Subsequent Abscess Research Articles

Bacterially preexposed T cells impair bacterial elimination by non-Th1/Th2 cell mechanisms in a model of intra- abdominal infection

Background: Escherichia coli preexposure in mice results in impaired elimination of subsequent intra-abdominal infections by a CD4+ T cell–dependent process. Certain gram-negative infections have been shown to induce T-helper–(Th)2-type CD4+ T-cell differentiation, which correlates with impaired elimination of infection and death. We hypothesized that E coli preexposure impairs subsequent bacterial elimination as a consequence of Th2 differentiation and that interleukin-12 (IL-12) treatment could reverse this differentiation and minimize the effects of E coli preexposure. Methods: After preexposure to E coli or other species, BALB/c mice or interferon-γ (IFN-γ)–deficient mice, treated with or without IL-12, were given a standard intra-abdominal infection ( E coli, Bacteroides fragilis, and adjuvant). Cohorts were killed for abscess quantification, in vitro T-cell proliferative responsiveness, and cytokine secretory profiles. Splenic lymphocytes preexposed in vivo to other types of bacteria were transferred to naive mice before intra-abdominal infection to determine whether preexposure, eliciting the lymphocyte-dependent response, was species specific. Results: E coli preexposure alone caused no Th1 or Th2 shift; increased the proliferative responses of T cells; and, in combination with IL-12 therapy, caused markedly decreased IL-2 and IL-4 responses and an increased IFN-γ response. IL-12 therapy did not change the response to intra-abdominal infection despite its ability to cause marked Th1 polarization. IFN--γ-deficient mice responded to E coli preexposure no differently than did wild-type mice. Transfer of lymphocytes preexposed to Pseudomonas aeruginosa, Klebsiella pneumoniae, and hemolytic E coli but not other types of nosocomial pathogens caused the development of more abscesses just as transfer of E coli preexposed lymphocytes had. Conclusions: CD4+ T cells responsive to E coli preexposure regulate subsequent intra-abdominal abscess formation by a mechanism not explained by the Th1/Th2 paradigm. Preexposure to hemolytic E coli and other Enterobacteriaceae alters responses to intra-abdominal infection. (Surgery 1998;124:418-28.)

Intrascleral dissemination of infectious scleritis following pterygium excision

AIMSTo assess the clinical pictures, possible pathogenesis, management, and therapy of patients with infectious scleritis associated with multifocal scleral abscesses following pterygium excision.METHODSThe records of patients with infectious scleritis after...

Avoidance of anastomotic complications in low anterior resection of the rectum.

This retrospective study was designed to evaluate the efficacy of suction-irrigation drainage systems in reducing anastomotic complications. The current trend for lesions of the upper and middle rectum emphasizes maintaining an intact anal sphincter mechanism as long as limits of resection are not compromised. Removal of the rectosigmoid colon with an anastomosis below the peritoneal reflection accomplishes this goal but with appreciable morbidity and mortality, which is in great part related to subsequent anastomotic breakdown and resultant pelvic abscess and fecal fistula formation. The presence of collections of blood, serum, and cellular debris contribute significantly to anastomotic disruption by serving as a culture medium in which bacteria may thrive, leading to abscess formation with subsequent deleterious effects on the integrity of the adjacent low lying anastomosis. Many surgeons accepted this risk and routinely performed diverting colostomies to minimize the consequences of anastomotic disruption below the peritoneal reflection. The authors felt that if this risk could be sufficiently reduced, it would obviate the need for a protecting stoma. From 1980 to 1988, 60 consecutive patients were subjected to anterior or low anterior resections in which a closed Shirley sump irrigation system was used to facilitate postoperative drainage of the pelvis and thus avoid hematoma formation. Since this original study group of 60 patients, another 100 consecutive patients have been entered into this study. This cohort group again consisted of patients with lesions of the upper, middle, and lower rectum who underwent anterior or low anterior resections of the rectum. Fifty-three of the original 60 patients did not have protecting stomas. Clinical leak rate for this series was 1.67 percent. Clinical leak rate for this updated series of 100 patients was 1 percent, with overall clinical leak rate of 1.25 percent in 160 consecutive patients. There were no deaths in the series, and overall morbidity was 7.5 percent. The authors felt that removing blood, serum, and cellular debris from the pelvis following resections of all or part of the rectum minimizes the risk of anastomotic disruption. With this routine, covering colostomies are no longer required for most patients undergoing anterior or low anterior resections of all or part of the mesorectum.

72 MULTIPLE PERIANAL ABSCESSES: A MANIFESTATION OF FOOD ALLERGY?

Fistula in ano, a relatively common condition in infants, may lead to perianal abscess formation. Although most fistulae are isolated, some infants develop multiple abscesses. The development of fistula is thought to be the result of cryptitis and may be congenital or linked to immunodeficiency in some patients. We report 5 infants, 1½ to 6 months of age, who presented with multiple perianal abscesses. Surgical excision and antibiotic therapy was provided for all patients; however, recurrent abscesses developed. Two patients were hemoccult-positive at evaluation, 3 patients had IgE and RAST testing for milk allergy—all results were normal. Each patient underwent sigmoidoscopy and biopsy. Rectal biopsy in all patients revealed histologic evidence of eosinophilic proctitis. Accordingly, each patient was placed on a hypoallergenic formula. Table RESULTS: In all 5 patients, rapid resolution of abscess occurred and no subsequent abscess developed following placement on hypoallergenic formula (follow-up > 6 months in all patients). CONCLUSIONS: Recurrent fistulae in ano and perirectal abscess in infants may be related to allergic colitis and respond to a hypoallergenic diet. Sigmoidoscopy and biopsy should be considered in patients with multiple perirectal abscesses as part of their evaluation.

CD4 + T cells mediate preexposure-induced increases in murine intraabdominal abscess formation

We have previously shown that an increased number of Escherichia coli/Bacteroides fragilis intraabdominal abscesses are produced in mice after preexposure to small numbers of live E. coli or B. fragilis. Splenic lymphocyte subset changes and the importance of different elements of the immune response in this system were studied. Preexposure to bacteria induced a significant increase in the percentage of splenic T cells without altering the CD4/CD8 ratio. The passive transfer of either 10 7 mixed splenic lymphocytes, 5 × 10 6 mixed T cells, or 2.5 × 10 6 CD4 + T cells from preexposed animals to naive siblings 24 hr prior to abscess induction resulted in increased abscess formation. Transfer of serum, B cells, <10 7 lymphocytes, CD8 + T cells, or any cell type from naive animals did not change abscess number. The bacterial composition of abscesses changed only in animals receiving either serum or B cells from donors preexposed to B. fragilis, where an increased number of B. fragilis per abscess was found. The CD4' T cell response can be altered by transient infections and is critical to subsequent abscess formation, and a concurrent humoral response may play a role in determining an abscess' ultimate bacterial composition.

Communicating double uterus with obstructed hemivagina and subsequent abscess formation: A case report

Background: Communicating double uterine anomalies are defined as müllerian defects which involve two hemiuteri with communication between the uterine halves. Nine subcategories of communicating uterine anomalies have been described; only two of these subcategories are associated with hemivaginal obstruction.Case: An 11-year-old white female was brought to the Emergency Department with fever and acute pelvic pain. This condition was found to be caused by abscess formation behind an obstructed left hemivagina with involvement of a communicating double uterine anomaly.Conclusion: To our knowledge, this is the first case report involving a communicating double uterine anomaly in which fever was a presenting symptom.

下咽頭梨状窩痩の2症例とその治療

Unlike subacute and chronic thyroiditis, acute suppurative thyroiditis with subsequent abscess formation is rarely encountered in clinical practice. The route of infection in recurrent acute suppurative thyroiditis was obscure until Tucker et al first suggested the presence of a congenital fistulous tract extending from the piriform sinus to the side of the neck. The relation between acute suppurative thyroiditis and an internal fistulous tract (piriform sinus fistula) as the route of infection was confirmed by Miyauchi et al. Since then, a number of similar cases have been reported and, at present, piriform sinus fistulae are considered to be the most common route of infection inducing recurrent acute suppurative thyroiditis.Piriform sinus fistula is a persistent congenital sinus tract, which arises from the apex of the piriform sinus and ends in or adjacent to the thyroid lobe, and is characterized by the exclusively leftsided occurrence. The fistulae are assumed to arise from remnants of the 3rd or 4th pharyngeal pouch, or the ultimobranchial body, but its exact origin remains controversial.In this paper, we describe two patients with recurrent acute suppurative thyroiditis and abscess caused by infection through the piriform sinus fistula. Repeated barium meal studies demonstrated a thin fistula in one of the two patients. After fistulectomy, recurrent disease developed in one of the two, indicating incomplete removal of the fistula. This patient underwent revision surgery later. Barium contrast studies and endoscopic examination were useful in making the diagnosis accurately, and surgical exploration of the neck with excision of the entire fistulous tract to the level of the piriform sinus is the treatment of choice.

Perianal Hidradenitis Suppurativa

The management of hidradenitis suppurativa is individualized according to the site and extent of the disease. Initially, short-term antibiotics, local care, and incision and drainage are helpful. Unroofing of sinus tracks, total disease excision, and vigorous physical therapy are more beneficial. Primary or secondary closure or closure by an advancement flap or selective split-thickness skin grafting should be considered in some refractory cases. In most areas, recurrence rates are high unless wide excisions are performed, but perianal hidradenitis can usually be managed more conservatively. Patients with intra-anal disease are better allowed to heal secondarily than by grafting. Split-thickness grafts may contract and lead to anal stenosis, and grafts that are rejected may lead to deep scarring and anal dysfunction. The perianal region is best treated by local excision with secondary closure or by unroofing and curettage when the perianal region is more extensively involved.

Antibiotic treatment of anaerobic infections.

The discovery of effective antimicrobial drugs has substantially improved the therapeutic outlook for patients with anaerobic infections. In addition, the pathophysiology of anaerobic infections has been elucidated by comparative antibiotic trials and the use of antibiotic probes in experimental animal models. Facultative bacteria, such as Escherichia coli, are responsible for acute peritonitis and sepsis associated with bowel perforation. Anaerobes, particularly Bacteroides fragilis, play the seminal role in subsequent abscess formation. Treatment of only the facultative bacteria, without adequate antibiotic coverage for anaerobic bacteria, leads to clinical failures with complications of abscess formation. Such therapeutic misadventures have been witnessed in the treatment of mixed infections with cephalosporins and penicillins that lack significant activity against anaerobes. Similarly, use of metronidazole or clindamycin as a single agent is associated with failures caused by infection with facultative bacteria. Mixed infections involve complex interactions between facultative bacteria and strict anaerobes, many of which possess intrinsic pathogenicity. The best therapeutic results are realized with antimicrobial drugs that are active against both types of microorganisms.

Pleurocerebral Nocardia in a Patient with Human Immunodeficiency Virus

To report a case of Nocardia asteroides pneumonia and subsequent brain abscess in an immunocompromised host. Private, community, teaching hospital. A man readmitted to the hospital for a third time with a fatal brain abscess, after responding to (misdirected) therapy in previous admissions. Treatment with cefuroxime, erythromycin, trimethoprim/sulfamethoxazole at different times. Patient's condition deteriorated and he died after one month of intravenous trimethoprim/sulfamethoxazole therapy. Because it is an infection of the immunocompromised host, it may be considered an AIDS-defining illness. Several other similar cases have been reported in the literature.

Benign nasal polyposis presenting as an intracranial mass: Case report

An interesting case of benign nasal polyposis with intracranial extension and subsequent abscess formation is described. Its diagnosis and treatment are presented and the pathology is demonstrated. The literature related to this rare disease process is discussed in detail.

Patient costs for prophylaxis and treatment of obstetric and gynecologic surgical infections

The use of newer broad-spectrum antimicrobials for prophylaxis and treatment in obstetric and gynecologic surgery can reduce patient morbidity and hospital costs. For prophylaxis, a single dose of a cephalosporin with a long elimination half-life can be as effective as a more prolonged course. Single-dose prophylaxis reduces not only toxicity and cost to the patient but also the likelihood of colonization of the vagina by resistant organisms. Treatment regimens for postoperative pelvic infections should have broad-spectrum coverage against aerobic and anaerobic pathogens to ensure high cure rates and prevent subsequent abscess formation. With the introduction of newer cephalosporins and penicillin combinations that include a beta-lactamase inhibitor, it is now possible to treat these polymicrobial infections effectively with monotherapy. Compared with traditional antibiotic combinations, these drugs can reduce side effects and the costs of drug administration as well as the need for therapeutic monitoring. The use of oral antibiotics to complete a course of treatment can also help decrease the high costs of parenteral antibiotic therapy and hospitalization.

Preexposure of the Peritoneum to Live Bacteria Increases Later Mixed Intraabdominal Abscess Formation and Delays Mortality

Intraabdominal infections are a major source of morbidity and mortality for the trauma and postoperative patient. Transient peritoneal contamination with bacteria after either intentional or unintentional violation of the gut are common. The effect of this intermittent antigen exposure upon later formation of intraabdominal abscesses is unclear. Previous experiments by others have demonstrated that repeated exposure to Bacteroides fragilis capsular polysaccharide can induce a T lymphocyte-mediated immunity to subsequent induction of pure B. fragilis abscess formation. In a murine mixed intraabdominal abscess model, preexposure to live Escherichia coli, B. fragilis, or both increased the number of later abscesses and in some cases their bacterial composition. Further, immunization with E. coli alone increased late mortality without altering overall mortality. These data suggest that the alterations of immune function produced by live, transient bacteria upon subsequent mixed intraabdominal abscess induction result in fundamentally different consequences from those observed after specific polysaccharide antigen exposure and subsequent monomicrobial abscess induction.

Mycobacterium kanasii infection limited to skin and lymph node in a patient with AIDS

The case of a 36-year-old HIV-1-positive patient is presented. After an episode of Pneumocystis carinii pneumonia and cytomegalovirus retinitis a pruritic lesion developed on the thigh with subsequent intracutaneous abscess formation and regional lymph-node enlargement. Mycobacterium kansasii was demonstrated in lymph-node and abscess material. With a tuberculostatic triple-drug regimen the lesions resolved completely. Cutaneous involvement in the course of non-tuberculous mycobacteriosis in the acquired immunodeficiency syndrome is discussed.

Septic complications associated with the use of peritoneal drains in liver trauma.

This study reviewed all 164 cases of liver trauma seen at the Charity Hospital of New Orleans from 1980 through 1984, in 12 of whom intra-abdominal abscesses formed. Thirty four per cent of the patients had no peritoneal drainage and an abscess rate of 1.8%, 18% had only closed suction drainage and 0% abscess rate, 15% had only open sump drainage and a rate of 8.3%, 14% had only open Penrose drainage with a rate of 8.7%, and 19% had a combination of both open Penrose and sump drainage with a rate of 22.5%. Certain findings or conditions were related to the development of postoperative sepsis. Gunshot wounds were associated with a 9.9% abscess rate, blunt trauma with 3.8%, and stabbings with 0%. Patients who presented in shock were at a threefold increased risk for intra-abdominal abscess formation, those who needed blood transfusions of greater than 6 units were at a tenfold increased risk, those with major liver injuries were at a sixfold increased risk, and those with a total of three or more abdominal organs injured were at a threefold increased risk for abscess formation. There was no significant relation between presence of gastrointestinal perforation and subsequent abscess formation. For patients without the specific risk factors mentioned above, the probability of developing an intra-abdominal abscess is low. This group of patients would therefore benefit little from the presence of a drain, but might very well be harmed by the introduction of external contaminant bacteria into the peritoneal cavity by the drain itself.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial hematoma with subsequent brain abscess after carotid endarterectomy

A 62-year-old man developed an infected left carotid endarterectomy with false aneurysm formation and subsequent bacteremia after staged carotid endarterectomies. He was found to have a right frontal lobe hemorrhage that developed into a staphylococcal brain abscess. We postulate there was bacterial seeding of the hematoma resulting in brain abscess formation.

X-linked hypophosphataemic vitamin D-resistant rickets.

Abstract— Familial hypophosphataemia, commonly known as vitamin D‐resistant rickets, is inherited in an X‐linked dominant manner. The basic genetic defect, a selective failure of renal tubular reabsorption of phosphate, results in clinical signs of rickets and characteristic dental manifestations. Defective dentine formation with abnormally large pulp chambers predispose the teeth to pulp exposures and subsequent abscess formation from even normal attrition. Effective strategies for the management of these dental problems are available, hence the importance of early diagnosis. Furthermore, as the skeletal signs of rickets may be mild and easily missed, early recognition of the disease frequently rests on appreciation of the characteristic dental manifestations. It is important that the disease be diagnosed and treatment instituted early if the crippling deformities of rickets are to be avoided.

Synergistic effect of bacteroides, Clostridium, Fusobacterium, anaerobic cocci, and aerobic bacteria on mortality and induction of subcutaneous abscesses in mice.

The potential for synergy between aerobic, facultative, and anaerobic bacteria was studied by subcutaneous inoculation of mixtures of these organisms into mice and observation of subsequent mortality and abscess formation. The anaerobic bacteria tested included 12 strains of gram-positive cocci and two strains each of Bacteroides species, Clostridium species, and Fusobacterium species. The facultative and aerobic bacteria included one strain each of Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis. Mortality increased significantly when each aerobic organism was inoculated along with either of the Bacteroides species. A similar increase occurred when the anaerobic gram-positive cocci were inoculated along with P. aeruginosa (four of six combinations) or S. aureus (four of six). The rate of abscess induction increased significantly when 10 of the 12 strains of anaerobic gram-positive cocci were injected along with B. fragilis and when nine of these strains were inoculated along with Bacteroides asaccharolyticus . The results demonstrate synergistic potential between Bacteroides species and all aerobic bacteria tested, between Bacteroides species and most anaerobic gram-positive cocci, and between most anaerobic gram-positive cocci and P. aeruginosa or S. aureus.

Trichosporon capitatum: Thrush-like oral infection, local invasion, fungaemia and metastatic abscess formation in a leukaemic patient

A thrush-like oral infection with subsequent alveolar abscess formation and a positive blood culture due to Trichosporon capitatum developed in a patient with acute myelogenous leukaemia. Later T. capitatum was identified by indirect immunofluorescence in multiple splenic abscesses. The infection was controlled by immediate aggressive treatment with amphotericin B, flucytosine and rifampicin and by splenectomy. This case of systemic T. capitatum infection resembles somewhat the invasive mycosis due to candida.

Host response to mixed anaerobic infection with Bacteroides melaninogenicus and Fusobacterium necrophorum.

This study characterizes the acute phase of the host response to mixed infection withBacteroides melaninogenicus andFusobacterium necrophorum. Female NMRI mice were injected intraperitoneally with 0.5 ml of 1:1 mixtures ofB. melaninogenicus andF. necrophorum (total inoculum = 1 × 109 bacteria). This infectious dose was sufficient to produce septicemia within 24 hours, with subsequent hepatic abscess formation in survivors at one to two weeks. A 25–30% mortality rate was seen during the acute phase (0–96 h) of infection. Blood, liver and spleen samples were obtained at various intervals after infection; quantitative anaerobic bacteriology was performed. Laked blood BHI agar roll tubes were used to differentiate black-pigmentingB. melaninogenicus fromF. necrophorum. Other tests performed included: the limulus amebocyte lysate (LAL) assay for endotoxin, total white blood cell (WBC) count, differential WBC, hematocrit, blood glucose levels, and serum glutamic-pyruvic transaminase (SGPT) activity. An acute to chronic infection progressed in mice infected with this mixture of anaerobic bacteria, whereas no infection resulted when either organism was injected alone. The first 96 hours of infection demonstrated a typical acute inflammation, documented by blood chemistry, hematology and histology. Quantitativein vivo growth patterns were obtained for both of the infecting bacteria. The liver and spleen were the tissues containing the most bacteria. The modified LAL assay revealed circulating endotoxin during the early phase of the infection. In nearly all of the survivors, chronic intrahepatic abscesses developed two to six weeks after the acute phase. The results suggest thatFusobacterium, which contains the more potent endotoxin, predisposes the animals to chronic infection withBacteroides which predominates during the chronic phase. Bacterial endotoxins probably play a more central role in this type of infection than was previously thought.