in comparison with only 21% of S. intermedius cases. Among the obligate anaerobes species, Bacteroides spp. was significantly accompanied with S. anginosus. Susceptibility to penicillin, ampicillin, cefotaxime, erythromycin, clindamycin, levofloxacin, and vancomycin was 100%, 100%, 100%, 77%, 89%, 97% and 100%, respectively. S. anginosus was often isolated from balanoposthitis among children.

Septic thrombosis of cavernous sinus extended to the ipsilateral internal jugular vein and transversal sinus with favorable outcome: Clinical and radiological features of a Lemierre syndrome.

An 86-year-old patient was hospitalized for fever and left acute orbital syndrome (red eye with moderate visual impairment, chemosis, ophthalmoplegia without proptosis, or any fundus involvement). CT scan showed superior ophthalmic vein and cavernous sinus enlargement complicating ipsilateral sphenoidal sinusitis. Magnetic resonance imaging (MRI) demonstrated the left cavernous sinus thrombosis extended to the ipsilateral jugular vein and transversal sinus (Lemierre syndrome). Intravenous broad-spectrum antibiotics and curative anticoagulation were prescribed. Blood cultures allowed the identification of Streptococcus intermedius and Staphylococcus warneri species. Evolution was favorable and the patient was discharged 3 weeks after. Antibiotics and anticoagulation were carried out for a total duration of 4 and 12 weeks, respectively. Lemierre syndrome is a potentially life-threatening emergency rarely encountered; thus, ophthalmologists should be cognizant of clinical and radiological features. Broad-spectrum antibiotics are the mainstay of treatment. Curative anticoagulation may be added if no blood coagulation disorder nor bleeding on neuroimaging has been identified.

Characterization of the Pathogenicity of Streptococcus intermedius TYG1620 Isolated from a Human Brain Abscess Based on the Complete Genome Sequence with Transcriptome Analysis and Transposon Mutagenesis in a Murine Subcutaneous Abscess Model.

Streptococcus intermedius is known to cause periodontitis and pyogenic infections in the brain and liver. Here we report the complete genome sequence of strain TYG1620 (genome size, 2,006,877 bp; GC content, 37.6%; 2,020 predicted open reading frames [ORFs]) isolated from a brain abscess in an infant. Comparative analysis of S. intermedius genome sequences suggested that TYG1620 carries a notable type VII secretion system (T7SS), two long repeat regions, and 19 ORFs for cell wall-anchored proteins (CWAPs). To elucidate the genes responsible for the pathogenicity of TYG1620, transcriptome analysis was performed in a murine subcutaneous abscess model. The results suggest that the levels of expression of small hypothetical proteins similar to phenol-soluble modulin ß1 (PSMß1), a staphylococcal virulence factor, significantly increased in the abscess model. In addition, an experiment in a murine subcutaneous abscess model with random transposon (Tn) mutant attenuation suggested that Tn mutants with mutations in 212 ORFs in the Tn mutant library were attenuated in the murine abscess model (629 ORFs were disrupted in total); the 212 ORFs are putatively essential for abscess formation. Transcriptome analysis identified 37 ORFs, including paralogs of the T7SS and a putative glucan-binding CWAP in long repeat regions, to be upregulated and attenuated in vivo This study provides a comprehensive characterization of S. intermedius pathogenicity based on the complete genome sequence and a murine subcutaneous abscess model with transcriptome and Tn mutagenesis, leading to the identification of pivotal targets for vaccines or antimicrobial agents for the control of S. intermedius infections.

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.

An in vivo comparison of internal bacterial colonization in two dental implant systems: identification of a pathogenic reservoir.

OBJECTIVES: The aim of this study was to compare internal bacterial colonization in two implant systems, one screw root form (SRF) with an external hexagon connection and one plateau root form (PRF) with a Morse taper internal connection. MATERIALS AND METHODS: Thirty-two implants; 12 SRF and 20 PRF, were sampled in 15 patients. All implants had been in function for at least 6 months prior to sampling. The implant restoration was removed and 10 µl of sterile saline was introduced into the implant well via a sterile glass syringe. The saline was drawn back up and transferred to the laboratory for microbiological analysis. The number of aerobic and anaerobic colony forming units per millilitre was determined and the dominant micro-organism in each sample was identified by 16s rRNA gene amplicon sequencing. RESULTS: There was a significant difference between bleeding on probing around the SRF implants (3%) and the PRF implants (28%) (p = 0.0496). Bacterial colonization was identified at 11 SRF and 19 PRF implants. The numbers of anaerobic bacteria recovered from PRF implants was significantly higher than that from SRF implants (p = 0.0002). Streptococcus species and Enterococcus faecalis were found to dominate. CONCLUSIONS: This in vivo study demonstrated bacterial colonization in both types of implant systems, irrespective of the type of connection. Significantly greater anaerobic counts were found in the Morse taper internal connection implants.

Lung abscess by Streptococcus intermedius: An unusual first case report from India.

A unique case report, probably first case from India, of lung abscess caused by Streptococcus intermedius in a previously untreated patient with Type 2 diabetes mellitus is reported here. The patient presented with non-productive cough and right-sided chest pain. Microbiological evaluation confirmed the presence of Streptococcus intermedius and the patient responded positively to antibiotic therapy. This case highlights the fact that S.intermedius may act as pathogen in immunocompromised individuals. So, a caution is needed by the medical fraternity before disregarding it as a commensal.

The role of Streptococcus intermedius in brain abscess.

Brain abscess represents a significant medical problem, despite recent advances made in detection and therapy. Streptococcus intermedius, a commensal organism, has the potential to cause significant morbidity. S. intermedius expresses one or more members of a family of structurally and antigenically related surface proteins termed antigen I/II, which plays a potential role in its pathogenesis. It is involved in binding to human fibronectin and laminin and in inducing IL-8 release from monocytes, which promotes neutrophil chemotaxis and activation. There are few published data on the role of this organism in brain abscess. This review focuses on the clinical evidence, pathogenic role, mechanism of predisposition, and currently employed strategies to fight against S. intermedius associated to brain abscess.

Identification of Streptococcus intermedius central nervous system infection by use of PCR and electrospray ionization mass spectrometry.

We describe the utility of PCR and electrospray ionization with mass spectrometry (PCR/ESI-MS) of culture-negative cerebrospinal fluid (CSF) in order to identify Gram-positive cocci noted on a Gram stain of CSF from a previously healthy 26-year-old man with community-acquired pneumonia (CAP) and multiple brain abscesses. CSF samples were obtained 2 weeks apart, first by lumbar puncture and 2 weeks later from an external ventricular drain that was inserted into the right ventricle. Both CSF cultures were negative. A Gram stain of bronchoalveolar lavage (BAL) fluid was notable for many Gram-positive cocci (GPC), but cultures of BAL fluid and subcarinal lymph node biopsy tissue were negative. PCR/ESI-MS detected Streptococcus intermedius, a common cause of brain abscesses, in both CSF samples as well as in the fixed tissue from the biopsy. This unique case confirms S. intermedius pulmonary infection as the source of metastatic CNS infection and reveals the potential of PCR/ESI-MS to detect a streptococcal pathogen not captured by conventional cultures.

Milleri group streptococcus--a stepchild in the viridans family.

The purpose of this investigation was to provide a comprehensive review of the pathogenic role and spectrum of disease of milleri group streptococci, with special attention to bloodstream invasion and to possible differential roles among the three species. All consecutive isolates of milleri group streptococci from any anatomic source, during a 37-month period, in a tertiary care teaching hospital in Tel-Aviv, Israel, were thoroughly investigated. Identification to the species level was performed by an automated system.Streptococcus anginosus constituted 82% of the 245 patient-unique isolates from hospitalized patients. All nonurinary isolates were involved in pyogenic infections mostly originating from the gastrointestinal tract, with bacteremia in 28 cases. The 71 urinary isolates represented either urinary tract infection or nonsignificant bacteriuria. No specific association could be detected between species and the infection site, except for a higher relative representation of Streptococcus constellatus in bacteremia. Milleri group streptococci are common in clinical practice and play a different pathogenic role to other viridans streptococci. Due to their invariable association with pyogenic processes, their presence in blood warrants immediate focus identification. In addition, they have a previously unappreciated clinical niche concerning urinary tract infection. The identification of viridans streptococci to the species level is of paramount clinical significance.

Streptococcal lung abscesses from a dental focus following tocilizumab: a case report.

Patients suffering from dental infections and concurrently using immunosuppressive medication are at increased risk of developing systemic streptococcal infections. Tocilizumab is a novel therapeutic agent targeting interleukin-6. We describe a case of streptococcal lung abscesses from a dental focus after use of tocilizumab for treatment of Takayasu arteritis.

Successful closure of an open-window thoracostomy wound by negative-pressure wound therapy: report of a case.

Negative-pressure wound therapy is a newly developed, noninvasive technique to manage a wide variety of wounds. This novel therapy was successfully used to heal the wound after open-window thoracostomy without surgical closure. A 46-year-old woman was admitted to hospital because of a painful mass on the right side of her chest. Radiological findings revealed an abscess on the right chest wall that had ruptured into the right lung and caused empyema. Antibiotic therapy did not yield sufficient improvement. Open-window thoracostomy was performed to achieve a sterile pleural space, and negative-pressure wound therapy was then applied. The pleural space was reduced, and the patient was discharged home with self-administered wound care. The wound healed completely in 5 months without any need for surgical closure.

Encephalitozoon cuniculi genotype I as a causative agent of brain abscess in an immunocompetent patient.

A brain abscess caused by Encephalitozoon cuniculi genotype I together with Streptococcus intermedius occurred in a patient without major immunocompromise and with diabetes. The distinguishing clinical signs were hemiparesis and epilepsy. The microsporidium was observed in the abscess aspirate, and its specific DNA was also detected in stool and urine. The patient was successfully treated with albendazole and mebendazole.

Pott's puffy tumor and epidural abscess arising from pansinusitis.

BACKGROUND: Sinusitis is a common disorder that can result in rare but serious complications including periorbital or orbital cellulitis, intracranial abscess or meningitis, subperiosteal scalp abscess ("Pott's puffy tumor"), osteomyelitis, and cavernous sinus thrombosis. CASE REPORT: We report a case of a 41-year-old man who presented to our Emergency Department with pansinusitis. He did not obtain recommended follow-up treatment after discharge and 26 days later returned with a persistence of sinusitis, Pott's puffy tumor, and an intracranial abscess caused by Streptococcus intermedius. The patient required multiple otolaryngological and neurosurgical interventions and was treated with long-term antibiotic therapy. CONCLUSIONS: Pott's puffy tumor is a complicated infection that requires intravenous antibiotic and surgical treatment. Diagnosis is made by contrast-enhanced computed tomography scan. Early treatment significantly contributes to favorable outcome and decreases the risk of further complications such as epidural abscess.