Case Report: Ascending Myelo-Encephalitis after a Penetrating Injury to the Foot: An Atypical Case of Neuromelioidosis.

Organisms penetrate the central nervous system (CNS) via three routes. The commonest is the hematogenous route, and other routes include contiguous or penetrating injury or rarely via retrograde axoplasmic route. Although the axoplasmic highway is often used by viruses, only a few bacteria are known to penetrate the CNS via this route. We present a 57-year-old man who developed a penetrating injury while working in a field. Over the next 4 months, he developed pain at the site of the poorly healing wound, which ascended up the right leg and presented as a conus-cauda syndrome. Magnetic resonance imaging (MRI) showed an enhancing intradural intramedullary enhancing lesion in the conus on the right side with cord edema from D11 to L1 level. Extensive evaluation was negative, and he continued to progress to holocord myelitis and developed bilateral corticospinal tract lesions ("tractopathy") in the brain stem and internal capsule. He died after developing a right-sided cerebritis with mass effect. Tissue biopsy from the brain at the time of decompressive craniectomy grew Burkholderia pseudomallei and confirmed a diagnosis of neuromelioidosis (NM). We reviewed the literature for NM, its variable presentations, and the concept of an "infectious tractopathy" and imaging findings which could generate suspicion of this entity.

Microbiological evaluation of resection margins of the infected diabetic foot ulcer.

AIM: To evaluate the impact of surgical debridement on the microbiology of resection margins of an infected diabetic foot ulcer and to compare the use of marginal sampling as a guide for antimicrobial therapy. METHODS: Forty consecutive participants were studied. Tissue samples from infected diabetic foot ulcers were obtained at first contact by podiatrists. After surgical debridement to macroscopically healthy tissue, multiple samples were obtained from the margins of the residuum and also from excised non-viable tissue. Debridement was done by a single surgeon. Bacterial species were classified according to pathogenic potential a priori into Red Group-Definite pathogen causing infection, Yellow Group-Likely to be causing infection if present in more than one specimen and Green Group -Commensals, not causing infection. RESULTS: There was a relative reduction of 49% (p = 0.002) in bacteria in the most pathogenic (red) group, and 59% (p = 0.002) in the yellow group in podiatry samples compared with resection specimen. Positive cultures from margins of the residuum were observed in 75% of cases. There was a relative reduction of 67% (p = 0.0001) in bacteria in the red and 48% (p = 0.06) in the yellow group in marginal samples from the residuum compared with podiatry samples. CONCLUSIONS: After surgical debridement to healthy tissue, positive cultures from marginal tissue samples provided vital information on the presence of pathogenic bacteria. This allowed antibiotics to be individualised post-surgical debridement.

Joint infection due to Elizabethkingia miricola / Infección articular debida a Elizabethkingia miricola

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Treatment of Traumatic Degloving Injury of the Foot Using a Biologic Dressing in a Pediatric Patient.

INTRODUCTION: Degloving injuries of the foot involve the management of extensive soft tissue and osseous damage secondary to significant forced avulsion of soft tissue, which can present a major challenge for the surgeon. Surgical procedures on pediatric foot degloving involving split-thickness and/or full-thickness skin grafts and rotational flaps can result in negative consequences, such as donor site comorbidities and psychosocial implications when the pediatric patient returns to daily life. CASE REPORT: The authors report the case of a 16-year-old girl with no past medical history who sustained an extensive degloving injury to her right foot involving severe subcutaneous and muscular soft tissue disruption and contamination. The initial treatment consisted of debridement, copious irrigation, primary wound closure at several sites, and application of an extracellular matrix (ECM) substitute graft. Shortly thereafter, secondary treatment consisted of application of primary musculoskeletal repair, negative pressure wound therapy (NPWT), and application of a dermal regeneration template. Over the 5-month course of treatment, an additional 3 trips to the operating room occurred, involving serial irrigation and debridement, NPWT application, and dermal/ECM substitute graft applications, leading to full epithelialization. CONCLUSIONS: To the best of the authors' knowledge, this is the first reported case in which an instance of pediatric foot degloving is presented with serial debridement, NPWT, and biological dressings, resulting in no additional plastic surgical techniques needed to provide return to functional outcome.

Hypermucoviscous capsular 1 (K1) serotype Klebsiella pneumoniae necrotising fasciitis and metastatic endophthalmitis.

A 48-year-old man presented with a non-healing wound on his left foot after stepping on a nail. He self-medicated with amoxicillin, but the wound progressed prompting consult. On examination, his left foot was diffusely swollen with surrounding erythema, areas of gangrene, foul-smelling purulent discharge and subcutaneous emphysema. He was managed as a case of necrotising fasciitis and underwent emergent amputation. Three days after amputation, he developed a sudden and progressive blurring of vision, swelling and conjunctival erythema, with purulent discharge and the presence of hypopyon on the left eye. He was then managed as a case of endophthalmitis of the left eye and underwent pars plana vitrectomy. All cultures (blood, tissue and vitreous fluid) grew pan-susceptible hypermucoviscous Klebsiella pneumoniae, with positive string tests and confirmed by multilocus gene sequencing and sequence type analysis. He gradually improved with intravenous antibiotics, but only regained light perception in the left eye.

First case of chromoblastomycosis due to Phoma insulana.

Chromoblastomycosis is a chronic infection, caused by pigmented fungi affecting skin and subcutaneous tissues characterized by verrucous nodules or plaques. Fonsecaea pedrosoi and Cladophialophora carrionii are the prevalent agents in the endemic areas. Phoma is an uncommon agent of human infection and involved mainly with phaeohyphomycosis cases. The case of a patient with a history of laceration in foot followed by verrucous aspect and scaly lesions, which had evolved for 27 years is presented. On physical examination disease was clinically compatible with chromoblastomycosis and the microscopic examination of scales showed fumagoid cells. On culture a dematiaceous fungus was grown. The agent was confirmed to be Phoma insulana based on its morphology and PCR-sequencing. This fungal agent has not been previously reported in association with this pathology.

Autochthonous lepromatous leprosy in a Spanish woman with burns on both feet and skin lesions.

The incidence of leprosy is decreasing worldwide and it is considered a rare disease in developed countries. In Spain, leprosy is mainly an imported disease with only few autochthonous cases seen. The diagnosis is difficult because of a low index of suspicion and the absence of visualisation of fast-acid bacilli in the lesions. Here, we report an autochthonous case of leprosy diagnosed after 4 years of evolution of skin lesions. Mechanical rupture of the biopsy helped finally to make the correct diagnosis of the disease.

A Case of Diabetic Mellitus Foot Infection by a Newly Reported Neisseria Skkuensis: Case Report.

In pus and wound samples collected from the right second toe of a 61-year-old woman with diabetes mellitus (DM), gram-negative diplococci bacterium was observed. However, the bacterium could not be identified by conventional microbiological methods and mass spectrometry. In the partial 16S rRNA gene sequence analysis, the bacterium showed a 100% identity match with GenBank sequence FJ0763637.1 (Neisseria skkuensis). N. skkuensis, SMC-A9199 strain, was reported as a novel species in 2010 based on its phenotypic characteristics and the 16S rRNA gene sequence, which was isolated from the blood and wound pus of a DM patient with a foot ulcer. The second reported N. skkuensis was identified from the blood cultures of a patient with endocarditis. To the best of our knowledge, this is only the third report of N. skkuensis.

Three cases of cutaneous mucormycosis with Lichtheimia spp. (ex Absidia/Mycocladus) in ICU. Possible cross-transmission in an intensive care unit between 2 cases.

Mucormycoses are rare but emerging diseases with poor prognosis caused by ubiquitous fungi from the environment. In November 2008, our teaching hospital experienced three cutaneous mucormycosis due to Lichtheimia spp. (ex Absidia/Mycocladus) in the intensive care and orthopaedic units. Environmental and epidemiological investigations suggested a possible cross-transmission of L. ramosa between two patients in intensive care. This is the first report of possible person-to-person transmission of mucormycosis species. These cases show the ineffectiveness of hydro-alcoholic solutions against spores and underline the need to respect standard precautions to prevent fungi dissemination.

Shellfish-acquired Vibrio cholerae cellulitis and sepsis from a vulnerable leg.

The following case concerns a soft tissue Vibrio cholerae (V. cholerae) infection in a fisherman who cut his foot while retrieving his fishing dinghy. It is rare for V. cholerae to cause extraintestinal infection. This V. cholera was identified as a non-toxigenic organism. The patient was successfully treated with medical therapy at Waikato Hospital (Hamilton, New Zealand) and discharged home after 10 days.

Deep wound cultures correlate well with bone biopsy culture in diabetic foot osteomyelitis.

BACKGROUND: Osteomyelitis is a major complication in patients with diabetic foot ulceration. Accurate pathogenic identification of organisms can aid the clinician to a specific antibiotic therapy thereby preventing the need for amputation. METHODS: All diabetic patients with bone biopsy-confirmed osteomyelitis were included into the study: biopsies were performed either during surgical removal of infected bone or percutaneously under guided fluoroscopy through non-infected tissue. The depth and extent of the ulcer was assessed using a sterile blunt metal probe. Deep wound cultures were taken from the wound base after sharp debridement. RESULTS: Of 66 cases of suspected osteomyelitis in 102 joints, 34 patients had both bone biopsies and deep wound cultures over the study period. Thirty two of 34 (94%), had a history of preceding foot ulceration, and in 25 of the cases a positive probe to bone test was recorded. In a high proportion of patients, at least one similar organism was isolated from both the deep wound culture and bone biopsy procedures (25 of 34 cases, 73.5%, p<0.001). When organisms were isolated from both wound cultures and bone biopsies, the identical strain was identified in both procedures in a significant proportion of cases (16 of 25 cases, 64%, p<0.001, total sample analysis in 16 of 34 cases, 47%). CONCLUSIONS: Deep wound cultures correlate well with osseous cultures and provide a sensitive method in assessing and targeting likely pathogens that cause osseous infections. This will help aid the clinician in guiding antibiotic therapy in centers where bone biopsies may not be readily available.

[Cedecea lapagei traumatic wound infection: case report and literature review]. / Infección de herida traumática por Cedecea lapagei: Comunicación de un caso y revisión de la literatura.

Cedecea lapagei is a gram-negative, facultative anaerobic, non-spore-forming bacteria, belonging to the family Enterobacteriaceae. It has been reported as a pathogen in few cases of bacterial peritonitis, wound infection, chemicals burns and pneumonia. We report a case of traumatic wound infection by this pathogen with a pertinent review.

Infección de herida traumática por Cedecea lapagei: Comunicación de un caso y revisión de la literatura / Cedecea lapagei traumatic wound infection: Case report and literature review

Cedecea lapagei is a gram-negative, facultative anaerobic, non-spore-forming bacteria, belonging to the family Enterobacteriaceae. It has been reported as a pathogen in few cases of bacterial peritonitis, wound infection, chemicals burns and pneumonia. We report a case of traumatic wound infection by this pathogen with a pertinent review.

Cedecea lapagei es un bacilo gramnegativo, anaerobio facultativo, no formador de esporas, perteneciente a la familia Enterobacteriaceae. Se han comunicado escasos casos en la literatura científica entre los cuales se destacan una peritonitis bacteriana, una infección de herida por quemadura química y una neumonía. A continuación se presenta el caso de una infección por este patógeno en una herida traumática. Se realiza una revisión bibliográfica del tema.

[Diabetic foot infections: microbiological aspects]. / Le infezioni del piede diabetico: aspetti microbiologici.

The diagnosis of wound infection is based on clinical signs and local and/or systemic inflammation. Therefore, the examination has a major role in the diagnosis of infected lesions of the foot. Once the clinical diagnosis of infection is made, the next step is to determine the etiology with the aim to undertake a rational and appropriate treatment. The most reliable method for assessing microbiological etiology is the specimen of material from infected lesion to perform a bacterioscopic examination and culture. The microorganisms involved in the etiology of diabetic foot depends on the type of injury and on specific patient features (antibiotic therapy, previous hospitalization). The most frequently detected pathogen is Staphylococcus aureus. Mild infections are mostly caused by Gram positive cocci, with a prevalence of S. aureus. Moderate infections are mostly supported by pyogenic Gram positive cocci, but also Gram-negative bacteria can be involved. In severe infections the etiology is polymicrobial. As regards the involvement of fungi in diabetic foot infections data are few and mostly conflicting.

Stingray injury to the webspace of the foot.

Stingrays are cartilaginous fish that are related to sharks. They are one of the largest groups of venomous marine animals. Stingrays account for 750 to 2000 injuries annually. They are generally passive, reclusive creatures that only sting in self-defense. Most injuries caused by these animals are nonfatal. A stingray possesses between 1 and 4 venomous stings, which are located along the caudal spine. If a stingray injury is sustained, parts of the spine may be left in the lacerations, which prolongs exposure to venom and increases the risk of subsequent wound infection. Stingray venom is unique in its enzymatic composition and results in distinct soft tissue injury patterns. Typically, a pattern of acute inflammation occurs, with a predominantly lymphoid cellular infiltrate followed by necrosis. The environment in which stingray injuries occur presents unique bacterial flora, and subsequent wound infections require careful antibiotic selection.This article describes a case of a healthy 31-year-old woman who sustained a stingray injury to the webspace of the foot while in Costa Rica. Initial basic first aid measures were applied. However, the wound subsequently became infected, and formal irrigation and debridement were performed. The initial wound cultures grew Staphylococcus viridans. Two months postoperatively, the incision was well healed, and the patient was pain free and returned to work.

Rare extraintestinal infection caused by toxin-producing Clostridium difficile.

Toxigenic Clostridium difficile is a well known cause of antibiotic-associated diarrhea mainly among hospitalized patients, at the same time we have little information about extraintestinal infections caused by this bacterium. We report here on rare extraintestinal infection caused by toxigenic C. difficile: 31-year-old male, accident victim was admitted to the hospital because of polytrauma. Microbiological examination of the pus revealed a toxin-producing C. difficile as an etiologic factor of this infection. Empiric antibiotic treatment with cefuroxime had been administered right after the positive microbiological result. On the basis of antibiotic susceptibility testing, the isolated strain was susceptible to most antimicrobials, except from cefoxitin, thus cefuroxime was changed to imipenem.