- Volume 1, Issue 4, 2014

Mycotic popliteal aneurysms are not a common phenomenon. They can initially be easily confused with other more trivial conditions such as a Baker’s cyst. We present a case of a patient presenting with a progressively worsening leg swelling which was initially misdiagnosed. Only until symptoms rapidly progressed was a popliteal aneurysm diagnosed. To our knowledge this is the only identified case of a Streptococcus sanguinis mycotic popliteal aneurysm.

An 81‐year‐old gentleman presented to the surgical assessment unit with a six‐week history of a painful, diffuse swelling in the left popliteal fossa. Initially, when symptoms developed a provisional diagnosis of a Baker’s cyst was made. When the symptoms progressed to involve swelling of the entire lower limb, an ultrasound was arranged. Detailed Imaging revealed a popliteal aneurysm with signs of rupture. Urgent repair was performed, with high suspicion of a mycotic aneurysm intra‐operatively. Cultures confirmed this, isolating Streptococcus sanguinis. Multiple investigations failed to isolate an acute infective source of this infection. The patient recovered promptly with a long course of intravenous antibiotics, being able to mobilize normally.

Mycotic popliteal aneurysms are not very common and can easily be confused with other benign lesions. The key to diagnosis is the presence of a pulsatile mass and further detailed imaging. This case was unique in that Streptococcus sanguinis has not been isolated from such an aneurysm until now. The most likely explanation of this case was that the aneurysm was secondary to transient bacteraemia of this organism through the oral cavity, in the absence of any cardiac involvement.

Actinomycosis is a granulomatous suppurative infection caused by filamentous Gram‐positive anaerobic bacteria from the family Actinomycetaceae. To our knowledge, this is the first reported case of otogenic brain abscess associated with Actinomyces turicensis.

We report the case of an immunocompetent 5‐year‐old boy with recurrent otitis media who re‐presented to the emergency department with a 3‐week history of otorrhoea, progressive anorexia, vomiting and lethargy. He was admitted with a working diagnosis of otitis media and dehydration, and was treated with intravenous fluids and oral co‐trimoxazole. He subsequently developed abnormal posturing with a reduced Glasgow coma score and seizures. Urgent computed tomography revealed a cerebellar abscess with obstructive hydrocephalus for which he underwent urgent neurosurgical intervention. Tissue and aspirate cultures revealed a polymicrobial infection with A. turicensis. The patient has since undergone long‐term antibiotic treatment and has made a good recovery.

This case demonstrates the successful use of long‐term antibiotic therapy and neurosurgical intervention to treat otogenic brain abscess associated with A. turicensis infection. To the best of our knowledge, this is the first such documented case. Our report also provides a timely reminder that, despite a reduced incidence in the developed world, intracranial complications of otitis media continue to occur and a high index of suspicion is required.

Cryptococcus neoformans is an encapsulated budding yeast that is a common cause of opportunistic infections, rarely giving rise to cellulitis, vasculitis or fasciitis. Necrotizing fasciitis caused by C. neoformans is a rare but serious problem in post‐transplant immunosuppression.

We report a case of cryptococcal necrotizing fasciitis in the left adductor longus of a patient on immunosuppressive therapy. The patient’s medical history was significant for orthotopic heart transplant secondary to cardiac and systemic amyloidosis (AL type) with subsequent cardiac biopsy demonstrating mild rejection (grade 1R). A thigh muscle biopsy demonstrated numerous encapsulated fungi in the fascia and no evidence of myositis. Cryptococcal antigen was subsequently identified in the patient’s serum and cerebrospinal fluid. The patient progressed to involvement of the central nervous system, left biceps femoris and skin of the left lower leg by fluconazole‐resistant C. neoformans.

This case illustrates a rare initial presentation of disseminated fluconazole‐resistant C. neoformans as an isolated necrotizing fasciitis of the thigh. Necrotizing fungal fasciitis should be considered in immunosuppressed patients with clinical findings of either myositis or cellulitis of a lower extremity.

Sarcocystosis is mainly a veterinary problem; however, humans can serve as the definitive host for at least two species (Sarcocystis hominis and Sarcocystis suihominis). Intestinal infections occur in the definitive host after ingesting the intramuscular cysts (sarcocysts) in the intermediate host, which initiate sexual stages in the intestine that terminate in oocysts excreted in the faeces.

A 19‐year‐old male presented with diffuse abdominal pain, watery non‐bloody diarrhoea, nausea, vomiting and intermittent low‐grade fever that lasted for more than 3 weeks. Multiple stool cultures on enriched and selective media gave negative results. Microscopic examination of wet mounts of stool prepared from formalin/ethyl acetate concentrates, together with permanent staining helped in making a definitive diagnosis and ruling out other coccidian parasites. Diagnosis of the parasite as S. hominis was made based on the size and morphology of the individual sporocysts that were observed in the wet‐mount preparations. This severe case of intestinal sarcocystosis in a healthy adult after eating undercooked beef shawarma meat is described.

The unusual presentation of intestinal sarcocystis described in this case is very rare. The clinical signs and size and morphology of both oocysts and sarcocysts observed in concentrated wet mounts of stool helped in the definitive diagnosis. The food ingested prior to the appearance of symptoms was important in making the definitive diagnosis of the parasite as S. hominis, as well as the incubation period and treatment.

Gastrointestinal basidiobolomycosis (GIB) is an emerging fungal infection with a few cases reported worldwide. It is caused by Basidiobolus ranarum, which does not usually invade blood vessels and rarely disseminates.

We present a rare case of GIB with hepatic dissemination in a 12‐year‐old Yemeni boy living in southwestern Saudi Arabia. The initial provisional diagnosis was intestinal lymphoma, and a right hemicolectomy was carried out, but histopathological assessment ruled out lymphoma and suggested intestinal tuberculosis. Two weeks after starting antituberculous medications, the patient was referred to our hospital because of fever and right upper abdominal discomfort. There was leukocytosis with marked eosinophilia, and a liver biopsy showed evidence of B. ranarum infection. A second opinion by histopathological examination of resected tissues diagnosed colonic basidiobolomycosis. The patient was treated successfully with itraconazole.

GIB is an emerging disease in southwestern Saudi Arabia and should be considered in a patient with an abdominal mass and eosinophilia coming from this region. Persistent elevation of leukocytes and eosinophils after surgical resection of the affected tissue could be used as a predictor of fungal dissemination. Further research is needed for a better understanding of GIB.

Peritonitis is a severe complication of peritoneal dialysis (PD) due to associated morbidity and mortality. Although Bacillus cereus is mostly considered as a contaminant, its role as a causative agent in a few cases of PD peritonitis has been documented. Peritonitis due to B. cereus has been associated with high rates of catheter removal and resistance to beta‐lactam antibiotics.

A case of relapsing peritonitis caused by B. cereus in a 69‐year‐old man with end‐stage renal disease on continuous ambulatory PD for 3 years is described. B. cereus was recovered from the patient’s peritoneal fluid and was identified by phenotypic and molecular methods. The patient was treated, according to the susceptibility test, with tobramycin for 14 days. Cultures became sterile and the patient was discharged from hospital. Three days after discharge, the patient reported recurrence of abdominal pain and a new antibiotic regimen based on the previous culture results was initiated consisting of vancomycin and ciprofloxacin. The presence of B. cereus in the peritoneal fluid was confirmed, whereas repeated cultures for the next 15 days were positive. All B. cereus isolates produced biofilm. On day 16, the PD catheter was removed and the patient was transferred to haemodialysis. A review of previously reported cases is also presented.

Since peritonitis is the most common cause of transition to haemodialysis, isolation of B. cereus from PD patients, even though rare, should not be considered as a contaminant. An appropriate antibiotic regimen and, whenever necessary, catheter removal should be applied.

Escherichia coli causes gastroenteritis in humans and animals.

In this study, both Shiga toxin‐producing E. coli (STEC) and atypical enteropathogenic E. coli (EPEC) strains were identified in a stool sample from a healthy child, and they were serotyped as Shiga toxin‐producing E. coli (STEC) ONT : H19 and atypical enteropathogenic E. coli (EPEC) O37 : H45.

This is the first report, to our knowledge, of a concomitant presence of diarrhoeagenic E. coli (DEC) strains in an asymptomatic child. None of the microorganisms was able to produce diarrhoea, maybe because they were transient bacteria or because of the good immune status of the child. Attention should be paid to this result and it could be of interest in vaccine prospects.

Human leptospirosis is a global zoonotic infection with a characteristic biphasic illness and protean clinical manifestations. The majority are mild flu‐like infections. The severe forms cause multiorgan damage with a greater predilection to hepatorenal failure.

We attempted to analyse the clinical presentation of severe leptospirosis and decipher the clinical spectrum within this group by reviewing a series of 15 patients with leptospirosis requiring intensive care support for their management. We noticed complications becoming apparent before antibodies became detectable in the blood in a significant number of patients. This appears to belie the biphasic nature of leptospirosis and raises the question of whether the complications occur during the leptospiraemic phase or the immune phase of the infection. The presence of leptospiral DNA in the blood at this time as detected by a molecular assay strengthened this suspicion. Among the 15 patients with severe leptospirosis, only 3 (20 %) had an overseas travel history and the remaining 12 patients acquired their infection within the UK. Fourteen of the 15 patients had hepatorenal dysfunction, with seven requiring dialysis. Eight of the 15 patients received intravenous ceftriaxone with very good outcomes. Three showed significant clinical improvement after the administration of steroids.

Many patients with severe leptospirosis will have complications on presentation. Molecular testing is now available for early diagnosis, facilitating early interventions. Ceftriaxone has been effective in treating severe leptospirosis. This study reminds clinicians to consider leptospirosis in the differential diagnosis of similar clinical spectra and offers tools for appropriate management.

Rapidly growing mycobacteria (RGM) are ubiquitous and are usually considered as saprophytes, and have been recovered from the environment, particularly in dust, watery soil and water distribution systems. However, Mycobacterium massiliense is a rare causative agent of ocular infection.

We report a case of M. massiliense in a 44‐year‐old female with signs and symptoms of a corneal ulcer. We carried out PCR‐based DNA sequencing targeting the hsp 65 gene for the identification of M. massiliense. To confirm the identification, we also performed PCR‐based RFLP targeting the hsp65 gene and PCR‐based DNA sequencing targeting the internal transcribed spacer region, which showed 97 % nucleotide identity with M. massiliense.

To the best of our knowledge, this is the first study in India to report the detection of M. massiliense from a corneal biopsy.

Voriconazole and posaconazole are often used to treat invasive Aspergillus infections. We describe a patient with chronic pulmonary aspergillosis (CPA) who experienced peripheral eosinophilia and eosinophilic colitis while on voriconazole, and also experienced gastrointestinal symptoms and recurrent eosinophilia while on subsequent posaconazole therapy.

A 75‐year‐old female with recurrent pulmonary mucus plugs due to CPA was treated with long‐term oral voriconazole. The patient had no clinical evidence of CPA exacerbations while on such antifungal treatment but developed peripheral eosinophilia, diarrhoea and eosinophilic colitis after >5 years of voriconazole therapy that resolved after cessation of azole therapy. Due to a CPA exacerbation after stopping voriconazole, the patient was started on posaconazole as an alternative CPA therapy. However, after 15 months, the patient developed a recurrence of peripheral eosinophilia and diarrhoea while on posaconazole.

Long‐term use of voriconazole and posaconazole can be used successfully to reduce the incidence of CPA exacerbations. However, such antifungal therapy may also lead to peripheral eosinophilia, diarrhoea and eosinophilic colitis.

Viruses are major aetiological agents of acute respiratory infection in young children. Although many studies have reported detection and analysis of respiratory viruses in sporadic cases, there have been few follow‐up studies of individuals. The purpose of this study was to investigate the frequency of respiratory viral infections in a young child and to examine the duration of viral genome detection in clinical specimens.

A total of 284 nasal swabs were collected during symptomatic (196 specimens) and asymptomatic (88 specimens) periods of respiratory symptoms from a young female child (from 4 months to 31 months of age, who was admitted to a nursery school at 9 months). Multiplex real‐time PCR for 19 respiratory viruses or subtypes was performed. One hundred and ninety‐eight of the tested specimens were virus positive (69.7 %) (symptomatic periods, 149/196, 76.0 %; asymptomatic periods, 49/88, 55.7 %). Rhinovirus was the most frequently detected (26 times). Long durations of detection were observed for human coronavirus NL63 (30 days), rhinovirus (28 days) and human bocavirus 1 (22 days).

Young children living in a group context have a high risk of respiratory virus infections, especially rhinovirus. In some instances, viral genomes were detectable for about 1 month by PCR.

In June 2012, the presence of a severe highly pathogenic avian influenza (HPAI) outbreak produced by an influenza type A, subtype H7N3 (A/H7N3) virus was reported in Mexico, which significantly affected the region of Los Altos de Jalisco, the most important table‐egg production zone in Mexico.

To the best of our knowledge, this is the first report describing the occurrence of infection in wild endemic birds, and particularly in the great‐tailed grackle (Quiscalus mexicanus), by an HPAI A/H7N3 orthomyxovirus, during the avian influenza epizootic, which occurred in June–October 2012, in the Los Altos region of Jalisco, Mexico, a highly significant poultry area. The great‐tailed grackle population has increased significantly due to intense agricultural and livestock farming expansion throughout North and Central America and northern South America, in diverse ecological systems. The great‐tailed grackle’s infectious/epidemiological role is unknown, as is its role as the avian influenza virus reservoir and as disseminator of other infectious diseases.

Because of the huge impact that avian influenza virus has on food production, on the economic activity of the affected areas and on the public health of animal and human populations, it is necessary to further investigate the significance of a wild population existing in the vicinity of industrial poultry farms and backyard poultry operations.

Serratia marcescens is a Gram‐negative, aerobic, motile bacillus belonging to the family Enterobacteriaceae. S. marcescens has been implicated in different types of infections including urinary tract infection, septicaemia, meningitis and wound infections. Very few cases of skin infections caused by this organism have been reported in the medical literature. S. marcescens is an important nosocomial pathogen but has rarely been implicated as a cause of community‐acquired soft‐tissue infections.

We present a rare case of a community‐acquired spontaneous cutaneous ulcer in an immunocompetent child from a sub‐Himalayan region. Infections caused by S. marcescens may be difficult to treat because of its ability to produce a β‐lactamase, which confers resistance to broad‐spectrum, β‐lactam antibiotics.

In our patient, the treatment was modified to ceftazidime and amikacin after sensitivity testing and the patient’s condition improved. This necessitated isolation by culture and antimicrobial susceptibility testing to ensure appropriate therapy.

Fonsecaea nubica is a newly described species in the genus Fonsecaea.

We describe here a clinical case of chromoblastomycosis in a 66‐year‐old man who presented a 3‐year history of leg lesions. F. nubica was identified by morphological and molecular methods. Four months of treatment with itraconazole (300 mg daily) significantly improved the lesions.

To the best of our knowledge, this case represents the first clinical case of F. nubica described in France. Particular attention should be paid to microscopic examination for fungal cultures in order to avoid confusion with a contaminating fungus. Moreover, recurrent, wide and deep biopsies should be performed to monitor the evolution of the lesions.

Melanized or dematiaceous fungi are associated with a wide variety of infectious syndromes. Cladophialophora bantiana is one of the most common and dangerous neurotropic fungi, able to cause brain abscess and disseminated infection.

We report a new case of phaeohyphomycosis brain abscesses caused by C. bantiana in Slovakia. The patient was a 63‐year‐old man having undergone heart transplantation, with dyspnoea, left‐sided bronchopneumonia and fevers. CT (computed tomography) and MRI (magnetic resonance imaging) of the brain revealed numerous abscesses. Bacterial infection was proven by neither the growth of bacteria in culture nor the presence of bacterial antigens. Direct microscopy of the pus from the brain abscess showed Gram‐positive hyphae. The isolate was finally identified as C. bantiana based on morphological and physiological features, and on DNA sequence analysis.

In spite of appropriate therapy, neurological complications and accelerated respiratory insufficiency resulted in the patient’s death. Concerning clinical manifestation of the brain phaeohyphomycosis that can sometimes be a problem to distinguish from malignancy, physicians should also assume infection caused by this serious pathogen.

Mycobacterium haemophilum is one of the non‐tuberculous mycobacteria (NTM) that can cause cutaneous infection. As acid‐fast staining cannot distinguish NTM from Mycobacterium tuberculosis, and as skin culture for M. haemophilum is not performed routinely, the diagnosis of M. haemophilum infection in Thailand is rarely made.

Between 2006 and 2009, five patients with M. haemophilum infection were diagnosed in Ramathibodi Hospital, a tertiary care centre in Bangkok, Thailand. The patients were aged 3, 29, 47, 75 and 76 years, and four were immunocompromised. Three patients received immunosuppressive medication. Most patients presented with subacute cutaneous infection. A suboptimal response to conventional antibiotics raised suspicions of M. haemophilum cutaneous infections, which can occur in immunocompromised patients. Diagnoses of these cases were made by skin culture for mycobacteria at an incubating temperature of around 30 °C with iron supplementation, DNA sequencing, or PCR/restriction enzyme analysis. Rifampicin, ofloxacin and clarithromycin were active against all isolates, whereas ethambutol and streptomycin were inactive.

Skin culture should be performed under special conditions or molecular technique should be used to identify M. haemophilum in susceptible patients.

Unlike other Legionella species, Legionella longbeachae has been associated with soil and potting composts instead of water systems, and it has caused pneumonia in gardeners.

We report, to our knowledge, the first case of prolonged localized L. longbeachae infection in an accidental wound on the back of a hand caused by a broken flowerpot.

Identification of L. longbeachae requires awareness and expertise, since commercial tests are most often specific for L. pneumophila.

Rhizobium radiobacter is an opportunistic human pathogen in debilitated patients with foreign plastic intravascular devices and peritoneal dialysis (PD) catheters. We performed a Medline search of the English‐language literature on R. radiobacter continuous ambulatory peritoneal dialysis (CAPD) peritonitis in end‐stage renal disease (ESRD) and reviewed 13 cases.

A 54‐year‐old male with ESRD secondary to chronic long‐standing type II diabetes mellitus presented to the nephrology outpatient department with fever, abdominal pain and cloudy PD effluent. The patient was admitted to the hospital. PD fluid was sent for cell count, Gram stain and culture. The white blood cell (WBC) count in the PD fluid was 6400 mm−3 with 82 % neutrophils. Gram staining of the fluid showed plenty of Gram‐negative bacilli. A presumptive diagnosis of CAPD peritonitis was made and empiric intraperitoneal cefazolin and tobramycin were started. The PD fluid culture grew non‐fermenting, Gram‐negative bacilli identified as R. radiobacter. Empiric antibiotic therapy was continued and the patient’s abdominal pain subsided. The peritoneal fluid counts decreased to 50 WBCs mm−3 on day 4. However, his abdominal pain recurred on day 8 and his PD fluid count increased to 300 cells mm−3. The catheter was therefore surgically removed.

Although R. radiobacter is considered a contaminant, it can cause relapsing symptomatic peritonitis peritoneal catheter removal.