1
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Yokose M, Hirosawa T, Tsunashima K, Shimizu T. A Typical Case of Atypical Disease: "Three Noes" Infective Endocarditis. Cureus 2024; 16:e65325. [PMID: 39184702 PMCID: PMC11344238 DOI: 10.7759/cureus.65325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
Recognizing typical presentations of atypical cases is essential to reduce diagnostic errors and achieve better diagnoses. To better understand this, we report a typical case of "three noes" infective endocarditis (no left-sided, no intravenous drug use, and no intracardiac devices) with some different characteristics from well-known infective endocarditis. A 16-year-old boy with a history of atopic dermatitis presented with a one-month history of intermittent fever and shaking chills. The patient became afebrile with oral antibiotics, and initial investigations did not detect any evidence of bacterial infection, including heart murmurs and peripheral embolic manifestations. However, his symptoms relapsed one week after the cessation of antibiotics. A repeated workup revealed tricuspid valve infective endocarditis due to methicillin-susceptible Staphylococcus aureus. The relationship between atopic dermatitis and infective dermatitis has been reported in some literature, and clinicians should consider three noes infective endocarditis in patients with atopic dermatitis presenting with fever and unremarkable physical examination.
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Affiliation(s)
- Masashi Yokose
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, JPN
| | - Takanobu Hirosawa
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, JPN
| | - Keita Tsunashima
- Department of Emergency and General Medicine, Dokkyo Medical University Nikko Medical Center, Nikko, JPN
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Mibu, JPN
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2
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Dai M, Suzuki K, Sato H, Tabata S, Kume H, Nishikata M, Tamada K, Ooigawa H, Kurita H. Intracranial mycotic aneurysm rupture following cupping therapy. Surg Neurol Int 2024; 15:119. [PMID: 38742002 PMCID: PMC11090582 DOI: 10.25259/sni_99_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 03/15/2024] [Indexed: 05/16/2024] Open
Abstract
Background Cupping therapy is an alternative treatment that uses a small glass cup to suck the skin with a needle and has been used to manage skin problems and pain. However, serious complications have been reported. Herein, we describe a case of intracranial mycotic aneurysm rupture after cupping therapy. Case Description A 25-year-old male patient presented with a headache and fever after cupping therapy for atopic dermatitis. He was diagnosed with infective endocarditis, and antibiotic therapy was initiated. After that, he suddenly lost consciousness, and head imaging revealed a cerebral hemorrhage due to a ruptured intracranial mycotic aneurysm. He underwent craniotomy, which was successful, and he was transferred to a rehabilitation center with a modified Rankin scale score of 2 at three months post-stroke. Conclusion This case serves as a reminder of life-threatening infectious complication risks after cupping therapy. A patient who has a compromised skin barrier may experience serious adverse effects, especially when cupping is performed without implementing suitable infection prevention measures.
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Affiliation(s)
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
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3
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Tamura Y, Abe T. Infective endocarditis associated with atopic dermatitis. Clin Case Rep 2023; 11:e8321. [PMID: 38130851 PMCID: PMC10733789 DOI: 10.1002/ccr3.8321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
Infective endocarditis caused by atopic dermatitis is common in young patients and has a high potential for causing embolism. Because of the high risk of mediastinitis postoperatively, minimally invasive cardiac surgery could be effective.
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Affiliation(s)
- Yamato Tamura
- Department of Cardiovascular SurgeryNara Prefectural Seiwa Medical CenterNaraJapan
| | - Takehisa Abe
- Department of Cardiovascular SurgeryNara Prefectural Seiwa Medical CenterNaraJapan
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4
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Kubota S, Nemoto M, Sakaeyama Y, Nakada C, Mikai M, Fuchinoue Y, Kondo K, Harada N, Sugo N. Repeated intracranial empyema following cranioplasty in a patient with atopic dermatitis: a case report. J Med Case Rep 2021; 15:373. [PMID: 34261534 PMCID: PMC8281563 DOI: 10.1186/s13256-021-02898-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Atopic dermatitis is a chronic inflammatory skin disease associated with pruritus. Skin affected by atopic dermatitis not only shows a high percentage of Staphylococcus aureus colonization, but corneal barrier dysfunction is also known to occur. It is considered a risk factor for bacterial infections in various areas of the body. However, the relationship between atopic dermatitis and bacterial infection following neurological surgery has not yet been reported. Here, we present a case of atopic dermatitis in which the surgical site became infected twice and finally resolved only after the atopic dermatitis was treated. Case presentation A 50-year-old Japanese woman with atopic dermatitis underwent cerebral aneurysm clipping to prevent impending rupture. Postoperatively, she developed repeated epidural empyema following titanium cranioplasty. As a result of atopic dermatitis treatment with oral antiallergy medicines and external heparinoids, postoperative infection was suppressed by using an absorbable plastic plate for cranioplasty. The patient’s postoperative course was uneventful for 16 months. Conclusions Atopic dermatitis is likely to cause surgical-site infection in neurosurgical procedures, and the use of a metal implant could promote the development of surgical-site infection in patients with dermatitis.
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Affiliation(s)
- Shuhei Kubota
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan.
| | - Masaaki Nemoto
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Yuki Sakaeyama
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Chie Nakada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Masataka Mikai
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Yutaka Fuchinoue
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Kosuke Kondo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Naoyuki Harada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Nobuo Sugo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University, 6-11-1, Omori-nishi, Ota-Ku, Tokyo, 143-8541, Japan
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5
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Pulido-Pérez A, Bergón-Sendín M, Suárez-Fernández R, Muñoz-Martín P, Bouza E. Skin and sepsis: contribution of dermatology to a rapid diagnosis. Infection 2021; 49:617-629. [PMID: 33860474 DOI: 10.1007/s15010-021-01608-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/19/2021] [Indexed: 11/24/2022]
Abstract
In patients who develop sepsis, whether due to primary, secondary or metastatic lesions, the skin is frequently affected. However, there are unresolved aspects regarding the general clinical manifestations in the skin or the prognosis and/or therapeutic implications. The main challenge in the approach to sepsis is its early diagnosis and management. In this review, we address the sepsis-skin relationship and the potential impact of early dermatological intervention on the septic patient through ten basic questions. We found little evidence of the participation of the dermatologist in sepsis alert programs. There are early skin changes that may alert clinicians on a possible sepsis, such as skin mottling or variations in acral skin temperature. In addition, the skin is an accessible and highly cost-effective tissue for etiological studies of some forms of sepsis (e.g., meningococcal purpura) and its involvement defines the prognosis of certain patients (e.g., infective endocarditis).
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Affiliation(s)
- A Pulido-Pérez
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo 46, 28007, Madrid, Spain. .,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.
| | - M Bergón-Sendín
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo 46, 28007, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - R Suárez-Fernández
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo 46, 28007, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - P Muñoz-Martín
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - E Bouza
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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6
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Woodun H, Bouayyad S, Sahib S, Elamin N, Hunter S, Al-Mohammad A. Tricuspid valve infective endocarditis in a non-IVDU patient with atopic dermatitis. Oxf Med Case Reports 2020; 2020:omaa045. [PMID: 32728448 PMCID: PMC7376984 DOI: 10.1093/omcr/omaa045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/21/2020] [Accepted: 04/28/2020] [Indexed: 11/12/2022] Open
Abstract
A 29-year-old male, with chronic atopic dermatitis (AD), presented with a 2-week history of fatigue, pyrexia and weight loss. Examination showed eczematous patches with lichenified papules, erosions on the right shin and a new murmur. Blood cultures isolated methicillin-sensitive Staphylococcus aureus. Transthoracic echocardiography showed vegetation on the tricuspid valve (TV) that was adherent to the septal leaflet. He was treated for infective endocarditis, attributed to poorly controlled AD, with intravenous Flucloxacillin. Due to ongoing sepsis and pulmonary septic emboli, Clindamycin was added. He underwent TV repair; the septal leaflet was excised, and the remnant two leaflets were brought together with a ring. His patent foramen ovale was closed. His skin was treated with topical steroids and emollients. Right-sided endocarditis of an intact TV is uncommon in a non-intravenous drug user. Therefore, this novel case portrays the importance of aggressively managing AD as it is a risk factor for significant systemic infections.
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Affiliation(s)
- Heerani Woodun
- Cardiology Department, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK
- Correspondence address. Tel: +447958911373; E-mail: ; ORCID Identifier: https://orcid.org/0000-0003-2051-3906
| | - Sarah Bouayyad
- ENT Department, Tameside General Hospital, Ashton-Under-Lyne OL6 9RW, UK
| | - Sura Sahib
- Dermatology Department, Doncaster Royal Infirmary, Doncaster DN2 5LT, UK
| | - Nadir Elamin
- Cardiology Department, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK
| | - Steven Hunter
- Cardiothoracic Department, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK
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7
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Akagi M, Iwanaga N, Torisu Y, Fujita H, Kawahara C, Horai Y, Izumi Y, Kawakami A. IgA Vasculitis Triggered by Infective Endocarditis of Pulmonary Artery with Congenitally Corrected Transposition of the Great Arteries. Int Heart J 2020; 61:404-408. [PMID: 32173704 DOI: 10.1536/ihj.19-446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A man in his 40s with a history of congenitally corrected transposition of the great arteries (CCTGA) and closure of ventricular septal defect was referred to our hospital with purpura and hematuria. Presence of purpura, renal damage, and pathological findings on skin biopsy led to the diagnosis of IgA vasculitis (IgAV). Oral prednisolone (PSL) was initiated. However, Streptococcus pseudoporcinus was isolated from blood cultures, and transthoracic echocardiogram revealed vegetation on the pulmonary valve. From these findings, the diagnosis of infective endocarditis (IE) was made. Although the patient's condition improved after PSL interruption and antibiotic administration, his purpura relapsed. PSL readministration improved symptoms, with no further relapse even after gradual PSL dose reduction. The present case raises awareness of the importance of recognizing the occurrence of IE in IgAV patients, especially in those with congenital heart disease. CCTGA should be acknowledged as a risk factor for IE in the right-sided heart.
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Affiliation(s)
- Midori Akagi
- Department of General Internal Medicine, National Hospital Organization Nagasaki Medical Center.,Department of Rheumatology, JCHO Isahaya General Hospital
| | - Nozomi Iwanaga
- Department of Rheumatology, National Hospital Organization Nagasaki Medical Center
| | - Yuichi Torisu
- Department of General Internal Medicine, National Hospital Organization Nagasaki Medical Center
| | - Hisayuki Fujita
- Physiological Laboratory, National Hospital Organization Nagasaki Medical Center
| | - Chieko Kawahara
- Department of General Internal Medicine, National Hospital Organization Nagasaki Medical Center
| | - Yoshiro Horai
- Department of Rheumatology, National Hospital Organization Nagasaki Medical Center.,Clinical Research Center, National Hospital Organization Nagasaki Medical Center
| | - Yasumori Izumi
- Department of General Internal Medicine, National Hospital Organization Nagasaki Medical Center
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences
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8
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Oral Microbiome Alterations Associated with Early Childhood Caries Highlight the Importance of Carbohydrate Metabolic Activities. mSystems 2019; 4:4/6/e00450-19. [PMID: 31690590 PMCID: PMC6832018 DOI: 10.1128/msystems.00450-19] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Dental caries is a highly prevalent oral disease that can lead to severe dental damage and may greatly compromise the quality of life of the affected individuals. Previous studies, including those based on 16S rRNA gene, have revealed that the oral microbiota plays a prominent role in development of the disease. But the approach of those studies was limited in analyzing several key microbiome traits, including species- or strain-level composition and functional profile. Here, we performed metagenomic analyses for a cohort of preschool children with or without caries. Our results showed that caries was associated with extensive microbiota differences at various taxonomic and functional levels. Some caries-associated species had not been previously reported, some of which may have significant clinical implications. A microbiome gene catalogue from children with caries was constructed for the first time. The results demonstrated that caries is associated with alterations of the oral microbiome, including changes in microbial composition and metabolic functional profile. Globally, dental caries is the most prevalent chronic oral disease and affects roughly half of all children. The aim of this report was to use metagenomic analyses to investigate the relationship between the oral microbiome and caries in preschool children. A total of 25 preschoolers, aged 3 to 5 years old with severe early childhood caries (ECC), and 19 age-matched, caries-free children as controls were recruited. Saliva samples were collected from the participants and were subjected to metagenomic analyses, whereby the oral microbial communities were investigated. The metagenomic analyses revealed substantial microbiota differences between the two groups, indicating apparent shifts of the oral microbiome present in the ECC group. At the species level, the ECC-enriched microbes included Prevotella amnii, Shuttleworthia satelles, Olsenella uli, and Anaeroglobus geminatus. Interestingly, Actinomyces odontolyticus and Actinomyces graevenitzii exhibited apparent differences at the strain level but not the species level between the ECC and control groups. Functional examination showed that the ECC group displayed extensive alterations in metabolic genes/pathways/modules, including enriched functions in sugar metabolism. Finally, an SVM (support vector machine) classifier comprising seven species was developed and generated a moderately good performance in predicting caries onset (area under the receiver operating characteristic curve [AUC] = 78.33%). Together, these findings indicate that caries is associated with considerable changes in the oral microbiome, some of which can potentially be exploited as therapeutic targets or diagnostic markers. (This study has been registered at ClinicalTrials.gov under registration no. NCT02341352.) IMPORTANCE Dental caries is a highly prevalent oral disease that can lead to severe dental damage and may greatly compromise the quality of life of the affected individuals. Previous studies, including those based on 16S rRNA gene, have revealed that the oral microbiota plays a prominent role in development of the disease. But the approach of those studies was limited in analyzing several key microbiome traits, including species- or strain-level composition and functional profile. Here, we performed metagenomic analyses for a cohort of preschool children with or without caries. Our results showed that caries was associated with extensive microbiota differences at various taxonomic and functional levels. Some caries-associated species had not been previously reported, some of which may have significant clinical implications. A microbiome gene catalogue from children with caries was constructed for the first time. The results demonstrated that caries is associated with alterations of the oral microbiome, including changes in microbial composition and metabolic functional profile.
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9
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Takahashi F, Wada Y, Hasebe N. Case of Invasive Streptococcus Dysgalactiae Infection Presenting as Infective Endocarditis with Multiple Brain Embolisms. Int Heart J 2019; 60:204-207. [DOI: 10.1536/ihj.17-700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Yoshiki Wada
- Department of Cardiovascular Medicine, Rumoi City Hospital
| | - Naoyuki Hasebe
- Department of the Internal Medicine, Cardiovascular, Respiratory and Neurology Division, Asahikawa Medical University
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10
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Nakanishi M, Oota E, Tomita Y, Kato T, Imanishi T. A case of infective endocarditis associated with atopic dermatitis perioperatively treated with dupilumab. J DERMATOL TREAT 2019; 30:674-676. [PMID: 30628496 DOI: 10.1080/09546634.2019.1568379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Several case reports and reviews support a relationship between atopic dermatitis (AD) and infective endocarditis (IE). Here, we present a case of severe AD suspected of causing IE. Case presentation: A 21-year-old man with severe AD was admitted to our hospital due to unidentified fever, syncope, and headache. He was diagnosed with IE with cerebral embolism and mitral regurgitation. Before elective cardiac surgery, he was subcutaneously administered dupilumab for 2 months to control AD. Dupilumab improved AD, and cardiac surgery was performed without complications. Conclusions: Dupilumab may be effective in AD cases as preparation for cardiac surgery.
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Affiliation(s)
- Mika Nakanishi
- a Department of Anesthesia, Osakafu Saiseikai Noe Hospital , Osaka City , Osaka , Japan
| | - Eri Oota
- a Department of Anesthesia, Osakafu Saiseikai Noe Hospital , Osaka City , Osaka , Japan
| | - Yukihiko Tomita
- a Department of Anesthesia, Osakafu Saiseikai Noe Hospital , Osaka City , Osaka , Japan
| | - Takeshi Kato
- a Department of Anesthesia, Osakafu Saiseikai Noe Hospital , Osaka City , Osaka , Japan
| | - Toshihiro Imanishi
- a Department of Anesthesia, Osakafu Saiseikai Noe Hospital , Osaka City , Osaka , Japan
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11
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Darisipudi MN, Nordengrün M, Bröker BM, Péton V. Messing with the Sentinels-The Interaction of Staphylococcus aureus with Dendritic Cells. Microorganisms 2018; 6:microorganisms6030087. [PMID: 30111706 PMCID: PMC6163568 DOI: 10.3390/microorganisms6030087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/12/2018] [Accepted: 08/14/2018] [Indexed: 12/14/2022] Open
Abstract
Staphylococcus aureus (S. aureus) is a dangerous pathogen as well as a frequent colonizer, threatening human health worldwide. Protection against S. aureus infection is challenging, as the bacteria have sophisticated strategies to escape the host immune response. To maintain equilibrium with S. aureus, both innate and adaptive immune effector mechanisms are required. Dendritic cells (DCs) are critical players at the interface between the two arms of the immune system, indispensable for inducing specific T cell responses. In this review, we highlight the importance of DCs in mounting innate as well as adaptive immune responses against S. aureus with emphasis on their role in S. aureus-induced respiratory diseases. We also review what is known about mechanisms that S. aureus has adopted to evade DCs or manipulate these cells to its advantage.
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Affiliation(s)
- Murthy N Darisipudi
- Department of Immunology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße DZ7, D-17475 Greifswald, Germany.
| | - Maria Nordengrün
- Department of Immunology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße DZ7, D-17475 Greifswald, Germany.
| | - Barbara M Bröker
- Department of Immunology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße DZ7, D-17475 Greifswald, Germany.
| | - Vincent Péton
- Department of Immunology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße DZ7, D-17475 Greifswald, Germany.
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