Streptococcus Milleri Research Articles

Identification of oral bacteria by 16S rRNA gene analysis in elderly persons requiring nursing care

After incubation of saliva from 58 semi-bedridden elderly persons, the cultures were identified based on the 16S rRNA gene base sequence to compare the identification by the conventional culture method. As a result, the 16S rRNA gene base sequence of 198 strains identified by the culture method showed 98.5% or more homology in some of the Human Oral Microbiome database, and the identification of bacterial species and genus was possible. When an organism identified by the 16S rRNA gene sequencing method was compared with that by the culture method, the concordance rates were 54.5% at the genus level and 35.9% at the species level. Streptococcus mitis strains most frequently isolated from saliva that were identified by the culture method were identified as the same species by the 16S rRNA gene sequencing method (32/35), and all the 11 Streptococcus salivarius strains identified by the culture method were identified as the same species by the 16S rRNA gene sequencing method. All the strains identified as Streptococcus anginosus group by the culture method and 8 of the 9 strains identified as Prevotella species by the culture method were identified as the same group and genus by the 16S rRNA gene sequencing method. When an oral microbial flora test with saliva samples from elderly persons is performed, the 16S rRNA gene sequence identification enables us to identify major indigenous bacteria and pathogenic bacteria and is considered useful as a means of supplementing the conventional culture method.

Precipitating factors in the pathogenesis of peritonsillar abscess and bacteriological significance of the Streptococcus milleri group

Peritonsillar abscess (PTA) is conventionally considered to be a complication of acute tonsillitis, but no pathogenical association has been demonstrated. To investigate the precipitating factors in the pathogenesis of PTA, the clinical status of 117 patients with PTA and 78 patients with peritonsillar cellulitis (PC) were reviewed, comparing them with 188 cases of acute tonsillitis as a control group. The period between the onset of symptoms and the date of starting hospitalized medication was 4 to 5 days in all the three groups, with no significant differences. Higher prevalence of smoking habit was noted in the PTA group (odds ratio, 1.92; 95% confidence interval, 1.17-3.16). Bacteriological culture revealed that 55 of 67 aerobic isolates were Streptococcus subspecies, with the Streptococcus milleri group (SMG) as the most common (20 isolates). Twenty-three anaerobic species were isolated. Only 51% of the patients with neither the SMG nor anaerobic bacteria were smokers, whereas 90% of the patients with both the SMG and anaerobic bacteria were smokers. We hypothesize that delay or failure to receive medical care do not contribute to the pathogenesis of PTA or PC, and that smoking is positively correlated with the occurrence of PTA, as well as the bacteriological character.

Streptococcus milleri Group Pleuropulmonary Infection in Children

Streptococcus milleri group streptococci have recently been increasingly recognized as important pulmonary pathogens, but their imaging features have not been well documented in children. We have recently observed a number of cases of this infection among pediatric patients at our tertiary care, children's hospital. Our purpose was to investigate the computed tomographic (CT) findings and clinical features of S. milleri group pleuropulmonary infection in children. We used our hospital information system to identify all consecutive pediatric patients (<18 years of age) who had both a microbiologically proven S. milleri group infection and a chest CT scan between December 1996 and May 2009. Each scan was systemically reviewed by 2 pediatric radiologists for pleural and lung parenchymal abnormalities. Pleural effusions were classified as either simple or complex and correlated with results of pleural fluid analysis. Computed tomographic findings were compared with chest radiographic findings in the subset of patients who underwent radiography within 24 hours of CT. Microbiological data, risk factors, immune status, patient management, and clinical outcome were systematically reviewed. The final study cohort consisted of 15 children (6 boys and 9 girls), ranging in age from 4.2 years to 17.7 years (mean, 10.8 years). All patients were immunocompetent without recognized risk factors for this infection. Thirteen pleural effusions were identified in 10 (67%) of the 15 patients, including 10 complex and 3 simple pleural effusions. All complex effusions at CT were consistent with empyemas by pleural fluid analysis. Lung parenchymal abnormalities were identified in 7 (47%) of the 15 patients, including lung abscess in 4 patients, consolidation in 2, and multiple bilateral pulmonary nodules and lung abscesses in 1. In the subset of 7 patients with comparison radiographs, radiographic and CT findings were concordant for the detection of lung abnormalities, except one case in which consolidation was diagnosed on chest radiography, whereas CT scan showed a lung abscess. Radiographs detected all 4 complex pleural effusions seen on CT scan, although it was not possible to characterize the effusions as simple or complex on the radiographs. Interventional procedures were required in all 15 patients, most commonly thoracentesis (n = 11) and chest tube drainage (n = 9). In children with S. milleri group pleuropulmonary infection, CT often demonstrates complex pleural effusions and lung abscesses, which usually require interventional procedures for effective treatment.

Meningitis bacteriana asociada a analgesia y anestesia espinal

Introduction Although rare, infectious complications from spinal analgesia and anaesthesia (SA) can have serious morbidity and mortality. This study describes the clinical features and outcome of SA-associated bacterial meningitis in adults seen in a hospital over a 25 yearperiod. Methods We reviewed the charts of all patients (aged ≥14 years) diagnosed with SA-associated bacterial meningitis between 1982 and 2006. Results Eight cases of SA-associated bacterial meningitis were diagnosed (3.3% bacterial meningitis), with a median age of 62 years (range, 35-80). SA procedures were: morphine infusion pumps with epidural (3 cases) or intrathecal (3) catheters, spinal cord stimulation with epidural neuroelectrode (1), and epidural anesthesia (1). Site of spinal insertion was: cervical (2 cases), thoracic (3), and lumbar (3). The median time to onset of meningitis was 26 days (range, 7-101) after AE. The most common clinical findings were fever (8 cases, 100%), headache (7 cases, 87.5%), and neck stiffness (4 cases, 50%). CSF abnormalities were pleocytosis (8 cases, 100%), elevated protein level (8 cases, 100%), and hypoglycorrhachia (5 cases, 62.5%). The causative organisms were Staphylococcus epidermidis (2 cases), Staphylococcus aureus (2), Enterococcus faecalis (1), Streptococcus milleri (1), and S. epidermidis and Pseudomonas fluorescens (1); one patient had a negative CSF culture. Treatment included antibiotics and to remove the analgesia device in all patients. There was one death (12.5%). Conclusions SA is a rare predisposing condition to bacterial meningitis but, due to the seriousness of the infection, it should be considered in the differential diagnosis for any patient who develops fever or headache in this setting.

Hepatic Arteriovenous Malformations from Hereditary Hemorrhagic Telangiectasia: Treatment with Liver Transplantation

A 47-year-old handyman presented to the emergency department with worsening exertional dyspnea and persistent lassitude at rest for 2 weeks. He had experienced moderate unremitting epigastric pain over the preceding months requiring narcotics, as well as intermittent jaundice and low-grade fever. His epigastric pain frequently worsened after meals, resulting in anorexia and weight loss, but also was present at rest and radiated through to his back. He denied epistaxis, hemoptysis, and gingival or gastrointestinal bleeding. Although he admitted binge drinking of alcohol in the past, without obvious social or medical complications, he had been sober for several years. He continued to chew tobacco daily. His mother reportedly had alcoholic liver disease, and his two children were healthy. Physical examination revealed a slender man with a fever of 102 F but in no obvious distress. His conjunctivae were anicteric, and his oropharynx did not reveal any lesions or bleeding. His breath sounds were normal. Cardiac examination revealed tachycardia, a 3/6 systolic ejection murmur best heard over the apex, and jugular venous distention. His abdomen was soft and not distended, but tender over the epigastrium, where a loud bruit was also present. The liver and spleen were both enlarged. No jaundice, palmar erythema, or rashes were present. The patient was fully alert and oriented, without asterixis. Comprehensive laboratory studies were significant for a normocytic anemia with a hematocrit of 35%, mild thrombocytopenia with a platelet count of 142,000/mm, and abnormal liver tests with a total bilirubin of 3.7 mg/dl, aspartate aminotransferase (AST) 43 U/l, alanine aminotransferase (ALT) 55 U/l, and alkaline phosphatase of 579 U/l. His international normalized ratio for prothrombin time (INR) was normal at 1.1. B-type natriuretic peptide was elevated at 1,067 pg/ml. Blood cultures grew Streptococcus anginosus (a member of the Streptococcus milleri family). Echocardiogram revealed moderate left ventricular enlargement with normal left ventricular systolic function, and mild right ventricular enlargement with mildly decreased right ventricular systolic function. There was trace aortic regurgitation and mild mitral regurgitation, with increased aortic flow velocity with a mean gradient of 19 mmHg. There was also mild tricuspid regurgitation with an estimated right ventricular systolic pressure of 51 mmHg. No other valvular lesions or vegetations were found. Abdominal computed tomography (CT) revealed diffuse angiomatous tissue within the liver, early opacification of all hepatic veins, and low-attenuation tissue in segment 7 of the liver likely representing biliary necrosis (Fig. 1). Abdominal magnetic resonance imaging (MRI) confirmed the diffuse heterogeneous enhancement of the liver and presence of multiple arteriovenous malformations (Fig. 2). Angiography was performed, and the initial aortogram revealed a hugely dilated celiac artery and replaced left hepatic and common hepatic arteries (Fig. 3). The proper M. Lee (&) T. J. Daugherty Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, 300 Pasteur Drive, Alway Building, M211, Stanford, CA 94305-5187, USA e-mail: maxlee@stanford.edu

An analysis of clinical risk factors of deep neck infection

Objectives To clarify the clinical risk factors that aggravate deep neck infection. Patients and methods Sixty-five patients with deep neck infection (abscess or cellulitis), 42 males and 23 females, who were treated at the ear, nose, and throat department in Iwaki Kyoritsu General Hospital in the past 10 years, were retrospectively reviewed. Cases of inflammation of the upper airway including the oral cavity, laryngopharynx, palate tonsil and salivary gland, and cases of lymphadenitis were investigated. These patients were divided into five localized types and one wide range type according to the abscess locations as follows: oral cavity floor type, upper deep cervical type, submandibular type, submental type, retropharyngeal type, and wide range type. Results Seventeen of the 65 patients had diabetes, and significantly more diabetics had the wide range type than the localized type ( P < 0.05, Fisher's test). Diabetes complication was more often seen in the upper deep cervical type among patients aged 61 years or older, and in the wide range type among males aged 41 years or older and elderly women aged 61 years or older. No patients with odontogenic infection or sialolithiasis had associated diabetes mellitus. Two cases developed mediastinitis, and one was caused by retrotonsillar abscess and needed thoracic drainage. More than half of the wide range type cases and more than a quarter of each of the localized type cases except the upper deep cervical type also had laryngeal edema, and eight of them needed emergency tracheotomy. Thirteen of the 40 cases had bacteria belonging to the Streptococcus milleri group (SMG), and all were detected in patients who underwent surgical drainage. Four of the 13 cases where SMG was detected showed drug resistance to some sorts of antibiotics. Conclusion Oral disorders can develop deep neck infection independently of the presence of diabetes mellitus, compared with other causes. The presence of diabetes mellitus is associated with deep neck infection, aggravating parotitis and wide spread of inflammation. Retrotonsillar abscess often spreads to the retropharyngeal and parapharyngeal spaces, causing mediastinitis, so caution is necessary. Infection due to SMG tends to form abscess independently of diabetes mellitus. Since more than half of the wide range type and more than a quarter of each of the localized types except the upper deep cervical type were associated with laryngeal edema, airway management should be considered.

Abdominal abscesses with Streptococcus milleri group after laparoscopic chromopertubation

Sir, Laparoscopic chromopertubation is a basic and safe lement in infertility evaluation (1). Complications of this procedure are uncommon. Vaginal bleeding, mild pelvic pain and vasovagal response have been described. Severe complications such as pulmonary edema, anaphylactic shock and methemoglobinemia are rare (2-4). We wish to call attention to a patient with multiple abdominal abscesses after laparoscopic chromopertubation. A 22-year-old nulligravida underwent laparoscopic chromopertubation as part of an evaluation for primary infertility. Her medical history revealed polycystic ovarian syndrome and morbid obesity. The chromopertubation was uncomplicated and tubal patency was established. Two days after the procedure the patient experienced abdominal pain and fever. A week after chromopertubation she was presented at the Emergency Department with clinical signs of peritonitis. Laboratory data showed leukocytes of 26.3 × 109/L and C-reactive protein of 341 mg/L. Computed tomogram of the abdomen showed an abscess measuring 20 × 10 × 5 cm in the lower abdomen. Laparotomy with drainage of the abscess was performed. Postoperatively she was admitted to the Intensive Care Unit (ICU) with septic shock. The patient was initially treated with cefuroxime (1.5 g three times a day) and metronidazole (500 mg three times a day) and after 2 days piperacillin/tazobactam (4 g/0.5 g three times a day). Cultures of drained material grew Streptococcus milleri group. Pre-procedure cultures revealed no potentially pathogenic flora. The patient deteriorated with respiratory failure. She was transferred to our ICU. A second laparotomy revealed diffuse peritonitis with multiple abscesses which were drained. Despite adequate antibiotic therapy the patient continued to have fever. CT scan revealed another right paracolic abscess that was percutaneously drained. After 22 days the patient was discharged to the surgical ward. Post-procedural infection after chromopertubation is rare. We did not find previous reports. In the case presented here, the reason for the intra-abdominal abscesses most likely was the introduction of Streptococcus milleri in the abdomen via the transcervical injection of methylene blue since Streptococcus milleri is a commensal of the urogenital tract. Introduction via the laparoscopic route is less likely. The Streptococcus milleri group is a heterogeneous complex of streptococci and consists of the species Streptococcus intermedius, Streptococcus constellatus and Streptococcus anginosus. These organisms are not only commensals of the oral cavity, genitourinary tract and gastrointestinal tract, but also notorious causes of pyogenic, invasive infections. Patients with underlying medical conditions, such as cirrhosis, diabetes mellitus and malignancies are predisposed to invasive infections with Streptococcus milleri. Most infections with Streptococcus milleri group organisms respond well to combined surgical and antibiotic treatment but may require multiple procedures and the course can be protracted (5). Although this complication seems to be rare, awareness is of utmost importance because immediate surgical or percutaneous intervention and antibiotic treatment can mitigate the course of the disease and can even be life saving. Patient instruction might have prevented delay in this case.

If You See Me, Look Deeper

If you see me, look deeper. Streptococcus constellatus is a member of the Streptococcus anginosus group, with a known propensity for invasive pyogenic infections, and as this association is well known, one should always look for occult pyogenic or suppurative collections in a patient with S. constellatus bacteremia. A 62-year-old diabetic man with history of traumatic brain injury and dementia was admitted to the hospital with a fever (104°F), tachypnea, and leukocytosis and normal liver function test results were found to have S. constellatus bacteremia. As the nature of this organism is known, although he had no localizing foci of infection and was asymptomatic with normal liver function test results, further workup was done which revealed occult abscesses in his gall bladder.

A curious case of convulsion

In July, 2007, an afebrile 61-year-old man presented with a fi rst episode of a generalised convulsion. Medical history included previous smoking and haemoptysis in the previous few weeks. Laboratory blood tests, viral serology, and blood cultures were unremarkable, except for a C-reactive protein of 35 mg/L (normal <5) and leucocytes of 17×109/L (3-9×109/L). MRI of the brain showed multiple bihemispherical foci, ring-enhanced with perifocal oedema, without midline shift (fi gure A). An opacity was seen on the chest radiograph, so CT was done, which showed a mass in the upper lobe of the right lung that was centrally liquefi ed, and modestly enlarged mediastinal lymph nodes. Dexamethasone and levetiracetam were given to prevent brain swelling and convulsions, and antibiotic treatment was initiated. Our patient improved over 3 days. We suspected he had lung cancer with metastases. At the meeting of the interdisciplinary tumour board, the diff erential diagnosis of cerebral abscesses was discussed, but considered unlikely because of absence of clear indicators of infection in clinical, laboratory, and radiological examination. The subtle signs of infection were attributed to superinfection of pulmonary malignancy. Chemotherapy and cerebral radiotherapy were planned. Surprisingly, bronchoalveolar lavage (BAL) and transbronchial and CTguided transthoracic biopsies failed to confi rm malignancy. Cytologically, BAL fl uid yielded druses structures surrounded by neutrophils, suggestive of actinomyces (fi gure B). Nonetheless, lobectomy was done because the lobe was completely destroyed and non-functional and also histological tissue examination was necessary for defi nitive exclusion of malignancy, potentially hidden by infection. Histological examination of the resected tissue showed an abscessing infl ammation with caverns. Malignancy was ruled out. No microorganisms were detected in staining or cultures. Unexpectedly, panbacterial PCR showed Streptococcus intermedius, but no actinomyces. Restaining of preoperative BAL fl uid showed gram-positive cocci in colonies or chains within the actinomyces-like druses (fi gure C). No fi lamentous structures characteristic of actinomyces were seen. It became apparent that a S intermedius lobar pneumonia was the primary site of infection which had subsequently spread to the brain. Our patient was discharged in good condition 8 days after surgery under appropriate antibiotic and antiepileptic treatment. Antibiotics were continued for 1 year. At fi nal follow-up in March, 2010, the patient had fully recovered and the cerebral lesions had completely regressed aside from a few scarred residues. S intermedius, S constellatus, and S anginosus form the Streptococcus milleri group (SMG). Purulent infections, often abscessing, subacute presentation, and absence of bacteraemia, are characteristic of SMG, and each species has certain sites that it characteristically infects. Typically, S intermedius aff ects brain or liver, whereas thoracic infections, in particular lobar pneumonia, are rare. Identifi cation of SMG is challenging; confusingly, in our case S intermedius had formed structures reminiscent of actinomyces druses. Clinical presentation of brain abscesses includes headache, fever, vomiting, mental change, focal neurological defi cit, and, seizures; SMG species, primarily S intermedius, are the most common pathogens. Brain abscesses and SMG infection tend to be associated with immunodefi ciency, but SMG species are increasingly recognised as important pathogens in previously healthy individuals. Radiological diff erentiation from neoplastic brain masses is diffi cult and can be aided by magnetic resonance spectroscopy. Management by surgery and/or antibiotics depends on abscess number, size, location, and mass eff ects. Even with a seemingly clear working diagnosis of malignancy with brain involvement, a thorough work-up must carefully distinguish neoplastic from infectious disease.

Macrolide and Clindamycin Resistance inStreptococcus milleriGroup Isolates from the Airways of Cystic Fibrosis Patients

Organisms belonging to the Streptococcus milleri group (SMG) are known for their role in pyogenic infections but have recently been implicated as etiological agents of pulmonary exacerbation in adult patients with cystic fibrosis (CF). The prolonged exposure of CF patients to antibiotics prompted us to investigate the susceptibility profiles of 118 SMG isolates from the airways of CF patients to 12 antibiotics compared to 43 SMG isolates from patients with invasive infections. We found that approximately 60% of all isolates failed to grow using the standard medium for disc diffusion, Mueller-Hinton blood agar (MHBA), so we explored the usefulness of brain heart infusion (BHI) agar for susceptibility testing. Zone-of-inhibition comparisons between BHI and MHBA showed strong correlations for six antibiotics, and interpretations were similar for both medium types. For ceftriaxone and cefepime, both groups of isolates were highly susceptible. Tetracycline resistance levels were comparable between the two groups (22% in CF isolates and 17.4% in invasive isolates). However, more than half of the CF isolates were not susceptible to azithromycin, erythromycin, and clindamycin, compared to 11%, 13%, and 6.5% of invasive isolates, respectively. There were 5-fold and 8-fold increased risks of azithromycin and clindamycin resistance, respectively, for the isolates from the airways of CF patients relative to the invasive isolates. Macrolide resistance was strongly linked to chronic azithromycin therapy in CF patients. This study shows that BHI agar is a suitable alternative for antimicrobial susceptibility testing for the SMG and that SMG isolates from the airways of CF patients are more resistant to macrolides and clindamycin than strains isolated from patients with invasive infections.

Necrotizing fasciitis following drainage of Streptococcus milleri empyema

Streptococcus milleri (SM) is a heterogeneous group of Streptococci, which is a recognized cause of purulent infections of the mediastinal and pleural spaces. These infections are notoriously resistant and require aggressive surgical management. We present our experience with a 60-year-old patient, who developed necrotizing fasciitis of the chest wall after initial bedside drainage of a SM empyema. He required extensive debridement with significant soft tissue loss and subsequent latissimus dorsi flap reconstruction to cover the defect.

Bacteriological and clinical studies in 23 cases of thoracic empyema--the role of oral streptococci and anaerobes

The bacteriology of empyema fluid and the clinical background of 23 cases from July 1987 through July 1992 were studied. Nineteen cases were male and 4 female, with a mean age of 59.6 years (range; 33 to 84 y.o.). There were 15 cases of community-acquired infection and 8 of nosocomial infection. Acute pneumonia and/or lung abscess developed into empyema in 19 cases. Sixteen cases had associated predisposing conditions, such as diabetes, chronic bronchitis, disorders with dysphagia, and excess alcohol intake. Forty-one strains were isolated from empyema in 22 cases. The predominant organisms, in order of prevalence, were "Streptococcus milleri" group (11 strains), Peptostreptococcus spp. (6), Prevotella spp. (6), Fusobacterium spp. (5) and other viridans streptococci (3). The majority of streptococcal infections, which were primarily caused by "S. milleri" group, were mixed with anaerobes and/or aerobes/facultatives. These results demonstrate that oral streptococci, especially "S. milleri" group, and anaerobes play a significant role as pathogens in empyema.

Development of Real-Time PCR Assays for Detection of the Streptococcus milleri Group from Cystic Fibrosis Clinical Specimens by Targeting the cpn60 and 16S rRNA Genes

Cystic fibrosis (CF) is a multiorgan disease, with the majority of mortalities resulting from pulmonary failure due to repeated pulmonary exacerbations. Recently, members of the Streptococcus anginosus group (S. anginosus, S. constellatus, and S. intermedius), herein referred to as the "Streptococcus milleri group" (SMG) have been implicated as important etiological pathogens contributing to pulmonary exacerbations in CF patients. This is partly due to better microbiological detection of the SMG species through the development of a novel specific medium termed "McKay agar." McKay agar demonstrated that SMG has been an underreported respiratory pathogen contributing to lung exacerbations. Our aim was to develop a real-time PCR assay to expedite the detection of SMG within diagnostic samples. The cpn60 gene was chosen as a target, with all three members amplified using a single hybridization probe set. SMG strain analysis showed that speciation based on melting curve analysis allowed for the majority of the S. constellatus (96%), S. intermedius (94%), and S. anginosus (60%) strains to be correctly identified. To increase specificity for S. anginosus, two 16S rRNA real-time PCR assays were developed targeting the 16S rRNA gene. The 16s_SA assay is specific for S. anginosus (100%), while the 16s_SCI assay is specific for S. constellatus and S. intermedius (100%). These assays can detect <10 genome equivalents in pure culture and >10(4) genome equivalents in sputum samples, making this a great tool for assessment of the presence of SMG in complex polymicrobial samples. Novel molecular methods were developed providing detection ability for SMG, an emerging opportunistic pathogen.

McKay agar enables routine quantification of the ‘Streptococcus milleri’ group in cystic fibrosis patients

The 'Streptococcus milleri' group (SMG) has recently been recognized as a contributor to bronchopulmonary disease in cystic fibrosis (CF). Routine detection and quantification is limited by current CF microbiology protocols. McKay agar was developed previously for the semi-selective isolation of this group. Here, McKay agar was validated against a panel of clinical SMG isolates, which revealed improved SMG recovery compared with Columbia blood agar. The effectiveness of this medium was evaluated by appending it to the standard CF sputum microbiology protocols in a clinical laboratory for a 6-month period. All unique colony types were isolated and identified by 16S rRNA gene sequencing. Whilst a wide variety of organisms were isolated, members of the SMG were the most prevalent bacteria cultured, and McKay agar allowed routine quantification of the SMG from 10(3) to >10(8) c.f.u. ml(-1) directly from sputum. All members of the SMG were detected [Streptococcus anginosus (40.7 %), Streptococcus intermedius (34.3 %) and Streptococcus constellatus (25 %)] with an overall prevalence rate of 40.6 % in our adult CF population. Without exception, samples where SMG isolates were cultured at 10(7) c.f.u. ml(-1) or greater were associated with pulmonary exacerbations. This study demonstrates that McKay agar can be used routinely to quantify the SMG from complex clinical samples.

A Rare Cause for Alarm

A Rare Cause for Alarm

Bacterial meningitis secondary to spinal analgesia and anaesthesia

Introduction Although rare, infectious complications from spinal analgesia and anaesthesia (SA) can have serious morbidity and mortality. This study describes the clinical features and outcome of SA-associated bacterial meningitis in adults seen in a hospital over a 25 yearperiod. Methods We reviewed the charts of all patients (aged ≥14 years) diagnosed with SA-associated bacterial meningitis between 1982 and 2006. Results Eight cases of SA-associated bacterial meningitis were diagnosed (3.3% bacterial meningitis), with a median age of 62 years (range, 35–80). SA procedures were: morphine infusion pumps with epidural (3 cases) or intrathecal (3) catheters, spinal cord stimulation with epidural neuroelectrode (1), and epidural anesthesia (1). Site of spinal insertion was: cervical (2 cases), thoracic (3), and lumbar (3). The median time to onset of meningitis was 26 days (range, 7–101) after AE. The most common clinical findings were fever (8 cases, 100%), headache (7 cases, 87.5%), and neck stiffness (4 cases, 50%). CSF abnormalities were pleocytosis (8 cases, 100%), elevated protein level (8 cases, 100%), and hypoglycorrhachia (5 cases, 62.5%). The causative organisms were Staphylococcus epidermidis (2 cases), Staphylococcus aureus (2), Enterococcus faecalis (1), Streptococcus milleri (1), and S. epidermidis and Pseudomonas fluorescens (1); one patient had a negative CSF culture. Treatment included antibiotics and to remove the analgesia device in all patients. There was one death (12.5%). Conclusions SA is a rare predisposing condition to bacterial meningitis but, due to the seriousness of the infection, it should be considered in the differential diagnosis for any patient who develops fever or headache in this setting.

入院加療を行った深頸部膿瘍例の検討

We reviewed 42 cases of deep neck abscess drained surgically or treated conservatively between February 2001 and August 2008, based on age, gender, primary focus, main symptom, abscess location, systemic disease, pathogenic bacteria, hospital treatment, hospitalization length, complications and long-term hospitalization. Of the 42, 26 were men and 16 women aged 14 to 80 (central age: 54.5 years). Abscess was caused most by tonsil inflammation (38.1%). Main symptom were sore throat (54.8%) and neck swelling (35.7%). Abscesses were found in the supra- and infrahyoid region in 30 cases and extended to the mediastinum in 2. Of the 42, 14 (33.3%) had hypertension and 11 (26.2%) diabetes mellitus (DM). Inflammation was due to aerobic bacteria (mainly Streptococcus milleri) in 23 cases (54.8%) and to anaerobic bacteria (mainly Peptostreptococcus) in 11 cases (26.2%). Flexible fiberscopic examination was important in evaluating pharyngeal and laryngeal mucosal disorders and enhanced computed tomography was useful in both diagnosis and postoperative observation. Of the 42, 38 required surgical drainage and 4 were cured using needle aspiration and antibiotics. Of the 38 undergoing surgery-tracheostomy was required in 22. Hospitalization for those with tracheostomy and DM was longer than in those without these factors. Complications included 2 cases each of, mediastinal abscess, sepsis, disseminated intravascular coagulation (DIC), acute renal failure, severe pneumonia, upper digestive tract bleeding and swallowing disorder. Early surgical drainage and intravenous antibiotic administration are thus essential for treating deep neck abscesses.

Multiple liver abscesses with isolation of streptococcus intermedius related to a pyogenic dental infection in an immuno-competent patient

IntroductionStreptococcus intermedius - a member of the Streptococcus anginosus group - is part of the normal microbial flora of the oral cavity. Despite being regarded as a harmless apathogenic commensal, Streptococcus intermedius has been described to cause abscesses in various locations of the body.Case PresentationWe report the clinical case and course of treatment of a 18-year-old male patient presenting with multiple hepatic abscesses associated with an untreated pyogenic dental infection.ConclusionStreptococcus intermedius can cause liver abscesses emerging from dental infectious foci even in previously healthy patients without underlying innate or aquired immunodeficiency. The case illustrates the potential danger and underestimated risk associated with untreated dental infections.

Characterization ofStreptococcus milleriGroup Isolates from Expectorated Sputum of Adult Patients with Cystic Fibrosis

With the recent insights into the Streptococcus milleri group (SMG) as pulmonary pathogens in patients with cystic fibrosis (CF), we sought to characterize 128 isolates from the sputum of adults with CF, along with 45 isolates from patients with invasive diseases for comparison. The tests performed included Lancefield grouping; tests for hemolysis; tests for the production of hyaluronidase, chondroitin sulfatase, DNase, proteases, and hydrogen peroxide; and PCR for the detection of the intermedilysin gene (ily). We also generated biochemical profiles with the Rapid ID Strep 32 API system and tested cell-free supernatants for the presence of the signal molecule autoinducer-2 (AI-2) using a Vibrio harveyi bioassay with a subset of CF strains. The S. intermedius isolates from both strain collections were similar, while the S. constellatus and S. anginosus isolates yielded several biotypes that differed in prevalence between the two strain collections. Beta-hemolytic, Lancefield group C S. constellatus comprised 74.4% of the S. constellatus isolates from patients with CF but only 13.3% of the corresponding isolates from patients with invasive infections. This was the only S. constellatus biotype associated with pulmonary exacerbations. Hyaluronidase-positive S. anginosus was detected only among the isolates from patients with CF. Strain-to-strain variability in AI-2 expression was evident, with the mean values being the highest for S. anginosus, followed by S. constellatus and then S. intermedius. Cluster analysis and 16S rRNA sequencing revealed that the species of SMG could be accurately determined with a minimum of three phenotypic tests: tests for the Lancefield group, hyaluronidase production, and chondroitin sulfatase production. Furthermore, isolates from patients with invasive infections clustered with isolates from the sputum of patients with CF, suggesting that the respiratory tract isolates were equally pathogenic.

Streptococcus anginosus (Streptococcus milleri Group) Pyomyositis in a 50-Year-Old Man with Acquired Immunodeficiency Syndrome: Case Report and Review of Literature

We describe the first reported case of bacterial pyomyositis of the right thigh caused by Streptococcus anginosus (S. milleri group) in an HIV-infected patient. The clinical presentation was complicated by multiple ring-enhancing lesions detected on magnetic resonance imaging of the brain. Evaluation for central nervous system toxoplasmosis,syphilis, and cryptococcal infection was negative. Aggressive antibiotic therapy directed against S. anginosus and surgical debridement were limb salvaging. Clinicians should considerS. anginosus as a causative pathogen in HIV-associated pyomyositis, particularly in complex presentations. Prompt surgical drainage may minimize complications due to S. anginosus, a pathogen associated with significant sequelae due to its invasive nature.