Fatal Bacillus cereus endocarditis masquerading as an anthrax-like infection in a patient with acute lymphoblastic leukemia: case report

A 38-year-old male farm worker with relapsing acute lymphoblastic leukemia spontaneously developed an ulcerating ulcer on his anterior thigh which was surrounded by a non-tender area of erythema. Bacillus cereus was isolated from the ulcer and blood, and the patient received intravenous penicillin and vancomycin for one week. When sensitivity studies were returned he was treated with gatifloxacin orally. After two weeks of combined antimicrobial therapy and negative blood cultures, the patient received combination chemotherapy with vincristine, prednisone, doxorubicin and cyclophosphamide. He was hospitalized a day after completing chemotherapy with neutropenic sepsis due to B. cereus. He received similar antimicrobial therapy as previously, but died three days later. At autopsy, the patient was found to have acute mitral valve endocarditis and bilateral brain abscesses. This was the first case of B. cereus endocarditis reported in a patient with acute lymphoblastic leukemia.     

Bacillus cereus fatal bacteremia and apparent association with nosocomial transmission in an intensive care unit

Bacillus cereus has sometimes been implicated in food poisoning and in opportunistic infections of seriously ill patients. This report describes an unusual case of persistent bacteremia and multiple organ failure associated with B. cereus in a patient admitted to our institution for lung cancer. The patient was undergoing treatment with an antimicrobial agent (imipenem) that was shown to be effective against the micro-organism in vitro. No portal of entry for the strain was detected. After treatment with vancomycin, also shown to be effective in vitro, no clinical improvement was noted and the patient died. Molecular studies showed that the same strain caused an episode of pseudobacteremia in another patient admitted to the same ICU room.     

Bacillus cereus brain abscesses occurring in a severely neutropenic patient: successful treatment with antimicrobial agents, granulocyte colony-stimulating factor and surgical drainage

Multiple brain and liver abscesses developed immediately after Bacillus cereus bacteremia in a neutropenic patient with acute lymphoblastic leukemia. After even 8 weeks of antimicrobial chemotherapy together with administration of granulocyte colony-stimulating factor, every infectious process disappeared but the patient's headache has still persisted. Because the wall of one brain abscess became thin and was in danger of rupturing into the ventricle, surgical drainage was performed, resulting in disappearance of headache and resolution of brain abscess. The present case indicates that a combined medical and surgical approach is mandatory to treat patients with brain abscesses.     

Cord blood transplantation after successful treatment of brain abscess caused by Bacillus cereus in a patient with acute myeloid leukemia

Central nervous system infection caused by Bacillus cereus is a rare condition, which often progresses rapidly and is fatal in immunocompromised patients. A 54-year-old woman with acute myelogenous leukemia fell into a coma with high fever during severe neutropenia while undergoing chemotherapy. A blood culture demonstrated the presence of B. cereus and magnetic resonance imaging showed multiple abnormal lesions in her brain. The patient was treated with meropenem and vancomycin, and recovered from the coma in a week. Antibiotic therapy was administered for seven weeks, and then she underwent cord blood transplantation for refractory acute myelogenous leukemia with successful engraftment without exacerbation of the brain abscess. This case demonstrates that brain abscess caused by B. cereus can be treated without surgical treatment.     

Life-threatening complications associated with Bacillus cereus pneumonia

Bacillus species are identified as pathogens in lung and pleural space infections with increasing frequency. We report a patient who developed life-threatening complications of Bacillus cereus pneumonia, including massive hemoptysis, acute respiratory failure, tension pneumothorax, empyema, and bronchopleural fistula. We also review the pertinent literature concerning the associated underlying disorders, complications, and therapy of Bacillus species pulmonary infections.     

Bacillus cereus endocarditis: report of a case and review.

Bacillus cereus is a ubiquitous organism that infrequently causes serious infections. We report a patient with B. cereus endocarditis involving a mechanical aortic valve. Data for 10 cases of B. cereus endocarditis reported in the literature are summarized. B. cereus is resistant to many commonly used antibiotics, a finding that has clinical significance for empirical antibiotic selection in patients with suspected endocarditis. Infection in patients with valvular heart disease in the few cases reported is associated with significant mortality and morbidity.     

Central nervous system infection caused by Morganella morganii

Central nervous system (CNS) infection with Morganella morganii is very rare. We describe a 38-year-old female patient with frontal brain abscess caused by M morganii who was unsuccessfully treated. We also review all reported cases of Morganella CNS infections with an emphasis on treatment modalities and outcomes. Aggressive surgical management and appropriate antimicrobial therapy can lead to cure, but the mortality rate for these infections remains high.     

Mycotic aortic aneurysm. A complication of Campylobacter fetus septicemia

The first surviving case, to our knowledge, of a Campylobacter fetus mycotic aortic aneurysm is reported. Bacteremia and an ileofemoral thrombophlebitis preceded the development of the infected aneurysm, reconfirming the vascular tropism of this organism. The clinical similarity with infections caused by Salmonella choleraesuis is illustrated by this case. The full recovery of our patient attests to the efficacy of extralanatomic bypass combined with long-term antibiotic therapy in the treatment of aortic mycotic aneurysm. Because of frequent changes in nomenclature and insufficient emphasis on speciation of the various campylobacters, pathogenesis and optimal antimicrobial therapy for systemic C fetus infections have not yet been adequately defined.     

The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome

Cardiovascular infections due to Salmonella enterica are infrequently reported, so their clinical features, prognosis, and optimal treatment are not completely known. Mortality associated with aortitis and endocarditis caused by nontyphoidal Salmonella remains exceedingly high.In this review of cases of cardiovascular infections due to Salmonella enterica studied in 2 hospitals in Madrid, we tried to assess the clinical manifestations and the procedures leading to diagnosis in addition to treatment and outcome. To complete the spectrum of infections related to cardiovascular surgery, cases of postoperative mediastinitis, pericarditis, and infections associated with cardiac devices were also included.Twenty-three patients were reviewed: 11 had mycotic aneurysms; 7 had endocarditis; 2 had device-related infections; and 3 had pericarditis, mediastinitis, and infection of an arteriovenous fistula, respectively. The risk of endovascular infection in patients older than 60 years with bacteremia due to nontyphoidal Salmonella was 23%. Most patients with aortitis had risk factors for atherosclerosis, and 6 had preexisting atherosclerotic aortic aneurysms. All except 1 patient with endocarditis had underlying cardiac disorders. Acquired immunodeficiency disease (AIDS) was a major risk factor for salmonella bacteremia in 1 patient with aortitis and 1 with endocarditis. Fever, unremitting sepsis, "breakthrough" and relapsing bacteremia were the most common clinical findings. In addition, abdominal or thoracic pain and cardiac failure and pericarditis were common features in patients with aortitis and endocarditis respectively. Computed tomography (CT) scan, arteriography, and echocardiography were the main diagnostic tools.Mortality associated with mycotic aneurysms and endocarditis due to S. enterica was 45% and 28%, respectively. Thoracic aneurysms, rupture, and shock at the time of diagnosis were associated with increased mortality in patients with aortitis. In situ bypass grafting was successfully performed in most cases. After surgery, antimicrobial therapy was continued for 4-9 weeks. No relapses were observed after a mean follow-up of 64 months. Antimicrobial therapy alone or combined with valve replacement or excision of a ventricular aneurysm was successful treatment for most patients with salmonella endocarditis. Combined medical and surgical treatment was required for patients with mediastinitis and pericarditis, and patients with device-related infections needed removal of the complete device.Diagnosis of aortitis due to nontyphoidal Salmonella should be established as early as possible to reduce mortality. Patients older than 60 years who have positive blood cultures for Salmonella along with fever and back, abdominal, or chest pain should have an extensive workup for infective aortitis. Immediate bactericidal antimicrobial therapy should be started and a CT scan should be performed on an emergency basis. If a mycotic aneurysm is found, surgical resection should follow as soon as possible. Resection of the aneurysm with in situ bypass grafting is the procedure of choice. Postoperative antimicrobial therapy for 6-8 weeks seems enough to avoid relapses. Optimal treatment of patients with endocarditis occurring on ventricular aneurysms must include resection of the aneurysmal sac. Salmonella endocarditis can be successfully treated with antimicrobials alone. Valve replacement should be reserved for patients with cardiac failure or persisting sepsis, and for those who relapse after discontinuation of antimicrobial therapy.     

Fatal Bacillus cereus sepsis following resolving neutropenic enterocolitis during the treatment of acute leukemia

Bacillus cereus is increasingly being acknowledged as a serious bacterial pathogen in immunosuppressed hosts. We report a case of fatal B. cereus sepsis in a patient with newly diagnosed acute leukemia following resolving neutropenic enterocolitis. Gastrointestinal complaints are common during induction chemotherapy, yet some antimicrobial coverage suitable for generalized neutropenia is not optimal for the eradication of B. cereus. This case demonstrates that, in the neutropenic patient with gastrointestinal complaints or in the setting of resolving neutropenic enterocolitis, it is important to anticipate possible B. cereus infection and sepsis.     

Diagnosis and treatment of prosthetic joint infections

Prosthetic replacement surgery for hip, knee, shoulder, and elbow joints has become commonplace due to the great success of these procedures in restoring function to persons disabled by arthritis. One of the most feared complications is prosthetic joint infection, which is associated with significant morbidity and health care costs. The pathogenesis of prosthetic joint infections is influenced by microorganisms growing in biofilms, making these infections difficult to diagnose and eradicate. Low-grade infections are often manifest as early loosening with or without pain. They are therefore difficult to distinguish from aseptic failure. For an accurate diagnosis of prosthetic joint infections, a combination of preoperative and intraoperative tests is usually needed. Underlying rheumatologic disease can lead to periprosthetic inflammatory changes in tissue. Therefore, only the culture of the microorganism is definitive proof of infection. Successful treatment requires long-term antimicrobial therapy, ideally with an agent acting on adhering stationary-phase microorganisms, combined with an adequate surgical procedure. In this article, the epidemiology, pathogenesis, diagnosis and treatment of prosthetic joint infections are reviewed. We focus on difficult diagnostic aspects in the context of underlying rheumatologic disease.     

Diagnose und Therapie von Gelenkprotheseninfektionen

Prosthetic replacement surgery for hip, knee, shoulder, and elbow joints has become commonplace due to the great success of these procedures in restoring function to persons disabled by arthritis. One of the most feared complications is prosthetic joint infection, which is associated with significant morbidity and health care costs. The pathogenesis of prosthetic joint infections is influenced by microorganisms growing in biofilms, making these infections difficult to diagnose and eradicate. Low-grade infections are often manifest as early loosening with or without pain. They are therefore difficult to distinguish from aseptic failure. For an accurate diagnosis of prosthetic joint infections, a combination of preoperative and intraoperative tests is usually needed. Underlying rheumatologic disease can lead to periprosthetic inflammatory changes in tissue. Therefore, only the culture of the microorganism is definitive proof of infection. Successful treatment requires long-term antimicrobial therapy, ideally with an agent acting on adhering stationary-phase microorganisms, combined with an adequate surgical procedure. In this article, the epidemiology, pathogenesis, diagnosis and treatment of prosthetic joint infections are reviewed. We focus on difficult diagnostic aspects in the context of underlying rheumatologic disease.     

Diagnosis and treatment of implant-associated septic arthritis and osteomyelitis

Implant-associated infections are caused by microorganisms growing in biofilms, rendering these infections difficult to diagnose and to eradicate. Delayed-onset low-grade infection is difficult to distinguish from aseptic failure, often presenting without signs of infection, but only with early loosening and persisting pain. A combination of criteria is needed for an accurate diagnosis: clinical signs and symptoms, laboratory signs of infection, microbiology, histology, and imaging. The treatment goals in prosthetic joint-associated infection are eradication of infection and an optimal functional result. The goal in internal fixation device-associated infection is consolidation of the fracture and avoidance of chronic osteomyelitis. Successful treatment requires an adequate surgical procedure combined with long-term antimicrobial therapy, ideally with an agent acting on adhering biofilm microorganisms. This article reviews the epidemiology, pathogenesis, diagnosis, and management of implant-associated infections, and presents pathogenesis and risk of hematogenous infection.     

Serious infections caused by Bacillus species

Thirty-eight patients with serious infections caused by organisms belonging to the genus Bacillus are described. Our experience, and that reported in the literature, indicates that, in most cases, isolated Bacillus bacteremia is not a particularly serious disease. Therefore, under most circumstances, empiric antibiotic therapy designed specifically for treatment of Bacillus is probably not necessary. Endocarditis can occur, but apparently follows bacteremia only infrequently. When these bacteria cause localized infection such as pneumonia, pan-ophthalmitis, visceral abscess, or musculoskeletal infections, tissue necrosis and profound morbidity are the rule. The frequency of these complications following bacteremia appears to be low but cannot be estimated from our experience or that reported in the literature reviewed. The role of intravascular devices and trauma as predisposing factors is emphasized. Immunocompromised hosts and intravenous drug abusers appear predisposed, but intravascular devices in the former group may play an important role in the pathogenesis of Bacillus infections. Antibiotics which appear especially useful in the treatment of Bacillus infections are clindamycin and vancomycin, to which the vast majority of strains are susceptible in vitro. Beta-lactam antibiotics, including the new cephalosporins and penicillins, are of little value in this setting.     

Severe infective endocarditis due to Neisseria sicca: case report and review of literature

We report a case of infective endocarditis (IE) caused by an unusual micro-organism in a previously healthy young man. Our patient presented with meningo-encephalitis and embolic signs due to IE caused by Neisseria sicca. Risk factors for IE due to Neisseria sicca, such as intravenous drug use and pre-existing heart disease were absent. The patient recovered well after mitral valve surgery and antimicrobial therapy. IE due to Neisseria spp. is associated with embolic manifestations and valve destruction. However, no deaths have been reported in patients who are treated with appropriate antimicrobial and surgical therapy.     

Harnwegsinfektionen

Urinary tract infections occur very frequently in the community and in hospitalized patients and are mainly caused by Escherichia (E.) coli. Depending on virulence determinants of uropathogenic microorganisms and host-specific defense mechanisms, urinary tract infections can manifest as cystitis, pyelonephritis (bacterial interstitial nephritis), bacteremia or urosepsis. Uncomplicated urinary tract infections in otherwise healthy women should be treated for 3?C7 days depending on the antibiotic therapy chosen, even if spontaneous remission rates of up to 40% have been reported. Antibiotics of the first choice for empirical treatment of uncomplicated urinary tract infection are fluoroquinolones, pivmecillinam and fosfomycin. A huge problem is the increasing antimicrobial resistance of uropathogenic microorganisms. Complicated urinary tract infections associated with anatomical and/or functional abnormalities of the urinary tract and/or comorbidities such as diabetes or immunosuppressive therapy, need longer antibiotic treatment (e.g. 10?C14 days) as well as interdisciplinary diagnostic procedures. Treatment of community acquired urosepsis includes cephalosporins of the third generation, piperacillin/tazobactam or ciprofloxacin. For nosocomial urosepsis the combination with an aminoglycoside or a carbapenem is recommended.     

Urinary tract infections

Urinary tract infections occur very frequently in the community and in hospitalized patients and are mainly caused by Escherichia (E.) coli. Depending on virulence determinants of uropathogenic microorganisms and host-specific defense mechanisms, urinary tract infections can manifest as cystitis, pyelonephritis (bacterial interstitial nephritis), bacteremia or urosepsis. Uncomplicated urinary tract infections in otherwise healthy women should be treated for 3-7 days depending on the antibiotic therapy chosen, even if spontaneous remission rates of up to 40% have been reported. Antibiotics of the first choice for empirical treatment of uncomplicated urinary tract infection are fluoroquinolones, pivmecillinam and fosfomycin. A huge problem is the increasing antimicrobial resistance of uropathogenic microorganisms. Complicated urinary tract infections associated with anatomical and/or functional abnormalities of the urinary tract and/or comorbidities such as diabetes or immunosuppressive therapy, need longer antibiotic treatment (e.g. 10-14 days) as well as interdisciplinary diagnostic procedures. Treatment of community acquired urosepsis includes cephalosporins of the third generation, piperacillin/tazobactam or ciprofloxacin. For nosocomial urosepsis the combination with an aminoglycoside or a carbapenem is recommended.     

Changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria.

Over the past 3 decades, considerable changes have occurred in the types of bacteria causing infection in febrile patients with neutropenia and cancer. Twenty years ago, gram-negative bacteria caused approximately 70% of bloodstream infections. As a probable consequence of long-dwelling intravascular devices, fluoroquinolone prophylaxis, and high-dose chemotherapy-induced mucositis, there has been a shift toward gram-positive coccal bacteremia. In most centers today, approximately 70% of bacteremic isolates are gram-positive cocci. Of potential concern is that antimicrobial-resistant gram-positive organisms are becoming increasingly frequent in patients with neutropenia. Fluoroquinolone-resistant Escherichia coli are being isolated from several cancer centers. Several "new" organisms, such as Stomatococcus mucilaginosus, Bacillus cereus, Leuconostoc species, Corynebacterium jeikeium, Rhodococcus species, Stenotrophomonas maltophilia, Moraxella catarrhalis, Burkholderia cepacia, and Bartonella species, now cause infections in these patients. Careful application of infection-control principles, judicious prophylaxis, appropriate evaluation of new antibiotics, and prompt effective therapy will maximize benefits for these patients.     

Prosthetic joint infections: update in diagnosis and treatment

The pathogenesis of prosthetic joint infection is related to microorganisms growing in biofilms, rendering these infections difficult to diagnose and to eradicate. Low-grade infections in particular are difficult to distinguish from aseptic failure, often presenting only with early loosening and persisting pain, or no clinical signs of infection at all. A combination of preoperative and intraoperative tests is usually needed for an accurate diagnosis of infection of prosthetic joint infections. Successful treatment requires adequate surgical procedure combined with long-term antimicrobial therapy, ideally with an agent acting on adhering stationary- phase microorganisms. In this article, epidemiology, pathogenesis, diagnosis and treatment of prosthetic joint infections are reviewed.