Diagnosis and treatment of cryptococcal osteomyelitis in a pediatric lung transplant patient.

BACKGROUND: Asymptomatic pulmonary nodules may appear at any point after lung transplantation. The differential diagnosis is broad and includes serious life-threatening disease entities. METHODS: A retrospective case report of a single patient who developed a pulmonary nodule after lung transplantation. RESULTS: At 2 years post-transplant, an 11-year-old with cystic fibrosis was asymptomatic and had normal lung function. A single nodule was noted on surveillance chest CT scan. Initial evaluation was negative, but subsequently, he was diagnosed with cryptococcal osteomyelitis in a thoracic rib. He responded well to an extended course of antifungal therapy without loss of allograft function or infectious complications. CONCLUSION: Pulmonary nodules after lung transplantation may be a harbinger of serious complications. A systematic approach to evaluation and follow-up is recommended.

A Pilot Study of Microbial Succession in Human Rib Skeletal Remains during Terrestrial Decomposition.

The bones of decomposing vertebrates are colonized by a succession of diverse microbial communities. If this succession is similar across individuals, microbes may provide clues about the postmortem interval (PMI) during forensic investigations in which human skeletal remains are discovered. Here, we characterize the human bone microbial decomposer community to determine whether microbial succession is a marker for PMI. Six human donor subjects were placed outdoors to decompose on the soil surface at the Southeast Texas Applied Forensic Science facility. To also assess the effect of seasons, three decedents were placed each in the spring and summer. Once ribs were exposed through natural decomposition, a rib was collected from each body for eight time points at 3 weeks apart. We discovered a core bone decomposer microbiome dominated by taxa in the phylum Proteobacteria and evidence that these bone-invading microbes are likely sourced from the surrounding decomposition environment, including skin of the cadaver and soils. Additionally, we found significant overall differences in bone microbial community composition between seasons. Finally, we used the microbial community data to develop random forest models that predict PMI with an accuracy of approximately ±34 days over a 1- to 9-month time frame of decomposition. Typically, anthropologists provide PMI estimates based on qualitative information, giving PMI errors ranging from several months to years. Previous work has focused on only the characterization of the bone microbiome decomposer community, and this is the first known data-driven, quantitative PMI estimate of terrestrially decomposed human skeletal remains using microbial abundance information. IMPORTANCE Microbes are known to facilitate vertebrate decomposition, and they can do so in a repeatable, predictable manner. The succession of microbes in the skin and associated soil can be used to predict time since death during the first few weeks of decomposition. However, when remains are discovered after months or years, often the only evidence are skeletal remains. To determine if microbial succession in bone would be useful for estimating time since death after several months, human subjects were placed to decompose in the spring and summer seasons. Ribs were collected after 1 to 9 months of decomposition, and the bone microbial communities were characterized. Analysis revealed a core bone decomposer microbial community with some differences in microbial assembly occurring between seasons. These data provided time since death estimates of approximately ±34 days over 9 months. This may provide forensic investigators with a tool for estimating time since death of skeletal remains, for which there are few current methods.

Postmortem submersion interval (PMSI) estimation from the microbiome of sus scrofa bone in a freshwater lake.

While many studies have developed microbial succession-based models for the prediction of postmortem interval (PMI) in terrestrial systems, similar well-replicated long-term decomposition studies are lacking for aquatic systems. Therefore, this study sought to identify temporal changes in bacterial community structure associated with porcine skeletal remains (n = 198) for an extended period in a fresh water lake. Every ca. 250 ADD, one cage, containing 5 ribs and 5 scapulae, was removed from the lake for a total of nineteen collections. Water was also sampled at each interval. Variable region 4 (V4) of 16S rDNA was amplified and sequenced for all collected samples using Illumina MiSeq FGx Sequencing platform; resulting data were analyzed with the mothur (v1.39.5) and R (v3.6.0). Bacterial communities associated with ribs differed significantly from those associated with scapulae. This difference was mainly attributed to Clostridia, Holophagae, and Spirochaete relative abundances. For each bone type, α-diversity increased with ADD; similarly, ß-diversity bacterial community structure changed significantly with ADD and were explained using environmental parameters and inferred functional pathways. Models developed using 24 rib and 34 scapula family-level taxa allowed the prediction of PMSI with root mean square error of 522.97 ADD (~57 days) and 333.8 ADD (~37 days), respectively.

Postmortem submersion interval (PMSI) estimation from the microbiome of Sus scrofa bone in a freshwater river.

Due to inherent differences between terrestrial and aquatic systems, methods for estimating the postmortem interval (PMI) are not directly applicable to remains recovered from water. Recent studies have explored the use of microbial succession for estimating the postmortem submersion interval (PMSI); however, a non-disturbed, highly replicated and long-term aquatic decomposition study in a freshwater river has not been performed. In this study, porcine skeletal remains (N = 200) were submerged in a freshwater river from November 2017-2018 (6322 accumulated degree days (ADD)/353 days) to identify changes and successional patterns in bacterial communities. One cage (e.g., 5 ribs and 5 scapulae) was collected approximately every 250 ADD for twenty-four collections; baseline samples never exposed to water acted as controls. Variable region 4 (V4) of 16S rDNA, was amplified and sequenced via the Illumina MiSeq FGx sequencing platform. Resulting sequences were analyzed using mothur (v1.39.5) and R (v3.6.0). The abundances of bacterial communities differed significantly between sample types. These differences in relative abundance were attributed to Clostridia, Holophagae and Gammaproteobacteria. Phylogenetic diversity increased with ADD for each bone type; comparably, ß-diversity bacterial community structure ordinated chronologically, which was explained with environmental parameters and inferred functional pathways. Models fit using rib samples provided a tighter prediction interval than scapulae, with a prediction of PMSI with root mean square error of within 472.31 (∼27 days) and 498.47 (∼29 days), respectively.

An unusual cause for rib osteomyelitis in the tropics: Cryptococcal osteomyelitis.

The more common manifestations of cryptococcal infections are restricted to the central nervous system and lungs. We report an unusual case of fungal osteomyelitis due to Cryptococcus. The patient was a young man who had been adequately treated for pulmonary tuberculosis three years prior. Three months before, he sustained a minor road-traffic accident with only minor abrasions. He presented with subacute chest pain of 15 days' duration and was found to have radiological evidence of a lytic lesion of the fifth rib. Given prior tuberculosis, he was thought to have a relapse of disease with tuberculous osteomyelitis. Surprisingly, a biopsy revealed evidence of fungal osteomyelitis with Cryptococcus. An evaluation for primary immunodeficiency revealed low CD4 cell counts with undetectable serum IgA and IgM levels. Genetic sequencing proved a genetic mutation consistent with primary T-cell immunodeficiency. The patient responded well to treatment and is asymptomatic on follow-up.

Metagenomic Next-Generation Sequencing Technique Helps Identify Cryptococcal Infection in the Rib: A Report of 2 Cases and Review of the Literature.

CASE: Two patients presented with pathological lytic bone lesions in the rib and associated soft tissue mass believed initially to represent soft tissue neoplasm. However, further consideration of infectious etiologies led to the identification of cryptococcal osteomyelitis. In one case, the microbiological culture was negative, but Cryptococcus neoformans was identified with the help of the metagenomic next-generation sequencing (mNGS) technique. Both patients received oral fluconazole-only treatment, and the infections were successfully eradicated. CONCLUSIONS: The mNGS technique helps identify cryptococcal infection in the rib.

Fluorescence spectroscopy of Candida albicans biofilms in bone cavities treated with photodynamic therapy using blue LED (450 nm) and curcumin.

Fluorescence spectroscopy may assisst in the diagnosis and control of infectious processes associated with bone lesions of the oral cavity. The aim of this study was to analyze, through fluorescence spectroscopy, Candida albicans biofilms formed in artificial bone cavities treated with photodynamic therapy (PDT) mediated with 450-nm blue light-emitting diode (LED) and curcumin. Another aim of this study was to analyze the existence of a correlation between the effectiveness of the photodynamic treatments and the fluorescence spectroscopy images. Artificial bone lesions (n = 40) were made in bovine bones and inoculated with standard suspensions of Candida albicans (ATCC 18804) for biofilm formation (14 days / 36 °C ± 1 °C). The 40 specimens were distributed among four experimental groups (n = 10): L-C- (control), L + C- (LED for 5 min), L-C+ (curcumin for 5 min), and L + C+ (PDT). Aliquots of 100 µL were collected from the bone cavities after treatments and were seeded in duplicate on Sabouraud dextrose agar for 24 h at 36 °C ± 1 °C and the colony-forming units (CFU/ mL) were counted. Before and after each treatment, the specimens were subjected to spectral fluorescence and the images were compared using the Image J program. The log10 CFU/mL were compared with Kruskal-Wallis and Dunn's Multiple Comparison post-test (significance level at 0.05). The fluorescence histogram values before and after treatment were compared using Wilcoxon test (95%).The correlation between Candida albicans log10 CFU/mL and the number of the fluorescence red pixels spectroscopy was verified using Spearman correlation test. The reduction of Candida albicans log10 CFU/mL in the L + C+ (PDT) group was the most relevant and the fluorescence spectroscopy was correlated to the microbiological result. It was concluded that there was a consistency between the number of Candida albicans log10 CFU/mL and the red pixel data of the fluorescence images, demonstrating that the fluorescence diagnostic device reflects the true microbiological condition of Candida albicans biofilms in the bone cavities during the pre-treatment and post-treatment, thus providing the clinician the ability to dynamically, simply, and instantaneously verify the performance of the treatment used.

Salmonella Osteomyelitis Of Ribs.

A 45-year-old diabetic male who was a farmer by profession, presented to Khyber Teaching Hospital with swelling and redness on the right side of the chest at the level of 8th rib for the past 5 months which was accompanied by fever and pain. He went to a local hospital where he was given broad spectrum antibiotics. He presented again with yellowish discharge from the wound. Dressing of the wound was done and he was referred to Khyber Teaching Hospital. On presentation, there was an open wound of about 4 cm on the right side of the chest wall at the level of 8th rib near the midclavicular line. X-ray revealed a lytic bone lesion near the costo-chondral junction of the 8th rib. CT scan also showed erosive changes at the above mention site. His fasting blood sugar was well above the normal range and his Alkaline Phosphatase was slightly raised. He was started on Insulin. Debridement and dressing were done and samples were taken for investigations. Bone tissue biopsy revealed inflammatory non-caseating tissue. Culture report was positive for Salmonella Typhi which was resistant to Ciprofloxacin. The patient was given antibiotic (co-amoxiclave) treatment to which he responded leading to a satisfactory recovery.

Indolent Rib Osteomyelitis Following Breast Implant Reconstruction: An Unusual Case and Review of the Literature.

Rib osteomyelitis is an infrequently occurring but important complication of breast implant surgery. Although prosthetic or surgical site infection (SSI) and rib osteomyelitis as separate entities are well described in the literature, only five cases of rib or sternal osteomyelitis related to implant placement have been reported globally. Historically patients who experience this complication have not demonstrated an identifiable prevalence of the traditional risk factors associated with SSI or rib osteomyelitis. This report describes the sequence of clinical manifestations of an unusual case of breast implants complicated by rib osteomyelitis. A 56-year-old female underwent mastectomy and insertion of tissue expanders for bilateral invasive ductal carcinoma following which the tissue expanders became infected in the early postoperative period and were subsequently removed. The patient underwent successful expander insertion and subsequent implant exchange surgery several years later and enjoyed an uncomplicated recovery from this. Following nipple reconstruction more than 12 months after successful implant placement, she presented with Staphylococcus epidermidis bacteremia and a left-sided clinical peri-implant infection. Upon removal of her implant, an intraoperative discovery of rib necrosis/osteomyelitis was made for which she was treated. To provide context, the literature was reviewed for other reported cases of rib osteomyelitis following breast implant surgery. This patient, in combination with others reported in the literature, emphasises the diagnostic difficulties posed by this condition as a result of its low incidence and variable or absent clinical features. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Microbiological Safety of Commercial Prime Rib Preparation Methods: Thermal Inactivation of Salmonella in Mechanically Tenderized Rib Eye.

Boneless beef rib eye roasts were surface inoculated on the fat side with ca. 5.7 log CFU/g of a five-strain cocktail of Salmonella for subsequent searing, cooking, and warm holding using preparation methods practiced by restaurants surveyed in a medium-size Midwestern city. A portion of the inoculated roasts was then passed once through a mechanical blade tenderizer. For both intact and nonintact roasts, searing for 15 min at 260°C resulted in reductions in Salmonella populations of ca. 0.3 to 1.3 log CFU/g. For intact (nontenderized) rib eye roasts, cooking to internal temperatures of 37.8 or 48.9°C resulted in additional reductions of ca. 3.4 log CFU/g. For tenderized (nonintact) rib eye roasts, cooking to internal temperatures of 37.8 or 48.9°C resulted in additional reductions of ca. 3.1 or 3.4 log CFU/g, respectively. Pathogen populations remained relatively unchanged for intact roasts cooked to 37.8 or 48.9°C and for nonintact roasts cooked to 48.9°C when held at 60.0°C for up to 8 h. In contrast, pathogen populations increased ca. 2.0 log CFU/g in nonintact rib eye cooked to 37.8°C when held at 60.0°C for 8 h. Thus, cooking at low temperatures and extended holding at relatively low temperatures as evaluated herein may pose a food safety risk to consumers in terms of inadequate lethality and/or subsequent outgrowth of Salmonella, especially if nonintact rib eye is used in the preparation of prime rib, if on occasion appreciable populations of Salmonella are present in or on the meat, and/or if the meat is not cooked adequately throughout.

Candida albicans osteomyelitis as a cause of chest pain and visual loss.

Candida albicans osteomyelitis is a rare disease that occurs in immunocompromised individuals, sometimes with a late diagnosis related to the mismatch between symptoms and candidemia. This case refers to a 36-year-old male patient with a history of oesophageal surgery for achalasia with multiple subsequent surgeries and hospitalisation in the intensive care unit for oesophageal fistula complication. Four months after discharge, the patient was admitted to the infectious diseases department with pain in the 10th-12th left ribs, swelling of the 4th-6th costal cartilage and decreased visual acuity. An MRI study showed thickening and diffuse enhancement, with no defined borders in the cartilage and ribs, compatible with infection. After performing a CT-guided bone biopsy, isolated C. albicans sensitive to antifungal agents was detected. The patient started therapy with liposomal amphotericin B and maintenance fluconazole for 6 months and showed clinical and radiological improvement within this time.

[Evaluation of biological properties of Pseudomonas aeruginosa strains isolated from patients with sternum and rib osteomyelitis].

AIM: Study of the role of P. aeruginosa in the development of osteomyelitis of sternum and ribs in cardio-surgery patients, and analysis of the main biological properties of the isolated bacterial strains. MATERIALS AND METHODS: 132 bacterial cultures were isolated from 83 hospital patients as a result of bacteriological examination during 2007-2013. Wound discharge was the study mate- rial. Sampling, seeding and identification of the isolated cultures was carried out by using the respective test-systems; antibiotic sensitivity was studied by disc-diffusion method. RESULTS: The proportion of P. aeruginosa was 10.6% (n = 14) that is comparable with data on wound infections of general surgery hospitals. A direct and strong correlation (R = 0.846, p = 0.000132) between hemolytic and phospholipase activity was established during evaluation of virulence properties of the isolated-strains. The degree of film-forming ability varied significantly from 0.122 to 1.412 OD; 64.3% ofthe studied cultures were highly film-forming variants. Statistically significant association between biofilm formation and other studied properties was not found. 4 strains produced VIM2-type metallo-betalactamase and had identical RAPD profiles. CONCLUSION: Considering that earlier the similar cultures were not detected and all of them were isolated at a short interval of time, we have made a conclusion, that their short-term circulation is probably associated with introduction, which was the reason for patient infection. P. aeruginosa could be the etio-pathogen of both early and later complications of cardio-surgical interventions.

Potential Use of Bacterial Community Succession in Decaying Human Bone for Estimating Postmortem Interval.

Bacteria are taphonomic agents of human decomposition, potentially useful for estimating postmortem interval (PMI) in late-stage decomposition. Bone samples from 12 individuals and three soil samples were analyzed to assess the effects of decomposition and advancing time on bacterial communities. Results indicated that partially skeletonized remains maintained a presence of bacteria associated with the human gut, whereas bacterial composition of dry skeletal remains maintained a community profile similar to soil communities. Variation in the UniFrac distances was significantly greater between groups than within groups (p < 0.001) for the unweighted metric and not the weighted metric. The members of the bacterial communities were more similar within than between decomposition stages. The oligotrophic environment of bone relative to soft tissue and the physical protection of organic substrates may preclude bacterial blooms during the first years of skeletonization. Therefore, community membership (unweighted) may be better for estimating PMI from skeletonized remains than community structure (weighted).

Osteological and biomolecular evidence of a 7000-year-old case of hypertrophic pulmonary osteopathy secondary to tuberculosis from neolithic hungary.

Seventy-one individuals from the late Neolithic population of the 7000-year-old site of Hódmezovásárhely-Gorzsa were examined for their skeletal palaeopathology. This revealed numerous cases of infections and non-specific stress indicators in juveniles and adults, metabolic diseases in juveniles, and evidence of trauma and mechanical changes in adults. Several cases showed potential signs of tuberculosis, particularly the remains of the individual HGO-53. This is an important finding that has significant implications for our understanding of this community. The aim of the present study was to seek biomolecular evidence to confirm this diagnosis. HGO-53 was a young male with a striking case of hypertrophic pulmonary osteopathy (HPO), revealing rib changes and cavitations in the vertebral bodies. The initial macroscopic diagnosis of HPO secondary to tuberculosis was confirmed by analysis of Mycobacterium tuberculosis complex specific cell wall lipid biomarkers and corroborated by ancient DNA (aDNA) analysis. This case is the earliest known classical case of HPO on an adult human skeleton and is one of the oldest palaeopathological and palaeomicrobiological tuberculosis cases to date.

Costal BCG osteomyelitis developing 1 year after BCG vaccination.

Reported here is the case of a 15-month-old boy with costal osteomyelitis due to the bacillus Calmette-Guérin (BCG) vaccine against tuberculosis. Mild complications of this vaccine, such as localized abscess and regional lymphadenitis, are occasionally recognized, but its association with osteomyelitis is extremely rare.

Bone-destroying candida infection following left ventricular assist device explant.

Infections associated with left ventricular assist devices (LVADs) constitute an important clinical issue because they are difficult to completely eradicate without removal of the LVAD itself and can sometimes be fatal. We encountered a case of extracorporeal LVAD-related candida infection in a patient who was successfully weaned from LVAD support. Although the patient appeared to have recovered from the infection, the patient was readmitted to our institute due to a relapse of candida infection 9 months after LVAD removal. Although the patient did not demonstrate any systemic sign of infection on admission, computed tomography images clearly showed that the residual apical cuff of the LVAD inflow cannula, which was infected with Candida albicans during the initial admission, resulted in re-infection that involved the chest wall with destruction of the adjacent rib.