Introduction Nocardia nova complex has been associated with infections in both immunocompetent and immunocompromised patients. Infection can be localized or disseminated, affecting skin and soft tissues, the respiratory system, bones and joints, the circulatory system and especially the central nervous system. Ocular infections such as keratitis, scleritis, conjunctivitis, dacryocystitis, orbital cellulitis and endophthalmitis due to Nocardia spp. are infrequently reported, and usually described after penetrating corneal trauma or ocular contact with plants and soils. Case presentation An immunocompetent male presented with a history of penetrating ocular trauma that had evolved to infectious endophthalmitis, which was refractory to different antibiotic treatments. No micro-organisms were isolated from repeated conjunctival smear and corneal scraping cultures between the ocular trauma (August 2014) and the endophthalmitis diagnosis (November 2015). After this period, N. nova sensu stricto was isolated in aqueous humour aspirate. Treatment was adjusted and clinical improvement was obtained after an adequate microbiological procedure, including an optimal sampling and an antimicrobial-susceptibility testing report. Conclusion Nocardia identification to the species level and performance of antimicrobial-susceptibility tests are both essential tools for treatment adjustment and clinical improvement.
Introduction Osteoarthritis (OA) is a common cause of knee pain in older adults. OA is primarily caused by deterioration of cartilage in the knee, which decreases the ability of synovial fluid to absorb shock and increases the opportunity for bones of the joint to rub together. Hylan G-F 20 (Synvisc-One) is a compound that can be injected directly into the knee to help combat the pain associated with OA by lubricating and cushioning the joint. Case presentation. A 92-year-old male reported to his primary care provider with complaints of pain due to OA. An ultrasound-guided injection of Hylan G-F 20 was administered without complication; however, the patient presented to an emergency department approximately 10 h after the injection complaining of stabbing pain and swelling in the same knee. Specimens submitted for culture 12 h post-injection yielded a Methylobacterium spp. that was identified following biochemical testing, MALDI-TOF (matrix-assisted laser desorption/ionization-time of flight) MS analysis and bacterial sequencing. Interestingly, symptoms began to subside following aspiration of synovial fluid, and new cultures of synovial fluid collected 24 h post-Hylan G-F 20 injection were negative for the presence of Methylobacterium. The patient’s knee returned to baseline with diminished pain due to OA approximately 1 week after the initial injection without antibiotic treatment. Conclusion We report short-term complications following treatment of OA with a Methylobacterium-contaminated lot of Hylan G-F 20.
INTRODUCTION:Although more often recognized as a culprit in female urinary tract infection, coagulase-negative staphylococci (CoNS) can cause severe genitourinary infections in men. While positive blood cultures with CoNS are usually thought to be contaminants, in the setting of a severe genito-urinary infection they can represent true infection.CASE PRESENTATION:We present the case of a 70-year-old male without a central venous catheter or urinary catheter who developed Staphylococcus haemolyticus bloodstream infection secondary to epididymo-orchitis.CONCLUSION:This case highlights the importance of prompt recognition of serious CoNS infections, including bacteraemia, in the setting of CoNS genitourinary tract infections.
INTRODUCTION:Non-tuberculous mycobacteria (NTM) are environmental bacteria capable of causing an opportunistic myriad of infections. Mycobacterium kansasii, one such NTM, is responsible for causing pulmonary disease in immunocompromised patients. Rare extrapulmonary manifestations such as lymphadenitis, osteoarticular manifestations, and skin and soft tissue infections are also observed.CASE PRESENTATION:Here, we report an unusual case of sternoclavicular joint and elbow joint infection with M. kansasii in a relatively immunocompetent patient. Histopathology did not show classic granulomas and mycobacterial infection was not initially considered as a possibility. However repeat biopsies were sent for mycobacterial cultures which then grew M. kansasii.CONCLUSION:Diagnosis of M. kansasii in such cases can be difficult and culture-positive results may not necessarily imply positive diagnosis as they can be environmental contaminants. Furthermore, M. kansasii can cause infections without the characteristic granuloma formation, which can further complicate tissue diagnosis. This underlines the importance of ensuring that tissue samples obtained are cultured for mycobacteria.
INTRODUCTION:In people, Salmonella is a common agent of gastroenteritis, but it can also cause extraintestinal disease such as urinary tract infections. In addition, Salmonella is often linked to the post-infection development of reactive arthritis. In canines, cases that document extraintestinal Salmonella infections or diseases similar to reactive arthritis have not been thoroughly described. CASE PRESENTATION:A case of a 5-year-old German shepherd dog with Salmonella bacteriuria during treatment for immune-mediated polyarthritis (IMPA) is described. The patient first suffered from a 3 month period of diarrhoea and presented for evaluation of a 2 month history of shifting-leg lameness. A diagnosis of IMPA was made based on cytological examination and negative synovial fluid culture. Treatment with immunosuppressive doses of prednisone lead to clinical resolution of lameness, but on a recheck abnormal urine was noted. Salmonella enterica serovar Typhimurium was isolated using standard culture methods. The patient was treated with enrofloxacin to control the bacteriuria. CONCLUSION:This case report is, to the best of our knowledge, the first to describe Salmonella bacteriuria in a dog and suggests that Salmonella infection may be a potential inciting factor for IMPA.
Introduction Chagas disease is caused by infection with the protozoan Trypanosoma cruzi. It is endemic to the American continent due to the distribution of its insect vectors. The disease is occasionally imported to other continents by travel of infected individuals. It is rarely diagnosed in the Netherlands and exact numbers of infected individuals are unknown. Clinical manifestations can start with an acute phase of 4–8 weeks with non-specific, mild symptoms and febrile illness. In the chronic phase, it can lead to fatal cardiac and gastro-intestinal complications. Case presentation We describe a case of a 40-year-old man with end-stage cardiomyopathy due to Chagas disease. He lived in Surinam for more than 20 years and had an unremarkable medical history until he was hospitalized due to pneumonia and congestive heart failure. Despite antibiotic treatment and optimizing cardiac medication, his disease progressed to end-stage heart failure for which cardiac transplantation was the only remaining treatment. A left ventricular assist device (LVAD) was implanted as a bridge to transplantation. Tissue analysis after LVAD surgery revealed ongoing myocarditis caused by Chagas disease. Based on a literature review, a scheme for follow up and treatment after transplantation was postulated. Conclusion Chagas disease should be taken into account in patients from endemic countries who have corresponding clinical signs. Heart transplantation in patients with Chagas cardiomyopathy is accompanied by specific challenges due to the required immunosuppressive therapy and the thereby increased risk of reactivation of a latent T. cruzi infection.
Introduction Pseudomonas aeruginosa has the ability to acquire plasmids and other mobile genetic elements that confer resistance to antibiotics. Bacterial genes encoding different β-lactamases (bla), such as metallo-β-lactamases (MBLs) and extended-spectrum β-lactamases (ESBL), can confer resistance to multiple classes of β-lactam antibiotics. Case presentation An 83 year old female was admitted in 2012 to the Peruvian Naval Hospital, Centro Médico Naval ‘Cirujano Mayor Santiago Távara’ (CEMENA), in Lima, Peru. A midstream urine sample was collected and sent to the local CEMENA laboratory for routine urine culture. P. aeruginosa was isolated and initial antibiotic susceptibility testing showed it to be sensitive to imipenem. The clinicians started a course of meropenem, but the patient did not improve. After 5 days, a second urine culture was performed and a P. aeruginosa was isolated again, but this time the strain showed resistance to imipenem. The treatment course was changed to fosfomycin and the patient improved. Phenotypic and molecular laboratory testing to characterize the antibiotic resistance were performed, demonstrating the presence of both MBL and ESBL genes. Conclusion To our knowledge, this is the first report of a P. aeruginosa XDR clinical isolate that co-expresses an MBL (VIM-2), OXA-1 beta-lactamase and the ESBL (GES-1) in Peru. It is also the first report of a VIM carbapenemase in Peru.
Introduction Pythiosis is caused by Pythium insidiosum, a fungus-like organism in the class Oomycetes. It can infect humans and a variety of animal species in tropical, subtropical and some temperate regions. Cases of animal pythiosis have occurred predominantly in horses in the skin and subcutaneous tissue at the limbs and in the ventral portion of thoracoabdominal wall - lesions in the nasal region are rarely reported. Moreover, although many human pythiosis cases have been reported in Thailand, no cases of animal pythiosis in Thailand have been reported. Case presentation We report a case of pythiosis in a horse infected at the nasal cavity. Diagnosis was performed by zoospore formation by bait technique, immunohistochemical stain, immunochromatography and sequence analysis. Conclusion The sequences of rDNA were 99 % and 96 to 99 % identical to GenBank isolates of Pythium insidiosum from two Thai human patients and horses from various countries, respectively. This represents the first confirmed report of nasal equine pythiosis in Thailand.
INTRODUCTION:Schistosomiasis, a travel-related trematode infection, can cause a range of symptoms with potentially life-threatening complications. In this report, we describe an outbreak of schistosomiasis in a Scottish school group that had travelled to Uganda. We discuss the requirement for robust and accurate pre-travel advice, and the importance of raising awareness in travellers, particularly due to the asymptomatic nature of the disease. In addition, we highlight the need to submit a serum sample for laboratory testing on return from endemic regions where freshwater exposure has occurred.CASE PRESENTATION:A Scottish school group consisting of 19 individuals visited Uganda during July 2016 with one positive symptomatic case identified on return to the UK. As three of the individuals were not Scottish residents, their data were excluded from this report. Freshwater exposure was noted from taking part in activities which included swimming in the Nile. The Scottish Parasite Diagnostic and Reference Laboratory performed serology testing using sera from 16 Scottish residents to detect IgG towards Schistosoma egg antigens. Thirteen were positive despite only one case being symptomatic.CONCLUSION:The high positivity rate raised several issues. These included the lack of a robust risk assessment by the travel company organizing the trip, the lack of awareness of schistosomiasis by some individuals, the lack of appropriate and accurate pre-travel advice, and the asymptomatic nature of the infection. This report provides supportive evidence to strengthen the need for improvements to prevent largely asymptomatic cases being missed in future.
Introduction Ehrlichia are obligate intracellular pathogens transmitted to vertebrates by ticks. Case presentation We report the case of a 59-year-old man who presented to the University of Kentucky Albert B. Chandler Medical Center (Lexington, KY, USA) after being found fallen down in the woods. A lumbar puncture revealed what appeared to be bacterial meningitis, yet cerebrospinal fluid cultures, Gram stains and a meningitis/encephalitis panel were inconclusive. However, an Ehrlichia DNA PCR of the blood resulted as being positive for Ehrlichia chaffeensis antibodies. The patient received a 14 day course of doxycycline, and recovered from his multiple organ failure. The aetiology of the ehrlichial meningoencephalitis was likely transmission through a tick-bite, due to the patient’s outdoor exposure. Conclusion While it is rare to see Ehrlichia as a cause of meningitis, this illness can progress to severe multisystem disease with septic shock, meningoencephalitis or acute respiratory distress syndrome (ARDS). Those with compromised immunity are at a higher risk of developing the more severe form of the disease and have higher case fatality rates.
Introduction. LPS-responsive beige-like anchor (LRBA) protein deficiency is a disease of immune dysregulation with autoimmunity affecting various systems. Case Presentation. Two male siblings with a novel LRBA mutation had different primary findings at admission: the younger sibling had chronic early-onset diarrhoea and the elder one had autoimmune haemolytic anaemia. During long-term follow-up for IPEX phenotype, both developed hypogammaglobulinaemia, enteropathy and lung involvement. The patients partially responded to immunosuppressive therapies. A homozygous c.2496C>A, p.Cys832Ter (p.C832*) mutation in the LRBA gene causing a premature stop codon was detected. After molecular diagnosis, abatacept, as a target-specific molecule, was used with promising results. Conclusion. LRBA deficiency is a recently defined defect, with variable presentations in different patients; a single, definitive treatment option is thus not yet available.
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Vital parameters of patient A at first presentation were within the normal range: temperature 37.9 C, blood pressure 121/78mm Hg and pulse rate 90 bpm. The results for laboratory tests performed on admission were notable for a white blood cell (WBC) count of 18.4 10 cells l 1 (reference, 2.5–8.2 10 cells l ) with 90.9% neutrophils, and a CRP of 86mg l 1 (reference, <10mg l ). Physical examination revealed a swollen and necrotic fingertip of the left index finger (Fig. 1a). Flexion was limited, and palpation of the tendon at the mid phalanx was painful. Examination of the left arm revealed lymphangitis on the dorsoradial side of the underand upper arm, reaching up to the left axilla (Fig. 1b). Intravenous treatment with benzylpenicillin and clindamycin was initiated. Exploration of the index finger by incision revealed transparent serous fluid but no pus. A sample was obtained for Gram staining and culture.
Introduction Hypervirulent capsular type K1 Klebsiella pneumoniae strains of clonal complex 23 (CC23) are associated with severe community-acquired pyogenic liver abscesses, often complicated by metastatic infections and significant mortality. The majority of hypervirulent strains reported are susceptible to most antibiotics except ampicillin. To the best of our knowledge, this is the first case of New Delhi metallo-β-lactamase (blaNDM)-producing hypervirulent K. pneumoniae from the UK. Case presentation We present a case of pyogenic liver abscess in a 63-year-old female of Bangladeshi origin, with a recent diagnosis of pancreatic cancer. The patient was treated with piperacillin/tazobactam and blood cultures grew a fully susceptible Escherichia coli. Despite antimicrobial therapy and drainage of the abscess, the patient continued to deteriorate and died on day seven of admission. The fluid drained from the liver abscess grew a fully susceptible E. coli and a multi-drug-resistant K. pneumoniae. Two weeks prior to admission, a rectal screening swab grew a metallo-β-lactamase-producing K. pneumoniae. Molecular characterization revealed that both the K. pneumoniae isolates belonged to the hypervirulent K1 cluster of CC23, sequence type 23. The isolate from the rectal screen was positive for the blaNDM metallo-β-lactamase gene. Conclusion The emergence of carbapenemase-producing hypervirulent K. pneumoniae strains presents a new and significant threat to global public health. Management of these infections will be extremely challenging due to the limited treatment options available and they are likely to be associated with an even greater mortality.
INTRODUCTION:Infective endocarditis (IE) is an important clinical condition with significant morbidity and mortality among the affected population. A single etiological agent is identifiable in more than 90 % of the cases, however, polymicrobial endocarditis (PE) is a rare find, with a poor clinical outcome. Here we report a case of native valve dual pathogen endocarditis caused by Burkholderia cepacia and Aspergillus flavus in an immunocompetent individual. It is among unique occurrences of simultaneous bacterial and fungal etiology in IE.CASE PRESENTATION:A 30-year-old male was admitted to a cardiology institute with complaints of low grade intermittent fever and progressive shortness of breath for last two months. He was a known case of rheumatic heart disease and had suffered an episode of IE three years ago. On the basis of clinical presentation and the results of radiological investigations, a diagnosis of infective endocarditis was made. Paired blood samples for culture and sensitivity, sampled before the commencement of antimicrobial therapy, yielded growth of Burkholderia cepacia which was highly drug resistant. Sensitivity results-directed therapy consisting of tablet Trimethoprim-Sulfamethoxazole, two double-strength tablets 12 hourly, and Meropenem, 1 g IV every 8 h, was commenced. Despite mild relief of fever intensity, overall clinical condition did not improve and double valve replacement therapy was carried out. Excised valves were sent for microbiological analysis. Burkholderia cepacia was grown on tissue culture with a similar antibiogram to that previously reported from the blood culture of this patient. Direct microscopy of section of valvular tissue with 10 % KOH revealed abundant fungal hyphae. Patient serum galactomannan antigen assay was also positive. Histopathological examination of vegetations also revealed hyphae typical of species of the genus Aspergillus. The patient was successfully treated with meropenem, trimethoprim-sulfamethoxazole and voriconazole.CONCLUSION:The hallmark of successful treatment in this case was exact identification of pathogens, antibiogram-directed therapy and good liaison between laboratory experts and treating clinicians.
Introduction Raoultella is a genus of aerobic Gram-negative bacilli belonging to the family Enterobacteriaceae that are commonly found in water, soil and aquatic environments. With improved bacterial identification techniques, Raoultella species (namely R. planticola and R. ornithinolytica) have been an increasingly reported cause of infections in humans. Case presentation An 85-year-old man presented to hospital with a several-week history of left jaw pain and trismus. His medical history was significant for left mandibular osteomyelitis treated 1 year previously with amoxicillin-clavulanate. On admission, a computed tomography scan demonstrated a 2.6×1.7×1.6 cm peripherally enhancing collection surrounding the left posterior mandibular body. Two aspirates of the abscess grew a bacterium belonging to the genus Raoultella, with discordant species identification (R. ornithinolytica versus R. planticola) using two different techniques. A potential source of infection included a left lower molar tooth which was extracted months preceding the original diagnosis of osteomyelitis. Conclusion This is the first case of mandibular osteomyelitis caused by Raoultella species reported in the literature. In contrast to other forms of osteomyelitis, the pathogenesis of mandibular osteomyelitis involves contiguous spread from an odontogenic focus. Risk factors for mandibular osteomyelitis include a history of fracture, irradiation, diabetes and steroid therapy. This report adds to the growing literature of infections caused by this genus of bacteria, and raises the possibility of this organism’s role in odontogenic infections.
Introduction. Diagnosis of schistosomiasis in travellers is a clinical challenge, since cases may present with no symptoms or a few non-specific symptoms. Here, we report on the laboratory and clinical findings in Danish travellers exposed to Schistosoma-infested water during white-water rafting on the Ugandan part of the upper Nile River in July 2009. Case presentation. Forty travellers were offered screening for Schistosoma-specific antibodies. Serological tests were performed 6–65 weeks after exposure. A self-reporting questionnaire was used to collect information on travel activity and health history, fresh water exposure, and symptoms. Seropositive cases were referred to hospitals where clinical and biochemical data were collected. Schistosoma-specific antibodies were detected in 13/35 (37 %) exposed participants, with 4/13 (31 %) seroconverting later than 2 months following exposure. Four of thirteen (31 %) cases reported ≥3 symptoms compatible with schistosomiasis, with a mean onset of 41 days following exposure. No Schistosoma eggs were detected in stool or urine in any of the cases. Peripheral eosinophilia (>0.45×109 cells l−1) was seen in 4/13 cases, while IgE levels were normal in all cases. Conclusion. Schistosomiasis in travellers is not necessarily associated with specific signs or symptoms, eosinophilia, raised IgE levels, or detection of eggs. The only prognostic factor for infection was exposure to freshwater in a Schistosoma-endemic area. Seroconversion may occur later than 2 months after exposure and therefore – in the absence of other diagnostic evidence – serology testing should be performed up to at least 2–3 months following exposure to be able to rule out schistosomiasis.
INTRODUCTION:Aureobasidium pullulans is a dematiaceous, yeast-like fungus that is ubiquitous in nature and can colonize human hair and skin. It has been implicated clinically as causing skin and soft tissue infections, meningitis, splenic abscesses and peritonitis. We present, to our knowledge, the second case of isolation of this organism in a patient with AIDS along with a review of the literature on human infection with A. pullulans.CASE PRESENTATION:A 49-year-old man with advanced AIDS and a history of recurrent oesophageal candidiasis was admitted with nausea with vomiting, and odynophagia. He was treated as having a recurrence of oesophageal candidiasis. Given prior Candida albicans isolate susceptibilities and chronic suppression with fluconazole, he was started on micafungin with eventual improvement in his symptoms. A positive blood culture from admission was initially reported to be growing yeast, but four days later the isolate was recognized as a dematiaceous fungus. The final identification of A. pullulans was not available until 1 month after admission. He had completed a 3-week course of micafungin prior to the identification of the isolate, and repeat cultures were negative.CONCLUSION:A. pullulans fungemia is rare but can occur in patients with immune suppression or indwelling catheters. The significance of isolating A. pullulans from a blood culture in terms of whether it is the causative agent of a state of disease often cannot be determined because skin colonization is possible. Further work is needed to clarify the clinical implications of A. pullulans fungemia.
INTRODUCTION:Corynebacterium coyleae is a Gram-stain-positive non-lipophilic coryneform rod first described in blood samples and pleural fluid. There is scarce information about the clinical relevance of C. coyleae and none on complicated urinary tract infections has been described so far.CASE PRESENTATION:A 36-year-old woman with a history of chronic kidney failure, under thrice-weekly haemodialysis since 2014 due to polycystic kidney disease, presented with hypogastric pain, lower left quadrant pain and nausea. Since 1997, the patient had developed several episodes of urinary tract infection. On admission, the patient presented tenderness in the lower abdomen and fist positive lumbar percussion. Urine culture showed significant bacterial growth (>105 c.f.u. ml-1). Slightly glistening colonies of 1 mm in diameter were observed after a 24 h incubation. Gram staining showed coryneform Gram-stain-positive rods. The patient was diagnosed as having a complicated urinary tract infection. A bilateral nephrectomy was performed on the fourth day of hospitalization. Two samples of kidney tissue were sent for culture. Direct examination of the material revealed the presence of abundant inflammatory reaction and Gram-positive diphtheroid rods. The organism was identified using MALDI-TOF and conventional biochemical tests; in both isolates further identification was performed by PCR amplification and sequence analysis of the rpoB gene as Corynebacterium coyleae.CONCLUSIONS:C. coyleae is an infrequent species among the genus Corynebacterium that should be considered as an emerging pathogen that can be involved in nosocomial infections and complicated urinary tract infections.
Introduction. Enterococcus faecium is a commensal organism commonly colonizing the human gastrointestinal tract. Although it is generally a non-virulent organism, E. faecium can cause significant morbidity and mortality due to its inherent and acquired resistances to commonly used antimicrobials. Patients who are immunosuppressed are particularly vulnerable. Case presentation. A 65–75-year-old patient with a history of an orthotopic liver transplant for hepatitis C infection and diabetes was re-admitted to the hospital with abdominal pain and fever. The patient had several recent admissions related to the presentation reported here, which included treatment with a prolonged course of broad-spectrum antibiotics. The patient was found to have a recurrent liver abscess and blood cultures grew vancomycin-resistant E. faecium, non-susceptible to all tested agents: ampicillin, penicillin, vancomycin, daptomycin and linezolid. The patient was started initially on chloramphenicol intravenously while awaiting additional susceptibility testing, which ultimately revealed chloramphenicol non-susceptibility. Tigecycline was started but the patient ultimately decided to pursue hospice care. Conclusion. Multi-drug-resistant organisms are increasingly being recognized and are associated with poorer outcomes, particularly in immunosuppressed patients. We describe a particularly resistant organism and discuss potential therapeutic options.
