Cutaneous Hyalohyphomycosis Caused by Paecilomyces lilacinus in an Immunocompetent Host Successfully Treated with Itraconazole: Case Report and Review

 Paecilomyces lilacinus is an emerging fungal pathogen that is highly resistant to many antifungal drugs. Skin and subcutaneous soft tissue infections caused by this organism are very unusual. Most cases occur in patients with impaired host defenses or following surgical procedures. There has been only one previous report of a histologically confirmed cutaneous infection due to Paecilomyces lilacinus in a patient without predisposing factors. Described here is the second histopathologically proven case of Paecilomyces lilacinus cutaneous infection in a healthy patient without any apparent portal of entry. Prolonged antifungal chemotherapy with itraconazole led to resolution of the skin lesion. This case of sporadic cutaneous infection due to Paecilomyces lilacinus is believed to be the first reported in Europe and the first histopathologically proven case successfully treated with itraconazole.     

The Successful Implantation of Continuous-Flow Left Ventricular Assist Device as a Destination Therapy in Korea: Echocardiographic Assessment

Left ventricular assist device (LVAD) is a good treatment option for the patients ineligible for cardiac transplantation. Several studies have demonstrated that a ventricular assist device improves the quality of life and prognosis of the patients with end-stage heart failure. A 75-yr-old man debilitated with New York Heart Association (NYHA) functional class III-IV due to severe left ventricular systolic dysfunction received LVAD implantation as a destination therapy. The patient was discharged with improved functional status (NYHA functional class II) after appropriate cardiac rehabilitation and education about how to manage the device and potential emergency situations. This is the first case of successful continuous-flow LVAD implantation as a destination therapy in Korea.     

High-resolution typing by MLVF unveils extensive heterogeneity of European livestock-associated methicillin-resistant Staphylococcus aureus isolates with the sequence type 398

Methicillin-resistant Staphylococcus aureus sequence type 398 (MRSA ST398) has emerged in livestock worldwide. In particular, areas in Europe with high densities of livestock farming are affected. Consequently, the incidence of human colonization and infection with ST398 is rapidly increasing. Distinguishing different ST398 isolates with standard typing tools is problematic. The objective of this study was to examine the discriminatory power of Multiple-Locus Variable number tandem repeat Fingerprinting (MLVF) on a highly diverse ST398 collection. Our data show that MLVF combined with spa-typing is an attractive approach for high-resolution typing of ST398 isolates and unveiling their relatedness.     

Host defence against Staphylococcus aureus biofilms by polymorphonuclear neutrophils: Oxygen radical production but not phagocytosis depends on opsonisation with immunoglobulin G

Bacterial biofilms are increasingly recognised as a major cause of persistent infection and destructive inflammatory processes. In patients with biofilm infection, massive infiltration of leukocytes, particularly polymorphonuclear neutrophils is seen, and previous in vitro studies showed that PMN were able to phagocytose Staphylococcus aureus biofilms. We now addressed the question whether opsonisation of biofilms with immunoglobulin G and complement enhances the efficiency of phagocytosis, as it has been shown for “free-living” planktonic bacteria and other particulate materials. We found that incubation of biofilms with normal human serum resulted in IgG binding and in complement activation with deposits on the biofilm of C3bi. This “opsonisation”, however, did not affect the adherence of PMN to the biofilms nor did it enhance degranulation or phagocytosis. The clearance of biofilms, however, was increased, and the oxygen radical production by the PMN depended critically on the coating of biofilms with IgG.     

Hardware Infection with Corynebacterium spp.: a Case Report and Review of the Literature

There are over 120 species in the genus Corynebacterium, many of which are generally non-pathogenic. Isolates are frequently recovered from human clinical specimens, but because Corynebacterium spp. are known to be colonizers of human skin and mucosal surfaces, they are often not identified to the species level due to limitations in identification methods and lack of consensus concerning their clinical relevance. In this article, we present a case report demonstrating the difficulty and importance of distinguishing different strains of Corynebacterium isolated from a patient with a post-operative spine infection and review the current literature. This case illustrates not only the role of molecular diagnostics in determining the etiology of infection, but also the diagnostic subtleties that remain for the clinical microbiologist and infectious disease practitioner regarding the genus Corynebacterium.     

Methicillin resistance in Staphylococcus isolates: The “mec alphabet” with specific consideration of mecC, a mec homolog associated with zoonotic S. aureus lineages

Livestock-associated (LA) methicillin-resistant Staphylococcus aureus (MRSA) have globally emerged during the past decade. In Europe, this was particularly due to the occurrence of LA-MRSA strains associated with the clonal complex (CC) 398 as defined by multilocus sequence typing. However, more recently animal-adapted clonal lineages of S. aureus showing phenotypic methicillin resistance have been identified such as CC130, CC599, CC59, CC1943 and CC425. These newly emerging LA-MRSA CCs/STs caused infections in animals and zoonoses in humans. In contrast to other S. aureus clonal lineages, the methicillin resistance of the latter CCs/STs is based on a mecA gene homolog, designated mecC, which is part of a distinct SCCmec type (SCCmec XI). Including mecB found in Macrococcus caseolyticus, henceforth, the “mec alphabet” comprises three major gene types with several allotypes. As known for mecA, the gene homolog mecC is also not restricted to S. aureus, but found in several staphylococcal species including S. sciuri, S. stepanovicii and S. xylosus (mecC1 allotype). First investigations showed a wide geographical distribution of mecC-MRSA in Europe and a broad diversity of host species including livestock, companion and wildlife animals. In particular, wild rodents and insectivores might serve as reservoir for staphylococci harboring mecC. Economic burden may be caused by mastitis of dairy cattle. Livestock animals may likely serve as source for human infections with mecC-MRSA; reported cases comprise skin and soft tissue infections, osteomyelitis and bacteremia. Due to the divergent molecular nature of mecC-MRSA, its diagnostics is hampered by difficulties to verify the methicillin resistance using phenotypic as well as DNA-based procedures, which could have negative consequences for therapy of mecC-MRSA-caused infections.     

Wohlfahrtiimonas chitiniclastica: Two Clinical Cases and a Review of the Literature

Wohlfahrtiimonas chitiniclastica has been identified as an emerging pathogen predominantly associated with cutaneous myiasis and poor hygiene. Traditional biochemical methods can be unreliable and misleading when identifying this organism, and modern molecular techniques are often necessary for high-confidence identification. There have been very few cases of human infection with W. chitiniclastica reported in the literature. We present two recent cases identified at the University of Kentucky Medical Center (a male with myiasis related to gangrene and an elderly female with a left-leg wound and myiasis), both of which were identified using matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) for identification, and describe the clinical and microbiologic characteristics associated with this microorganism.     

Atypical Severe Combined Immunodeficiency Caused by a Novel Homozygous Mutation In Rag1 Gene in a Girl who Presented with Pyoderma Gangrenosum: A Case Report and Literature Review

Severe combined immunodeficiency (SCID) is a heterogeneous group of inherited defects involving the development of T- and/or B-lymphocytes. We report a female with atypical severe combined immunodeficiency caused by a novel homozygous mutation at cDNA position 2290 (c.2290C?>?T) in exon 2 of the RAG1 gene. The patient presented with bronchopneumonia, pyoderma gangrenosum (PG), pancytopenia and splenomegaly. She presented to us with pancytopenia and splenomegaly at the age of 11. Her condition was complicated by PG on left lower ankle at the age of 12. She experienced bronchopneumonia at the age of 15. She was diagnosed with RAG1 deficiency at the age of 16. Her immunological presentation included leucopenia and diminished number of B cells.     

Resistance of alloxan-diabetic rats to the behavioral activation induced by d-amphetamine: partial restoration with a high fat/protein diet

Rats which were diabetic following the subcutaneous injection of alloxan monohydrate have been found to be resistant to the locomotor stimulant and stereotypy inducing actions of d-amphetamine. By using behavioral ratings to assess the effect of amphetamine, the resistance of the diabetic rat has been found modifiable by dietary manipulation. Whereas alloxan-injected rats maintained on a high carbohydrate diet (Purina powder) show predominantly increased forward locomotion and weak stereotyped sniffing following 2.0 mg/kg d-amphetamine sulfate, this same dose typically induces moderately intense stereotyped sniffing in alloxan-injected rats which have ingested a high/fat protein diet for 6 weeks. The strength of the behavioral activation produced by d-amphetamine in non-diabetic control rats (1) is not influenced by whether they ingest a high carbohydrate or high fat/protein diet, and (2) is significantly greater than the behavioral activation seen in diabetics maintained on high carbohydrate diet, but (3) does not differ significantly from the degree of behavioral activation seen in diabetic rats maintained for 6 weeks on a high fat/protein diet. Thus, it appears that the ingestion of a high fat/protein food source largely restores the diabetic rat's behavioral response to this dose of amphetamine. Because the ingestion of a high fat/protein diet ameliorates the hyperglycemia and hyperdipsia and facilitates the weight gain of the diabetic animal, it is suggested that this diet restores the responsiveness of alloxan-injected rats to d-amphetamine by partially correcting the metabolic deficiencies associated with the diabetic state.     

Performance of the EUCAST Disk Diffusion Method,the CLSI Agar Screen Method,and the Vitek 2 Automated Antimicrobial Susceptibility Testing System for Detection of Clinical Isolates of Enterococci with Low- and Medium-Level VanB-Type Vancomycin Resistance: a Multicenter Study

Different antimicrobial susceptibility testing methods to detect low-level vancomycin resistance in enterococci were evaluated in a Scandinavian multicenter study (n = 28). A phenotypically and genotypically well-characterized diverse collection of Enterococcus faecalis (n = 12) and Enterococcus faecium (n = 18) strains with and without nonsusceptibility to vancomycin was examined blindly in Danish (n = 5), Norwegian (n = 13), and Swedish (n = 10) laboratories using the EUCAST disk diffusion method (n = 28) and the CLSI agar screen (n = 18) or the Vitek 2 system (bioMérieux) (n = 5). The EUCAST disk diffusion method (very major error [VME] rate, 7.0%; sensitivity, 0.93; major error [ME] rate, 2.4%; specificity, 0.98) and CLSI agar screen (VME rate, 6.6%; sensitivity, 0.93; ME rate, 5.6%; specificity, 0.94) performed significantly better (P = 0.02) than the Vitek 2 system (VME rate, 13%; sensitivity, 0.87; ME rate, 0%; specificity, 1). The performance of the EUCAST disk diffusion method was challenged by differences in vancomycin inhibition zone sizes as well as the experience of the personnel in interpreting fuzzy zone edges as an indication of vancomycin resistance. Laboratories using Oxoid agar (P < 0.0001) or Merck Mueller-Hinton (MH) agar (P = 0.027) for the disk diffusion assay performed significantly better than did laboratories using BBL MH II medium. Laboratories using Difco brain heart infusion (BHI) agar for the CLSI agar screen performed significantly better (P = 0.017) than did those using Oxoid BHI agar. In conclusion, both the EUCAST disk diffusion and CLSI agar screening methods performed acceptably (sensitivity, 0.93; specificity, 0.94 to 0.98) in the detection of VanB-type vancomycin-resistant enterococci with low-level resistance. Importantly, use of the CLSI agar screen requires careful monitoring of the vancomycin concentration in the plates. Moreover, disk diffusion methodology requires that personnel be trained in interpreting zone edges.