Staphylococcal Abscesses Research Articles

Multiple Cold Abscesses of a Chest Wall with Ribs Destruction in a Hemodialysis Patient

Cold abscess of the chest wall is an uncommon disease that is mainly caused by tuberculous infection. Staphylococcal cold abscesses of the chest wall are extremely rare and usually clinically occult, frequently leading to a delay in diagnosis and consequently severe infectious complications. We report an 88-year-old woman with end-stage renal disease, who presented with an exit site infection of a cuffed tunneled dialysis catheter caused by methicillin-resistant Staphylococcus aureus (MRSA). Despite the removal of the catheter and administration of antibiotics, she developed refractory MRSA bacteremia. Computed tomography (CT) of the chest revealed septic thrombophlebitis with metastatic cold abscesses of the chest wall and ribs destruction. Although CT-guided drainage and vancomycin therapy eliminated MRSA bacteremia, the chest wall abscesses did not resolve. Patients fitted with a central venous dialysis catheter are at risk of septic thrombophlebitis with metastatic cold abscesses of the chest wall that are resistant to antibiotic therapy. Early identification is based on serial blood cultures and prompt CT scans. Surgical management coupled with antibiotic therapy can eradicate the source of infection and improve patients’ outcomes.

Intraoral and maxillofacial abnormalities in patients with autosomal dominant hyper-IgE syndrome.

Autosomal dominant hyper-IgE syndrome (AD-HIES) is an inborn error of immunity (IEI) caused by a dominant-negative mutation in the signal transducer and activator of transcription 3 (STAT 3). This disease is characterized by chronic eczematoid dermatitis, recurrent staphylococcal skin abscesses, pneumonia, pneumatoceles, and extremely high serum IgE levels. Loss-of-function STAT3 mutations may also result in distinct non-immunologic features such as dental, facial, skeletal, and vascular abnormalities, central nervous system malformations and an increased risk for bone fractures. Prophylactic treatment of Candida infections and prophylactic antimicrobial therapy for staphylococcal skin infections and sinopulmonary infections are essential. An awareness of the oral and maxillofacial features of HIES may facilitate early diagnosis with genetic counselling and may improve future patient care. This study describes oral, dental, and maxillofacial manifestations in 14 patients with genetically defined AD-HIES. We also review the literature and propose recommendations for the complex care of patients with this rare primary immunodeficiency.

Dominant-negative signal transducer and activator of transcription (STAT)3 variants in adult patients: A single center experience.

Autosomal dominant hyper-IgE syndrome (AD-HIES) caused by dominant negative (DN) variants in the signal transducer and activator of transcription 3 gene (STAT3) is characterized by recurrent Staphylococcal abscesses, severe eczema, chronic mucocutaneous candidiasis (CMC), and non-immunological facial and skeletal features. To describe our experience with the diagnosis and treatment of adult patients with AD-HIES induced by DN-STAT3 variants. The medical records of adult patients (>18 years) treated at the Allergy and Clinical Immunology Clinic of Hadassah Medical Center, Jerusalem, Israel, were retrospectively analyzed. Immune and genetic workups were used to confirm diagnosis. Three adult patients (2 males; age 29-41 years) were diagnosed with DN-STAT3 variants. All patients had non-immunological features, including coarse faces and osteopenia. Serious bacterial infections were noted in all patients, including recurrent abscesses, recurrent pneumonia, and bronchiectasis. CMC and diffuse dermatophytosis were noted in two patients. Two patients had severe atopic dermatitis refractory to topical steroids and phototherapy. Immune workup revealed elevated IgE in three patients and eosinophilia in two patients. Whole exome sequencing revealed DN-STAT3 variants (c.1166C>T; p.Thr389Ile in two patients and c.1268G>A; p. Arg423Gln in one patient). Variants were located in DNA-binding domain (DBD) and did not hamper STAT3 phosphorylation Treatment included antimicrobial prophylaxis with trimethoprim/sulfamethoxazole (n=2) and amoxycillin-clavulanic acid (n=1), and anti-fungal treatment with fluconazole (n=2) and voriconazole (n=1). Two patients who had severe atopic dermatitis, were treated with dupilumab with complete resolution of their rash. No adverse responses were noted in the dupilumab-treated patients. Dupilumab can be used safely as a biotherapy for atopic dermatitis in these patients as it can effectively alleviate eczema-related symptoms. Immunologists and dermatologists treating AD-HIES adult patients should be aware of demodicosis as a possible manifestation. DN-STAT3 variants in DBD do not hamper STAT3 phosphorylation.

Oral observations of hyper immunoglobulin-e syndrome: A case report

The hyperimmunoglobulin E syndrome is a rare primary immunodeficiency, characterized by a triad of clinical signs including elevated serum IgE levels, recurrent staphylococcal skin abscesses and pneumonia. It can be autosomal dominant or recessive and is characterized by immunological and non-immunological abnormalities. Individuals with HIES share characteristic facial features, with many oral manifestations like retained deciduous teeth, missing permanent tooth buds, high arched palate, oral and gingival lesions, etc. This report aimed to describe a rare clinical case of a 13-year-old girl, that was referred to our paediatric dentistry department at the Mohammed V University Hospital in Rabat-Morocco, diagnosed with autosomal dominant hyperimmunoglobulin E syndrome with numerous oral manifestations.

FUNGAL NEUROLOGICAL SEQUELAE IN A HYPER IMMUNOGLOBULIN E SYNDROME FROM PESHAWAR, PAKISTAN: AN UNUSUAL PRESENTATION

Hyper IGE syndrome is one of the primary immunodeficiency syndromes characterized by the presence of abnormally raised serum IGE levels (2000 IU/ml) with defective humoral and cell mediated immunity presenting in infancy or early childhood. It is a rare disease with only about 200 cases reported in literature. Usually, it is diagnosed clinically and by raised serum IGE levels. Mostly, it presents with recurrent staphylococcal skin abscesses, sinopulmonary infections, and opportunistic mycotic infections due to the immunodeficient state. Rarely, the central nervous system is involved by this condition.This case study deals with an 11-year-old girl who was diagnosed as a case of hyper IGE syndrome. She presented with low GCS and focal neurological deficits which were attributed to aspergillus fumigatus infection spreading to the brain resulting in multiple abscesses and eventually to death of the patient despite treatment interventions. This case emphasizes the likelihood of dissemination of fungal infections to multiple organs including the brain and the potential role of early neuroimaging to detect such lesions. Moreover, it shows significance of serial imaging in admitted patients particularly with the onset of new and unusual neurological symptoms. With more extensive studies, we may be able to diagnose and treat such infections and their complications on time with better outcomes.

Chronic lymphocytic leukaemia‐associated insect bite‐like reaction responding to ibrutinib, an immunomodulatory Bruton tyrosine kinase inhibitor

A 57-year-old man, being managed with a watchful waiting strategy for Stage A chronic lymphocytic leukaemia (CLL), presented, eight years following diagnosis, with itchy spots involving the face, trunk and limbs (Figure 1a). Individual lesions came spontaneously and resolved completely over several weeks. Clinically, there were crops of 4 to 10 mm pruritic, acneiform papules that were not folliculocentric, some of which had a central area of erosion(Figure 1b). Despite trials of lymecycline, topical clindamycin and fucibet therapy, the striking skin eruption progressed in severity becoming widespread and complicated by recurrent secondary Staphylococcal abscesses and an episode of facial erysipelas.

Microbial aetiology of brain abscess in a UK cohort: Prominent role of Streptococcus intermedius

Brain abscess is an uncommon condition, but carries high mortality. Current treatment guidelines are based on limited data. Surveillance of clinical, radiological and microbiology data is important to inform patient stratification, interventions, and antimicrobial stewardship. We undertook a retrospective, observational study of patients with brain abscess, based on hospital coding, in a UK tertiary referral teaching hospital. We reviewed imaging data, laboratory microbiology, and antibiotic prescriptions. Over a 47 month period, we identified 47 adults with bacterial brain abscess (77% male, median age 47 years). Most of the abscesses were solitary frontal or parietal lesions. A microbiological diagnosis was secured in 39/47 (83%) of cases, among which the majority were of the Streptococcus milleri group (27/39; 69%), with a predominance of Streptococcus intermedius (19/27; 70%). Patients received a median of 6 weeks of intravenous antibiotics (most commonly ceftriaxone), with variable oral follow-on regimens. Ten patients (21%) died, up to 146 days after diagnosis. Mortality was significantly associated with increasing age, multiple abscesses, immunosuppression and the presence of an underlying cardiac anomaly. Our data suggest that there has been a shift away from staphylococcal brain abscesses, towards S. intermedius as a dominant pathogen. In our setting, empiric current first line therapy with ceftriaxone remains appropriate on microbiological grounds and narrower spectrum therapy may sometimes be justified. Mortality of this condition remains high among patients with comorbidity. Prospective studies are required to inform optimum dose, route and duration of antimicrobial therapy.

Factors causing oral and skin pathological features in the hyperimmunoglobulin E syndrome patient including the environmental component: a review of the literature and own experience.

The hyperimmunoglobulin E syndrome (HIES) is a rare multi-system disease with non-immunological as well as immunological abnormalities. The syndrome is characterized by a triad of the most distinctive symptoms, such as pneumonia with pneumatocele formation, recurring staphylococcal skin abscesses and a high serum concentration of IgE. Central mediators of immune responses such as STAT1 and STAT3 affect immune responses and contribute to changes of the skin microbiome which subsequently can amplify the defective immune response against microbial and fungal pathogens. Reactions related to an environmental factor, such as sun-induced skin changes, in individuals during long-term medication therapy have also been reported. The dermatological symptoms, oral status and other health problems of a hyperimmunoglobulin E syndrome paediatric patient are presented. HIES is of great importance to different professionals because sufferers require special preventive and therapeutic management from early infancy in order to avoid complications which can even prove to be life-saving for such patients.

IRF and STAT Transcription Factors - From Basic Biology to Roles in Infection, Protective Immunity, and Primary Immunodeficiencies.

The induction and action of type I interferon (IFN) is of fundamental importance in human immune defenses toward microbial pathogens, particularly viruses. Basic discoveries within the molecular and cellular signaling pathways regulating type I IFN induction and downstream actions have shown the essential role of the IFN regulatory factor (IRF) and the signal transducer and activator of transcription (STAT) families, respectively. However, the exact biological and immunological functions of these factors have been most clearly revealed through the study of inborn errors of immunity and the resultant infectious phenotypes in humans. The spectrum of human inborn errors of immunity caused by mutations in IRFs and STATs has proven very diverse. These diseases encompass herpes simplex encephalitis (HSE) and severe influenza in IRF3- and IRF7/IRF9 deficiency, respectively. They also include Mendelian susceptibility to mycobacterial infection (MSMD) in STAT1 deficiency, through disseminated measles infection associated with STAT2 deficiency, and finally staphylococcal abscesses and chronic mucocutaneous candidiasis (CMC) classically described with Hyper-IgE syndrome (HIES) in the case of STAT3 deficiency. More recently, increasing focus has been on aspects of autoimmunity and autoinflammation playing an important part in many primary immunodeficiency diseases (PID)s, as exemplified by STAT1 gain-of-function causing CMC and autoimmune thyroiditis, as well as a recently described autoinflammatory syndrome with hypogammaglobulinemia and lymphoproliferation as a result of STAT3 gain-of-function. Here I review the infectious, inflammatory, and autoimmune disorders arising from mutations in IRF and STAT transcription factors in humans, highlightning the underlying molecular mechanisms and immunopathogenesis as well as the clinical/therapeutic perspectives of these new insights.

Multiple neonatal staphylococcal cold abscesses in large skin folds: a benign neonatal skin infection

Multiple neonatal staphylococcal cold abscesses in large skin folds: a benign neonatal skin infection

Hyper IgE recurrent infection syndrome in South Asia: is there a different outcome?

BackgroundHyper IgE recurrent infection syndrome (HIES) is a rare immune deficiency, characterized by recurrent staphylococcal skin and lung abscesses, pneumonia and increased IgE levels. The majority of autosomal dominant HIES (AD HIGE) is due to hypomorphic mutations in the signal transducer and the activator of transcription 3 (STAT3) gene.Case presentationFive patients were diagnosed with HIES, based on the clinical criteria and scoring system developed at the National Institutes of Health (NIH), USA. The STAT3 gene was sequenced and previously described mutations were identified in all five patients. We compare the clinical features of our patients with those from Asia, Europe and the US.ConclusionEven though the number of patients is limited, there are some clinical differences in patients from South Asia compared to European and even East Asian patients. However, the mutations detected are located at hot spots seen in western and Asian patients with AD HIGE.

Development of a Computational Model of Abscess Formation.

In some bacterial infections, the immune system cannot eliminate the invading pathogen. In these cases, the invading pathogen is successful in establishing a favorable environment to survive and persist in the host organism. For example, S. aureus bacteria survive in organ tissues employing a set of mechanisms that work in a coordinated and highly regulated way allowing: (1) efficient impairment of the immune response; and (2) protection from the immune cells and molecules. S. aureus secretes several proteins including coagulases and toxins that drive abscess formation and persistence. Unless staphylococcal abscesses are surgically drained and treated with antibiotics, disseminated infection and septicemia produce a lethal outcome. Within this context, this paper develops a simple mathematical model of abscess formation incorporating characteristics that we judge important for an abscess to be formed. Our aim is to build a mathematical model that reproduces some characteristics and behaviors that are observed in the process of abscess formation.

Dietary Manganese Promotes Staphylococcal Infection of the Heart

Diet, and specifically dietary metals, can modify the risk of infection. However, the mechanisms by which manganese (Mn), a common dietary supplement, alters infection remain unexplored. We report that dietary Mn levels dictate the outcome of systemic infections caused by Staphylococcus aureus, a leading cause of bacterial endocarditis. Mice fed a high Mn diet display alterations in Mn levels and localization within infected tissues, and S.aureus virulence and infection of the heart are enhanced. Although the canonical mammalian Mn-sequestering protein calprotectin surrounds staphylococcal heart abscesses, calprotectin is not released into the abscess nidus and does not limit Mn in this organ.Consequently, excess Mn is bioavailable to S.aureus in the heart. Bioavailable Mn is utilized by S.aureus to detoxify reactive oxygen species and protect against neutrophil killing, enhancing fitness within the heart. Therefore, a single dietary modification overwhelms vital host antimicrobial strategies, leading to fatal staphylococcal infection.

A Prescription for Resistance: Management of Staphylococcal Skin Abscesses by General Practitioners in Australia.

Objectives: We investigated the management of staphylococcal abscesses (boils) by general practitioners (GPs) in the context of rising antibiotic resistance in community strains of Staphylococcus aureus.Design, Setting, Participants: We analyzed patient-reported management of 66 cases of uncomplicated skin abscesses from the frequency matched methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) Community-Onset Staphylococcus aureus Household Cohort (COSAHC) study (Melbourne, Australia, 2008–2012). Susceptibilities in all cases were known: 50/66 abscesses were caused by MRSA. In order to investigate GP-reported management of staphylococcal abscesses, we surveyed a random subset of GPs, from the COSAHC study (41), and of GPs (39) who used the same community-based pathology service (December 2011–May 2012).Main outcome measures: Patient outcomes, antibiotics prescribed, antibiotic resistance profiles of infecting strains, rates of incision and drainage (I&D), and attitudes to ordering microbiological cultures.Results: MRSA was three times more likely to be cultured from an abscess than MSSA. Patient-reported management revealed 100% were prescribed antibiotics and only 60.6% had I&D. Of those 85% who remembered their prescription(s), 81% of MRSA cases and 23% of MSSA cases initially received inactive antibiotics. Repeat GP visits where antibiotics were changed occurred in 45 MRSA and 7 MSSA cases, although at least 33% of subsequent prescriptions were inactive for the MRSA infections.Patients treated with I&D and antibiotics did no better than those treated with only I&D, regardless of the antibiotic activity. In the GP surveys, 89% reported I&D, with or without antibiotics, to be their preferred management. Only 29.9% of GPs would routinely swab abscesses.Conclusion: The recommended management of uncomplicated Staphylococcus abscesses is I&D without antibiotics to reduce exposure to unnecessary antibiotics. In our study, I&D was performed in only 60.6% of 66 patients, and antibiotics were always prescribed. The prescribed antibiotics were frequently inactive and often changed, and did not appear to affect patient recovery. Our results show that community GPs can confidently reduce their use of antibiotics for patients with skin abscesses and should be aware that MRSA is a much more common in this type of infection.

Optimizing antimicrobial therapy in children

Management of common infections and optimal use of antimicrobial agents are presented, highlighting new evidence from the medical literature that enlightens practice. Primary therapy of staphylococcal skin abscesses is drainage. Patients who have a large abscess (>5cm), cellulitis or mixed abscess-cellulitis likely would benefit from additional antibiotic therapy. When choosing an antibiotic for outpatient management, the patient, pathogen and invitro drug susceptibility as well as tolerability, bioavailability and safety characteristics of antibiotics should be considered. Management of recurrent staphylococcal skin and soft tissue infections is vexing. Focus is best placed on reducing density of the organism on the patient's skin and in the environment, and optimizing a healthy skin barrier. With attention to adherence and optimal dosing, acute uncomplicated osteomyelitis can be managed with early transition from parenteral to oral therapy and with a 3-4 week total course of therapy. Doxycycline should be prescribed when indicated for a child of any age. Its use is not associated with dental staining. Azithromycin should be prescribed for infants when indicated, whilst being alert to an associated ≥2-fold excess risk of pyloric stenosis with use under 6 weeks of age. Beyond the neonatal period, acyclovir is more safely dosed by body surface area (not to exceed 500mg/m(2)/dose) than by weight. In addition to the concern of antimicrobial resistance, unnecessary use of antibiotics should be avoided because of potential later metabolic effects, thought to be due to perturbation of the host's microbiome.

Liver abscess in a boy with hyper IgE syndrome

Hyper immunoglobulin-E syndrome is a rare primary immunodeficiency disease, characterized by the classical triad of recurrent staphylococcal skin abscesses, pneumonia with pneumatocele formation, and elevated levels of serum IgE, usually over 2000 IU/mL. Chronic granulomatous disease, hyper IgE, and complement deficiencies are immunopathologies known to be associated with liver abscesses. We present a 2 ½-year-old boy with liver abscess and associated hyper IgE.

Hyper-IgE syndrome: Varied infectious presentations in four cases and review of literature

The hyper-IgE syndrome (HIES) is a relatively rare primary immunodeficiency syndrome characterized by recurrent severe staphylococcal abscesses of skin, lungs, and other viscera as well as sinusitis, mastoiditis, eczema, markedly elevated levels of serum IgE and distinctive musculoskeletal features. High index of suspicion is required in children who present with recurrent pyogenic infections (especially staphylococcal) to diagnose this rare condition. We report four cases of HIES with different infectious presentations in whom diagnosis was established clinically and supported by elevated IgE levels and hy- per-IgE score. The management includes use of intravenous antibiotics and early surgical intervention (in whom required) which resulted in resolution of symptoms in all patients. These patients were discharged on antibiotic prophylaxis and are well on follow-up.

Hyperimunoglobuline e syndrome: case report

Background Hyperimmunoglobulin E syndrome (HIES) is a rare desease caused by a primary complex immunodeficiency, with IgE serum levels over 2,000U/mL. The syndrome is characterized by the following triad: 1) recurrent staphylococcal abscesses, 2) recurrent airway infections; 3) elevated serum IgE concentration. Our pacient presented signs that are compatible with HIES in distinct moments of his life – microabscesses associated with eczema at adolescence, respiratory infections from childhood until present moment and seric IgE level of over 2,000 in recent dosage.

Evidence for increasing severity of community-onset boils and abscesses in UK General Practice.

In England, hospital admissions for severe staphylococcal boils and abscesses trebled between 1989 and 2004. We investigated this trend using routine data from primary and secondary care. We used The Health Improvement Network (THIN), a large primary-care database and national data on hospital admissions from Hospital Episode Statistics (HES). Time trends in the incidence of primary-care consultations for boils and abscesses were estimated for 1995-2010. HES data were used to calculate age-standardized hospital admission rates for boils, abscesses and cellulitis. The incidence of boil or abscess was 450 [95% confidence interval (CI) 447-452] per 100 000 person-years and increased slightly over the study period (incidence rate ratio 1·005, 95% CI 1·004-1·007). The rate of repeat consultation for a boil or abscess increased from 66 (95% CI 59-73) per 100 000 person-years in 1995 to peak at 97 (95% CI 94-101) per 100 000 person-years in 2006, remaining stable thereafter. Hospital admissions for abscesses, carbuncles, furuncles and cellulitis almost doubled, from 123 admissions per 100 000 in 1998/1999 to 236 admissions per 100 000 in 2010/2011. Rising hospitalization and recurrence rates set against a background of stable community incidence suggests increased disease severity. Patients may be experiencing more severe and recurrent staphylococcal skin disease with limited treatment options.

Right-sided endocarditis in an adult patient with hyperimmunoglobulin-E syndrome successfully treated with high-dose daptomycin

Hyperimmunoglobulin-E syndrome is a syndrome of recurrent staphylococcal abscesses, sinopulmonary infections, and severe eczema, which is characterized by increased IgE and specific facial features. Herein, we describe a patient with hyperimmunoglobulin-E syndrome and right-sided endocarditis due to Staphylococcus aureus, which was successfully treated with high-dose daptomycin.