Rare Etiologic Agent Research Articles

The silent beast – a case of late‐onset postoperative endophalmitis

AbstractLate‐onset postoperative cataract surgery endophthalmitis remains a rare but sight‐threatening complication usually caused by slow‐growing pathogenic agents: bacterial or fungus. The delayed diagnosis and the potential irreversible ocular damage make this condition a challenging case for ophthalmologists.Herein, we present a 71‐year‐old woman with late‐onset fungal endophthalmitis after cataract surgery caused by candida parapsilopsis, a rare etiologic agent. This diagnosis should be taken into consideration in every late‐onset postoperative persistent panuveitis with no response to antibiotics and partial response to topical steroids, even after negative vitreous or tap culture. White deposits on the surface of the intraocular lens or the capsule are a crucial sign. Systemic and intraocular antifungal therapy along with vitrectomy and intraocular lens removal—if necessary—are the main therapy to ensure the best visual prognosis.

Karaciğer ve Böbrek Nakli Olan Çocuk Hastada Plesiomonas Shigelloides Gastroenteriti

Plesiomonas hastalığında altta yatan risk faktörünü tanımlayan bilgiler çoklu vaka raporlarından elde edilmiştir. İmmün sistemi baskılanmış hastalar ve yabancı ülkelere seyahat öyküsü Plesiomonas gastroenteritiyle ilişkili önemli risk faktörleridir. Plesiomonas shigelloides, farklı derecelerde ishal kliniğine yol açabilen ülkemizde nadir görülen bir gastroenterit etkenidir. Sulu ishal, Plesiomonas gastroenteritinin en yaygın klinik sunumudur, tüm hastaların %50 ila %88’i bu tip diyare ile başvurmaktadır. Bu yazıda 2012 yılında karaciğer nakli, 2015 yılında böbrek nakli olmuş 11 yaşında kız hastada Plesiomonas shigelloides’e bağlı ortaya çıkan ağır kolera benzeri ishal sırasında yaşanan aşırı sıvı kaybı, akut böbrek hasarı, metabolik asidoz, elektrolit dengesizlikleri, immunsüpresif doz ayarlamaları gibi önemli sorunlar ve çözümleri paylaşılmak istenmiştir. 

Uncommon clinical presentation of a common bug: Group A Streptococcus meningitis.

Group A Streptococcus (GAS) is a common pathogen in paediatric infections. However, it is a rare etiologic agent of bacterial meningitis. We describe a case of Streptococcus pyogenes meningitis complicated by sensorineural hearing loss in an immunocompetent 7-year-old boy. Clinicians should be aware of GAS as a potential cause of paediatric meningitis, especially with prominent symptoms suggestive of frontal sinusitis. Meningitis caused by GAS has been shown to be associated with significant mortality and morbidity, including neurological complications. Early screening for sensorineural hearing loss in patients with GAS meningitis can facilitate timely cochlear implant.

Pestalotioid fungi: A rare agent of onychomycosis among agriculture workers.

Background and Purpose: Pestalotioid fungi are ubiquitous environmental molds that have received considerable attention in recent times not only because of their role as a plant pathogen but also owing to their high frequency of retrieval from human diseases. Regarding this, the present study was conducted to investigate onychomycosis caused by pestalotioid fungi, commonly considered important phytopathogens causing grey blight disease in Camellia sinensis.Materials and Methods: A total of 122 agriculture workers were enrolled from Assam, India. Direct microscopic examination was carried out using 40% KOH to determine the presence of any fungal element. Further processing of the specimens for the isolation of fungi was performed using the standard protocol. In addition, the keratinolytic potential of the isolates was evaluated by means of the in vitro hair perforation test.Results: Out of 103 culture-positive samples, non-dermatophyte and dermatophyte molds constituted 82.52% (n=85) and 6.79% (n=7) of the samples, followed by yeasts (n=1, 0.9%) and sterile hyphae (n=10, 9.7%). With regard to the isolated non-dermatophyte molds (82.69%), 4 cases belonged to pestalotioid fungi, such as Neopestalotiopsis piceana (n=1), Pestalotiopsis species (n=1), and Pseudopestalotiopsis theae (n=2). The keratinolytic activity of Pestalotiopsis species showed perforation by disrupting the hair cortex; furthermore, macroconidia were found to be present inside the human hair.Conclusion: A high rate of NDM isolation may be attributed to constant exposure to adverse environmental and occupational hazards. This study highlighted the importance of “pestalotioid fungi” as the rare etiologic agent of onychomycosis. Another remarkable finding was the keratinolytic potential of Pestalotiopsis species, which is unique in this study.

Plesiomonas shigelloides Gastroenteritis from Freshwater Ingestion in Western Pennsylvania

Abstract Plesiomonas shigelloides is a rare etiologic agent of bacterial gastroenteritis. Since the year 2000, there is only one published case report of P. shigelloides gastroenteritis. Presented here is a case reporting the typical presentation and successful oral antibiotic treatment of a rarely reported cause of gastroenteritis in the United States, after ingestion of freshwater from a stream in western Pennsylvania.

PP-412 - Catheter-Related Fungal İnfective Endocarditis Leading to Septic Embolism and Aortic Regurgitation

Fungal endocarditis is an emerging cause of infective endocarditis (IE). They are described as a rare etiological agent in culture negative infective endocarditis.

Corynebacterium Bone and Joint Infection (BJI): A Retrospective Cohort Study in a Reference Center for BJI Management

Background Corynebacterium is a rare etiologic agent of BJI. We aimed to describe this rare clinical condition and to assess treatment failure determinants.Methods All adult patients with proven Corynebacterium BJI (i.e., consistent clinical/radiological signs, AND ≥2 reliable positive bacteriological samples, AND treated as such) were included in a retrospective cohort study. After cohort description, determinants of treatment failure (i.e., infection persistence, relapse, requirement of additional surgical procedure, and BJI-related death) were determined using stepwise logistic regression and Kaplan-–Meier curve analysis.ResultsThe 51 included BJI were more frequently chronic (88.2%), orthopaedic device related (ODI, 74.5%) and polymicrobial (78.4%). Surgery was performed in 92.2% of cases, and considered as appropriate in 76.5% of them. The main first-line antimicrobials were glycopeptides (68.6%), β-lactams (50%), and/or clindamycin (10.0%). Three (5.9%) patients received daptomycin as part of first-line regimen, and 8 (15.7%) at any point of treatment. After a follow-up of 60.7 (IQR 30.1–115.1) weeks, 20 (39.2%) treatment failures were observed, including 4 (20%) Corynebacterium-documented relapse. Independent risk factors were initial biological inflammatory syndrome (OR 16.1; P = 0,030) and inappropriate surgical management (OR 7.481; P = 0.036). Interestingly, all patients receiving daptomycin as part of first-line regimen failed (P < 0.001), including one patient with a Corynebacterium-documented relapse with a daptomycin increased MIC. Among patients with ODI, survival curve analysis disclosed a worst prognosis in case of prosthetic joint infection (P = 0.030), unappropriate surgical management (P = 0.029) and daptomycin use as first-line regimen (P < 0.001).Conclusion Corynebacterium BJI is a poorly known condition, frequently chronic, and polymicrobial. An important rate of failure was observed, associated with inappropriate surgical management and daptomycin use as part of first-line regimen. As described for other clinical conditions such as infective endocarditis, daptomycin should be avoid or used in combination therapy to prevent resistance selection and treatment failure.Disclosures T. Ferry, HERAEUS: Consultant, Speaker honorarium. S. Lustig, Heraeus: Consultant, Consulting fee

Aggregatibacter actinomycetemcomitans Kaynaklı Olası Enfektif Endokardit Olgusuna Mikrobiyolojik Yaklaşım

Aggregatibacter (Actinobacillus) actinomycetemcomitans, a small, gram-negative coccobacillus that grows slow and fastidious, is generally colonized in the oral cavity. It is a rarely seen bacterium because of the difficulty of isolation but it can be a causative agent for dental infections and infective endocarditis (IE) particularly in the persons having prosthetic heart valves. In this report, a possible IE case caused by A.actinomycetemcomitans in a patient with aortic valve replacement has been presented. A 36-year-old man has admitted to Trakya University Hospital, Health Center for Medical Research and Practice, with the complaints of chills, malaise, intermittent fever, severe arthralgia and weight loss (20 kg). During his follow-up period, the blood cultures that were obtained three week intervals yielded the identical gram-negative coccobacilli morphology. The patient was then diagnosed as possible IE on the basis of having one major (growth of the typical microorganisms that may cause IE in two different blood cultures) and two minor (presence of prosthetic valve and high fever) criterias. The isolate could not be identified with conventional methods, while it was identified as Francisella tularensis with VITEK 2 (bioMerieux, France) system. Hence this identification was not confirmed by real-time Taqman polymerase chain reaction, so MALDI-TOF mass spectrometry was used to identify this bacteria. In the first run of the study, the isolate was named as Shigella dysenteriae initially, however when it was retested the next day it was identified as A.actinomycetemcomitans. In order to enlighten these conflicting results, 16S and 23S ribosomal DNA sequence analysis was performed, and consequently the bacterium was identified as A.actinomycetemcomitans. Doxycycline (2 x 100 mg po, 20 days) and streptomycin (2 x 10 mg/kg im, 10 days) therapy were initiated, considering the initial suspicious identification (F.tularensis), and on the fifth day of therapy the blood culture was negative with the regression of patient's complaints. Therapy continued with the addition of rifampicin to doxycycline from the 21(st) day and the patient discharged with cure. As a result, the identification of an exceptional bacterium like A.actinomycetemcomitans may be difficult and time-consuming in certain laboratory facilities. So, the use of different identification methods in addition to classical methods are needed to overcome such a problem, especially for uncommon isolates and clinically discordant cases. This case was presented because A.actinomycetemcomitans is a rare etiological agent for IE patients and it could be a good example to draw attention to the problem when identifying the organism using automatized identification systems.

Catheter Related Escherichia hermannii Sepsis in a Haemodialysis Patient

Escherichia hermannii is an extremely rare etiological agent of invasive infection, and thus, the bacterium was initially considered non-pathogenic. However, in five previously reported case reports E. hermannii has been implicated as the sole pathogen. Our case report describes blood stream infection with E. hermannii in a haemodialysis patient with persisting symptoms, high fever and inflammatory markers despite appropriate antibiotic treatment until replacement of the dialysis catheter. We suspect biofilm formation to be a crucial pathogenic feature for E. hermannii in the maintenance of an infection, which stresses the necessity of antibiotic treatment along with catheter replacement in bloodstream- and catheter-related infection with E. hermannii.

A Case of Septic Shock caused by Achromobacter xylosoxidans in an Immunocompetent Female Patient after Extracorporeal Shock Wave Lithotripsy for a Ureteral Stone.

Achromobacter xylosoxidans can cause various types of infections, but its infection in humans is rare. A. xylosoxidans has been reported as a rare etiological agent of infections including primary bacteremia, catheter-related bloodstream infection, endocarditis, otitis, and pneumonia, particularly in immunocompromised hosts. We encountered a case of septic shock caused by A. xylosoxidans in a 52-year-old, immunocompetent woman with no underlying disease, who received extracorporeal shock wave lithotripsy to remove a left upper ureteral stone. She was treated with antibiotics to which the organism was susceptible but died as a result of septic shock.

Molecular Characterization of Aureobasidium Species in Iran

Background and Aim: Members of this genus Aureobasidium are ubiquitous microorganisms which can be isolated from wide ranges of substrates such as plant materials (phyllosphere, plant debris, bark, roots, fruits and wood), soil, dead wood, air, and as rare etiologic agent of pheohypho mycosis, keratomycosis, septicemia, peritoneal sepsis, and dermatological i nfections in human. Very little is known on the identity, substrates and distributi on of Aureobasidium spp. in Iran. Methods: 14 Aureobasidium isolates were recovered from vascular tissues of pome and stone fruit trees displaying decline sympt oms in orchards of West and East Azarbaijan provinces, Iran. Pure cultures were established by using a single spore technique. The identity of the isolates were determined using sequence data from ITS-rDNA region. Phylogenetic relationship among isolates was inferred based on sequence data from ITS-rDNA. Results: A megablast search analysis of ITS sequence data a t NCBI revealed the identity of Aureobasidium isolates as A. pullulans . A phylogeny inferred using sequence data from ITS region placed our isolates t ogether with the other A. pullulans var. pullulans in GenBank. Morphological and cultural characteris tics were in agreement with the description for A. pullulans var. pullulans . Conclusion: Our results represent new report on the occurrence of A. pullulans var. pullulans in Iran. As A. pullulans is known as rare etiologic agent of pheohyphomycosis, keratomycosis, septicemia, peritoneal sepsis, and dermatological infections in human, possible occurr ence and involvement of A. pullulans in human infections should be taken into account.

A case of prosthetic valve endocarditis caused by Streptococcus constellatus as a rare agent of endocarditis

We present a case of prosthetic valve endocarditis, which was caused by a rare etiological agent, Streptococcus constellatus. In our case, transesophageal echocardiography showed a large and broad abscess formation throughout the patient's aortic prosthetic valve ring and left atrium. Despite specific intravenous antibiotic therapy, the infection was uncontrollable, and the patient underwent surgical treatment. The pathogen rarely causes endocarditis, but it is known to have a strong potential to form abscess, and therefore its infection may be more serious than other Streptococcus species. Our case seems to be the first report of surgical treatment of PVE caused by S. constellatus. As in our case, transesophageal echocardiography is useful for the detection of vegetation and abscess, and early cardiac surgery may be a more appropriate therapeutic approach for endocarditis caused by S. constellatus.

Emphysematous Pyelonephritis Caused by Candida Parapsilosis: An Unknown Etiological Agent

Emphysematous pyelonephritis (EPN) a rare complication commonly seen in diabetic patients is a necrotising gas producing infection of the renal parenchyma and perinephric tissue predominantly caused by uropathogenic bacteria. Fungi have been rarely reported as the etiological agents, isolated from blood and/ or urine culture. We report a case of EPN caused by a rare etiological agent. A 60 year old diabetic female with no previous history of hospitalization presented to us with a short history of febrile illness associated with abdominal pain. Investigations revealed unilateral EPN “Wan type 1”. Patient was treated with systemic antifungal therapy as per culture sensitivity and it alone proved to be an effective treatment of this clinically difficult condition. Patient was discharged in a satisfactory clinical condition. A rare etiology should always be kept in mind while evaluating a case of EPN.

Aspergillus Nidulans: A Rare Etiological Agent of Eumycetoma

Mycetomas caused by true fungi are known as eumycetomas. Common causative species are Madurella, Leptosphaeria, Aspergillus, Exophiala, Fusarium, Acremonium, and Scedosporium. Aspergillus nidulans is a rare etiological agent, causing pale grain mycetoma. Only 7 cases of Aspergillus nidulans mycetoma have been reported in literature 1 from India (Rajasthan, 1985), 6 from Africa. We report this case of mycetoma because of the rarity of Aspergillus nidulans as an etiological agent. A 41 year old male shopkeeper presented with multiple painful nodules and discharging sinuses on the right upper extremity since 12 years. The affected limb was swollen and woody hard. There was a single enlarged (3 cm) firm, non-tender right axillary lymph node. There was no fever or other constitutional symptoms. The initial nodule had appeared on the distal right forearm 12 years earlier without preceding trauma. Gradually similar lesions had appeared extending up to the upper arm, breaking down discharging seropurulent material without grains. He had been treated empirically with oral antibiotics and had undergone surgical drainage of the nodules, with temporary relief. Right sided axillary lymph node dissection had been performed 10 years ago; however no organism had been detected. Routine blood investigations were normal. X-ray of the involved extremity showed soft tissue swelling without evidence of bony involvement. Histopathology from a recent discharging nodule showed a mixed inflammatory infiltrate of mononuclear cells, neutrophils, plasma cells and eosinophils along with marked thickening and fibrotic changes in the dermis. Culture from the nodules repeatedly grew Aspergillus nidulans. The patient is currently under treatment with itraconazole and potassium iodide since 1 month and, is responding well.

The neurotropic black yeast Exophiala dermatitidis has a possible origin in the tropical rain forest.

The black yeast Exophiala dermatitidis is known as a rare etiologic agent of neurotropic infections in humans, occurring particularly in East and Southeast Asia. In search of its natural habitat, a large sampling was undertaken in temperate as well as in tropical climates. Sampling sites were selected on the basis of the origins of previously isolated strains, and on the basis of physiological properties of the species, which also determined a selective isolation protocol. The species was absent from outdoor environments in the temperate climate, but present at low abundance in comparable habitats in the tropics. Positive outdoor sites particularly included faeces of frugivorous birds and bats, in urban as well as in natural areas. Tropical fruits were found E. dermatitidis positive at low incidence. Of the human-made environments sampled, railway ties contaminated by human faeces and oily debris in the tropics were massively positive, while the known abundance of the fungus in steam baths was confirmed. On the basis of the species' oligotrophy, thermotolerance, acidotolerance, moderate osmotolerance, melanization and capsular yeast cells a natural life cycle in association with frugivorous animals in foci in the tropical rain forest, involving passage of living cells through the intestinal tract was hypothesized. The human-dominated environment may have become contaminated by ingestion of wild berries carrying fungal propagules

Fatal pulmonary infection due to Rhizopusmicrosporus in a patient with sickle disease

Zycomycosis usually emerge in patients with severe immusupressed condition. Here, we report a fatal case of Rhizopus microsporus infection in a patient with sickle-cell disease and a transitory aplasia (five days). R. microsporus is a rare (about 2% of the cases) etiologic agent of zygomycosis with mainly digestive and cutaneous involvement. In our case the cumulative effect of several predisposing factors, all of mild intensity (aplasia, red blood cell transfusions, underlying pulmonary injury) may have play a role in the development of this infection.

Endocardite infecciosa causada por Eikenella corrodens

The HACEK microorganisms (Haemophilus spp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) account for 3% of the cases of endocarditis. They have the following similar clinical and microbiological properties: are Gram-negative bacilli, more easily isolated in aerobic media; their cultures require prolonged incubation time for growing (mean, 3.3 days); and may be considered part of normal flora of upper respiratory tract and oropharynx. The following characteristics have been identified in endocarditis caused by the HACEK microorganisms: insidious clinical findings; difficult diagnosis due to the fastidious nature of the microorganisms; and negative cultures. The Eikenella corrodens endocarditis was first described in 1972. That microorganism continues to be a rare etiological agent. We report the case of a female patient with native valve, who had Eikenella corrodens infective endocarditis.

Fatal Course of Pulmonary Absidia sp. Infection in a 4-Year-Old Girl Undergoing Treatment for Acute Lymphoblastic Leukemia

Absidia sp. is a rare etiologic agent responsible for infectious complications in immunosuppressed patients. The authors describe a 4-year-old girl with acute lymphoblastic leukemia complicated with pleuropneumonia caused by an Absidia infection during the induction of remission. A review of the published reports in current literature is included for comparison. To the authors' knowledge only six cases of primary pulmonary absidiomycosis have been published. Despite its uncommon pulmonary presentation, mucormycosis should be considered in patients with an immunosuppressing illness and positive risk factors and when a pulmonary lesion is not responding to appropriate antibiotic therapy.

Pseudotumor de pâncreas por corpo estranho

The diagnosis of pancreatic masses represents a great challenger for imaging studies. However the occurrence of pancreatic masses have been reported more frequently in the last years due to advances in imaging diagnostic methods. During the last decade, the surgical approach of pancreatic masses was limited to an attempt of establishing histological diagnosis, staging and evaluation of resection of these masses. Recently, the approach and staging of pancreatic masses was facilitated by sophisticated methods of diagnosis, especially, ultrasound, dynamic computerized tomography, magnetic resonance imaging (/RM), angiography, endoscopic retrograde cholangiopancreatography (CPRE), endoscopic ultrasound, laparoscopy and biochemical tumors markers. The present paper reports a case of a pancreatic mass due to foreign body in which the imaging study helped to determine out this rare etiological agent that has not been previouly described in literature.

Clinical significance of extraintestinal Hafnia alvei isolates from 61 patients and review of the literature.

Hafnia alvei is a gram-negative bacterium that is rarely isolated from human specimens and is rarely considered to be pathogenic. It has been associated with gastroenteritis, meningitis, bacteremia, pneumonia, nosocomial wound infections, endophthalmitis, and a buttock abscess. We studied 80 H. alvei isolates recovered from 61 patients within a period of 30 months. H. alvei was cultured from sites that included the respiratory tract (n = 38), the gastrointestinal tract (n = 16), and the urogenital tract (n = 12); the organism was found in blood cultures (n = 8), on central venous catheters (n = 3), and on the skin (n = 3). Only 25% of H. alvei isolates were recovered in pure cultures. Fifty-seven (93.4%) of the patients had an underlying illness. H. alvei proved to be the etiologic agent in two episodes of septicemia and in one episode of peritonitis and was probably responsible for septicemia in two other patients and pneumonia in one. All six of these patients recovered after receiving antibiotic treatment and/or standard surgical treatment, when needed. Three of these infections were nosocomial, and three were community acquired. Of the strains of H. alvei tested in our study, 100% were susceptible to netilmicin, ciprofloxacin, and imipenem; 92% were susceptible to piperacillin; 90% were susceptible to co-trimoxazole; and 88% were susceptible to ceftriaxone and ceftazidime. In this study, we found H. alvei to be a rare significant etiologic agent of nosocomial and community-acquired infections.