Septic shock, pneumonia, and soft tissue infection due to Myroides odoratimimus: report of a case and review of Myroides infections

The genus Myroides comprises aerobic, yellow-pigmented, non-motile, non-fermenting gram-negative rods formerly classified as Flavobacterium odoratum. Members of the genus are widely distributed in the environment, especially in water, and usually behave as low-grade opportunistic pathogens, having been found to cause urinary tract infection, endocarditis, ventriculitis, and cutaneous infections in severely immunocompromised patients. We report a case of soft tissue infection, septic shock, and pneumonia due to M. odoratimimus in an immunocompetent male. To our knowledge, this is the first description of life-threatening infection caused by this organism in an immunocompetent host. We have also reviewed the medical literature on the genus Myroides.

[Experimental study of combination of ciprofloxacin and oxytocin on formation of biofilms by opportunistic bacteria]

AIM

To study in vitro and in vivo effect of oxytocin and ciprofloxacin combination on formation of biofilms by agents of surgical infections.

MATERIALS AND METHODS

Microorganisms of different species isolated by conventional methods from patients with purulent soft tissue infections were used in experiments. Ciprofloxacin manufactured by "Dr. Reddys" (India) and oxytocin manufactured by "Gedeon Richter" (Hungary) were used. For in vitro experiments one-half of minimal inhibitory concentrations of drugs were used. Oxytocin-placebo ("Gedeon Richter", Hungary) was used for control tests. Formation of biofilms was assessed using method proposed by G. O'Toole (2000). For in vivo experiments septic wounds in 1st phase of wound process were modeled according to method proposed by E.M. Danilova (1992). Wounds were infected with Staphylococcus aureus strain 104, which has strong ability to form biofilms. Efficacy of treatment was assessed on signs of inflammatory process and microscopy of touch smears for detection of bacterial biofilms.

RESULTS

In experiments in vivo addition of oxytocin to nutrient medium resulted in suppression of biofilm formation by studied microorganisms. Obtained data were confirmed by in vivo experiments which demonstrated higher efficacy of local application of ciprofloxacin and oxytocin combination for treatment of septic wounds compared to separate use of ciprofloxacin or oxytocin.

CONCLUSION

Studies performed in vitro and in vivo showed efficacy of oxytocin and ciprofloxacin combination, which is determined not only by enhancement of antimicrobial effect of the drug against pathogen but also by suppression of biofilm formation in the wound during infection.

The use of drotrecogin alpha for necrotizing soft tissue infections

The use of Drotrecogin alfa (DAA) (Xigris) in select patients with sepsis has had demonstrable improvement in survival, though its benefit in necrotizing soft tissue infections (NSTI) is unclear. A retrospective review of NSTI patients receiving DAA at our institution from 2006 to 2009 was performed. Our previously derived mortality prediction model, based on classification and regression tree analysis, was applied to patients and the predicted mortality was compared with the actual mortality rate. Ten patients with severe NSTI received DAA. The median admission values were: white blood cell count of 27,000/mm3, serum lactate of 4.0 mmol/L, and serum sodium of 128 mEq/L. Four (40%) patients had systemic complications, five (50%) patients required amputation, and one died (10%). Median time to DAA administration was 12 hours after debridement. There were no bleeding complications attributed to DAA use. Mortality in this series of severe NSTI was only 10 per cent, which compares favorably with the predicted mortality of 18 per cent based on classification and regression tree analysis (P = 0.2). A prospective, randomized study is warranted to determine if the use of DAA should be part of the standard therapy for NSTI patients with a predicted high mortality.

Necrotizing soft tissue infections

Necrotizing soft tissue infections (NSTIs) are aggressive severe soft tissue infection that cause rapid and widespread infection and necrosis of the skin and soft tissues and are highly lethal. NSTIs include necrotizing cellulitis, adipositis, fasciitis and myositis/myonecrosis and have significant potential for extensive soft tissue and limb loss. Early diagnosis and treatment of NSTIs remains the cornerstone of therapy. Timely aggressive surgical debridement and early appropriate antibiotic treatment are required for a successful outcome and clinical cure. Mortality rate has decreased from 25-50% in past years, to 10-16% in recent years with aggressive surgical and medical management. Additional innovative strategies for the treatment of NSTIs, including intravenous immuno-globulin G (IVIG), hyperbaric oxygen, and vacuum-assisted closure, do not yet have definitive evidence of efficacy, but may be considered in patients at high risk of death. A comprehensive knowledge of the pathophysiology, diagnostic features, causative microbial pathogens, and treatment strategies (including surgical debridement and antimicrobial therapy) is required for successful management of NSTIs.

[Myonecrosis in users of injecting drugs (a clinical case)]

Myonecrosis remains one of the severest manifestations of skin and soft tissue infections. Clostridia (C. perfringens, C. novyi, C. septicum, C. sordellii, C. histolyticum) are dominant and Staphylococcus aureus, Streptococcus pyogenes, Bacillus cereus, and Bacteriodes fragilis are much less in the etiology of myonecrosis. Cases of gas gangrene have recently become more frequent among injection drug users all over the world. Russia has become the largest opiate market in Europe and consumption of these narcotic drugs is annually growing. In the Russian Federation, a larger number of injection drug users uniquely results in a rise of cases of Clostridium- and mixed flora-induced myonecrosis. Gas gangrene in HIV-positive drug abusers seems to rapidly progress to multiple organ failure and to show high death rates, rather than to develop a localized form. The analyzed case of mixed flora-induced gas gangrene is of interest to physicians of any specialties who can encounter this wound infection in HIV-positive patients.

[Application of combined bandaging material with antioxidant activity for suppurative diseases of soft tissues]

Role of <<immunomodulating perforated atraumatic germicidal plaster>> in complex treatment of patients with suppurative diseases of soft tissues was analyzed. It is estimated that application of <<immunomodulating perforated atraumatic germicidal plaster>> allows normalizing of free radical peroxidation processes in the blood, increases tissue antioxidant activity compared with traditional methods of treatment.

[Skin and skin tissue infections: main clinical patterns/pictures]

Skin and soft tissue infections represent a heterogeneous group of clinical entities that require to be accurately identified for an appropriate and immediate management. Clinicians are challenged by the need to rapidly select those patients requiring hospitalization and medical therapy only and those to be immediately submitted to surgery. Erysipelas and several forms of cellulitis, involving the superficial structures of epidermis and dermis, are medical conditions; some cutaneous abscess may require surgical drainage, and all the necrotizing infections, involving the subcutaneous tissue (necrotizing fasciitis) or muscles (myonecrosis) are surgical conditions. Among the clinical clues useful for the diagnosis are the presence of severe pain disproportionate to the clinical evidence of the lesion (necrotizing fasciitis), the presence of crepitus (gas gangrene) and signs of systemic toxicity (high fever, hypotension, tachycardia, shock and multiple organ failure).

[Effect of estrogens and liposomes on the course of the purulent wounds healing in elderly and senile patients]

The cytological changes dynamics during the process of the purulent wounds healing in elderly and senile patients using estrogens and liposomes in complex of treatment are adduced.

[Unusual localization of echinococcosis in Cukurova (134 cases)]

Echinococcosis is a parasitic disease frequently occurring in societies where agriculture and raising animals are common. In Turkey, it is more commonly observed in eastern and middle Anatolia and in Marmara and Trakya regions. While there is a high rate of occurrence in the liver and lungs, Echinococcosis can occasionally be present in other tissues and organs. In this study which was carried out in the Cukurova region, we found 962 echinococcosis cases in a ten year period. Of these, 134 (13.9%) were located outside the liver and the lung. Our aim was to determine the rate of unusual location of echinococcosis cases in our region and draw attention to the issue.

Diagnostic and treatment options for skin and soft tissue abscesses in injecting drug users with consideration of the natural history and concomitant risk factors

OBJECTIVE

Skin and soft tissue abscesses are common findings in injecting drug users (IDUs) who present to the surgical emergency department for evaluation and treatment. Although most cases can be managed by incision and drainage, they do require special considerations as compared to abscesses which are not caused by intravenous drug abuse.

METHODS

Skin and soft tissue abscesses treated in the emergency department between 2005 and 2007 were reviewed and a systematic literature search of skin and soft tissue abscesses in IDUs was conducted, including the etiology, occurrence, risk factors, and treatment options, thus providing the rationale for the treatment algorithm presented herein.

RESULTS

The drugs injected, the technique by which they were injected, the attendant circumstances, as well as the immunological status of the IDUs were major factors for the development of abscesses. Skin and soft tissue abscesses in IDUs should be incised and drained under local or general anesthesia depending on the size, location, and association with neurovascular structures. Different factors have been taken into account when treating soft tissue abscesses in this population which predict their specific risks and therefore further therapy needs. The incidence of tetanus is high among IDUs compared to the general population, giving rise to the recommendation for a strict booster policy if the vaccination status is unclear when the patient presents to the emergency department. The presence of fever requires hospitalisation and evaluation for the presence of endocarditis. Foreign bodies, such as broken needles, should be ruled out by radiography, and duplex sonography should be performed to identify the presence of vascular complications. Prior to incision and drainage, prophylactic antimicrobial agents should be administered to every patient and as therapy for high-risk patients, such as immunocompromised patients and patients with fevers and chills.

CONCLUSIONS

IDUs presenting with skin and soft tissue abscesses can be managed safely if some special issues are taken in account. The presented algorithm may help facilitate the decision-making in this context.

Prevalence of community-acquired methicillin-resistant Staphylococcus aureus in a private dermatology office

BACKGROUND

The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infection (SSTI) in private practice dermatology office is largely unknown and the prescribing of antibiotic treatment could be influenced by such data.

OBJECTIVE

Investigators sought to examine the period prevalence of CA-MRSA infections involving skin and soft tissue in a suburban private practice dermatology setting.

METHODS

Chart reviews of 170 patients who had bacterial cultures taken from January 2007 to November 2007 were performed, with an analysis of sex, age, immune status, species of growth, type of lesion, and culture site.

RESULTS

The mean age of the study population was 54.0 years (SD 21.8) and 51.1 % were male. Of the 170 cultures taken, 135 (79%) grew 1 or more bacteria and MRSA positive cultures were found in 28 (21%) of 135 cultures.

LIMITATIONS

Only 1 geographic location was represented.

CONCLUSION

The rising rates of CA-MRSA skin and soft tissue infections should be evaluated with consideration of the unique populations that the majority of reports represent. There is little doubt that the prevalence of skin infections caused by CA-MRSA have increased dramatically and will likely continue to do so in the future. However, the authors caution the empiric prescribing of antibiotics presently known to be effective against CA-MRSA and advocate the culturing of all infectious lesions upon presentation and reserve these antibiotics (tetracyclines, trimethoprim-sulfamethoxazole [TMP-SMX], clindamycin, rifampin) for the treatment of high-risk patients and patients with culture proven CA-MRSA infections.

[The use of plasma lactoferrin in the diagnosis of pyonecrotic infections of soft tissues and sepsis]

Plasma lactoferrin dynamics was investigated in 120 of the 2250 patients with local and generalized soft tissue infections. Systemic symptoms were observed in 15% of the patients with soft tissue infections, syndrome of systemic inflammatory response in 13%, and sepsis in 42%. In 89% of the patients with systemic inflammatory reactions the blood lactoferrin level was 1.1-1.3 times the normal one within 72 hours after the onset of therapy; it dropped to the normal value in 12-15 days. Normalization of blood lactoferrin in patients with mild and moderate systemic inflammatory reactions roughly coincided with the disappearance of symptoms of generalized infection. It occurred 5-6 days after the septic process was resolved in patients with severe inflammatory reactions. Normal blood lactoferrin levels were characteristic of a mild inflammatory reaction and local forms of infection. A rise in blood lactoferrin above 1400 ng/ml combined with the syndrome of systemic inflammatory reaction over 72 hr in duration was regarded as a diagnostic criterion of sepsis. It is suggested that monitoring blood lactoferrin during treatment of systemic inflammatory reactions and sepsis be used for the choice of therapeutic strategy and the assessment of efficiency of its efficiency.

Staging of necrotizing fasciitis based on the evolving cutaneous features

BACKGROUND

Necrotizing fasciitis is a severe soft-tissue infection characterized by a fulminant course and high mortality. Early recognition is difficult as the disease is often clinically indistinguishable from cellulitis and other soft-tissue infections early in its evolution. Our aim was to study the manifestations of the cutaneous signs of necrotizing fasciitis as the disease evolves.

METHODS

This was a retrospective study on patients with necrotizing fasciitis at a single institution. Their charts were reviewed to document the daily cutaneous changes from the time of presentation (day 0) through to day 4 from presentation.

RESULTS

Twenty-two patients were identified. At initial assessment (day 0), almost all patients presented with erythema, tenderness, warm skin, and swelling. Blistering occurred in 41% of patients at presentation whereas late signs such as skin crepitus, necrosis, and anesthesia were infrequently seen (0-5%). As time elapsed, more patients had blistering (77% had blisters at day 4) and eventually the late signs of necrotizing fasciitis characterized by skin crepitus, necrosis, and anesthesia (9-36%) were seen. A clinical staging system was developed based on our observations. Stage migration from early to late stage necrotizing fasciitis was evident with majority of patients in stage 1 at day 0 (59%), whereas by day 4, majority had developed into stage 3 (68%).

CONCLUSION

This study has demonstrated the continuum of cutaneous manifestations as necrotizing fasciitis evolves. This will help in the early recognition and intervention of this devastating condition.

Meningococcal septicaemia complications involving skin and underlying deeper tissues--management considerations and outcome

OBJECTIVE

To describe surgical experience with purpura fulminans related to meningococcaemia in a single institution, and to suggest a management protocol.

METHODS

A retrospective review was done of patients admitted to the intensive care unit at Red Cross War Memorial Children's Hospital in Cape Town with the clinical diagnosis of purpura fulminans.

RESULTS

During a 28-year period (1977-2005) 112 children (average age 3.4 years) were treated for meningococcaemia with purpura fulminans. Overall mortality was 10.7%. Local treatment consisted of measures to improve circulation, infection control and healing of necrotic tissue. Demarcation of necrotic areas was evident at 5.5 days and the average area of skin necrosis was 14% total body surface area (range 2-85%). The lower limbs were predominantly affected. Purpura fulminans resolved in 35 children (31.2%) without skin necrosis. Skin grafting was required in 77 children (68.8%). Factors associated with a poor outcome for peripheral extremity salvage were progressive irreversible skin changes, early disappearance of distal pulses, tense cold swollen extremities and intense pain on passive movement of the affected extremity. Amputations were performed proximal to the area of necrosis, on average 27 days after injury.

CONCLUSIONS

Meningococcaemia is a disease with potentially devastating consequences. Early surgical consultation is essential. Skin- and soft-tissue-releasing incisions should be considered early to reduce the incidence of extremity necrosis. Small necrotic areas usually separate spontaneously with secondary healing or can be excised and sutured. Larger necrotic areas should be excised only after demarcation has been established, and can be covered with delayed skin grafting. Amputation should be conservative but may require revision.

Cryptococcal Inflammatory Pseudotumors

"Inflammatory pseudotumors" (IPTs) embrace a heterogeneous spectrum of reactive, infective, and neoplastic entities, that are characterized by a clinical mass composed of a histologic proliferation of spindle cells in a background of inflammatory cells and collagen fibers. Although a spectrum of microorganisms have been identified in infective IPTs, mycobacterial infective IPTs are reported most commonly. We document 5 solitary cryptococcal IPTs, in 2 males and 3 females, aged 19 to 43 years, in the soft tissues of the anterior chest wall, thigh, and arm. All were HIV-positive and had been treated for disseminated cutaneous and/or meningeal cryptococcosis with antifungal therapy, 6 to 12 months earlier. The specimens demonstrated a storiform arrangement of plump spindle cells, in addition to spindle and polygonal cells that were arranged in a haphazard manner. Background lymphocytes, plasma cells, and fibrosis were noted, in addition to scattered giant cells and focal necrosis. On high-power examination, Cryptococcus neoformans yeasts were identified within and between vacuolated spindle and polygonal cells on routine and special stains, confirming cryptococcal IPTs. Immunophenotyping of the spindle cells confirmed a mixed histiocytic and myofibroblastic lineage, with a predominance of the former. In documenting 5, hitherto unreported, pseudotumoral spindle cell reactions to C. neoformans, we not only highlight the need for intense appraisal of all IPTs for infective agents on routine and special stains and investigations, but also postulate that a complex host-fungus interaction, coupled with an exuberant, myofibroblastic response to incomplete therapy, are the pathogenetic drive for the pseudotumoral presentation.

A varied presentation of hydatid cyst: a report of four cases with review of literature

Contrary to the popular perception, hydatosis does not remain restricted to certain geographical locales but is a global health concern, particularly in the rural countryside. Although liver and lung involvement account for the majority of the lesions, primary breast, bone, kidney and soft tissue hydatosis with features of cystic echinococcosis are extremely rare. We report four such rare cases of cystic echinococcosis which were diagnosed and treated in our institute.