Melioidosis of the Musculoskeletal System.

OBJECTIVE: Recent studies indicate that India is an endemic region for Burkholderia pseudomallei infection. We aimed to describe the clinical presentation of B. pseudomallei infection of the musculoskeletal system and summarise the various treatment modalities used in our clinical practice. SUBJECTS AND METHODS: Patients with confirmed microbiological diagnosis of B. pseudomallei infection involving the musculoskeletal system treated from January 2007 to December 2016 with a minimum follow-up of 1 year were included. A retrospective review of medical records was carried out and patients' demographic data, co-morbidities, clinical presentation, and details of medical and surgical treatment were documented. RESULTS: Of 342 patients diagnosed with B. pseudomallei infection, 37 (9.2%) had musculoskeletal involvement; 26 patients (23 males) followed up for at least a year were included in the study. Four patients (15%) had multisystem involvement and 10 (37%) had multiple musculoskeletal foci of infection; 15 patients (58%) had osteomyelitis, 10 (38%) had septic arthritis with or without osteomyelitis, and 1 patient (4%) presented with only soft tissue abscess. All patients required surgical intervention in addition to medical management. Surgical treatment varied from soft tissue abscess drainage, arthrotomy for septic arthritis, decompression and curettage for osteomyelitis, and/or use of antibiotic (meropenem or ceftazidime)-loaded polymethylmethacrylate bone cement for local drug delivery. At final follow-up (average: 37 months, range: 12-120), all patients were disease free. CONCLUSION: We found the rate of musculoskeletal involvement in B. pseudomallei infection to be 9.2%. Appropriate surgical treatment in addition to medical management resulted in resolution of disease in all our patients.

Contamination profile in allografts retrieved from multitissue donors: longitudinal analysis.

Microbiological contamination of retrieved tissues has become an issue of key importance and is a critical aspect of allograft safety, especially in the case of multi-tissue donations, which frequently become contaminated during retrieval and handling. We analysed contamination in 11,129 tissues with a longitudinal contamination profile for each individual tissue. Specifically, 10,035 musculoskeletal tissues and 1094 cardiovascular tissues were retrieved from a total of 763 multi-tissue donors, of whom 105 heart-beating organ donors and 658 deceased tissue donors. Of the 1955 tissues found to be contaminated after the first decontamination step, 1401 tissues (72%) were contaminated by the same species as the one(s) isolated at retrieval (Time1) and 554 (28%) by different species. Among the 113 tissues testing positive after the 2nd decontamination (Time3), 36 tissues (32%) were contaminated by the same species detected at Timel while the contaminating species differed from Time1 in 77 tissues (68%). The higher the number of contaminating species per tissue the higher the percentage of tissues in which contamination changed over time compared to Time1. The analysis revealed a 28% incidence of new species in tissues already testing positive after retrieval and of 3.5% of tissues becoming positive after admission to the tissue bank. Of these, coagulase-negative Staphylococcus accounted for over 70% of new contaminations.

Analysis of potential contamination factors in musculoskeletal tissues.

Tissue Banks have become the main source for bone grafts, due to preference for homologous tissues. Notwithstanding the use of aseptic techniques for procurement of tissues and judicious selection of donors, microorganisms are frequently found in procured bones. Purpose of this study is to evaluate the factors that increase safety of procurement and minimize discard of procured tissues. Microbiological contamination was analyzed in 1271 musculoskeletal tissues removed from 138 multi-organ donors over a period extending from 2006 to 2016. Effects of various risk factors related with contamination were estimated using a logistic regression model. Microbiological contamination rate in the tissues was 17.1%; low pathogenic microorganisms were cultivated in 12.9% of the tissues, while highly pathogenic ones were cultivated in 4.2% of the tissues. Evolution of one single team was monitored during that period, verifying a fall in the general contamination level from 22.5 to 9.2%. Absence of antibiotics increased low pathogenic contamination risk. Every additional day in intensive care unit (ICU) increased the risk of highly pathogenic contamination. Time elapsed between death and the beginning of removal procedures was found to be relevant for both low pathogenic and highly pathogenic microorganisms. Among the studied factors, the following contributed for a significant increase in contamination by microorganisms in removed tissues: lack of use of prophylactic antibiotic therapy in donors, quantity of removed tissues, length of admission in ICU and the time elapsed between aortic clamping and beginning of the removal procedure.

Imaging paracoccidioidomycosis: A pictorial review from head to toe.

Paracoccidioidomycosis is an infectious disease characterized primarily by pulmonary involvement and potential dissemination to other organs, mainly mucosa and skin; however, it can affect any organ in the body. Although difficult to diagnose purely based on imaging, imaging is important for diagnosis, follow-up, and assessment of disease-related complications. We provide a comprehensive review of the most notable imaging findings of paracoccidioidomycosis.

Sporotrichal Tenosynovitis Diagnosed Helpfully by Musculoskeletal Ultrasonography.

A 72-year-old man presented with persistent oligoarthritis and positive results for rheumatoid factor and was suspected of having rheumatoid arthritis (RA). However, the musculoskeletal ultrasonography (MSUS) findings were not consistent with those of typical RA. He had undergone surgery for carpal tunnel syndrome, which allowed both histopathological and microbiological examinations to be performed. A synovial tissue culture was positive for Sporothrix schenckii, and he was diagnosed with sporotrichal tenosynovitis. He received anti-fungal therapy, and the sporotrichal tenosynovitis resolved. This case suggests that MSUS is a useful modality, and sporotrichal tenosynovitis, though rare, should be considered in the differential diagnosis of RA.

A Retrospective Analysis of Bacteriological Studies of Surgical Site Infections in a Monoprofile, Multidepartmental Orthopedic Hospital.

BACKGROUND: Despite improvements in surgical techniques, aseptics and prevention of infections, hospital surgical site infections (SSI) still remain one of the main reasons for failure in therapeutic musculoskeletal surgery. This study aimed to conduct a retrospective analysis of microbiological examinations and determine pathogen sensitivity to antibiotics as the basis for selecting methods for preventing and treating complicating infections. MATERIAL AND METHODS: The study is a retrospective analysis of bacteriological tests performed in the departments of the Public Clinical Hospital of the Medical Centre of Postgraduate Education in Otwock. Importantly, our monoprofile hospital specialising in musculoskeletal pathology is a reference centre, admitting patients from the entire country. Often these are patients transferred from Intensive Care Units at other hospitals with internally infected local emergencies (infections with local, complex, multidrug resistant bacterial flora). Bacteriological mapping of the hospital covered the period from 2009 to 2013 to indicate so called "strategic departments" demonstrating the most complex multidrug-resistant bacterial flora. Surgical site infections were managed by surgery with targeted antibiotic therapy. RESULTS: Analysis of patients' profiles revealed that SSIs detected across hospital departments in SPSK CMKP in Otwock mostly came from other medical centers where patients were initially hospitalized. The Osteomyelitis Department and the Department of Pelvic Pathology and Traumatology were identified as "strategic departments". CONCLUSIONS: 1. The analysis indicated that methicillin-sensitive Staphylococcus aureus (MSSA) was the most common pathogen responsible for complicating infections in our hospital. 2. The percentage of bacterial resistance to methicillin signifi -cantly increased in patients with multi-organ injuries who had previously been hospitalized at other centres. 3. Credible prevention and diagnosis of inflammatory risk factors in the preoperative period was of key importance in reducing the percentage of complicating infections.

Evaluation of two types of swabs for sampling allograft musculoskeletal tissue.

BACKGROUND: Allograft musculoskeletal tissue is commonly sampled by a swab for bioburden screening. To determine if bioburden recovery could be improved at the pre-analytical stage, two swab systems were evaluated: the Amies gel swab and the ESwab. METHODS: In vitro studies were performed to determine the recovery of each swab system with <100 colony-forming unit of challenge organisms using inoculated swabs and by sampling inoculated femoral heads. The standard culture protocol used in this laboratory was also evaluated after sampling of inoculated femoral heads. A prospective study was performed with both swab systems used in parallel to sample cadaveric allograft musculoskeletal tissue. RESULTS: The challenge organisms could be recovered from the in vitro inoculated studies. The standard culture protocol in this laboratory recovered all challenge organisms from both swab systems. One hundred and six paired Amies and ESwabs were collected from eight cadaveric donors with skin commensals the predominant isolates. CONCLUSIONS: The sampling of an inoculated femoral head was included to reflect routine swab sampling practice as was the inclusion of the standard method used in this laboratory. This appears to be the first study to compare Amies gel swabs with ESwabs to sample allograft femoral heads and in a prospective study with cadaveric allograft musculoskeletal tissue. Other comparative studies of swab systems have used a much higher inoculum to mimic an infection; however, sepsis is an exclusion criterion for allograft donors. It was found that the Amies gel swab and ESwab are both suitable sampling devices for bioburden testing of allograft musculoskeletal tissue.

Magnetic resonance imaging findings of musculoskeletal brucellosis.

OBJECTIVE: The aim of this retrospective study was to determine the magnetic resonance imaging (MRI) findings of patients with musculoskeletal brucellosis. MATERIALS AND METHODS: Sixty-eight among 304 patients with musculoskeletal brucellosis, aged 12-82 years (average, 50.2 years), were included in the study. Patients were diagnosed based on clinical findings, Brucella agglutination tests, and MRI findings. MRI was performed to all of the patients with sacroiliitis, spondylitis-spondylodiscitis, and peripheral arthritis. RESULTS: Brucella serum agglutination test was >1/160 in all cases and blood cultures were positive in twelve cases. The most commonly affected site was the spine (57.3%), wherein lumbar vertebrae were found to be most commonly affected. The second most common affected site was sacroiliac joint (26.4%), whereas peripheral joints were affected in 11 cases (16.1%). CONCLUSION: Brucellosis may affect various sites in musculoskeletal system. The spine was the most frequently affected site in our study. Sacroiliac joints and the other peripheral joints were less commonly involved sites. Brucellosis should be included in the differential diagnosis of a patient with arthralgia or symptoms of musculoskeletal system disorders especially in endemic areas.

Swab or biopsy samples for bioburden testing of allograft musculoskeletal tissue?

Swab and biopsy samples of allograft musculoskeletal tissue are most commonly collected by tissue banks for bacterial and fungal bioburden testing. An in vitro study was performed using the National Committee for Clinical Laboratory Standards standard 'Quality control of microbiological transport systems' (2003) to validate and evaluate the recovery of six challenge organisms from swab and biopsy samples of allograft musculoskeletal tissue. On average, 8.4 to >100 and 7.2 to >100 % of the inoculum was recovered from swab and biopsy samples respectively. A retrospective review of donor episodes was also performed, consisting of paired swab and biopsy samples received in this laboratory during the period 2001-2012. Samples of allograft femoral heads were collected from living donors during hip operations. From the 3,859 donor episodes received, 21 paired swab and biopsy samples each recovered an isolate, 247 swab samples only and 79 biopsy samples only were culture positive. Low numbers of challenge organisms were recovered from inoculated swab and biopsy samples in the in vitro study and validated their use for bioburden testing of allograft musculoskeletal tissue. Skin commensals were the most common group of organisms isolated during a 12-year retrospective review of paired swab and biopsy samples from living donor allograft femoral heads. Paired swab and biopsy samples are a suitable representative sample of allograft musculoskeletal tissue for bioburden testing.

Broth versus solid agar culture of swab samples of cadaveric allograft musculoskeletal tissue.

As part of the donor assessment protocol, bioburden assessment must be performed on allograft musculoskeletal tissue samples collected at the time of tissue retrieval. Swab samples of musculoskeletal tissue allografts from cadaveric donors are received at the microbiology department of the South Eastern Area Laboratory Services (Australia) to determine the presence of bacteria and fungi. This study will review the isolation rate of organisms from solid agar and broth culture of swab samples of cadaveric allograft musculoskeletal tissue over a 6-year period, 2006-2011. Swabs were inoculated onto horse blood agar (anaerobic, 35 °C) and chocolate agar (CO2, 35 °C) and then placed into a cooked meat broth (aerobic, 35 °C). A total of 1,912 swabs from 389 donors were received during the study period. 557 (29.1 %) swabs were culture positive with the isolation of 713 organisms, 249 (34.9 %) from solid agar culture and an additional 464 (65.1 %) from broth culture only. This study has shown that the broth culture of cadaveric allograft musculoskeletal swab samples recovered a greater amount of organisms than solid agar culture. Isolates such as Clostridium species and Staphylococcus aureus would not have been isolated from solid agar culture alone. Broth culture is an essential part of the bioburden assessment protocol of swab samples of cadaveric allograft musculoskeletal tissue in this laboratory.

Micro-organisms isolated from cadaveric samples of allograft musculoskeletal tissue.

Allograft musculoskeletal tissue is commonly used in orthopaedic surgical procedures. Cadaveric donors of musculoskeletal tissue supply multiple allografts such as tendons, ligaments and bone. The microbiology laboratory of the South Eastern Area Laboratory Services (SEALS, Australia) has cultured cadaveric allograft musculoskeletal tissue samples for bacterial and fungal isolates since 2006. This study will retrospectively review the micro-organisms isolated over a 6-year period, 2006-2011. Swab and tissue samples were received for bioburden testing and were inoculated onto agar and/or broth culture media. Growth was obtained from 25.1 % of cadaveric allograft musculoskeletal tissue samples received. The predominant organisms isolated were coagulase-negative staphylococci and coliforms, with the heaviest bioburden recovered from the hemipelvis. The rate of bacterial and fungal isolates from cadaveric allograft musculoskeletal tissue samples is higher than that from living donors. The type of organism isolated may influence the suitability of the allograft for transplant.

Infection not associated with use of human musculoskeletal tissue allografts.

The deaths of otherwise healthy patients that are attributable to contaminated allografts have heightened concerns about the screening, processing, and use of such tissues. We present one tertiary care institution's experience with musculoskeletal allografts and determine the frequency of postoperative Clostridium infection. We used an institutional microbiology database to identify all records of culture-confirmed Clostridium infection from January 1990 through July 2006. A comprehensive musculoskeletal database was cross-referenced to include all possible allograft samples surgically collected or implanted from January 1990 through July 2004 to determine the frequency of Clostridium infection associated with use of allograft musculoskeletal tissue. Musculoskeletal allografts were implanted in 16,314 patients during the study period. After a minimum follow-up of 2 years, no patient had development of a definite Clostridium infection that was attributable to the use of musculoskeletal allograft tissue. These outcomes can be achieved with established screening and processing techniques for donor tissue.

Fungal culture of musculoskeletal tissue: what's the point?

There have not been any studies that review the prevalence of fungal isolates using selective media from samples of banked musculoskeletal tissue retrieved from living and cadaveric donors. A total of 2,036 swab and 2,621 biopsy samples of musculoskeletal tissue from tissue banks were received from the 1st August 2008 till 31st December 2010. Routine culture for fungi using selective media with a prolonged incubation period failed to demonstrate a greater prevalence of fungal isolates than by using non-selective culture media alone. Using selective culture fungi were recovered from only two Sabouraud agar plates (0.1%) but not from non-selective media. During the same period fungi were isolated from three graft samples cultured in non-selective broth media only (0.1%). There was no correlation of fungal isolates from selective or non-selective media inoculated at the same time nor from multiple graft samples collected from the same donor supporting the possibility of an exogenous source for fungal isolates rather than an endogenous source.

Mycobacterial infection of the musculoskeletal tissues: the use of pathological specimens for identification of causative species by PCR-direct sequencing of 16S rDNA.

Mycobacterial infection of musculoskeletal tissue is a rare disease that may cause destruction of the tissues. Both Mycobacterium tuberculosis and non-tuberculous mycobacteria affect the tissues. Although surgical debridement and antibiotic therapy are required for the treatment, it is necessary to identify the causative species before selecting the antibiotics. However, it is difficult to identify the species in clinical samples from musculoskeletal tissue. In the current study, using pathological specimens, the causative species was identified by PCR amplification and direct sequencing of mycobacterial 16S rDNA containing a hypervariable region. Twelve cases of chronic granulomatous inflammation of musculoskeletal tissues were used for the study. DNA was extracted from paraffin sections, and mycobacterial 16S rDNA was amplified by PCR. The amplicons were obtained in 5 of 12 cases (41%), even in specimens in which the microorganism was only scarcely detected by using special stains. Direct sequencing of the amplified products presented high homology with M. tuberculosis in four cases and M. avium in one. Therefore, PCR-direct sequencing of 16S rDNA containing hypervariable region using pathological specimens is useful for the diagnosis and identification of causative species in mycobacterial infection of musculoskeletal tissues.

Pathological findings in harbour seals (Phoca vitulina): 1996-2005.

Between 1996 and 2005 the carcasses of 355 harbour seals originating from the coast of Schleswig-Holstein, Germany, were investigated for pathological changes. The animals were collected before (n=280) and after (n=75) the second phocine distemper virus (PDV) epizootic in 2002. The seals were either found dead or were killed due to severe illness. Necropsy was performed in each case, in addition to histopathological, immunohistochemical, microbiological and parasitological examinations. Throughout the period of study, the respiratory and alimentary tracts were the organ systems most consistently affected by pathological change. The most common cause of death was bronchopneumonia caused by parasitic and/or bacterial infection of the lung. Less frequently identified changes included: trauma, gastroenteritis, uterine torsion or dystocia, polyarthritis/polymyositis, intestinal torsion, septicaemia, dermatitis, and keratitis. The most frequent causes of bronchopneumonia, gastroenteritis, polyarthritis, dermatitis and septicaemia were infections with alpha/beta-haemolytic streptococci, Escherichia coli and Clostridium perfringens. A number of changes were more frequently identified after 2002. These included the presence of parasites in the lung, stomach and intestine; bronchopneumonia, gastritis, enteritis, septicaemia and perinatal death. The increased prevalence of these changes may have been related to the preceding PDV epidemic.

State-of-the-art treatment of coccidioidomycosis skeletal infections.

Coccidioidomycosis is a fungal infection endemic to the southwestern United States. Typically a respiratory illness, coccidioidomycosis can rarely present as extrapulmonary infection. Skeletal coccidioidomycosis occurs in 20% to 50% of disseminated infections. Skeletal coccidioidomycosis is a chronic and progressive infection that eventually results in bone destruction and loss of function and often involves adjacent structures, such as joints, muscles, and tendons and other soft tissues. Sinus tract formation may occur. This infection may be multifocal. Although radiographs, white blood cell count scans, and other imaging methods identify and define relevant abnormalities, histopathologic examination with culture of the involved bone is the only means to confirm the diagnosis. Serologic testing is adjunctive, and complement fixation titers can be evaluated serially to assess response to treatment. A number of studies addressing the efficacy of various antifungal agents have been performed, and the results of these studies as they pertain to skeletal coccidioidomycosis are summarized herein. Among the various studies, response rates ranged from 23% to 100%, but relapse was common. A combination of medical therapy-often, itraconazole or fluconazole-and surgical débridement is often needed to control skeletal coccidioidomycosis. Early diagnosis and treatment are critical to avoid long-term problems with chronically infected bones and joints. Anatomical issues, diagnostic studies, and data related to treatment of this form of extrapulmonary coccidioidomycosis are reviewed in this article.

Incidence of clostridial contamination in donors' musculoskeletal tissue.

Reports of infection by Clostridium sordellii associated with allograft transplantation have generated considerable interest. We report our experience in recognising clostridial contamination in cadaver donors of musculoskeletal tissue. Tissues obtained from 795 consecutive donors were excised using standard surgical techniques. Samples of blood and bone marrow were also obtained. Donors with clostridia recovered from any site were matched with the preceding donor without clostridia as a procedural and environmental control. The histories of the donors were analysed to determine which variables had a relationship to contamination by running a contingency table and chi-squared test on the variables against the event of a donor being contaminated. Sixty-four donors (8.1%) had clostridia, most commonly C. sordellii. Clostridia were grown from the blood, marrow and tissue samples of 52, 37 and 30 donors, respectively. In eight cases, they were cultured from the tissue samples alone. There was no significant difference in age or gender between the contaminated donors and the control group. Open wounds were more common in control than in contaminated subjects, but only death by drowning in the contaminated group was statistically significant (p = 0.02). The time between death and the excision of tissue which was contaminated (16 hrs 10 mins) compared with control (11 hrs 10 mins) donors was also significant (p < 10(-6)). We conclude that there is clostridial contamination in a significant number of tissue donors, particularly with increasing time between death and tissue excision. Among the most commonly encountered species is C. sordellii. Multiple microbiological cultures, including blood, are necessary in order to identify clostridial contamination.

Trends in pediatric emergency imaging.

Abdominal pain, respiratory infections, and skeletal trauma are among the most common reasons for imaging infants and children in the emergency department. The types of pathology and the imaging findings for the various causes of these conditions often differ significantly from those seen in adults with similar symptoms. Although radiographs remain the primary imaging tool, ultrasound, helical CT, and MR imaging play an increasingly important role in solving diagnostic problems in emergency pediatrics. This article highlights some of the common diagnostic dilemmas and discusses current trends in the use of advanced imaging in pediatric patients.

Pasteurella multocida in psittacines: prevalence, pathology, and characterization of isolates.

Although the pathogenicity of Pasteurella multocida for psittacines (parrots and their relatives) has been documented in several case reports, the associated pathologic syndromes have not been well defined nor have the isolates been characterized. In addition, the prevalence of P. multocida in psittacines has not been determined. Three hundred twenty-eight psittacines (253 clinically healthy and 75 clinically ill) were cultured for P. multocida. Pasteurella multocida was not isolated from the pharynx, choana, or cloaca of psittacines. However, in five dead psittacines submitted for necropsy, P. multocida was isolated. These isolates were characterized, and all belonged to either somatic serotype 3 or 4,7. Pasteurella multocida somatic serotype 3 was isolated from psittacines with septicemia, whereas P. multocida somatic serotype 4,7 was isolated from psittacines with cutaneous lesions. The majority (four out of five) of the P. multocida isolates belonged to the subspecies multocida, and all isolates were susceptible to penicillin G, sulfisoxazole, gentamicin, erythromycin, tetracycline, and trimethoprim-sulfamethoxazole but resistant to streptomycin. DNA fingerprints demonstrated that isolates belonging to the same somatic serotype were genetically related. The isolate from a cockatiel that had been caught by a cat belonged to somatic serotype 3 and was not genetically related to the other two isolates belonging to this somatic serotype.