Fournier's gangrene caused by Actinomyces funkei, Fusobacterium gonidiaformans and Clostridium hathewayi

Actinomyces funkei bacteraemia and infected pulmonary cavities in an intravenous drug user: a case report

BACKGROUND

Actinomyces spp. are most commonly found in human commensal flora; however, they have also been shown to cause suppurative infections. We present a case of a rare Actinomyces funkei bacteraemia from an infected deep vein thrombosis in a patient who went on to develop pulmonary cavities secondary to septic emboli. Infected thrombi and septic emboli have been associated with other Actinomyces spp. in the literature, often posing a diagnostic challenge and, in some cases, causing drastic clinical deterioration in patients. The literature regarding Actinomyces funkei is scarce and to our knowledge there are no reports of a relationship between this Actinomyces subspecies and infected thrombi or septic emboli.

CASE PRESENTATION

The patient was a 39-year-old known intravenous drug user who presented with a groin injecting site sinus and systemic symptoms. The bacteria was first observed by gram staining of a blood culture sample after 48 h of incubation and the species was identified using matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) as Actinomyces funkei. Sputum cytology/histology with cell block revealed a branching gram-positive species suspicious of slow growing bacteria or fungus. CT imaging of his lower limb and chest revealed an extensive DVT with inflammatory changes and pulmonary cavities respectively. The patient was treated with Ceftriaxone before being discharged with a 6-month course of Linezolid. He made a good recovery with reduction in size of the cavitating lung lesions on follow-up imaging.

CONCLUSIONS

This case report presents a difficult-to-diagnose bacterial infection in an intravenous drug user, complicated by bacteraemia and secondary septic emboli. Relatively little is known about Actinomyces funkei, and therefore this report aims to increase clinician awareness of diagnosis, management, and complications.

Polymicrobial infections with specific Actinomyces and related organisms, using the current taxonomy

Actinomyces organisms reside on mucosal surfaces of the oropharynx and the genitourinary tract. Polymicrobial infections with Actinomyces organisms are increasingly being reported in the literature. Since these infections differ from classical actinomycosis, lacking of specific clinical and imaging findings, slow-growing Actinomyces organisms can be regarded as contaminants or insignificant findings. In addition, only limited knowledge is available about novel Actinomyces species and their clinical relevance. The recent reclassifications have resulted in the transfer of several Actinomyces species to novel genera Bowdeniella, Gleimia, Pauljensenia, Schaalia, or Winkia. The spectrum of diseases associated with specific members of Actinomyces and these related genera varies. In human infections, the most common species are Actinomyces israelii, Schaalia meyeri, and Schaalia odontolytica, which are typical inhabitants of the mouth, and Gleimia europaea, Schaalia turicensis, and Winkia neuii. In this narrative review, the purpose was to gather information on the emerging role of specific organisms within the Actinomyces and related genera in polymicrobial infections. These include Actinomyces graevenitzii in pulmonary infections, S. meyeri in brain abscesses and infections in the lower respiratory tract, S. turicensis in skin-related infections, G. europaea in necrotizing fasciitis and skin abscesses, and W. neuii in infected tissues around prostheses and devices. Increased understanding of the role of Actinomyces and related species in polymicrobial infections could provide improved outcomes for patient care. Key messages Due to the reclassification of the genus, many former Actinomyces species belong to novel genera Bowdeniella, Gleimia, Pauljensenia, Schaalia, or Winkia.Some of the species play emerging roles in specific infection types in humans.Increasing awareness of their clinical relevance as an established or a putative pathogen in polymicrobial infections brings about improved outcomes for patient care.

Hungatella hathewayi bacteremia due to acute appendicitis: A case report and a narrative review

Hungatella species, including Hungatella hathewayi and Hungatella effluvii, previously identified as part of the Clostridium genus, are anaerobic bacteria primarily residing in the gut microbiome, with infrequent implications in human infections. This article presents the case of an 87-year-old Asian male admitted for a hyperosmolar hyperglycemic state with septic shock secondary to Hungatella hathewayi bacteremia originating from acute appendicitis. Remarkably, the bacterium was detected in the blood 48 hours before the emergence of clinical and radiographic evidence of acute appendicitis. Additionally, we conducted a literature review to identify all documented human infections caused by Hungatella species. Timely microbial identification in such cases is essential for implementing targeted antibiotic therapy and optimizing clinical outcomes.

Clinical characteristics and antimicrobial susceptibility of Fusobacterium species isolated over 10 years at a Japanese university hospital

PURPOSE

Anaerobic bacteria, existing on human skin and mucous membranes, can cause severe infections with complications or mortality. We examined the clinical characteristics of patients infected with Fusobacterium spp. and assessed their antibiotic susceptibility.

METHODS

Clinical data were collated from patients diagnosed with Fusobacterium infections in a Japanese university hospital between 2014 and 2023. Antibiotic susceptibility tests were conducted following the Clinical and Laboratory Standards Institute guidelines.

RESULTS

We identified 299 Fusobacterium isolates. The median age was 61 years (range, 14-95 years), with females constituting 43.1% of the patients. Most infections were community-acquired (84.6%, 253/299). Multiple bacterial strains were isolated simultaneously in 74.6% of cases. One-fourth of the patients had solid organ malignancies (25.4%, 76/299), and 14.5% (11/76) of those had colorectal cancer. The 30-day mortality rate was 1.3%. Fusobacterium species were isolated from blood cultures in 6% (18/299) of the patients. Patients, aged 75 years or older, with cerebrovascular disease or hematologic malignancy exhibited significantly higher prevalence of blood culture isolates in univariate analysis. Each Fusobacterium species had its characteristic infection site. Approximately 5% F. nucleatum and F. necrophorum isolates showed penicillin G resistance. Moxifloxacin resistance was observed in varying degrees across strains, ranging from 4.6 to 100% of isolates. All isolates were sensitive to β-lactam/β-lactamase inhibitors, carbapenems, and metronidazole.

CONCLUSION

We show a link between Fusobacterium species and solid organ malignancies. We observed resistance to penicillin, cefmetazole, clindamycin, and moxifloxacin, warranting caution in their clinical use. This study offers valuable insights for managing Fusobacterium infections and guiding empirical treatments.

Fournier's Gangrene with Growth of Actinomyces europaeus: A Case Report

Fournier's gangrene (FG) is a rare infectious disease with rapid disease progression and a high mortality rate. We report a case of a 61-year-old female with type 2 diabetes who developed FG caused by Actinomyces europaeus. A. europaeus is associated with abscesses, decubitus ulcers, and purulent urethritis. Although A. europaeus rarely causes FG as the main causative pathogen, we should still be alert to this pathogenic microorganism. To our knowledge, this is the first case report of FG caused by A. europaeus mono-infection, and it adds to the evidence that A. europaeus has the potential to cause necrotizing fasciitis.

Management of Fournier's gangrene during the Covid-19 pandemic era: make a virtue out of necessity

Background

Fournier’s gangrene (FG) is a necrotizing fasciitis caused by aerobic and anaerobic bacterial infection that involves genitalia and perineum. Males, in their 60 s, are more affected with 1.6 new cases/100.000/year. Main risk factors are diabetes, malignancy, inflammatory bowel disease. FG is a potentially lethal disease with a rapid and progressive involvement of subcutaneous and fascial plane. A multimodal approach with surgical debridement, antibiotic therapy, intensive support care, and hyperbaric oxygen therapy (HBOT) is often needed.

We present the inpatient management of an FG case during the Covid-19 pandemic period. A narrative review of the Literature searching “Fournier’s gangrene”, “necrotizing fasciitis” on PubMed and Scopus was performed.

Case presentation

A 60 years old man affected by diabetes mellitus, with ileostomy after colectomy for ulcerative colitis, was admitted to our Emergency Department with fever and acute pain, edema, dyschromia of right hemiscrotum, penis, and perineal region. Computed tomography revealed air-gas content and fluid-edematous thickening of these regions. Fournier’s Gangrene Severity Index was 9. A prompt broad-spectrum antibiotic therapy with Piperacillin/Tazobactam, Imipenem and Daptomycin, surgical debridement of genitalia and perineal region with vital tissue exposure, were performed. Bedside daily surgical wound medications with fibrine debridement, normal saline and povidone-iodine solutions irrigation, iodoform and fatty gauze application, were performed until discharge on the 40^th postoperative day. Every 3 days office-based medication with silver dressing, after normal saline and povidone-iodine irrigation and fibrinous tissue debridement, was performed until complete re-epithelialization of the scrotum on the 60^th postoperative day.

Conclusions

FG is burdened by a high mortality rate, up to 30%. In the literature, HBOT could improve wound restoration and disease-specific survival. Unfortunately, in our center, we do not have HBOT. Moreover, one of the pandemic period problems was the patient’s displacement and outpatient hospital management. For all these reasons we decided for a conservative inpatient management. Daily cleaning of the surgical wound allowed to obtain its complete restoration avoiding surgical graft and hyperbaric oxygen chamber therapy, without foregoing optimal outcomes.

A rare case of male Fournier's gangrene with mixed Actinomyces turicensis infection

BACKGROUND

Fournier's gangrene (FG), a urological emergency with high mortality, is an infectious necrotizing fasciitis of the perineal and genital regions. The majority of FG is caused by polymicrobial organisms involving mixed aerobes and anaerobes but rarely reveals Actinomyces species.

CASE PRESENTATION

We report a healthy 67-year-old Asian male who presented with rapidly progressive painful swelling of the scrotum. Clinically diagnosed with FG, the patient underwent an emergency radical debridement, followed by broad-spectrum antibiotics and negative pressure wound therapy. The identification of the causative microorganisms showed Actinomyces turicensis and the antibiotic treatment was adjusted accordingly. After wound bed preparation, we took split-thickness skin grafts to cover the scrotal wound. Active management to minimize faecal contamination was applied throughout the whole course of treatment and repair. The patient was satisfied with the outcome. This was an extremely rare case of A. turicensis as the main causative pathogen of FG.

CONCLUSIONS

FG due to Actinomyces species is rarely reported, but we should still consider this pathogenic microorganism that has long been neglected.

A rare case of necrotizing fasciitis of the abdominal wall due to Hungatella effluvii and Streptococcus constellatus

We report a rare case of necrotizing fasciitis of the abdominal wall caused by Hungatella effluvii and Streptococcus constellatus. Necrotizing fasciitis has high mortality, so early diagnosis and aggressive treatment are essential for good clinical outcome. Identification of the microbial contribution to these infections is crucial for targeted antibiotic treatment.

Associations between Dietary Fiber, the Fecal Microbiota and Estrogen Metabolism in Postmenopausal Women with Breast Cancer

Breast cancer is a hormonally-driven cancer, and various dietary factors are associated with estrogen metabolism, including dietary fiber. Several studies report associations between dietary fiber and breast cancer; however, research on whether fiber influences circulating estrogens through the gut microbiota is rare. The objective of this cross-sectional study among 29 newly-diagnosed (stage 0-II), post-menopausal breast cancer patients is to examine associations between dietary fiber and the gut microbiota that are linked with β-glucuronidase activity, and purportedly increase circulating estrogens. Spearman's and partial correlations controlling for body mass index and age were performed using dietary recall data, Illumina MiSeq generated microbiota relative abundance, and HPLC-mass spectrometry-derived estradiol and estrone levels.Major findings are: (1) total dietary fiber is inversely associated with Clostridium hathewayi (r= -0.419; p = 0.024); (2) soluble fiber is inversely associated with Clostridium (r=-0.11; p = 0.02); (3) insoluble fiber is positively associated with Bacteroides uniformis sp. (r = 0.382; p = 0.041); and (4) serum estradiol and estrone levels are not correlated with species/genera or dietary fiber, though there is a trend toward an inverse association between soluble fiber and estradiol levels (r= -0.30; p = 0.12). More studies are needed to understand the complex interaction between dietary fiber, intestinal microbiota, and hormonal levels in older females.

Fournier's Gangrene and Intravenous Drug Abuse: an Unusual Case Report and Review of The Literature

Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes. In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia. Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.

Rare isolation of Fusobacterium varium from a case of Fournier's gangrene

Fusobacterium is a gram negative obligate anaerobic bacilli, a normal inhabitant of gastrointestinal tract, oropharynx and female genital tract. Here we report a case of Fourniers gangrene from which Fusobacterium varium has been isolated along with certain other pathogens. There are only a few reported cases of Fusobacterium varium in literature and it has never been reported from Fournier's gangrene. Through this report we intend to shed some light on the pathogenic potential of anaerobes which are considered as normal flora.

A Clostridium hathewayi isolate in blood culture of a patient with an acute appendicitis

INTRODUCTION

Clostridium species is a group of anaerobic bacteria constituting the colonic microflora of the intestinal tract. Since molecular methodologies based on 16 rRNA have been established for the classification and the recognition of bacterial species, more than 150 species of Clostridium have been described. Most are considered harmless saprophytes; however, these bacteria may be involved in a wide variety of infections and may be a common cause of enteritis and enterotoxemias in humans.

CASE PRESENTATION

We present the case of a 60-year-old Asian patient admitted in the emergency room with an acute appendicitis where a blood culture showed the presence of a Clostridium hathewayi. This microorganism is an anaerobic bacteria described in 2001 as a Gram negative end-pointed bacillus, usually endospore-forming. It was reclassified in 2014 as Hungatella hathewayi. A literature review has been performed to find articles relating to this bacteria in a clinical case.

CONCLUSION

C. hathewayi is microorganism recently reclassified as Hungatella hathewayi. Its growth in blood cultures has been reported in a few cases in the literature. Although only a few articles have reported its involvement in clinical infections, we assess that its part in the cause of the illness should be evaluated.

Actinomyces and related organisms in human infections

Actinomyces israelii has long been recognized as a causative agent of actinomycosis. During the past 3 decades, a large number of novel Actinomyces species have been described. Their detection and identification in clinical microbiology laboratories and recognition as pathogens in clinical settings can be challenging. With the introduction of advanced molecular methods, knowledge about their clinical relevance is gradually increasing, and the spectrum of diseases associated with Actinomyces and Actinomyces-like organisms is widening accordingly; for example, Actinomyces meyeri, Actinomyces neuii, and Actinomyces turicensis as well as Actinotignum (formerly Actinobaculum) schaalii are emerging as important causes of specific infections at various body sites. In the present review, we have gathered this information to provide a comprehensive and microbiologically consistent overview of the significance of Actinomyces and some closely related taxa in human infections.