Metastatic Abscesses Research Articles

Role of echocardiography in the evaluation of patients with Staphylococcus aureus bacteraemia: time to look at the heart

This editorial refers to ‘Prevalence of infective endocarditis in patients with Staphylococcus aureus bacteraemia: the value of screening with echocardiography’ by R.V. Rasmussen et al ., on page 414. In the industrialized countries, the prevalence of Staphylococcus aureus infections is constantly rising, due to the increasing population age and modern invasive medical techniques.1 Staphylococcus aureus bacteraemia is frequently hospital- or health-care-related, encountered in post-operative patients, and almost any organ system can be involved. Owing to systemic dissemination, metastatic abscess, osteomyelitis, septic arthritis, and endocarditis can occur. Staphylococcus aureus is now the leading cause of infective endocarditis especially in Europe and the USA, and associated with high morbidity and mortality despite advances in antibiotic and surgical therapy options. Positive blood cultures and echocardiography are the pivotal cornerstones of diagnosis in infective endocarditis with the modified Duke criteria.2 Clinical manifestations of endocarditis are often unspecific or missing, new murmurs may occur during the course of disease, and immunologic or vascular phenomena may occur as splinter haemorrhages, Janeway lesions, or Roth spots in some patients. Intravenous drug abuse presents another cause of increase in S. aureus infections especially in larger cities and western countries, frequently leading to right-sided endocarditis. In this issue of the European Journal of Echocardiography, a multi-centre study of 244 patients with S. aureus bacteraemia in six Danish hospitals prospectively examined the prevalence of endocarditis with echocardiography screening.3 A key finding was the strikingly high prevalence of 22% of endocarditis even in patients without clinical manifestations pointing to valvular involvement. In view of the high mortality of untreated endocarditis even in the modern era, this finding underscores the importance of performing early and repeat echocardiography in all patients with S. aureus bacteraemia, as has been recommended by the current ESC guidelines.2 However, many patients still do not …

Lemierre's Syndrome Misdiagnosed as Swine Flu

Lemierre's syndrome is characterised by a potentially fatal septic thrombophlebitis and metastatic abscesses caused by Fusobacterium necrophorum (F. necrophorum). It probably occurs more commonly than realised, with 10% of cases of pharyngitis in young adults being due to F. necrophorum and an estimated 1 in 400 of these are likely to develop Lemierre's syndrome. Diagnosis by clinical means alone is difficult and requires a high degree of suspicion, pending laboratory/ radiological confirmation. We describe a case of a 26-year-old male who developed a coryzal illness with sore throat, misdiagnosed as H1N1 influenza in the recent surge, who failed to improve with conservative and antiviral treatment. He was subsequently hospitalised and ultimately required admission to the intensive care unit for the management of septic shock and respiratory failure. The diagnosis of Lemierre's syndrome was made after isolation of F. necrophorum in blood cultures and computerised tomography demonstration of diagnostic features, particularly a left internal jugular vein thrombosis. The mainstay of antibiotic management, as supported by the literature, is a beta-lactamase resistant penicillin or clindamycin together with metronidazole. The use of anticoagulation is controversial. This case highlights the increasing incidence of Lemierre's syndrome, partly due to the current trend to rationalise antibiotic use, and draws readers' attention to the current guidelines for management of pharyngitis from the USA and the National Institute for Health and Clinical Excellence, which recommends antibiotics for patients when three or more of the Centor criteria are met.

Incidence of various clinico-morphological variants of cutaneous tuberculosis and HIV concurrence: a study from the Indian subcontinent.

BACKGROUND AND OBJECTIVES:There are few reports of cutaneous tuberculosis with immunosuppressed states such as HIV, use of immunosuppressants or malignancy. Diagnosis is thus difficult and despite scientific advances such as polymerase chain reaction, it is frequently missed. Although rare, given its worldwide prevalence and the rising incidence of HIV, it is important for clinicians to recognize the variants and promptly treat the patient.DESIGN AND SETTING:Retrospective study of all cases of cutaneous tuberculosis diagnosed from October 2007 to November 2009 at an outpatient clinic of a tertiary-care hospital in northern India.METHODS:We collected information on the clinical form of disease, histopathology and HIV concurrence rates and looked for differences in presentation between mmunocompetent and immunocompromised states. We also looked for differences and HIV concurrence between immunocompetent and immunocomprised patients. Diagnosis was based on clinical, histopathological and microbiological tests for tuberculosis and a test for HIV.RESULTS:The overall incidence of cutaneous tuberculosis was 0.7% (131 of 18720 outpatients). HIV concurrence was 9.1% (12 cases) of all cutaneous tuberculosis cases. Most common variants seen were scrofuloderma (36.5%), lupus vulgaris (31%), tuberculosis verruca cutis (12.9%), lichen scrofulosorum (11.4%), papulonecrotic tuberculids (3.8%), erythema nodosum (2.2%) and erythema induratum of Bazin (1.5%).CONCLUSIONS:Cutaneous tuberculosis rates were slightly higher in our study than in other studies from India. HIV co-infection rates were similar to those in other studies. Many atypical morphological forms and presentations were observed in HIV co-infected patients. Due to the varied clinical presentations, physician awareness and a high index of suspicion are necessary to diagnose cutaneous forms of tuberculosis.

Bağışıklık Sistemi Normal Olan Bir Hastada Çok Odaklı Metastatik Tüberküloz Abseleri ve Pott Hastalığı

Bağışıklık Sistemi Normal Olan Bir Hastada Çok Odaklı Metastatik Tüberküloz Abseleri ve Pott Hastalığı

Staphylococcus aureus host cell invasion and virulence in sepsis is facilitated by the multiple repeats within FnBPA.

Entry of Staphylococcus aureus into the bloodstream can lead to metastatic abscess formation and infective endocarditis. Crucial to the development of both these conditions is the interaction of S. aureus with endothelial cells. In vivo and in vitro studies have shown that the staphylococcal invasin FnBPA triggers bacterial invasion of endothelial cells via a process that involves fibronectin (Fn) bridging to α5β1 integrins. The Fn-binding region of FnBPA usually contains 11 non-identical repeats (FnBRs) with differing affinities for Fn, which facilitate the binding of multiple Fn molecules and may promote integrin clustering. We thus hypothesized that multiple repeats are necessary to trigger the invasion of endothelial cells by S. aureus. To test this we constructed variants of fnbA containing various combinations of FnBRs. In vitro assays revealed that endothelial cell invasion can be facilitated by a single high-affinity, but not low-affinity FnBR. Studies using a nisin-inducible system that controlled surface expression of FnBPA revealed that variants encoding fewer FnBRs required higher levels of surface expression to mediate invasion. High expression levels of FnBPA bearing a single low affinity FnBR bound Fn but did not invade, suggesting that FnBPA affinity for Fn is crucial for triggering internalization. In addition, multiple FnBRs increased the speed of internalization, as did higher expression levels of FnBPA, without altering the uptake mechanism. The relevance of these findings to pathogenesis was demonstrated using a murine sepsis model, which showed that multiple FnBRs were required for virulence. In conclusion, multiple FnBRs within FnBPA facilitate efficient Fn adhesion, trigger rapid bacterial uptake and are required for pathogenesis.

A 21-year-old man with fever and abdominal pain after recent peritonsillar abscess drainage

Lemierre syndrome an extremely rare and unreported disease typically results from oropharyngeal infection and/or local tissue trauma with invasion of the parapharyngeal soft tissue with bacteria. Once local tissue invasion occurs, internal jugular vein septic thrombophlebitis with or without metastatic complications may occur. The etiology of Lemierre syndrome is generally Fusobacterium necrophorum, reported to be present in approximately 80% of the cases. The outcome of Lemierre syndrome in the preantibiotic era was nearly always fatal. The outcome today with the appropriate antibiotic coverage is quite good. The management of a patient with suspected Lemierre syndrome should be aggressive and comprehensive. Blood cultures as well as cultures from infection sites should be obtained. Computed tomography, magnetic resonance imaging, and ultrasound are all appropriate modalities to detect the presence of internal jugular vein thrombophlebitis. Treatment of Lemierre syndrome consists of prolonged antibiotic therapy (4 to 6 weeks) with appropriate anaerobic coverage. Typical antibiotics include penicillins, metronidazole, or clindamycin. Surgical drainage of metastatic abscesses is often needed ensure resolution of this disease process. Persistent sore throat syndrome caused by F necrophorum has been reported in the literature and the General Practitioners should be aware of this entity because they may see this in their practice.

Non-Tropical Pyomyositis Caused by Methicillin-Resistant Staphylococcus aureus: An Unusual Cause of Bilateral Leg Pain

Background: Pyomyositis (PM) is a primary suppurative infection of skeletal muscles that was originally described as a tropical disease and is now being seen with increasing frequency in temperate regions. Although PM is classically described as a disease of young, healthy individuals, its incidence is increasing in immunocompromised patients, particularly those with human immunodeficiency virus infection. Staphylococcus aureus is the etiologic agent in the majority of cases of PM worldwide, with methicillin-resistant Staphylococcus aureus (MRSA) being reported with increasing frequency. Mortality from PM is as high as 10%, and complications include metastatic abscesses, septicemia, and shock. Early signs and symptoms of PM are usually subtle and may be easily overlooked or misdiagnosed as a more benign condition. Case Report: A case of non-tropical PM due to MRSA in a young man is presented. This is followed by a review of the epidemiology, clinical findings, pathophysiology, diagnosis, differential diagnosis, treatment, and prognosis of this challenging and unusual condition. Conclusion: Because PM presents with subtle symptoms that are easily misunderstood as signs of more common and more benign conditions, it is often missed early in its course. By recognizing PM early in its course, it is possible to treat it before surgical drainage is required and before complications develop.

Principles of surgical management of brain multiple metastatic abscesses

Treatment outcomes of 56 patients with BMMA, who received surgical treatment between 1985 and 2007, are presented. MRI is the main diagnostic method that makes it possible to identify abscesses irrespective of their size, quantity and localization in the brain, as well as to differentiate them from other mass formations. In 19 patients chronic inflammation process in lungs was detected, in others — tonsillitis, osteomielitis, bacterial septicemia, in 4 cases a source of inflammation was not found or was questionable.Four methods of BMMA surgical removal were used: abscess puncturing and aspiration (in 26 patients), abscess opening and external draining (in 14 patients), abscess total excision without opening its capsule (in 7 patients), combined method — abscess puncturing or opening with its subsequent total excision (in 9 patients).The lethality rate was 19.6% (11 patients died). Deaths resulted from an irreversible cerebral dislocation disorders and heavy meningoencephalitis. Favorable outcomes of surgical intervention for BMMA are possible if simultaneous abscess sanation and evacuation from one or both cerebral hemispheres is used.

Fra tonsillitt til koksitt

We present a 19-year-old woman with a throat infection, increased temperature, a positive mononucleosis monospot test and clinical signs of a lower respiratory tract infection. The diagnosis was thought to be mononucleosis complicated by bacterial pneumonia, but she was later found to have Fusobacterium necrophorum in blood cultures. She subsequently developed metastatic abscesses in her lungs and hip joint and was diagnosed with Lemierre's Syndrome. This case report highlights the importance of close links between clinicians and microbiologists in order to prevent morbidity and mortality in patients with an infectious disease.

A Case of Squamous Cell Carcinomatous Lung Abscess with Multiple Metastatic Abscesses

Among the bronchogenic carcinomas, especially squamous cell carcinoma and large cell carcinoma frequently present with cavitation, which may result from tumor necrosis. Cavitary lesions of the tumor are occasionally associated with infection and misdiagnosed as benign lung abscess owing to the partial responsiveness to antibiotics. It is very difficult to distinguish the carcinomatous abscess from the benign lung abscess, because of their similar clinical and radiologic features. Delay in diagnosis of underlying lung cancer may result in poor outcome. Therefore, clinicians should remember that the patients with highly suspicious carcinoma of the lung should undergo further precise examinations to find out malignant cells.

Fatal cerebritis and brain abscesses following a nontraumatic subdural hematoma in a chronic hemodialyzed patient

Staphylococcus aureus is the leading cause of bacteremia in hemodialysis-dependent patients that can lead to metastatic abscesses with poor outcome. We report a case of a 65-year-old chronic hemodialyzed male patient who developed cerebritis and brain abscesses complicating a spontaneous subdural hematoma, following Staphylococcus aureus bacteremia related to infected arteriovenous fistula. In spite of adequate antibiotherapy and several surgical brain drainages, our patient did not survive. Prevention of S. aureus is highly important in hemodialysis patients.

Metastatic myocardial abscess on the posterior wall of the left ventricle: a case report

IntroductionMyocardial abscess is a rare and potentially fatal condition. Metastatic myocardial abscess in the setting of infective endocarditis has been infrequently reported in the medical literature. To the best of the authors' knowledge no case of myocardial abscess affecting the free wall of the left ventricle secondary to infective endocarditis of a right-sided heart valve has been reported previously.Case presentationWe report a case of tricuspid valve endocarditis caused by Staphylococcus aureus and resulting in a myocardial abscess on the posterior wall of the left ventricle, far from the active valvular infection. We also briefly discuss the role of different investigation modalities including cardiac magnetic resonance imaging in diagnosing myocardial abscess.ConclusionMyocardial abscess is a life-threatening illness. A high index of clinical suspicion is required to make a prompt diagnosis. Final diagnosis may need multi-modality imaging. An early diagnosis, aggressive medical therapy, multidisciplinary care and timely surgical intervention may save life in this otherwise fatal condition.

Concomitant cutaneous metastatic tuberculous abscesses and multifocal skeletal tuberculosis

Tuberculosis, one of the oldest diseases known to affect humans is caused by the bacteria mycobacterium tuberculosis. The disease usually affects the lungs, although, in up to one third of cases, other organs are involved. Metastatic tuberculosis abscess is a rare form of skin tuberculosis. It is characterized by nodule and abscess formation throughout the body after hematogenous spread of mycobacterium tuberculosis from a primary focus during a period of impaired immunity. Tuberculosis osteomyelitis is also a rare form of extrapulmonary tuberculosis in pediatric age group. Skeletal tuberculosis pathogenesis is related to reactivation of hematogenous foci or spread from adjacent paravertebral lymph nodes. Weight-bearing joints are affected most commonly. Bilateral hand and foot bone involvement is rarely reported. We present a five-year-old girl with two very rare presentations of the disease such as osteomyelitis and metastatic skin abscess.

A Case of a Type 2 Diabetic Patient with Pyogenic Liver Abscess and Metastatic Muscle Abscesses of the Lower Limb Caused by Klebsiella pneumoniae

A Case of a Type 2 Diabetic Patient with Pyogenic Liver Abscess and Metastatic Muscle Abscesses of the Lower Limb Caused by Klebsiella pneumoniae

Ｌｅｍｉｅｒｒｅ症候群例

We present a case of Lemierre syndrome characterized by thrombophlebitis of the internal jugular vein with multiple septic emboli to the lung caused by peritonsillar abscess.A 67-year-old male was admitted with progressive fever and sore throat caused by peritonsillar abscess. Despite drainage of the peritonsillar abscess and antibiotic therapy with imipenem following cefozopran, his condition worsened, and he presented with swelling, pain, and erythema of the right side of the neck. Contrast-enhanced computed tomography (CT) of the neck demonstrated thrombosis of the right internal jugular vein. CT scan of the thorax showed bilateral multiple septic emboli. Based on these findings, a diagnosis of Lemierre syndrome was made. The patient was treated with clindamycin and heparin in addition to imipenem and recovered slowly.Lemierre syndrome is one of the complications of acute tonsillitis or peritonsillar abscess, which causes thrombophlebitis of the internal jugular vein, leading to metastatic abscess, septic emboli, and significant mortality. Lemierre syndrome should be considered in cases of acute tonsillitis or peritonsillar abscess because the frequency of this syndrome is increasing.

Infection by Panton–Valentine leukocidin-producing Staphylococcus aureus clinically mimicking Lemierre's syndrome

Lemierre's syndrome is an oropharyngeal infection which leads to severe septic thrombophlebitis of the internal jugular vein and metastatic abscesses of the lungs and other organs. It is usually caused by Fusobacterium necrophorum, a Gram-negative obligate anaerobe. An unusual case of Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus infection masquerading as Lemierre's syndrome is reported here. A 32-year-old fit and otherwise healthy male presented on Christmas morning with a boil on his left cheek for 2 days and generalized rash for 3 h. His general condition began to worsen, he developed facial swelling and loss of vision in the left eye and was transferred to the intensive care unit. His treatment was taken over by team of specialists and further investigations revealed thrombophlebitis of the left internal jugular vein and cavernous sinus thrombosis with multiple brain infarcts and lung abscesses. His condition remained critical with multiple cranial nerve involvement despite being on broad-spectrum antibiotics. Blood cultures grew S. aureus which was producing PVL toxin. He improved gradually over several weeks. He underwent intensive physiotherapy and made a good recovery. Although a rare entity, it is important to consider Lemierre's syndrome in septic patients who present with rapidly worsening symptoms.

Lemierre's Syndrome with Septic Shock Caused by Fusobacterium Necrophorum

Fusobacterium necrophorum infections are rare. We report a 15-year-old male who presented with tachycardia, nausea, vomiting, diarrhoea and ankle pain. He rapidly deteriorated requiring ventilation and vasopressors. Imaging of his thorax showed airspace consolidation, pulmonary cavitations and empyema. The ankle required drainage of purulent material. A thrombus in his internal jugular vein (Lemierre's syndrome) and an abscess in his obturator internus were subsequently found. Fusobacterium necrophorum was identified in blood culture on day nine. The patient recovered with antibiotics and surgical interventions for empyema and septic arthritis. Fusobacterium necrophorum should be a suspected pathogen in septic shock complicated by metastatic abscess formation.

Lemierre's – the sinister sore throat

Lemierre's syndrome is a rare and sometimes life threatening condition that requires prompt management. A case is reported of a previously healthy young male with Lemierre's syndrome. He developed internal jugular vein and cavernous sinus thrombosis, metastatic abscesses in the temporal lobe and lungs, temporal lobe venous infarction and severe thrombocytopaenia. Discussed are aspects of clinical presentation, diagnosis and management issues.

Multiple Intracranial Tuberculomas Mimicking Granulocytic Sarcomas in Acute Myeloid Leukemia

The diagnosis of incracranial tuberculoma in immune-compromised hosts is often difficult because conventional magnetic resonance (MR) imaging of tuberculoma reveals various findings and neurologic symptoms are not typical. Here, we report a case of a 54-yr old man with multiple intracranial tuberculoma who was treated for acute myeloid leukemia. He complained of right-side paresthesia after the third consolidation chemotherapy without leukemic relapse and fever. MR imaging of the brain showed multiple ring-enhanced lesions in the cerebrum, cerebellar hemisphere, and pons. The lesions appeared to mimic a metastatic tumor or abscess. Cerebrospinal fluid analysis showed no abnormal cells, but the level of adenosine deaminase was elevated (28.8 IU/L, normal 0-8). Stereotactic brain biopsy was performed, but only reactive gliosis was observed. To confirm diagnosis, an open brain biopsy was performed. The histopathology demonstrated chronic granulomatous inflammation with caseous necrosis. Tuberculous-polymerase chain reaction of the biopsy showed a positive result. He was treated with anti-tuberculosis medication and a high dose of steroid. Paresthesia improved, and follow-up brain MR imaging showed the decreased size and numbers of ring-enhanced lesions and improvement of perilesional edema 1 month after treatment. Here, we report on an interesting case of intracranial tuberculoma in acute myeloid leukemia.

COMMUNITY-ACQUIRED, METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS INFECTION PRESENTING AS LEMIERRE SYNDROME

INTRODUCTION: Lemierre's syndrome, an oropharyngeal infection complicated by internal jugular vein thrombosis and metastatic abscesses in lung, is most commonly caused by the anaerobe Fusobacterium necrophorum. No cases, to date, have been found in current literature which document community- acquired Methicillin-resistant Staphylococcus Aureus (CA- MRSA) manifesting as Lemierre's Syndrome.