Negative Bacterial Cultures Research Articles

Fatal pneumonia cases caused by human adenovirus 55 in immunocompetent adults

Background: Adenovirus is a frequent cause of mild self-limiting upper respiratory tract infection, gastroenteritis, and conjunctivitis. Severe or fatal infection mostly occurs in newborn, elderly or immunocompromised persons. Methods: Fatal adenovirus pneumonia in three immunocompetent adults was identified. The clinical data and virological findings were reported from patients. Additional review of recently recorded fatal patients with adenovirus infection was carried out. Results: The patients presented with sudden onset respiratory distress that progressed rapidly to respiratory failure and death. Human adenovirus (HAdV)-55 was detected in both nasopharyngeal aspirates and serum samples in all three cases, and moreover detected in lung, liver, and kidney in one case. In another case, remarkably elevated aspartate aminotransferase, alanine transaminase, and lactate dehydrogenase were identified. Three HAdV-55 strains were isolated and genome sequencing revealed a high similarity with other strains from mild infection. Conclusions: Fatal infection with HAdv-55 might occur in otherwise healthy adults. Diagnosis of adenovirus infection should be considered in patients with severe pneumonia yielding negative bacterial culture and presenting no response to antibiotic therapy.

Leaking seroma following breast augmentation: technical fault or new complication?

Sir, Breast augmentation (BA) remains the most common aesthetical operation performedworldwide [1, 2]. It is considered as a simple, reliable procedure with a low complications rate. Early complications such as hematoma, seroma and infection are well known and were referenced in the scientific literature [3]. However, we have not found any published studies regarding early seroma, leaking through the surgical wound (leaking seroma). The goal of this letter is to describe leaking seroma (LS) as an early complication following breast augmentation, to present our thoughts regarding the etiology of LS, patients’ risk group, potential treatment and ways to prevent it. We reviewed 350 consecutive patients that underwent breast augmentation by the same surgeon (ABB) in a private medical center during the years 2007–2012. Breast fascial closure was performed with interrupted stitches in 172 patients (49.1 %) and with running interlocking stitches in 178 (50.9 %). Drainage was not used in any of the patients operated in this series. Medical files and operating records were extracted, and all data were statistically analyzed. We defined leaking seroma as a serous exudate discharging from surgical wound, ranging from spots on the dressing to massive fluid leak. Empirically, chosen regimen for treatment of LS, including oral antibiotic, iodine ointment dressing, non-steroidal anti-inflammatory drugs (NSAID), and complete patient rest, was employed. Seventeen patients (4.86 %) showed signs of leaking seroma, in 16 cases unilateral and in one case bilateral. Among 350 patients, two identical female twins were operated and both of them developed LS symptoms. The incidence of LS during the study period gradually decreased as shown in Table 1. Lag time between the operation date and first LS symptoms appearance varied from 5 to 50 days with mean value 15.9±11.6 days. In five patients with massive leak, the fluid from the wound was obtained for bacteriologic examination; in this group all bacterial cultures were sterile. LS treatment regimen included oral antibiotics (usually Ceftin 500 mg×2/day), iodine ointment dressings, nonsteroidal anti-inflammatory drugs (NSAID), and rest until the symptoms’ cessation. This treatment was successful in 13 out of 17 patients (76.5 %) and duration of their symptoms ranged from 3 to 20 days with mean value 8.6±4.8 days. Patients’ postoperative course was uneventful thereafter. The lack of data regarding LS in the plastic surgery literature can be explained by problematic definition of the subject. Usually, breast implant exposure and extrusion are the result of infection. It is very difficult to differentiate leaking seroma from sub-clinical infection. In our cases, the fluid discharge from the wound was serous and pellucid; all wound cultures obtained from patients with massive leak were sterile. Previous antibiotic treatment may have prevented bacterial growth and as a result, may lead to a negative bacterial culture. The lack of data can also be explained by under-reporting of postoperative complications in aesthetical plastic surgery due to the competitive character of the private plastic surgery sector. LS development can be explained by early tissue edema and exudate fluid accumulation around breast implant as a result of foreign body reaction. In some cases, excessive fluid production and non-infectious inflammatory reaction took place and caused partial wound dehiscence and subsequent LS. * Vasileios A. Pagkalos pagkalos_v@yahoo.gr

EARLY PREDICTION OF GRAM-POSITIVE BACTEREMIA IN FEVERISH EGYPTIAN PATIENTS USING SOME SELECTED INFLAMMATORY MEDIATORS

Bloodstream infection is an important cause of morbidity and mortality. Some components of the bacterial cell wall bind to receptors on the cell surface of the host monocytes and macrophages and induce cytokines production. This study assessed the levels of IL- 6 and TNF-α in 36 feverish Egyptian patients, with Gram positive bacterial infections. For early prediction of the infection, blood culture samples from feverish patients were collected from different medical hospitals in Cairo, Egypt. The recovered Gram-positive isolates were identified as Staphylococcus species and Micrococcus species. For patients, IL-6 and TNF-α were measured in the patients’ sera by ELISA. Antimicrobial susceptibility was determined for the tested isolates using 16 antibiotics by Kirby Bauer disk diffusion. Cell membrane protein profile was performed to detect the bands responsible for TNF- α production. The IL-6 and TNF-α in sera of all patients, with Gram-positive bacterial infections, showed significantly (P < 0.05) higher levels as compared to that of their counterparts with negative bacterial blood cultures. Tested isolates showed antimicrobial resistance to most tested antibiotics. The bacterial cell membrane proteins bands between 29-36 kDa were detected in the tested isolates. Some Inflammatory cytokines (IL-6 and TNF-α) can be used as valuable tools for early prediction of Gram-positive bacterial infections even before culture results are available.

Skull involvement in a pediatric case of chronic recurrent multifocal osteomyelitis.

An 11-year-old boy was diagnosed with chronic recurrent multifocal osteomyelitis (CRMO) and presented with right sacro-femoral and occipital lesions. Initially, a tumor was suspected. However, the bone biopsy showed osteomyelitis with a negative bacterial culture. Bone scintigraphy revealed inflammatory changes on multiple bone lesions. The slight elevation in inflammatory markers such as C-reactive protein was of little clinical value. He was diagnosed with CRMO by sacral biopsy, and the clinical course progressed, with the presence of a new occipital lesion observed after the 1-year follow-up. The administration of non-steroidal anti-inflammatory drugs successfully improved his clinical symptoms. The presence of a skull lesion in the occipital bone of a pediatric patient with CRMO has not been previously reported.

Bakteriális infekciók májátültetés után

The authors reviewed the prevalence of postoperative infections, the results of bacterium cultures, and the incidence of multidrug resistance in their liver transplanted patients during a period between 2003 and 2012. The aim of this study was to analyse risk factors and colonisations of bacterial infections. The files of 408 patients (281 bacterium cultures) were reviewed. Of the 408 patients 70 had a postoperative infection (17%); 58 patients (14.2%) had positive and 12 patients (2.9%) negative bacterial culture results. Cholangitis was found in 7 cases (12.1%), abdominal infection in 17 cases (29.3%), and pulmonary infection in 28 cases (48.3%). Postoperative infection was more frequent in patients with initial poor graft function, acute renal insufficiency, biliary complication, and in those with intraabdominal bleeding. The 1-, 3- and 5-year cumulative survival of patients who had infection was 70%, 56% and 56%, respectively, whereas the cumulative survival data of patients without infection was 94%, 87% and 85%, respectively (p<0.001). Multidrug resistance was found in 56% of the positive cultures, however, the one-year survival was not different in patients who had multidrug resistance positive and negative bacterial infection (both 70.2%). Infection control must target the management of multidrug resistance microbes through encouraging prevention, hygienic, and isolation rules, improving the operative, transfusion, and antimicrobial policy in a teamwork setting.

Rapid production of silver nanoparticles at large-scale using gallic acid and their antibacterial assessment

Gallic acid (trihydroxybenzoic acid) an abundantly available plant phenolic bioresource was utilized to establish a greener production of smaller sized (8±4nm) stable silver nanoparticles (AgNPs), without any waste byproducts. To improve quality of AgNPs, different concentrations of gallic acid (ranging from 2.50 to 11.25mM), furthermore reaction kinetics was remarkably improved up to fraction of minute using gallic acid:NaOH ratio. Highest transformation (95%) of initial Ag ions (250, 500, and 1000ppm) into highly dispersed AgNPs was successfully achieved using low concentration of gallic acid (9.375mM) without affecting the quality of AgNPs. The gallic acid bioprocess seems to be most suitable for the “exponential manufacturing”, it would play an important role to resolve the scale-up problem with low volume. Smaller AgNPs showed the minimum inhibitory concentration (MIC) at about 20 and 50ppm against gram negative and gram positive bacterial cultures, respectively.

Clinical Features and Prognostic Significance of Endobronchial Sarcoidosis

Aims: Endobronchial involvement may occur in patients with sarcoidosis. Although the prevalence of bronchial abnormalities is high, there are no firm data establishing the clinical features and prognosis of sarcoidosis in these patients. The aim of our study was to define the clinical characteristics and prognosis of patients with endobronchial sarcoidosis. Methods: Clinical and laboratory findings of 44 patients with endobronchial sarcoidosis and 46 patients without endobronchial involvement seen at our institution, were evaluated retrospectively. The patients fulfilled clinical, radiologic or both features of sarcoidosis supported by the histopathologic evidence of noncaseating granulomas. Six to ten bronchial biopsies were taken from each patient. The sample was considered positive if it demonstrated noncaseiting granulomas with negative bacterial, fungal and mycobacterial cultures. Results: Bronchial biopsy was more positive in 84% of the abnormal appearing airways, biopsy provided diagnostic tissue in 32% of the normal appearing mucosa. The most frequent Original Research Article Yanardag et al.; BJMMR, 9(1): 1-7, 2015; Article no.BJMMR.18441 2 bronchoscopic finding was miliary infiltration followed by nodular and erythematous lesions. Serum ACE, serum and urinary Ca levels were higher (51.4±14.3 IU/L vs 37.3±15.1 IU/L, p<0.01; 8.42±3.6 mg/dL vs 10.8±2.9 mg/dL, p<0.01; 244.9±32.4 mg/day vs 379.6±36.8 mg/day, p<0.01) in patients with endobronchial involvement. There was no significant difference between FEV1, FVC, TLC and DLCO/VA. The extrapulmonary organ involvement (p<0.02) and progressive disease (p<0.03) was more frequent in patients with endobronchial disease. Conclusion: Endobronchial involvement in sarcoidosis appears to be a significant predictive risk factor for progressive disease. Extrapulmonary organ involvement was also higher in these patients contributing to a worse prognosis.

Clinico-radiological Approach to a Rare Case of Early Clavicle Tuberculosis: A Case Discussion Based Review of Differential Diagnosis.

A patient of 41 years of age presented with insidious onset atraumatic swelling arising from medial end of right clavicle with apparently normal radiograph. Initial computed tomography ascribed it to benign bony pathology requiring no specific treatment but patient did not respond to symptomatic management. FNAC done elsewhere was inconclusive, with no bacteria on Gram's staining and negative bacterial culture and AFB smear examinations. Patient had possible exposure to tuberculosis and Mantoux skin test done which showed significant induration. Possible differential diagnoses related to clavicle including infective, neoplastic, rheumatological, degenerative and idiopathic conditions considered. Magnetic resonance imaging (MRI) showed focal periosteal reaction with marrow signal changes with sparing of sternoclavicular joint. Correlation between patient's history, clinical findings and investigations done and diagnosis of isolated clavicle tuberculosis was made. Patient showed good response to anti-tubercular chemotherapy. Repeat MRI showed resolution of initial imaging findings. At the end of 2 years patient was completely symptom free.

Parechovirus Sepsis and Meningitis in a Neonatal Intensive Care Unit

The majority of febrile neonates have negative bacterial cultures and presumed viral infections. During November 2014, four febrile neonates in southeastern Wisconsin required intensive care admission for human parechovirus (HPeV) infection in the blood and/or cerebral spinal fluid (CSF). Both vertical and horizontal transmission led to disease, and a variety of signs and symptoms, including tachycardia, hypotension, neutropenia, rash and irritability accompanied fever. All neonates recovered clinically, although concern for neurodevelopmental delay remains for those with meningoencephalitis. This case series describes the presentation and short-term outcomes of neonates requiring intensive care for HPeV infections.

SURGICAL TREATMENT FOR INFECTED LONG BONE DEFECTS AFTER LIMB-THREATENING TRAUMA: APPLICATION OF LOCKED PLATE AND AUTOGENOUS CANCELLOUS BONE GRAFT.

Treatment strategies for bone defects include free bone grafting, distraction osteogenesis, and vascularized bone grafting. Because bone defect morphology is often irregular, selecting treatment strategies may be difficult. With the Masquelet technique, a fracture site is bridged and fixed with a locking plate after treating deep infection with antibiotic-containing cement, and a free cancellous bone-graft is concomitantly placed into the defects. This procedure avoids excessive bone resection. We studied 6 patients who underwent surgical treatment for deep infection occurring after extremity trauma (2004 through 2009). Ages at surgery ranged from 29 to 59 years (largest age group: 30 s). Mean follow-up was 50.7 months (minimum/maximum: 36/72 months). One patient had complete amputation of the upper extremity, 3 open forearm fractures, 1 closed supracondylar femur fracture, and 1 open tibia fracture. In all patients, bone defects were filled with antibiotic-containing cement beads after infected site debridement. If bacterial culture of infected sites during curettage was positive, surgery was repeated to refill bone defects with antibiotic-containing cement beads. After confirmation of negative bacterial culture, osteosynthesis was performed, in which bone defects were bridged and fixed with locking plates. Concomitantly, crushed cancellous bone grafts harvested from the autogenous ilium was placed in the bone defects. Time from bone grafting and plate fixation to bone union was at least 3 and at most 6 months, 4 months on average. Infection relapsed in one patient with methicillin-resistant Staphylococcus aureus, necessitating vascularized fibular grafting which achieved bone union. No patients showed implant loosening or breakage or infection relapse after the last surgery during follow-up. The advantage of cancellous bone grafting include applicability to relatively large bone defects, simple surgical procedure, bone graft adjustability to bone defect morphology, rapid bone graft revascularization resulting in high resistance to infection, and excellent osteogenesis.

Detection of enteroviruses in pediatric patients with aseptic meningitis

Aseptic meningitis is an acute viral infection of the central nervous system that occurs most frequently in infants and young children. This study was conducted on 100 pediatric patients with ages range from 1.5 months to 6 years. Cerebrospinal fluid (CSF) specimens were obtained with criteria of aseptic CNS infections as documented by pleocytosis, negative Gram stain and negative bacterial culture. Clinical and CSF findings of the affected children were analyzed and CSF specimens were submitted to viral culture and polymerase chain reaction (PCR) techniques to determine the enteroviral etiology. Fifty six percent patients had positive PCR results for the enteroviral genome, compared with 20% by virus culture. We can conclude that PCR is a rapid, reliable and sensitive diagnostic tool for the detection of enteroviral infections. A positive EV-PCR result may affect clinical decision making and may significantly alter the medical care offered to infected patients.

Clinical features of patients of different ages with postoperative multi-space maxillofacial infection.

To investigate the clinical features of patients of different ages with multi-space infection after maxillofacial surgery. Three hundred and seven patients with infections in multiple spaces were enrolled in the study. They were classified into the senior (n = 149) and the younger group (n = 158). The clinic data were retrospectively analyzed. Male patients accounted for 63.09 and 63.29 % of the senior and the younger group, respectively. Sex composition between the two groups was not significantly different (p > 0.05). Senior patients were associated with significantly more complications than the younger adults (p < 0.05). 46.31 and 55.70 % of patients in the respective two groups had infections involving more than two spaces. Patients in both groups visited the hospital at a similar time after the symptoms manifested (p > 0.05). Elderly patients had similar glucose levels, white blood cell counts and neutrophil cell counts compared to those of the younger groups (p > 0.05). 55.06 % of the younger patients had negative bacterial culture results, which was significantly more than those of the senior groups (p < 0.05). The bacterial compositions of the infection of two groups were also found significantly different (p < 0.05). In the event of postoperative multi-space maxillofacial infection, senior patients shared many similar clinical features with the younger adults. But they also had unique features, such as more complications. As a result, it is more difficult to treat senior patients with multi-space infections. Therefore, more medical attention is required to senior patients.

Synthesis of new benzisoxazole derivatives and their antimicrobial, antioxidant and anti-inflammatory activities

A series of benzisoxazole derivatives were synthesized and evaluated for their antibacterial, antioxidant and anti-inflammatory activities. The results indicated that most of the compounds exhibit moderate antimicrobial activity against Gram negative ( Escherichia coli , Klebsiella pneumoniae , Salmonella typhi , Shigella flexineri ) and Gram positive ( Bacillus subtilis ) bacterial culture. The molecules were evaluated for antioxidant activities using 2,2-diphenyl-1-picrylhydrazyl scavenging, super oxide radical scavenging and hydroxyl radical scavenging assays and most of them showed good antioxidant activities. Also, the synthesized compounds were screened for anti-inflammatory activities such as lipoxygenase inhibition and indirect haemolytic assays.

A Case of Pyogenic Spondylitis Due toAggregatibacter aphrophilus

Aggregatibacter aphrophilus, a normal component of oral cavity flora, mostly causes infective endocarditis and only rarely causes spondylitis; no spondylitis cases have been previously reported in Korea. We report a case of pyogenic spondylitis due to A. aphrophilus without endocarditis. A 64-year-old man was admitted for back pain lasting 3 weeks. There was severe tenderness on lumbar spines but no fever. Laboratory evaluation showed leukocytosis and elevated C-reactive protein. Blood cultures were negative. Magnetic resonance imaging showed psoas abscess and vertebral inflammation. Pus was obtained by computerized tomography-guided aspiration from the psoas abscess and inoculated into blood culture bottles. After 5 days of incubation, growth was detected: the isolate was a Gram-negative short rod bacteria identified as A. aphrophilus by the automated system; this was confirmed by 16S ribosomal RNA sequencing. There was no evidence of endocarditis in echocardiography and retinal examination. Back pain persisted despite 8 weeks of antibiotic treatment, so vertebral corpectomy was performed. A. aphrophilus, a rare cause of pyogenic spondylitis, can induce spondylitis without endocarditis. If a patient with pyogenic spondylitis shows negative routine bacterial cultures, fastidious organisms such as A. aphrophilus should be suspected and the blood culture bottles could be used. (Ann Clin Microbiol 2014; 17:99-103)

Herpes simplex virus meningitis in children in South East of caspian sea, iran.

Background:Herpes simplex virus (HSV) is a member of Herpesviridae and a leading cause of human viral diseases. Meningitis occurs as a complication of HSV-1 or HSV-2 primary infection.Objectives:We aimed to evaluate HSV meningitis in children in Gorgan province, Iran.Patients and Methods:Forty-five cerebrospinal fluid samples were taken from children referred with meningitis symptoms. Samples with negative bacterial culture results were tested for viral, biochemical and cytological assays. DNA extraction and PCR were performed.Results:HSV-1 detected in 4 (8.8%) samples without any HSV-2 infections. Cases with positive results had fever and CSF pleocytosis. Vomiting, headache and higher count of WBC were observed in 3, 2 and 3 cases respectively. The cerebrospinal fluid (CSF) glucose and protein levels were normal and 3 cases showed positive C-reactive protein (CRP) results. Also erythrocyte sedimentation rate (ESR) was higher than normal in all positive cases.Conclusions:Distribution of HSV types in children with meningitis in our area predominantly was type 1 compared with type 2, which has been reported more in other area.

Diffuse descending necrotizing mediastinitis: surgical treatment and outcomes in a single-centre series

Objectives. Descending necrotizing mediastinitis is a severe infection spreading from the cervical region to the mediastinum. Since this pathology is uncom­mon, only a few reports of large series of patients with descending nec­rotizing mediastinitis have been published. The present aim was to eval­uate our treat­ment strategy and survival for this disease by a retrospective chart review. Methods. Retrospective analysis of 45 cases with descending necrotizing mediastinitis was performed between 2002 and 2011. The mean age was 55.3 ± 15.4 years. The primary oropharyngeal infection was found in 16 (35.6%), an odontogenic abscess in 17 (37.7%) and other causes in 12 (26.7%) patients. Endo type I mediastinitis was assessed in 25 (56%) patients, Endo type IIA in 10 (22%) and Endo type IIB in 10 (22%) patients. Broad spectrum antibiotics were administered empirically and surgical treatment consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum and placement of permanent mediastinal irrigation were performed in all the cases. Results. Collar incision and drainage only were performed in 16 (35.6%) patients, whereas only transthoracic approach was used in five cases (11%). In the remaining 24 (53.4%) patients cervical drainage and thoracic operation were performed. Fifteen patients had severe complications: septic shock, multiple organ failure and haemorrhage from mediastinal vessels. The median hospital stay was 21 days. The outcome was favourable in 35 patients. Ten patients died (overall mortality 22.2%). There was a negative correlation between the time from the onset of symptoms till the first admittance to hospital and hospitalization time (Pearson correlation coefficient 0.357, p = 0.016). That allows us to suggest that time of illness spent at home without appropriate treatment plays a crucial role on the survival. It was found that younger age, Endo type I, negative bacterial culture and longer hospital stay are true precursors of favourable outcome. Conclusions. For descending necrotizing mediastinitis limited to the upper part of the mediastinum a transcervical approach and drainage may be sufficient. However, in advanced cases an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients.

A pilot study of the efficacy and safety of empiric daptomycin therapy in oncology patients with fever and severe neutropenia.

Patients with extended periods of time spent with low or absent absolute neutrophil counts (ANCs) are at risk for bacterial infections. Febrile neutropenia is a complication in this patient population, requiring administration of antibiotics. The use of daptomycin in treating patients with febrile neutropenia is not well described. Our objective was to describe the clinical course of febrile neutropenic patients that received daptomycin therapy. This was an open-labeled, pilot study of 30 patients with documented febrile neutropenia treated with empiric daptomycin. Eligible patients received daptomycin 6 mg/kg/day, in addition to concomitant broad-spectrum antimicrobials. The Kaplan-Meier method was used to estimate the median days to reach an afebrile state and negative bacterial cultures. A total of 30 febrile neutropenic patients were enrolled and received daptomycin as part of an empiric antimicrobial regimen. All patients had severe neutropenia with ANC <100 cells/mm(3). Two patients were removed from study due to the development of pneumonia. Clinically, 87% patients improved on daptomycin in combination with Gram-negative coverage, with 73% of patients succeeding therapy. A total of 18 of 19 (95%) subjects with positive blood cultures had microbiological eradication, with the median time to reach an afebrile state of 4.3 days (range 1-13). Four patients were discontinued from daptomycin due to a suspected related adverse event or to clinical failure. This pilot study supports future evaluation of the use of empiric daptomycin therapy in combination with Gram-negative coverage compared with vancomycin in patients with neutropenic fever in a large, randomized controlled trial.

Viral CNS infections in children from a malaria-endemic area of Malawi: a prospective cohort study.

SummaryBackgroundFever with reduced consciousness is an important cause of hospital admission of children in sub-Saharan Africa, with high mortality. Cerebral malaria, diagnosed when acute Plasmodium falciparum infection and coma are recorded with no other apparent reason, is one important cause. We investigated whether viruses could also be an important cause of CNS infection in such patients, and examined the relative contribution of viral pathogens and malaria parasitaemia.MethodsWe did a prospective cohort study in Blantyre, Malawi. From March 1, 2002, to Aug 31, 2004, we enrolled children aged between 2 months and 15 years who were admitted to hospital with suspected non-bacterial CNS infections. Children with a cerebrospinal fluid (CSF) white cell count of less than 1000 cells per μL and negative bacterial microscopy and culture were deemed to have suspected viral CNS infection. Blood was examined for asexual forms of P falciparum. PCR was done on CSF or on post-mortem brain biopsy specimens to detect 15 viruses known to cause CNS infection.FindingsFull outcome data were available for 513 children with suspected viral CNS infection, of whom 94 (18%) died. 163 children (32%) had P falciparum parasitaemia, of whom 34 (21%) died. At least one virus was detected in the CNS in 133 children (26%), of whom 43 (33%) died. 12 different viruses were detected; adenovirus was the most common, affecting 42 children; mumps, human herpes virus 6, rabies, cytomegalovirus, herpes simplex virus 1, and enterovirus were also important. 45 (9%) of the 513 children had both parasitaemia and viral infection, including 27 (35%) of 78 diagnosed clinically with cerebral malaria. Children with dual infection were more likely to have seizures than were those with parasitaemia alone, viral infection only, or neither (p<0·0001). 17 (38%) of the 45 children with dual infection died, compared with 26 (30%) of 88 with viral infection only, 17 (14%) of 118 with parasitaemia only, and 34 (13%) of 262 with neither (p<0·0001). Logistic regression showed children with a viral CNS infection had a significantly higher mortality than did those who did not have a viral CNS infection (p=0·001).InterpretationViral CNS infections are an important cause of hospital admission and death in children in Malawi, including in children whose coma might be attributed solely to cerebral malaria. Interaction between viral infection and parasitaemia could increase disease severity.FundingWellcome Trust, US National Institutes of Health, and UK Medical Research Council.

Report of wood decay fungus Inonotus tropicalis (phylum Basidiomycota) from a dog with a granulomatous mediastinal mass

A 75.9-kg, 3.5-year-old male Irish Wolfhound dog with a 2-3-week history of gagging and eating difficulties was referred to the University of Florida Veterinary Medical Hospital (Gainesville, Florida) for evaluation of a large cranial mediastinal mass suspected to be a thymoma or lymphosarcoma. The patient had 4 months of nearly 10 kg progressive weight loss with severe flank sensitivity and radiographically apparent lumbar vertebral changes interpreted as discospondylitis. Lab work revealed hyperglobulinemia, mild proteinuria, normal T4, negative Brucella canis titer, and negative blood and urine bacterial cultures. A thoracotomy revealed a nonresectable, destructive, space-occupying mediastinal mass resulting in euthanasia without surgical recovery. Biopsies from the mass were collected during surgery for histology. Microscopic examination revealed extensive granulomatous cellulitis and lymphadenitis characterized by central cavitated necrotic areas containing debris and degenerate neutrophils, intermediate zones of fibrovascular proliferation with marked mixed inflammation, peripheral fibrosis, frequent multinucleated macrophages, and scattered mineralization. The necrotic material contained dense mats of 2 µm wide by 8-15 µm long fungal hyphae with parallel walls, acute angle branching, frequent septae, and occasional bulb-like dilations. DNA sequencing and phylogenetic analysis of the internal transcribed spacer region confirmed the presence of a fungus in the Inonotus tropicalis group. Inonotus tropicalis is primarily a wood decay fungus that is found on dead wood from angiosperms in tropical and subtropical habitats. Isolates of the I. tropicalis group have been detected a few times from immunosuppressed human beings with X-linked granulomatous disease.

Diagnostic Value of Polymerase Chain Reaction Analysis of Skin Biopsies in Purpura Fulminans

Even though prompt diagnosis and treatment of purpura fulminans (PF) is essential to reduce mortality, early administration of antibiotics may preclude identification of the causative agent by standard bacterial cultures and thus render definitive diagnosis impossible. Here we present a case of an infant with PF and negative bacterial cultures for whom polymerase chain reaction (PCR) analysis of a cutaneous biopsy specimen obtained 4days after initiation of antibiotics identified the genomic sequence of Neisseria meningitidis genogroup C. When bacterial cultures fail to provide useful information, PCR of skin biopsy specimens can be a valuable diagnostic tool in PF.