Daptomycin for methicillin-resistant Staphylococcus epidermidis native-valve endocarditis: a case report

Objective

Strongyloides stercoralis is a soil-transmitted intestinal nematode that has been estimated to infect at least 60 million people, especially in tropical and subtropical regions. Strongyloides infection has been described in immunosupressed patients with lymphoma, rheumatoid arthritis, diabetes mellitus etc. Our case who has rheumatoid arthritis (RA) and bronchial asthma was treated with low dose steroids and methotrexate.

Methods

A 68 year old woman has bronchial asthma for 55 years and also diagnosed RA 7 years ago. She received immunusupressive agents including methotrexate and steroids. On admission at hospital, she was on deflazacort 5 mg/day and methotrexate 15 mg/week. On her physical examination, she was afebrile, had rhonchi and mild epigastric tenderness. She had joint deformities at metacarpophalengeal joints and phalanges but no active arthritis finding.

Results

Oesophagogastroduodenoscopy was performed and it showed hemorrhagic focus at bulbus. Gastric biopsy obtained and showed evidence of S.Stercoralis infection. Stool and sputum parasitological examinations were also all positive for S.stercoralis larvae. Chest radiography result had no pathologic finding. Albendazole 400 mg/day was started for 23 days. After the ivermectin was retrieved, patient was treated with oral ivermectin 200 μg once a day for 3 days. On her outpatient control at 15th day, stool and sputum samples were all negative for parasites.

Conclusion

S.stercoralis may cause mortal diseases in patients. Immunosupression frequently causes disseminated infections. Many infected patients are completely asymptomatic. Although it is important to detect latent S. stercoralis infections before administering chemotherapy or before the onset of immunosuppression in patients at risk, a specific and sensitive diagnostic test is lacking. In immunosupressed patients, to detect S.stercoralis might help to have the patient survived and constitute the exact therapy.     

耐甲氧西林金黄色葡萄球菌感染控制策略的新进展

耐甲氧西林金黄色葡萄球菌(methicillin-resistant Staphylococcus Aureus, MRSA)已成为一种越来越具有侵袭性和流行性的病原菌。通过染色体介导、质粒转移、基因表达调控和主动外排系统等途径,MRSA对包括万古霉素在内的多种抗生素产生了抗药性。从生态学和进化的角度来考虑,仅仅通过利用抗生素本身来解决耐药性的困境是不够的。这就迫使人们去寻找一类完全不同于化学药物治疗MRSA感染的机制。随着对免疫学和生物学认识的不断深入,基于免疫逃逸、细菌群体感应、基因调控等理论的发现,涌现了一批生物制剂抗MRSA感染的研究,相对于传统的抗生素治疗这是一个全新突破的领域。此外还有传统中草药的研发也提示其在抗MRSA方面存在积极的活力。本综述总结了生物制剂、新型策略化学药物和传统中草药治疗MRSA感染的最新进展,以寻找解决抗生素治疗困境的新线索。     

Recurrent Staphylococcus lugdunensis central nervous system infection associated with a ventricular peritoneal shunt

A case of recurrent Staphylococcus lugdunensis central nervous system (CNS) infection associated with a ventricular peritoneal (VP) shunt is reported. A total of five S. lugdunensis isolates were isolated from the patient (four from ventricular fluid and one from a VP catheter tip). All five isolates share an indistinguishable pulsed-field gel electrophoresis profile. A full range of conventional biochemical tests and 16S rRNA gene nucleotide sequence analyses were performed to confirm identification of the organism. This is the first report of S. lugdunensis in catheter-related VP fluid infection. The isolate was capable of colonizing the CNS and was difficult to treat.     

Choroiditis in a HIV-infected patient with disseminated cryptococcal infection: A case report and literature review

BackgroundOcular involvement in AIDS patients is a common event mainly caused by inflammation or infection. Despite the high prevalence rate of cryptococcosis in these individuals, ocular features have been occasionally described.Case reportA 20-year-old Brazilian female with HIV infection recently diagnosed was admitted with a respiratory profile presumptively diagnosed as Pneumocystis jirovecii pneumonia; an ophthalmologic exam suggested choroiditis by this agent as well. She was complaining of headaches and blurred vision which led to cryptococcal meningitis diagnosis by a CSF positive India ink stain and Cryptococcus neoformans positive culture. Despite therapy based on amphotericin B plus fluconazole, her clinical state progressively worsened and the patient died one week later. At necropsy, disseminated cryptococcal infection was evidenced in several organs including eyes, which presented bilateral chorioretinitis.ConclusionsCryptococcal ocular involvement in AIDS patients has been occasionally proved among the cases already reported. Thus, the post mortem exam is still pivotal to improve the quality of the clinical diagnosis, especially in limited-resource settings.     

Successful salvage therapy with Daptomycin for osteomyelitis caused by methicillin-resistant Staphylococcus aureus in a renal transplant recipient with Fabry-Anderson disease

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal disorder that presents with hemolytic anemia, marrow failure and thrombophilia. During acute attacks, corticosteroid can alleviate the hemolytic paroxysm, but the prolonged administration induces serious toxicity including immunosuppression. So American thoracic society (ATS) for tuberculosis (TB) recommends prophylactic anti-TB medication in patients with a long-term steroid therapy. However, in the patient who was treated for active TB in the past, there are no guidelines of the test for determining patients who have latent TB infection (LTBI) and no recommendations of TB prophylaxis if there is no evidence of reactivation at present. A 40-year-old male patient presented with fever and aggravated weakness for a week. He was diagnosed with PNH a month ago and took corticosteroid for 3 weeks. In the past, he was diagnosed with pulmonary TB and completely cured after treatment. According to guideline, he was not indicated with TB prophylaxis. However, he caught miliary TB, progressed to acute respiratory distress syndrome. We experience this embarrassing case, and emphasize the need to investigate multicentral TB prevalence and to make the guidelines of anti-TB medication in subgroups of hematologic diseases including PNH.     

Evolutionary dynamics of methicillin-resistant Staphylococcus aureus within a healthcare system

BackgroundIn the past decade, several countries have seen gradual replacement of endemic multi-resistant healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) with clones that are more susceptible to antibiotic treatment. One example is Singapore, where MRSA ST239, the dominant clone since molecular profiling of MRSA began in the mid-1980s, has been replaced by ST22 isolates belonging to EMRSA-15, a recently emerged pandemic lineage originating from Europe.ResultsWe investigated the population structure of MRSA in Singaporean hospitals spanning three decades, using whole genome sequencing. Applying Bayesian phylogenetic methods we report that prior to the introduction of ST22, the ST239 MRSA population in Singapore originated from multiple introductions from the surrounding region; it was frequently transferred within the healthcare system resulting in a heterogeneous hospital population. Following the introduction of ST22 around the beginning of the millennium, this clone spread rapidly through Singaporean hospitals, supplanting the endemic ST239 population. Coalescent analysis revealed that although the genetic diversity of ST239 initially decreased as ST22 became more dominant, from 2007 onwards the genetic diversity of ST239 began to increase once more, which was not associated with the emergence of a sub-clone of ST239. Comparative genomic analysis of the accessory genome of the extant ST239 population identified that the Arginine Catabolic Mobile Element arose multiple times, thereby introducing genes associated with enhanced skin colonization into this population.ConclusionsOur results clearly demonstrate that, alongside clinical practice and antibiotic usage, competition between clones also has an important role in driving the evolution of nosocomial pathogen populations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13059-015-0643-z) contains supplementary material, which is available to authorized users.     

Typing of methicillin-resistant Staphylococcus aureus with IS256

A simple one-step procedure is described for specifically amplifying and labelling insertion element IS256 which is associated with the gentamicin-resistance transposon Tn4001. The product has been used to probe DNA digests of methicillin-resistant Staphylococcus aureus. The resulting restriction fragment length polymorphisms were found to be able to distinguish isolates which were indistinguishable by other typing methods. The probe also hybridised with methicillin-resistant Staphylococcus aureus which were isolated before the emergence of gentamicin resistance, demonstrating its usefulness in typing species other than those that are gentamicin-resistant.     

Marrow mesenchymal stromal cells reduce methicillin-resistant Staphylococcus aureus infection in rat models

Background aimsStaphylococci account for a large proportion of hospital-acquired infections, especially among patients with indwelling devices. These infections are often caused by biofilm-producing strains, which are difficult to eradicate and may eventually cause bacteremia and metastatic infections. Recent evidence suggests that mesenchymal stem cells can enhance bacterial clearance in vivo.MethodsIn this study, a rat model with carboxymethyl cellulose pouch infection was used to analyze the efficacy of bone marrow–derived mesenchymal stromal cells (BMSCs) against the methicillin-resistant Staphylococcus aureus.ResultsThe results showed that the administration of BMSCs effectively reduced the number of bacterial colonies and the expression of many cytokines and chemokines (such as interleukin [IL]-6, IL-1β, IL-10 and CCL5). Unlike the fibroblast control groups, the pouch tissues from the BMSC-treated rats showed the formation of granulations, suggesting that the healing of the wound was in progress.ConclusionsThe results indicate that the treatment of BMSCs can reduce methicillin-resistant S aureus infection in vivo, thereby reducing the inflammatory response.     

Probable disseminated Mycobacterium abscessus subspecies bolletii infection in a patient with idiopathic CD4+ T lymphocytopenia: a case report

ABSTRACT: INTRODUCTION: Rapidly growing mycobacteria are opportunistic pathogens in patients with underlying riskfactors. Mycobacterium abscessus subsp. bolletii is a newly recognized member of rapidlygrowing mycobacteria, isolated from respiratory tract and cutaneous infections. CASE PRESENTATION: We describe a case of chronic disseminated infection caused by M. abscessus subsp. bolletiiin a 38-year-old Sri Lankan man with idiopathic CD4+ T lymphocytopenia. Idiopathic CD4+T lymphocytopenia is a rare cause of immunodysfunction that, similar to humanimmunodeficiency virus infection. M. abscessus subsp. bolletii infection was diagnosed byculture isolation from two sputum samples. CONCLUSIONS: To the best of our knowledge this is the first report of M. abscessus subsp. bolletiidisseminated infection in a patient affected by idiopathic CD4+ T lymphocytopenia. Incontrast to previous reports, the isolate of M. abscessus subsp. bolletii presented intermediateresistance to clarithromycin and was susceptible to cefoxitin and imipenem.     

Primary central nervous system plasmablastic lymphoma presenting in human immunodeficiency virus-negative but Epstein-Barr virus-positive patient: A case report

ABSTRACT: We report a 32-year-old Outer Mongolian man, with plasmablastic lymphoma (PBL) primarily occured in the central nervous system and diagnosed by surgical resection. This patient appeared headache and Magnetic resonance imaging (MRI) showed multiple lesions in the right cerebral hemisphere including the right frontal-parietal lobe and right basal ganglia and the left cerebellum, he was diagnosed as lymphoma by stereotactic biopsy in January 2009 in local hospital, and was given radiotherapy 33 times after the biopsy. The patient was admitted to The Military General Hospital of Beijing PLA., Beijing, P.R. China on March 9th, 2011, with chief complaints of right limbs convulsioned suddenly, then fell down and lose of his consciousness, then awoke after 4 to 5 minutes, with symptoms of angulus oris numbness and the right upper limb powerless ten days ago. MRI of the brain revealed a well-defined hyperdense and enhancing mass in the left frontalparietal lobe, the meninges are closely related, there was extensive peritumoural edema noted with pressure effects, as evident by effacement of the left lateral ventricles and a 0.5 cm shift of the midline to the right side. Surgical resection showed markedly atypical, large singly dispersed or cohesive proliferation of plasmacytoid cells with frequent abnormal mitoses and binucleation, some neoplastic cells were large with round or oval nuclei and showed coarse chromatin and smaller or unapparent nucleoli, some neoplastic cells with prominent nucleoli, apoptosis and necrosis were often presented. Immunohistochemistry staining and gene rearrangement together with other supportive investigation confirmed the diagnosis of primary central nervous system plasmablastic lymphoma. A month later, he was started on chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, leurocristime and prednisone) for a week. Other supportive treatment was provided for symptomatic epilepsy. The patient regained muscle strength in both upper limbs and right lower limb and the symptomatic epilepsy was controlled after two weeks. Then the patient was discharged. Follow-up data shows the patient to be alive eleven months after discharge. Virtual Slides The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1649317674697046.     

Primary angiitis of the central nervous system presenting with subacute and fatal course of disease: a case report

Background

Primary angiitis of the central nervous system is an idiopathic disorder characterized by vasculitis within the dural confines. The clinical presentation shows a wide variation and the course and the duration of disease are heterogeneous. This rare but treatable disease provides a diagnostic challenge owing to the lack of pathognomonic tests and the necessity of a histological confirmation.

Case presentation

A 28-year-old patient presenting with headache and fluctuating signs of encephalopathy was treated on the assumption of viral meningoencephalitis. The course of the disease led to his death 10 days after hospital admission. Postmortem examination revealed primary angiitis of the central nervous system.

Conclusion

Primary angiitis of the central nervous system should always be taken into consideration when suspected infectious inflammation of the central nervous system does not respond to treatment adequately. In order to confirm the diagnosis with the consequence of a modified therapy angiography and combined leptomeningeal and brain biopsy should be considered immediately.

     

LysGH15 reduces the inflammation caused by lethal methicillin-resistant Staphylococcus aureus infection in mice

The endolysin LysGH15, derived from staphylococcal phage GH15, has a wide lytic spectrum and strong lytic activity against Staphylococcus aureus, especially methicillin-resistant S. aureus (MRSA), in vitro and in vivo. Here, the ability of lethal MRSA to induce mRNA levels of interleukin-6 (IL-6), interleukin-4 (IL-4), and interferon-γ (IFN-γ) in spleen tissues of mice was studied. A large number of bacteria were detected in spleens. The bacteria caused elevated expression levels of these three cytokines. Administration of LysGH15 significantly reduced the number of bacteria and the levels of IL-6, IL-4, and IFN-γ mRNA in spleen cells compared with those in untreated mice at 24 h (P < 0.05). LysGH15 can eliminate a large number of bacteria and effectively alleviate inflammation induced by infection with lethal MRSA.     

Detection of methicillin-resistant Staphylococcus aureus in Iberian pigs

Aims: Iberian pigs are bred in Spain for the production of high‐value dry‐cured products, whose export volumes are increasing. Animals are typically reared outdoors, although indoor farming is becoming popular. We compared carriage of methicillin‐resistant Staphylococcus aureus (MRSA) in Iberian pigs, raised indoors and outdoors, with intensively farmed Standard White pigs. Methods and Results: From June 2007 to February 2008, 106 skin swabs were taken from Iberian pigs and 157 samples from SWP at slaughterhouses in Spain. We found that Iberian pigs carried MRSA, although with a significantly lower prevalence (30/106; 28%) than SWP (130/157; 83%). A higher prevalence of indoor Iberian pigs compared with animals reared under outdoor conditions was not significant; however, all but one positive indoor Iberian pig samples were detected from one slaughterhouse. Overall, 16 different spa types were identified, with t011 predominating in all three animal populations. A subset of isolates was characterized by MLST. Most of these belonged to ST398. MRSA isolates from Iberian pigs presented a higher susceptibility to antibiotics than those isolated from SWP. Conclusions: Despite limited contact with humans, pigs raised outdoors are colonized by an MRSA population that genetically overlaps with that of intensively farmed pigs, although antimicrobial resistance is lower. Significance and Impact of the Study: To our knowledge, this is the first detection of MRSA in food animals raised in free‐range conditions.     

Transposition of penicillinase determinants in methicillin-resistant Staphylococcus aureus

Abstract A methicillin-resistant Staphylococcus aureus (MRSA) typical of those being isolated in Australian hospitals has been studied. It contains two plasmids, one of 1.4 megadalton (MDa) and one of 18 MDa. When selection is made for resistance to nucleic acid-binding (NAB) compounds in mixed-culture transfer, two types of transcipients are obtained; those containing an 18-MDa plasmid and resistant to NAB compounds, trimethoprim and aminoglycosides such as gentamicin and kanamycin and those having a 22 MDa plasmid and the additional phenotype of penicillinase production. The penicillinase determinants on the 22-MDa plasmid have been found to transpose to the chromosome and from the chromosome to an 18-MDa plasmid similar to that found in the original isolate. Restriction enzyme analysis has shown that a 7.3-kilobase pair (kb) element is involved. This has been designated Tn 3852 .     

Mapping the protein interaction network in methicillin-resistant Staphylococcus aureus

Mortality attributable to infection with methicillin-resistant Staphylococcus aureus (MRSA) has now overtaken the death rate for AIDS in the United States, and advances in research are urgently needed to address this challenge. We report the results of the systematic identification of protein-protein interactions for the hospital-acquired strain MRSA-252. Using a high-throughput pull-down strategy combined with quantitative proteomics to distinguish specific from nonspecific interactors, we identified 13,219 interactions involving 608 MRSA proteins. Consecutive analyses revealed that this protein interaction network (PIN) exhibits scale-free organization with the characteristic presence of highly connected hub proteins. When clinical and experimental antimicrobial targets were queried in the network, they were generally found to occupy peripheral positions in the PIN with relatively few interacting partners. In contrast, the hub proteins identified in this MRSA PIN that are essential for network integrity and stability have largely been overlooked as drug targets. Thus, this empirical MRSA-252 PIN provides a rich source for identifying critical proteins essential for network stability, many of which can be considered as prospective antimicrobial drug targets.     

A privileged intraphagocyte niche is responsible for disseminated infection of Staphylococcus aureus in a zebrafish model

The innate immune system is the primary defence against the versatile pathogen, Staphylococcus aureus. How this organism is able to avoid immune killing and cause infections is poorly understood. Using an established larval zebrafish infection model, we have shown that overwhelming infection is due to subversion of phagocytes by staphylococci, allowing bacteria to evade killing and found foci of disease. Larval zebrafish coinfected with two S. aureus strains carrying different fluorescent reporter gene fusions (but otherwise isogenic) had bacterial lesions, at the time of host death, containing predominantly one strain. Quantitative data using two marked strains revealed that the strain ratios, during overwhelming infection, were often skewed towards the extremes, with one strain predominating. Infection with passaged bacterial clones revealed the phenomenon not to bedue to adventitious mutations acquired by the pathogen. After infection of the host, all bacteria are internalized by phagocytes and the skewing of population ratios is absolutely dependent on the presence of phagocytes. Mathematical modelling of pathogen population dynamics revealed the data patterns are consistent with the hypothesis that a small number of infected phagocytes serve as an intracellular reservoir for S. aureus, which upon release leads to disseminated infection. Strategies to specifically alter neutrophil/macrophage numbers were used to map the potential subpopulation of phagocytes acting as a pathogen reservoir, revealing neutrophils as the likely ‘niche’. Subsequently in a murine sepsis model, S. aureus abscesses in kidneys were also found to be predominantly clonal, therefore likely founded by an individual cell, suggesting a potential mechanism analogous to the zebrafish model with few protected niches. These findings add credence to the argument that S. aureus control regimes should recognize both the intracellular as well as extracellular facets of the S. aureus life cycle.