- Volume 2, Issue 1, 2015
Volume 2, Issue 1, 2015
- Case Report
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- Blood/heart and lymphatics
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Multidrug‐resistant OXA‐48‐producing Klebsiella pneumoniae mediastinitis treated safely and effectively with imipenem and colistin
More LessIntroduction:Post‐operative mediastinitis due to multidrug‐resistant Gram‐negative bacteria has rarely been described and is associated with increased mortality.
Case presentation:We report a case of mediastinitis caused by a multidrug‐resistant OXA‐48‐producing Klebsiella pneumoniae isolate in a patient who underwent coronary artery bypass grafting. Successful treatment consisted of surgical debridement and prolonged administration of imipenem and colistin.
Conclusion:This result shows that a combination of imipenem/colistin could be used to treat serious infections with carbapenemase‐producing Enterobacteriaceae.
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A case of suspected infective endocarditis with Lactococcus garvieae: lack of in vitro synergy between ampicillin and gentamicin
More LessIntroduction:Lactococcus garvieae is an uncommon cause of infective endocarditis (IE) and, despite the fact that synergy between beta‐lactam antibiotics and aminoglycosides has not been demonstrated for lactococci, combination therapy is often used.
Case presentation:We report a case of suspected L. garvieae IE in an 82‐year‐old man, which was successfully treated with a combination of ampicillin and gentamicin. Despite careful dosing and monitoring of gentamicin levels, the patient developed a transient decrease in renal function and permanent bilateral vestibular deficiency. The combination of gentamicin and ampicillin did not demonstrate synergistic killing effects in vitro against the L. garvieae isolate from this patient. However, synergy was noted against two of the four L. garvieae isolates tested. Unfortunately, an Etest‐based method, which would be easy to use in a routine laboratory, was unable to predict synergy in the time‐kill methods.
Conclusions:The use of combination therapy in IE is based solely on in vitro synergy between beta‐lactams and aminoglycosides. Here we demonstrate that a combination of ampicillin and gentamicin induces synergistic killing only of some L. garvieae isolates. Since synergy does not seem to be omnipresent, the risks for aminoglycoside toxicity must be carefully weighed against the potential theoretical benefit of combination therapy in L. garvieae IE.
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Detection of Ehrlichia chaffeensis in a naturally infected elk (Cervus elaphus) from Missouri, USA
More LessIntroduction:Ehrlichia chaffeensis is an emerging zoonotic tick‐borne rickettsial pathogen that has been detected in a wide range of vertebrate hosts, including ruminants, canids and primates. Although white‐tailed deer (Odocoileus virginianus) are considered the primary reservoir of E. chaffeensis, this pathogen was also reported in other naturally infected cervids, including Korean spotted or sika deer (Cervus nippon) and Brazilian marsh deer (Blastocerus dichotomus).
Case presentation:A captive adult bull elk (Cervus elaphus) from east‐central Missouri was submitted for post‐mortem analysis. The elk was in poor body condition with easily palpable ribs and vertebral spinal processes. Excoriations were noted on the occipital region of the head and on the left scapula, which had moderate amounts of maggots within the lesions. Large numbers of ticks were scattered over the body. Novel and established PCR assays were used to detect E. chaffeensis in blood and spleen samples from this elk, but the pathogen was not detected in Dermacentor albipictus ticks collected at necropsy. Portions of several gene sequences were analysed from the infecting agent.
ConclusionTo the best of our knowledge this is the first report of E. chaffeensis infection in an elk. It was not determined whether the pathogen contributed to cause of death. Notably, the pathogen was not detected in D. albipictus ticks collected from the elk.
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TEM‐producing Capnocytophaga sputigena primary bactaeremia in a breast cancer patient
More LessIntroduction:Bacteraemia caused by Capnocytophaga sputigena is rarely reported. Here, we present a case of bacteraemia with C. sputigena in a breast cancer patient.
Case presentation:C. sputigena was isolated from blood in a breast cancer patient who suffered from oral mucosal barrier breakage for several years. The bacterium was initially identified in the blood culture of the patient by conventional techniques and confirmed by mass spectrometry and sequencing of the 16S rRNA gene. Antibiotics susceptible testing revealed the bacterium was resistant to penicillins, first‐, second‐ and third‐generation cephalosporins and monobactam. PCR was used to detect common β‐lactamase genes; the TEM gene was detected and confirmed by sequencing.
Conclusion:To the best of our knowledge, this is the first report of bacteraemia in a breast cancer patient caused by TEM‐producing C. sputigena.
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Septic thrombophlebitis of the internal jugular and subclavian veins treated with percutaneous mechanical thrombolysis
More LessIntroduction:Treatment of septic thrombophlebitis of the jugular vein may include both medical and surgical interventions. Historically, the goal of surgical interventions was not the restoration of blood flow through the affected vessel.
Case presentation:We present a case of a 19‐year‐old male with septic thrombophlebitis who, despite appropriate antibiotic treatment, experienced symptomatic thrombus progression. Percutaneous thrombolytic procedures were performed, successfully restoring blood flow without triggering clinically significant bacteraemia or septic emboli.
Conclusion:Thrombolysis may have a role in select patients, especially those with co‐existent thrombophilia or progressive thrombus development despite medical treatment.
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Elizabethkingia meningoseptica: an unusual cause for septicaemia
More LessIntroduction:Elizabethkingia meningoseptica, a Gram‐negative non‐fermenting bacterium, is usually associated with neonatal meningitis and other infections, especially in immunocompromised patients. It is a potential nosocomial pathogen and is usually resistant to several commonly used antimicrobials.
Case presentation:We here report a rare case of septicaemia caused by E. meningoseptica associated with peritonitis and choledocholithiasis. The patient succumbed in spite of diagnosis and institution of appropriate antibiotics.
Conclusion:A prompt diagnosis of infection with E. meningoseptica is important so as to guide the institution of appropriate antibiotic treatment.
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- Bone
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Fungal arthritis secondary to Colletotrichum gloeosporioides
Introduction:Colletotrichum spp. are common plant‐pathogenic fungi that usually occur as asymptomatic endophytes on aerial organs of host plants. Of the many Colletotrichum spp. described, only four have been associated with infections in humans, one of these being Colletotrichum gloeosporioides.
Case presentation:Infections cited in humans due to Colletotrichum spp. typically involve the eye (keratitis/keratomycosis/endophthalmitis) or are subcutaneous in nature and secondary to trauma. We report a clinical case of septic arthritis caused by Colletotrichum gloeosporioides in an immunocompetent 55‐year‐old male. DNA sequencing was performed for identification of the organism. Antifungal susceptibility testing was performed according to the Clinical and Laboratory Standards Institute M38‐A2 standard for broth microdilution testing against filamentous fungi.
Conclusion:To the best of our knowledge, this is the first case of a Colletotrichum sp., specifically Colletotrichum gloeosporioides, causing septic arthritis in humans. This report highlights the successful treatment of a case of septic arthritis due to Colletotrichum gloeosporioides with voriconazole.
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- Dental
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Mucormycosis presenting with dental pain and palatal ulcer in a patient with chronic myelomonocytic leukaemia: case report and literature review
Introduction:Mucormycosis is a rare fungal infection, with high morbidity and mortality. Palatal ulceration may suggest a number of differential diagnoses, one of which is rhinocerebral/craniofacial mucormycosis and for which it may be the first presenting clinical finding. We report a case of sinus mucormycosis in a patient with chronic myelomonocytic leukaemia‐2 (CMML‐2), now classified in the myelodysplastic/myeloproliferative neoplasms, presenting with dental pain and palatal ulcer.
Case presentation:A 72‐year‐old female with CMML‐2 presented with pain of the left maxillary molar and a dark‐brown necrotic ulcer with a white irregular border on the hard palate. Invasive fungal infection was included in the differential diagnosis. Computerized tomography disclosed inflammatory lesions in the left nasal, ethmoid and frontal sinuses. Histological examination of the ulcer showed fungal hyphae typical of agents of mucormycosis. Rhizopus arrhizus was isolated from the culture. Liposomal amphotericin B was introduced, combined with haematological support and maxillectomy. Mucormycosis was controlled, but the patient died of progressive acute myeloid leukaemia and multiple bacteraemias. A literature review of rhinocerebral mucormycosis with palatal involvement disclosed 109 cases; palatal involvement was present among other presenting signs in 34 patients and as the presenting sign leading to diagnosis in nine cases, including the present case. Six of the nine patients (66.6 %) survived the infection, compared with 43 of 101 (42.6 %) with other signs at presentation.
Conclusion:Palatal ulcer may represent an early sign of sinus mucormycosis. Awareness by healthcare professionals is critical for the prompt diagnosis of this rapidly developing and life‐threatening infection.
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- Gastrointestinal
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Gastrointestinal anthrax in coastal south India: a critical alert on a fatal masquerader
Introduction:Anthrax remains endemic to some parts of southern India including Pondicherry. Among various forms of the infection, gastrointestinal anthrax appears to be the least common. Cases of inhalational anthrax causing sepsis and disseminated intravascular coagulation have been reported in the literature.
Case presentation:We report the first case, to the best of our knowledge, of gastrointestinal anthrax with sepsis and disseminated intravascular coagulation from India. The patient ate raw meat under the influence of alcohol, following which he developed fever and gastrointestinal bleeding. Later, he presented with ascites, intracerebral haemorrhage, haematuria and a deranged coagulation profile. Culture of his blood yielded Bacillus anthracis. He succumbed to the infection after 18 h of admission in the intensive care unit. The case was reported to the public health authorities for the necessary follow‐up and preventive measures.
Conclusion:Gastrointestinal anthrax can have various non‐specific clinical manifestations, making diagnosis difficult. Meticulous history taking, a high index of suspicion and prompt institution of antibiotics with or without surgical intervention is likely to improve outcomes.
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- Occular
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A case of contact‐lens‐related keratitis caused by fluoroquinolone‐ and tobramycin‐resistant Capnocytophaga sputigena
Introduction:Capnocytophaga species are rare keratitis‐causing pathogens. We herein report a case of keratitis caused by a drug‐resistant Capnocytophaga species in association with contact lenses.
Case presentation:A 64‐year‐old female who wore a contact lens in her right eye to facilitate repair of the corneal epithelium complained of infection and discharge. Slit‐lamp biomicroscopy showed corneal abscessation and hypopyon. Thus, infectious keratitis was diagnosed. Direct microscopy and bacterial culture of a corneal scraping were performed. Because direct microscopy demonstrated the presence of Gram‐negative rods, we began treatment with topical 1.5 % levofloxacin and 0.3 % tobramycin every hour. The corneal infiltration increased 4 days after initiating the therapy. The culture report confirmed the presence of a Capnocytophaga species with fluoroquinolone and aminoglycoside resistance and susceptibility to cephalosporins and minocycline. We switched to topical 0.5 % cefmenoxime every hour and oral minocycline at 200 mg day−1. The corneal inflammation subsided within 2 weeks. The bacterial isolate was identified as Capnocytophaga sputigena using 16S rRNA sequencing.
Conclusions:We encountered a case of keratitis caused by C. sputigena with reduced fluoroquinolone and aminoglycoside susceptibility.
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- Oro-pharyngeal
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Fungal malignant otitis externa caused by Alternaria chlamydospora: first case report
Introduction:Malignant otitis externa (MOE) is a rare clinical entity, usually observed in diabetic or immunosuppressed patients, with serious morbidity due to associated osteomyelitis, cranial nerve palsies and intracranial infections. Pseudomonas aeruginosa is the main pathogen in over 95 % of cases; Aspergillus species and Candida albicans have also been implicated in fungal MOE.
Case presentation:Α 79‐year‐old male with type 2 diabetes with otalgia, otorrhoea and granulation tissue occupying the right external ear canal was diagnosed with MOE. Direct microscopy of a tissue biopsy specimen taken from the granulation tissue revealed septate branching hyphae and chlamydospores. An olivaceous‐black colony cultured within 3 days at 30 °C was identified microscopically as Alternaria sp. and molecularly as Alternaria chlamydospora using the restriction fragment length polymorphism pattern of the internal transcribed spacer (ITS) region on the basis of the 570 bp ITS amplicon, a BstUI largest band of 578 bp and absence of the TaqI 114 bp band. The patient was unresponsive to ciprofloxacin, whereas the pain was relieved after 2 weeks of voriconazole treatment followed by surgical debridement.
Conclusion:We present, we believe, the first reported case of MOE for which Alternaria sp. seems to be the causative pathogen. A high index of suspicion was needed in order to reach the diagnosis. We recommend taking tissue cultures when a high‐risk patient is not responsive to the initial antibiotic treatment, as fungal MOE could be a repercussion of unsuccessfully treated bacterial otitis externa or it could represent a de novo presentation of fungal disease.
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- Respiratory
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Infection caused by the yeast form of Paracoccidioides brasiliensis
Introduction:Paracoccidioidomycosis (PCM) is caused by the dimorphic fungus Paracoccidioides brasiliensis. Infection occurs mainly through the upper airways of the host by inhalation of spores or propagules of the micro‐organism that settle initially in the lungs. Here, we describe a clinical case report of PCM acquired by a researcher following a scientific laboratory accident; to the best of our knowledge, this is the first report of infection with the yeast form of P. brasiliensis.
Case presentation:A 40‐year‐old, white, healthy, male researcher, while undertaking experimental activities in a laboratory environment with P. brasiliensis fungus infection in guinea pigs, pierced the thumb of the left hand, with a 1 ml syringe containing 50 μl of a suspension of P. brasiliensis at a concentration of 1×106 c.f.u. ml−1. Seven days after the accident, the region had local swelling, redness and pain on stimulation. He was started on medical treatment and opted for surgical removal. A biopsy revealed an inflammatory infiltrate, numerous epithelioid granulomas and a discrete quantity of yeast organisms on the dermis, some with multiple budding yeast cells presenting characteristics of viability, with conclusive diagnosis of PCM. After 90 days of itraconazole treatment at 200 mg day−1, he reported healing with scar formation.
Conclusion:The yeast form of P. brasiliensis is able to cause infection. According to our knowledge, this is the first time that this has been reported in the medical literature.
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Fulminant psittacosis in a traveller
More LessIntroduction:Psittacosis is a rare cause of pneumonia, caused by Chlamydia psittaci. The disease is transmitted to humans via inhalation of dried bird faeces, feather dust, urine or respiratory secretions. The disease can range from a mild form with non‐specific symptoms to severe systemic disease with prominent respiratory symptoms. Psittacosis causing severe respiratory failure requiring mechanical ventilation is uncommon.
Case presentation:A 64‐year‐old male tourist from Hong Kong presented to the emergency department with a 5 day history of headache, myalgia and fever. He had a productive cough and was short of breath. The patient developed septic shock with multiorgan failure requiring intensive care support. We received information from the Centre for Health Diseases in Hong Kong about a psittacosis outbreak in an animal management centre where our patient had been working with recent occupational exposure to dead parrots. Despite a significant increased mortality rate associated with respiratory and renal involvement in psittacosis, our patient survived the sepsis and multiorgan failure and was repatriated back for further rehabilitation.
Conclusion:The case illustrates the importance of exploring a patient’s occupational history to establish an infection exposure. The respiratory symptoms, myalgia and fever warranted consideration of an atypical pneumonia. The patient had bilateral pulmonary infiltrates contrary to the unilateral involvement in the majority of the patients with chest X‐ray abnormalities. Despite a high mortality rate associated with respiratory and renal involvement, our patient survived the severe sepsis.
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Reversed halo sign caused by huge tricuspid native valve infective endocarditis associated with community-acquired methicillin-resistant Staphylococcus aureus
Introduction:A reversed halo sign (RHS) has diverse differential diagnoses such as cryptogenic organizing pneumonia, fungal, bacterial and mycobacterial infections, and systemic and neoplastic diseases. However, no report has been described regarding an RHS associated with infective endocarditis (IE).
Case presentation:A 43‐year‐old man was transferred to our hospital because of persistent pyrexia, chest pain with multiple cavitary lung lesions for a month. He was diagnosed with tricuspid native valve IE caused by massive vegetations in the context of CA‐MRSA (staphylococcal cassette chromosome mec type II, sequence type 91, clonal complex 509) infection with multiple pulmonary septic emboli, manifesting as an atypical RHS.
Conclusion:The present case showed huge tricuspid native valve IE associated with community‐acquired meticillin‐resistant Staphylococcus aureus (CA‐MRSA), which was analysed successfully by multilocus sequence typing.
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Two cases of community acquired Legionella pneumophila non‐serogroup 1 in patients undergoing extra corporeal membrane oxygenation for severe respiratory failure
Introduction:The Legionellaceae are fastidious Gram‐negative bacteria that reside in aquatic environments. They are a cause of severe community acquired pneumonia. Legionella pneumophila serogroup 1 is responsible for 70–90 % of human infection, with cases caused by some of the other 15 serogroups accounting for the rest. Most hospitals use the Legionella urinary antigen test for detection of legionellosis; however, this will only reliably detect L. pneumophila serogroup 1.
Case presentation:We report two cases of severe community acquired pneumonia in patients requiring extracorporeal membrane oxygenation, referred to our adult Severe Respiratory Failure Unit. Legionella urinary antigen was negative in both cases. As clinical presentation strongly suggested Legionnaires’ disease (LD), respiratory samples were sent to the reference laboratory for PCR, which confirmed L. pneumophila non‐serogroup 1 in both cases. Case 1 was subsequently confirmed by culture and confirmed as L. pneumophila serogroup 5. Case 2 was culture‐negative.
Conclusion:Legionella is an important pathogen. Recognition of the potential for non‐serogroup 1 strains to cause severe LD should prompt requests for further investigations including Legionella PCR in patients who present with suggestive symptoms when the urine antigen is negative. Reliance on the urine antigen test may result in a potentially serious under‐recognition of L. pneumophila non‐serogroup 1 and lead to mis‐diagnoses and inappropriate antimicrobial treatment.
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- Soft tissue
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Facial subcutaneous phaeohyphomycosis caused by Phialophora verrucosa: successful treatment with itraconazole and local resection
Introduction:The fungal disease phaeohyphomycosis tends to occur in immunosuppressed individuals and has rarely been reported to be caused by Phialophora verrucosa.
Case presentation:Here, we report a primary subcutaneous phaeohyphomycosis case caused by P. verrucosa in an immunocompromised Chinese female with a CARD9 mutation that was cured with local resection and further treated with itraconazole. The current case is placed in perspective with a review of the relevant literature. The patient presented with painless dark erythema and a plaque on the right part of her face that had been present for the past 20 years. Histological examinations revealed multiple brown hyphae, bead‐like pseudohyphae and yeast‐like cells either within the giant cell or distributed in the dermis and subcutaneous tissues. The fungal cultures were morphologically identified as P. verrucosa and were confirmed by internal transcribed spacer region nucleotide sequencing. A partial surgical focal excision was performed, and the patient was treated with oral itraconazole 200 mg daily for 1 year as maintenance therapy, resulting in complete resolution of the lesions.
Conclusion:This case is notable due to the prolonged course before a definitive diagnosis was made, the rarity of P. verrucosa as the cause of subcutaneous phaeohyphomycosis and the dramatic improvement after the focal lesion was excised and treated with itraconazole.
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A case of diabetic foot ulcers complicated by severe infection and sepsis with Trueperella bernardiae
More LessIntroduction:Matrix‐assisted laser desorption/ionization time‐of‐flight mass spectrometry (MALDI‐TOF MS) allows us to identify bacteria directly from positive blood cultures with detailed taxonomy naming of the bacterial strains. Knowing the name of the infective bacteria makes it possible to adjust the antibiotic therapy early on. However, it also gives rise to detection of a number of unusual pathogens, which raises new questions on the pathogenicity and medical importance of a number of rarely isolated bacteria such as Trueperella bernardiae.
Case presentation:We describe a case of diabetic foot ulcers in a 45‐year‐old male, which led to below‐the‐knee amputation due to widespread infection and sepsis with T. bernardiae and co‐infection with Peptoniphilus lacrimalis. The patient was treated initially with surgical debridement in combination with piperacillin/tazobactam and thereafter with amoxicillin for a total period of 1 month.
Conclusion:Based on this case, as well as previous case reports in the literature, we conclude that T. bernardiae is a rarely isolated low‐pathogenic bacterium in patients with severe co‐morbidities. Often co‐infection with other low‐pathogenic bacteria is observed. T. bernardiae is susceptible to and readily treated with β‐lactam antibiotics.
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Isolation of Brucella from a White’s tree frog (Litoria caerulea)
Introduction:Brucellosis is a zoonotic disease that has a significant economic, social and public health impact in many parts of the world. The causative agents are members of the genus Brucella currently comprising 11 species and with an expanding known host range in recent years.
Case presentation:One of a pair of White’s tree frogs (Litoria caerulea) developed skin lesions from which a pure growth of a haemolytic organism was obtained. The isolate was identified as Brucella melitensis by matrix‐assisted laser desorption/ionization time‐of‐flight mass spectrometry, although the colony morphology was inconsistent with this identification. Applying the classical biotyping approach used to subdivide members of the genus Brucella, the isolate did not correspond to any known Brucella sp. However, PCR targeting of genes specific for members of the genus Brucella was strongly positive and 16S rRNA gene sequencing revealed a close relationship with extant Brucella spp. In order to place the isolate more accurately, a multilocus sequencing approach was applied, which confirmed that the isolate represented a novel member of the emerging ‘atypical’ Brucella group, which includes isolates from human disease, from rodents and, more recently, reported isolations from frogs in Germany.
Conclusion:This case represents the first report of isolation of a Brucella sp. from frogs outside Germany and suggests that these isolates may be widespread. Whilst there is no evidence to date that these isolates represent a zoonotic threat, the association of other ‘atypical’ Brucella sp. with human disease suggests that appropriate measures should be taken to avoid unnecessary contact with potentially infected amphibians until the zoonotic potential of this group is better understood.
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Bovine pyogranulomatous mastitis caused by Mycobacterium goodii
Introduction:Mycobacterium goodii is a rapidly growing non‐tuberculous mycobacterium that has recently been associated with severe infections in animals and humans. The ecological niche of M. goodii remains unclear, and cases in large animals remain either undiagnosed or misdiagnosed.
Case presentation:We present a case of a 5‐year‐old Holstein cow showing mastitis signs of pronounced glandular hardening that did not respond to antibiotic therapy. During the milk bacteriological culture, we observed Gram‐positive and acid‐fast rods with an unusual profile in the milk diagnostic routine. Biochemical tests were performed and the results showed a bacterium belonging to the group Mycobacterium smegmatis. Antimicrobial susceptibility testing was performed, and the result for tobramycin indicated the presence of M. goodii. In order to confirm its identity, 16S rRNA gene sequencing and phylogenetic analysis were performed, showing 100 % nucleotide similarity with M. goodii. Histological analyses of a biopsy specimen obtained from the affected mammary quarter showed evidence of pyogranulomatous and diffuse mastitis, both suggestive of bacterial intracellular infection.
Conclusion:To the best of our knowledge, this is the first confirmed case of mycobacterial mastitis caused by M. goodii infection in cows, identified through isolation of the bacteria and 16S rRNA gene sequencing. Although the role of this agent in bovine mastitis remains unclear, we highlight its potential source for humans and the implications for the dairy industry.
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- Urinary tract and reproductive organs
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Intramammary coinfection by vaccinia virus and staphylococcus aureus in a bovine vaccinia outbreak
More LessIntroduction:Bovine vaccinia virus (VACV) is a well‐known zoonotic agent related to exanthemous lesions in skin and mucous membranes of dairy cattle and humans, characterized by the formation of vesicles, pustules and ulcers. Mastitis is one of the most common infectious diseases of dairy herds. Bovine mammary infections are caused mainly by bacterial micro‐organisms, especially staphylococci. To the best of our knowledge, intramammary coinfection with VACV and Staphylococcus aureus in cows has not been reported previously.
Case presentation:During an outbreak of exanthematic bovine VACV infection with animals showing vesicles, pustules and haemorrhagic ulcers on the teats, milk samples were collected for mastitis detection.
Conclusion:The present report describes a case of intramammary coinfection by VACV and S. aureus in a bovine VACV outbreak.
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