- Volume 2, Issue 3, 2015
Volume 2, Issue 3, 2015
- Case Report
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- Blood/heart and lymphatics
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Streptococcus thermophilus bacteraemia in a patient with transient bowel ischaemia secondary to polycythaemia
More LessIntroduction:The ability of Streptococcus thermophilus to convert lactose into lactic acid has long been utilized by the dairy industry. A seemingly low-pathogenicity organism, to the best of our knowledge there have been no previously published reports linking the consumption of foodstuffs to bacteraemia caused by this bacterium.
Case presentation:Here we present a case of a regular consumer of Activia yoghurt who developed S. thermophilus bacteraemia, probably due to transient bowel ischaemia secondary to polycythaemia.
Conclusion:The isolation of this bacterium from blood cultures may indicate underlying large bowel pathology and should not necessarily be dismissed as contamination.
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Rapidly growing mycobacteria as emerging pathogens in bloodstream and device-related infection: a case of pacemaker infection with Mycobacterium neoaurum
IntroductionWe present a case of pacemaker infection with a rapidly growing mycobacterium (RGM).
Case presentation:An 80-year-old woman presented with fever, weight loss and malaise for 2 months. Mycobacterium neoaurum was isolated from blood cultures and from cardiac pacing wires. She made an excellent recovery with combination antimicrobial therapy and removal of the device.
Conclusion:Such RGMs are encountered with increasing frequency in intravascular device-associated infections, posing challenges for both laboratory identification and clinical management.
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Genome sequence and analysis of resistance and virulence determinants in a strain of Neisseria mucosa causing native-valve endocarditis
More LessIntroduction:Neisseria mucosa colonizes mucosal surfaces in humans and can serve as a reservoir for resistance and virulence determinants for Neisseria meningitidis and Neisseria gonorrhoeae, but only on rare occasions has this species been documented as a cause of invasive infection. The host and pathogen factors that predispose to invasive infection with this organism are unknown.
Case presentation:A healthy 27-year-old female presented with fever. N. mucosa was isolated from two sets of blood cultures drawn on arrival. Transoesophageal echocardiogram revealed mitral valve vegetation. The patient was diagnosed with endocarditis by modified Duke's criteria. Genome sequencing was performed on the isolate and comparison was made with previously published Neisseria resistance and virulence determinants. Although putative virulence factors were present in this isolate, there is not a sufficient database of genetic information for this species to reach conclusions about the role of these virulence factors in predisposing to invasive disease.
Conclusions:For rare infections, like this case, only through reporting of the clinical course and pathogen genome can a sufficient dataset accumulate to make statistically significant inferences and to motivate hypothesis-based confirmatory experiments. This is the first report of whole genome sequencing for this species to be accompanied by a description of invasive clinical disease, and sets the precedent for future studies.
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- Central nervous system
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Myopericarditis and atrial fibrillation complicating meningococcal meningitis in a human immunodeficiency virus-infected man who has sex with men: a case report
More LessIntroduction:Neisseria meningitidis is the leading cause of bacterial meningitis in children and young adults. Multiple complications have been reported previously, either at the time of presentation or later during the recovery phase of the illness. Cardiac arrhythmias and electrocardiogram (ECG) abnormalities have rarely been reported in N. meningitidis infection.
Case presentation:We report a 48-year-old African-American man, with newly diagnosed human immunodeficiency virus infection, admitted with a diagnosis of meningococcal meningitis. An initial 12-lead ECG at admission showed a normal sinus rhythm with widespread concave ST elevation. The patient's troponin level was significantly elevated. A Transthoracic echocardiogram revealed left ventricle moderate anterior pericardial effusion. He was treated with antibiotics for meningitis and ibuprofen for myopericarditis. He subsequently developed atrial fibrillation, which was suppressed with metoprolol, diltiazem and amiodarone during hospitalization. To the best of our knowledge, this is the first reported case of atrial fibrillation complicating meningococcal meningitis.
Conclusion:Myopericarditis complicates the course of meningococcal meningitis. Various forms of cardiac arrhythmias can occur during the course of meningococcal infection. Therefore, telemetry and serial ECG monitoring are recommended throughout the course of meningococcal infection.
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Cryptococcus gattii genotype AFLP6/VGII meningoencephalitis in an immunocompetent Filipino male in Kuwait: activation of a dormant infection
More LessIntroductionCases of Cryptococcus gattii infections are being increasingly recognized in geographical regions that were traditionally regarded as non-endemic. Here, we describe a case of C. gattii meningoencephalitis in an immunocompetent Filipino male diagnosed in Kuwait.
Case presentation:A 34-year-old healthy Filipino male presented with a history of progressive generalized headache, nausea and repeated episodes of vomiting. The patient had continuously lived and worked in Kuwait for three consecutive years before developing the disease. The diagnosis of meningoencephalitis was established by demonstrating capsulated budding yeast cells in cerebrospinal fluid, isolating C. gattii in culture and detecting cryptococcal polysaccharide antigen in serum and cerebrospinal fluid specimens. Molecular characterization of the isolate confirmed its identity as C. gattii, genotype AFLP6/VGII. The isolate showed reduced susceptibility to fluconazole and was treated suboptimally until flucytosine became available.
Conclusions:A case of C. gattii meningoencephalitis in a healthy Filipino male, who apparently acquired the infection in his native country, is described. The infection remained dormant for several years before becoming clinically apparent. To the best of our knowledge, this is the first report of C. gattii meningitis diagnosed in Kuwait.
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Cerebellar cryptococcoma due to Cryptococcus gattii VGI; a rare and first report from India
Introduction:Cryptococcus gattii is an emerging global pathogen. Recent reports suggest that C. gattii cryptococcosis is more common in immunocompetent as well as HIV-infected patients than earlier estimated. We report the first case of cerebellar cryptococcoma from India due to C. gattii in an immunocompetent individual.
Case Presentation:A 73-year-old immunocompetent male, presented with a 3 month history of severe headache, neck stiffness, walking difficulty, bilateral papilloedema and slight cerebellar signs including gait imbalance and giddiness. Magnetic resonance imaging (MRI) revealed a well-defined enhancing lesion in the cerebellum, suggestive of abscess and mild hydrocephalus. Blood parameters and liver function tests were within normal limits. The patient underwent paramedian suboccipital craniotomy, and the aspirated purulent material grew Cryptococcus neoformans. Histologically, the lesion was a cryptococcoma. The isolate was further identified as C. gattii VGI, serotype C, mating type alpha, and produced extracellular phospholipase enzyme. It was sensitive to amphotericin B, 5-flucytosine and azoles. The patient was treated with intravenous amphotericin B (0.7 mg kg–1 day–1) for 15 days along with a maintenance dose of oral fluconazole (400 mg day–1) for 6 months. The patient's symptoms recovered while on treatment but he was lost to follow up.
Conclusion:Cryptococcus gattii is an emerging pathogen in India that affects otherwise healthy, immunocompetent individuals and requires rapid identification and treatment in order to prevent severe neurological sequelae.
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- Gastrointestinal
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Abdominal tuberculosis presenting as ascites in an older indigenous woman: a case report
More LessIntroduction:Indigenous people tend to have higher incidence of Mycobacterium tuberculosis infection (TB). The diagnosis of TB is a challenge among older patients because of its non-specific presentation, especially for cases of extrapulmonary TB.
Case presentation:A 77-year-old indigenous woman presented with ascites secondary to abdominal TB. A computed tomography scan of the abdomen showed free fluid. The patient had a positive tuberculin test, and the ascitic fluid was an exudate with an adenosine deaminase activity test value of 80.76 IU l − 1.The mesenteric lymph biopsy showed a central area with caseating granulomas and peripheral giant cells, suggestive of TB commitment at the mesenteric lymph node level. The diagnosis was confirmed by a positive TB ascitic fluid culture. Anti-TB treatment improved the patient's symptoms.
Conclusion:In patients with ascites as the primary symptom, abdominal TB should be suspected, especially among those belonging to special population groups such as indigenous or older people.
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Two cases of Clostridium difficile infection in unrelated oncology patients attributable to a single clone of C. difficile PCR ribotype 126
More LessIntroduction:Clostridium difficile is a significant gastrointestinal pathogen and a leading cause of life-threatening diarrhoea in the developed world. Antibiotic therapy and immunodeficiency are key risk factors for C. difficile infection (CDI); consequently, oncology patients are at high risk.
Case presentation:We present two cases of CDI in unrelated oncology patients from different Western Australian hospitals in 2012. The first, a 59-year-old male, presented with diarrhoea 3 weeks after admission to hospital for treatment of a grade IV glioblastoma. Symptoms commenced after receiving prophylactic perioperative cephazolin. The second case was a 2-year-old female who presented with several episodes of diarrhoea after extended hospitalization following treatment for a stage 4 neuroblastoma. The patient had been exposed to regimens of piperacillin/tazobactam and ciprofloxacin for febrile neutropaenia and intra-abdominal sepsis. In both cases, the diarrhoea resolved after commencement of oral metronidazole. Both patients had an uncommon strain of C. difficile (PCR ribotype 126) detected in stool specimens, and both strains belonged to an unusual multilocus sequence type (ST), ST258. Comparison of the genomes of both strains by whole-genome sequencing showed them to be indistinguishable (no single-nucleotide variants). No epidemiological link between the patients was identified.
Conclusion:These data suggest that both cases resulted from exposure to a common source, most likely food contaminated with livestock faeces. Moreover, this is the first report of ribotype 126 isolates belonging to a ST (ST258) other than ST11. Our cases highlight the need for continued molecular surveillance of C. difficile, and the genetic analysis of emerging ribotypes.
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- Hepatic
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Reactivation of a hepatitis B virus surface-antigen mutant following an autologous stem-cell transplant for multiple myeloma in an anti-HBc-negative patient
More LessIntroduction:Hepatitis B virus (HBV) surface-antigen mutants can present diagnostic difficulties when they are not recognized by commercial assays; HBV infection with undetectable core antibody is also described.
Case presentation:We report the case of a multiple myeloma patient who had no detectable serum HBV core antibody, HBV surface antigen (HBsAg) or HBV DNA prior to immunosuppressive treatment, who, after autologous stem-cell transplant, developed a reactivation of occult HBV with a HBsAg mutant, undetectable with a commercial HBsAg assay.
Conclusion:This case reminds clinicians to be mindful of the potential diagnostic difficulties of HBV serology in the immunosuppressed, and to remain vigilant for the possibility of the reactivation of HBV and the existence of HBsAg mutants, which can also reactivate, in the context of profound immunosuppression.
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- Respiratory
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Scedosporium apiospermum: a fungal pathogen causing pneumonia in a patient with cystic fibrosis
More LessIntroduction:Scedosporium apiospermum is a slow-growing pathogenic fungus that can cause pneumonia. Diagnosis of this rare filamentous fungus is challenging. To the best of our knowledge, this is the first case describing an acute pulmonary infection caused by this fungal pathogen in a patient with cystic fibrosis (CF).
Case presentation:A 35-year-old female with CF, with a 1-month history of irritating cough, increased sputum production and dyspnoea, was admitted to hospital. A chest computed tomography scan revealed new bilateral infiltrations, mediastinal lymphadenopathy and bronchiectasis. Pseudomonas aeruginosa and S. apiospermum were detected in the bronchoalveolar lavage. The patient's clinical status was not improved by standard antibiotic therapy. Antifungal systemic therapy consisting of systemic caspofungin and oral posaconazole against the highly suspected scedosporiosis was initiated, but the clinical outcome was not significantly improved. Antibodies against the S. apiospermum complex were present in the patient's serum. Only after the addition of 50 mg once a day of inhaled liposomal amphotericin B the patient was successfully treated.
Conclusion:The patient was cured by a combined therapy of two systemic antimycotic drugs and one local antimycotic drug.
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- Soft tissue
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A case of multiple cutaneous lesions due to Serratia marcescens in an immunocompromised patient
More LessIntroduction:Serratia marcescens is an opportunistic Gram-negative bacillus capable of causing serious nosocomial infection. Skin infections due to S. marcescens, although not frequently encountered, can have a variety of manifestations and may progress to become serious debilitating lesions if not diagnosed early and treated promptly. We report here a case of multiple skin lesions due to S. marcescens in an immunocompromised patient.
Case presentation:A 60-year-old patient on adjuvant chemotherapy for breast carcinoma developed a high fever followed by multiple painful nodular and ulcerated lesions over all four limbs. Multidrug-resistant S. marcescens was isolated from the blood as well as from several skin lesions. Removal of the infective source (a chemoport in this case) and administration of tigecycline resulted in resolution of the infection.
Conclusion:S. marcescens is a nosocomial pathogen capable of causing extensive cutaneous lesions. Multiple samples for culture from the lesions are recommended to identify the aetiological agent and institute appropriate antibiotics. The emergence of multidrug-resistant strains has compromised treatment options for this bacterium, which is intrinsically resistant to several groups of antibiotics.
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Rhinosinusitis caused by Saksenaea erythrospora in an immunocompetent patient in India: a first report
Introduction:Saksenaea erythrospora is a recently described species that has been reported in two human cases of cutaneous infection. The present case is, to the best of our knowledge, the first with invasive infection of the sinuses by this fungus and the first report of its isolation from India.
Case presentation:A 44-year-old woman was diagnosed with a pre-septal cellulitis and pansinusitis. She was non-diabetic and did not have any other co-morbidity. The patient underwent emergency endoscopic endonasal debridement for right pansinusitis with right orbital nerve decompression and left-sided functional endoscopic sinus surgery. A right orbital exenteration was performed to prevent further spread of the infection. Debrided material from the orbit grew S. erythrospora, the identity of which was confirmed by molecular techniques. The infection spread subcutaneously to the cheek and neck. The patient was treated with intravenous amphotericin B, to which she responded favourably.
Conclusion:S. erythrospora can cause rhinosinusitis and appears to have a propensity for subcutaneous spread. The fungus is present in the environment in India. Treatment with amphotericin B was successful in our case.
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Post-operative wound and vascular graft infection caused by Haemophilus parainfluenzae
More LessIntroduction:We present a rare case of wound and vascular graft infection caused by Haemophilus parainfluenzae after reconstruction of the femoral artery bifurcation.
Case presentation:H. parainfluenzae was isolated from pus samples taken from a patient who had undergone angioplasty of the superficial femoral artery and anastomosis with a synthetic graft. The pathogen was isolated from samples taken from both the wound and the graft. Management involved wide surgical debridement and irrigation, preservation of the prosthetic graft and transposition of muscle flaps in conjunction with the administration of culture-based antimicrobials.
Conclusion:H. parainfluenzae surgical wound and vascular graft infections are uncommon, and quick diagnosis and preservation of the graft is of great importance in treatment.
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- Urinary tract and reproductive organs
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Pseudomonas aeruginosa prostatic abscess: case report and review of the literature
More LessIntroduction:Prostate abscess (PA) is an uncommonly encountered clinical entity. The most commonly associated organisms have been Staphylococcus aureus, Escherichia coli and recently Klebsiella pneumoniae. Pseudomonas aeruginosa has rarely been associated with PA.
Case presentation:A 72-year-old developed confusion and hypotension during his hospital stay 2 weeks after an orthotropic heart transplant. P. aeruginosa was identified in his blood and urine. The patient had an ultrasound of the kidneys, which showed bilateral renal cysts, and a transrectal ultrasound, which showed 3 cm fluid in the peripheral zone of the prostate, suggestive of an abscess. The patient was treated with antibiotics for 2 months with resolution of the abscess.
Conclusion:The patient was successfully treated with antibiotics without surgical drainage. Clinicians should suspect PA in patients with persistent P. aeruginosa bacteraemia.
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Cyberlindnera fabianii in the neonatal and paediatric intensive care unit: case reports
Introduction:The number of infections due to uncommon yeast species is gradually increasing worldwide. In cases of high-risk paediatric patients, Cyberlindnera fabianii has been identified as the causal agent in a number of countries. In fact, we have recently reported the first proven occurrence, to the best of our knowledge, of this species as a causal agent of fungaemia in three neonatal patients in a Croatian hospital.
Case presentation:We report here six new instances of clinically manifested bloodstream and urinary tract infections caused by Cyberlindnera fabianii in five high-risk neonates and one child, during a 5-year period (2008–2012) in the aforementioned Croatian hospital. In addition, we have provided an account of their treatment strategy and the outcome, and the susceptibility profiles of 44 isolates of Cyberlindnera fabianii to amphotericin B, flucytosine, triazoles and echinocandins. Furthermore, we have described a novel molecular method suitable for the rapid and specific diagnosis of this species.
Conclusion:Our findings demonstrated: (i) the pathogenic activities of Cyberlindnera fabianii species in high-risk children; (ii) that administering fluconazole either prophylactically or therapeutically yielded no results in 50 % of the patients; (iii) that substituting fluconazole by liposomal amphotericin B or caspofungin managed to resolve sepsis in the remaining 50 % of patients; (iv) that, according to the examined sequences, all of the Cyberlindnera fabianii isolates were found to be identical independent of their source or study period; and (v) the existence of a higher proportion of non-susceptible isolates of Cyberlindnera fabianii for echinocandins (especially micafungin) compared with the other tested antifungals.
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