Cryptogenic Salmonella-infected ruptured aortic aneurysms

Salmonella-infected ruptured aortic aneurysms are a difficult surgical problem. Five patients with Salmonella-infected ruptured aortic aneurysms are presented. All patients were initially treated by in situ graft replacement, wide debridement of the infected aortic tissue and long-term systemic antibiotic therapy. The surgical technique of choice in acute situations, such as a rupture of the aneurysm, remains controversial. In the recent literature 26 reported cases were reviewed. Based on our clinical experience and these case reports, in situ bypass reconstruction can be justified as a surgical technique that gives at least a good short-term prognosis.     

Type B aortic dissection associated with <Emphasis Type="Italic">Salmonella</Emphasis> infection

A 59-year-old man with a long history of hypertension and diabetes was admitted to our hospital with acute type B aortic dissection 14 days after the sudden onset of back pain. The dissecting descending thoracic aorta was enlarged to 5.2 cm in diameter, and laboratory tests showed an elevated white blood cell count (15 530/mm³) and an increased C-reactive protein level (19.2 mg/dl). Computed tomography performed 2 days after admission revealed rapid growth of the aortic dissection. Blood cultures obtained upon admission were positive for Salmonella. Impending rupture of the aortic dissection complicated by Salmonella infection was strongly suspected, and the patient underwent emergency surgery consisting of debridement and prosthetic graft placement covered by an omental flap. In this case, it is believed that insidious Salmonella aortitis caused acute type B aortic dissection.     

Multiple Mycotic Aortic Aneurysms due to <Emphasis Type="Italic">Streptococcus pneumoniae</Emphasis>

Primary pneumococcal aortic mycotic aneurysms are rare clinical entities. Only a few cases have been reported in the literature. Extremely rare presentation is the occurrence of three simultaneous aneurysms. Treatment usually necessitates intravenous antibiotherapy combined with staged surgical interventions. This report highlights the case of a 52-year-old man with multiple Streptococcus pneumoniae mycotic aneurysms that were simultaneously and successfully treated during a one-stage surgical procedure. The aorta may be prone to infection, especially when its intima is structurally altered by pathologic processes like atherosclerosis, inflammation or trauma. Mycotic aneurysm is a rare but serious vascular condition needing urgent medical and surgical attention because of potential lethal complications.     

Mycotic aneurysm of the aortic arch due to <Emphasis Type="Italic">Salmonella</Emphasis>

We report the successful treatment of a 79-year-old man with an extremely rare mycotic aneurysm of the aortic arch due to Salmonella. The patient presented with persistent fever, hoarseness, and hemosputum. Computed tomography showed a large saccular aneurysm with a hazy aortic wall in the aortic arch. We conducted emergency total arch replacement, debriding surrounding infectious tissue. Cultures from the aneurysm grew Salmonella enteritidis. Infection recurred 1 week postoperatively, requiring open irrigation and omentum transposition. These surgical procedures, along with appropriate antibiotics, brought infection under control.     

Bacteroides <Emphasis Type="Italic">fragilis</Emphasis> aortic arch pseudoaneurysm: case report with review

We present a case of 58-year-old woman with underlying diabetes mellitus, hepatitis C virus-related liver cirrhosis, and total hysterectomy for uterine myoma 11 moths ago, who was diagnosed ruptured aortic arch mycotic pseudoaneurysm after a certain period of survey for her unknown fever cause. After emergent surgery with prosthetic graft interposition, all her blood cultures and tissue cultures revealed pathogen with Bacteroides fragilis. Although mycotic aneurysms have been well described in literatures, an aneurysm infected solely with Bacteroides fragilis is unusual, with only eight similar cases in the literature. Here we reported the only female case with her specific clinical and management course and summarized all reported cases of mycotic aneurysm caused by Bacteroides fragilis to clarify their conditions and treatments, alert the difficulty in diagnosis, and importance of highly suspicious.     

Abdominal septic aortic pseudoaneurysm caused by <Emphasis Type="Italic">Campylobacter jejuni</Emphasis> infection: Report of a case

Campylobacter jejuni infection is one of the most common bacterial causes of acute gastroenteritis worldwide. An extraintestinal manifestation is rare and, to our knowledge, an aortic aneurysm has until now never been documented. We report a case of a 72-year-old patient with a septic aortic pseudoaneurysm caused by C. jejuni infection. Computed tomography and magnetic resonance imaging showed a pseudoaneurysm in the abdominal aorta. The preoperative blood culture indicated a Gram-negative bacillus, which was identified 7 days later as C. jejuni. An aneurysmectomy, extensive debridement, and an in situ graft wrapped with the omentum were done, and the patient was given a 6-week course of antibiotics. Despite readmissions for abdominal infection and Salmonella bacteremia, a graft infection did not develop. In the 3 years since the procedure the patient has shown no signs of a relapse.     

Successful treatment of a<Emphasis Type="Italic">Salmonella</Emphasis> aortic arch aneurysm

A 52-year-old man hospitalized for hoarseness and chest pain was found in chest computed tomography to have an impending aortic arch aneurysm rupture. Laboratory studies showed the presence of severe inflammation. Based on a clinical diagnosis of infected aortic arch aneurysm, we conducted total arch replacement.Salmonella was identified in the aneurismal wall and antibiotics were administered longterm. The postoperative course was uneventful. The patient was discharged on postoperative day 48. He has remained afebrile and asymptomatic in the 10 months since surgery but continues to take 300 mg/d of oral levofloxacin.     

Aortocaval Fistula Complicated with Bacteremia Due to <Emphasis Type="Italic">Escherichia coli</Emphasis>: Report of a Case

We herein report a case of aortocaval fistula complicated with bacteremia due to Escherichia coli in a 78-year-old man who underwent an emergency operation. A surgical resection of the abdominal aortic aneurysm with a closure of the fistula, and reconstruction with an expanded polytetrafluoroethylene bifurcated graft and wrapping with an omental flap, were performed followed by a 9-week continuous administration of antibiotics. Thereafter, antifungal agents were administered and the results were good. Both an early diagnosis and prompt surgery are important for such patients, and long-term administration of antibacterial agents is also necessary. Received: March 21, 2001 / Accepted: November 20, 2001     

Infected Aneurysms of the Infrarenal Abdominal Aorta: Diagnostic Criteria and Therapeutic Strategy

Salmonella infection and two patients with spondylitis) had positive preoperative blood cultures. Salmonella was the most common microorganism (27%). Anaerobes accounted for 16%. In situ replacement was performed in 13 patients including three procedures performed under emergency conditions with frank purulent infection. Extraanatomic bypass was performed in five patients. Early postoperative death occurred in two patients (11%) due to septic complications (rupture of aortic anastomosis in one patient and rupture of aortic stump in one patient). All surviving patients underwent prolonged antibiotic therapy for at least 6 weeks. Overall mortality secondary to infected aneurysm was 16%. Infection of the aortic graft occurred in four patients (38%) including two patients with Salmonella infection and one patient with spondylitis. One patient developed a false anastomotic aneurysm 6 months postoperatively and was treated by in situ arterial allograft replacement. Postoperative blood cultures were positive in two patients presenting spondylitis and infection of the aortic prosthesis occurred in one of these patients. In addition to rupture, poor prognostic factors included spondylitis and Salmonella infection that were found to greatly enhance the risk of postoperative graft infection following in situ reconstruction.     

<Emphasis Type="Italic">Candida</Emphasis> in Acute Pancreatitis

Purpose A Candida infection of the pancreas, which previously was considered extremely unusual, has been increasingly reported in recent years. The present study was conducted with the aim of performing a cohort analysis of our patients with acute pancreatitis to find out the incidence, sites, and species of Candida involvement; and to evaluate the risk factors, severity, and course of illness of such patients. Methods A total of 335 patients with acute pancreatitis were investigated for a possible Candida infection of the pancreas from January 2000 to May 2003. The clinical records of all those patients who were positive for Candida spp. isolation from pancreatic tissue were analyzed. The clinical records of 32 more cases, randomly selected from the patients who were investigated for candidal pancreatitis but were negative for Candida spp., were also analyzed in order to compare their findings with those patients with a true Candida infection of the pancreas. Results A true or possible Candida infection was observed in 41 (12.2%) of those 335 patients and Candida tropicalis was the most common isolate (43.9%). Candida spp. were isolated from pancreatic necrotic tissue in 22 (6.6%) patients (true infection). A possible Candida infection (positive drain fluid effluents at least twice, without any Candida isolation from pre/per operative samples from pancreas) was seen in 19 (5.7%) patients. Candida was also isolated exclusively from the blood in another 19 patients with a clinical diagnosis of acute pancreatitis. A risk factor analysis showed that patients with severe injury to the pancreas, on prophylactic fluconazole, and after surgical intervention were significantly more prone to develop a Candida infection. Patients with a Candida superinfection also had a significantly increased hospital stay and higher mortality. Conclusion This study thus emphasizes the important role of Candida infection in patients with acute pancreatitis and demonstrates the need for early attention.     

<Emphasis Type="Italic">WT1</Emphasis> and <Emphasis Type="Italic">NPHS2</Emphasis> mutations in Korean children with steroid-resistant nephrotic syndrome

Although several genetic causes of steroid-resistant nephrotic syndrome (SRNS) have been identified, occurrence of these genetic abnormalities appears to be influenced by race. Seventy Korean children (39 girls, 31 boys) with SRNS underwent analysis for mutations of WT1 and NPHS2. Although NPHS2 mutations were not present in any of the patients, two different intronic mutations of WT1, IVS9+4 C>T and IVS9+5 G>A, were detected in four patients (three girls, one boy). Among the four patients with mutation, two girls with a karyotype of 46,XY had complete XY gonadal dysgenesis, one girl with a karyotype of 46,XX had normal genitalia, and one boy with a karyotype of 46,XY had hypospadia. A kidney biopsy conducted in three of the four patients revealed focal segmental glomerulosclerosis. The incidence of WT1 mutations observed in this study was similar to that of previous reports. However, the incidence of NPHS2 mutations seems to be very rare in Korean children. Genetic diagnosis of WT1 mutations should be recommended for children with SRNS, especially in cases involving a female phenotype or males with genital anomalies.     

Mutational analysis of <Emphasis Type="Italic">NPHS2</Emphasis> and <Emphasis Type="Italic">WT1</Emphasis> in frequently relapsing and steroid-dependent nephrotic syndrome

Idiopathic nephrotic syndrome is a common pediatric kidney disease, 80% of all cases are steroid sensitive (SSNS). A significant proportion of children with SSNS will have a frequently relapsing or steroid-dependent course (FRNS/SDNS) that is associated with significant treatment-related morbidity. Mutations in NPHS2 account for more than 28% of all cases of steroid-resistant nephrotic syndrome (SRNS) and dominant mutations in WT1 for 5%; while mutations are absent from children with uncomplicated SSNS. Since FRNS/SDNS is phenotypically positioned within a spectrum between SSNS and SRNS, we hypothesized that heterozygous mutations of NPHS2 may be causing FRNS/SDNS. Mutational analysis of NPHS2 and WT1 was carried out in a single-center cohort of 20 children with FRNS/SDNS, ten children with uncomplicated SSNS (control), and 22 children with SRNS (control). Renal biopsy findings were available in 15/20 children with FRNS/SDNS and revealed IgM nephropathy, MCNS, and FSGS in six, five, and four children, respectively. Children with FRNS/SDNS were significantly younger at first presentation than those with SSNS and SRNS (median age: 3.0 years in FRNS/SDNS patients, 7.0 years in SSNS patients, and 5.0 in SRNS patients; p < 0.001). No NPHS2 or WT1 mutations were found in patients with FRNS/SDNS and uncomplicated SSNS. The hypothesis that FRNS/SDNS may be associated with heterozygous mutations in NPHS2 or WT1 was not confirmed.     

Hemochromatosis,<Emphasis Type="Italic"> HFE</Emphasis> C282Y Homozygosity,and Bariatric Surgery: Report of Three Cases

Background: Iron absorption is decreased in some individuals who have undergone bariatric surgery. Methods: We evaluated measures of iron metabolism and therapeutic phlebotomy in 3 adults with hemochromatosis and HFE C282Y homozygosity who underwent bariatric surgery. Results: 1 male and 1 female had surgery before diagnosis of hemochromatosis (jejuno-ileal bypass and Roux-en-Y gastric bypass, respectively); neither had iron overload. Another man was treated with serial phlebotomy to induce iron depletion; later, he underwent Roux-en-Y gastric bypass. His maintenance phlebotomy requirement for hemochromatosis decreased substantially (on average ~1 unit each 71 days before surgery, and ~1 unit each 173 days after surgery). None of these patients developed iron deficiency, and none took supplemental iron. Conclusions: Iron absorption is decreased in some patients with hemochromatosis and HFE C282Y homozygosity after bariatric surgery, but their risk of developing iron deficiency may be diminished.     

Cbfa1/osf2 Transduced Bone Marrow Stromal Cells Facilitate Bone Formation <Emphasis Type="Italic">In Vitro</Emphasis> and <Emphasis Type="Italic">In Vivo</Emphasis>

It has been well established that core binding factor a-1/osteoblast-specific factor-2 (cbfa1/osf2) is a key regulator of osteoblast differentiation and function, however, it is not known whether it can induce bone formation in vitro and in vivo. To investigate the effect of cbfa1/osf2 on bone formation, we used a recombinant adenoviral vector carrying the mouse cbfa1/osf2 gene to transduce primary cultured bone marrow stromal cells (MSCs) of BALB/c mice. We found that Ad-cbfa1/osf2-transduced MSCs produced cbfa1/osf2 protein and differentiated into osteoblast-like cells. The transduced MSCs had increased alkaline phosphatase activity, increased expression of osteocalcin, osteopontin and bone sialoprotein, and increased matrix mineralization in vitro. To observe the induction of bone formation in vivo, MSCs transduced with Ad-cbfa1/osf2 were transplanted into a 5 mm diameter critical-sized skull defect in BALB/c mice, with type I collagen as scaffolding material. Healing of the defect in treatment and control groups was examined grossly and histologically at four weeks. Skull defects transplanted with Ad-cbfa1/osf2-transduced MSCs had an average of 85% osseous closure at four weeks. Control groups in which the defects were not treated (group 1), treated with collagen only (group 2), or treated with collagen and nontransduced MSCs (group 3) showed little or no osseous healing. These studies indicate that cbfa1/osf2 can induce osteoblast differentiation and bone formation both in vitro and in vivo, suggesting that MSCs transduced with the cbfa1/osf2 gene may be useful in treating bone defects.     

Methicillin resistant <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> versus methicillin sensitive <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> adult haematogenous septic arthritis

Introduction Septic arthritis is an orthopaedic emergency and Staphylococcus aureus (SA) is the number one cause. Methicillin resistant Staphylococcus aureus (MRSA) is increasing in incidence but how it differs from methicillin sensitive Staphylococcus aureus (MSSA) septic arthritis is unclear. Our aim was to delineate the differences in clinical features and outcomes between patients with MRSA and MSSA septic arthritis. Materials and methods We performed a retrospective review of all adult patients presenting to our institute over a 5 year period from June 2000 to June 2005 with haematogenous septic arthritis. We identified 15 cases of MRSA and 43 cases of MSSA septic arthritis. Fisher’s exact test and the Student’s t-test were used in analysis. Results MRSA and MSSA predominantly affected males 60 versus 79%. MRSA cases were older with a mean age of 76 versus 44 years (P < 0.05), and had more comorbidities with a mean of 2.7 versus 1.35 (P < 0.05). In MRSA and MSSA cases the main sources of sepsis were unknown (20 vs. 47%), intravenous lines (47 vs. 2%), soft tissue infection (13 vs. 2%) and intravenous drug use (7 vs. 49%). MRSA was significantly more associated with intravenous line sepsis (P < 0.05), soft tissue infection (P = 0.05) and to be nosocomial (P < 0.05). MSSA was significantly more associated with IVDU (P < 0.05). Presentation was similar in both groups although MRSA patients were significantly more likely to be pyrexial (80 vs. 40%, P < 0.05) and to have glenohumeral involvement (P < 0.05) while MSSA was significantly more likely to affect the knee (P < 0.05). There were no significant differences between the total length of antimicrobial therapy in MRSA and MSSA patients (43 vs. 38 days, P > 0.2), or the number of surgical interventions required (1.8 vs. 1.6, P > 0.2). However MRSA patients were significantly more likely to be placed on inappropriate empirical antimicrobials pending sensitivities (93 vs. 0%, P < 0.05). Outcomes were similar in MRSA and MSSA patients with no significant differences in recurrences (0 vs. 10%, P > 0.2) or sepsis related mortality (13.3 vs. 6.9%, P > 0.2). MRSA, however, did show a strong towards a higher all cause 6 month mortality (26 vs. 7%, P = 0.07). Conclusion MRSA septic arthritis tends to affect older patients with multiple comorbidities and has a tropism for the glenohumeral joint while MSSA has a tropism for the knee. We did not find a significant difference in required length of antimicrobials, number or requirement of operative interventions or outcomes in terms of number of recurrences or sepsis related mortality. However MRSA septic arthritis patients were found to have a strong trend towards an increased all cause 6 month mortality and were significantly more likely to receive inappropriate empirical antimicrobials.     

Intratumoral Heterogeneity in Microsatellite Alterations in <Emphasis Type="Italic">BRCA1</Emphasis> and <Emphasis Type="Italic">PTEN</Emphasis> Regions in Sporadic Colorectal Cancer

Background: Chromosome regions 17q21 (BRCA1) and 10q23 (PTEN) have been found deleted in colorectal cancer.Methods: We studied the frequency of loss of heterozygosity (LOH) in these 2 regions in 214 patients with only 1 sample per tumor and in 100 patients with several samples per tumor. Three microsatellite markers of each region were used for the LOH test. The polymerase chain reaction product was electrophoresed in 8% polyacrylamide gels, and band intensity was shown by silver staining.Results: The proportions of LOH in the two regions were 38.4% for 17q21 and 30.8% for 10q23 in the group of 214 and were 47.7% for 17q21 and 34.7% for 10q23 in the group of 110434_2003_Article_876. We found a high correlation between the LOH in both regions (P < .001), where 81% of LOH in 10q23 region was matched by concomitant LOH in 17q21. In the group of tumors with several samples (group of 100), 39% and 68% did not present LOH in the 17q21 and 10q23 regions, respectively, in all of their tumor samples. However, in the 20 patients with LOH in both regions in the group of 100 (several samples per tumor), all samples with LOH in 10q23 also had LOH in 17q21, whereas not all samples with LOH in 17q21 had LOH in 10q23.Conclusions: These results show that colorectal cancer is highly heterogeneous, at least for these tumors markers, and suggest a sequential acquisition pattern of these anomalies during tumor growth, in which changes in 17q21 could occur before those in 10q23.     

Ruptured inflammatory aortic aneurysm with aortoenteric fistula and infected with <Emphasis Type="Italic">Streptococcus pneumoniae</Emphasis>: a review of the literature

We present a case report of a 65-year-old gentleman who presented with an aortoenteric fistula along with a review of the literature. He was found, in addition, to have an inflammatory infrarenal aortic aneurysm with a posterior rupture. Cultures of the aneurysm sac confirmed a Streptococcus pneumoniae infection. The patient had previously presented with pneumonia. Antibody testing revealed an isolated pneumococcal IgG deficiency. The case demonstrates the diverse pathologies associated with aortic aneurysms and a need to be vigilant and occasionally expect the unusual.     

Susceptibility of <Emphasis Type="Italic">Candida albicans</Emphasis>, <Emphasis Type="Italic">Staphylococcus aureus</Emphasis>, and <Emphasis Type="Italic">Streptococcus mutans</Emphasis> biofilms to photodynamic inactivation: an in vitro study

The purpose of this study was to evaluate specific effects of photodynamic inactivation (PDI) using methylene blue as photosensitizer and low-power laser irradiation on the viability of single-, dual-, and three-species biofilms formed by C. albicans, S. aureus, and S. mutans. Biofilms were grown in acrylic discs immersed in sterile brain heart infusion broth (BHI) containing 5% sucrose, inoculated with microbial suspension (10⁶ cells/ml) and incubated for 5 days. On the fifth day, the effects of the methylene blue (MB) photosensitizer at a concentration of 0.1 mg/ml for 5 min and InGaAlP laser (660 nm) for 98 s, alone and conjugated were evaluated. Next, the discs were placed in tubes with sterile physiological solution [0.9% sodium chloride (NaCl)] and sonicated for to disperse the biofilms. Ten-fold serial dilutions were carried and aliquots seeded in selective agar, which were then incubated for 48 h. Then the numbers CFU/ml (log₁₀) were counted and analyzed statistically (ANOVA, Tukey test, p < 0.05). Scanning electron microscopy (SEM) on discs treated with PDI and control biofilms groups was performed. Significant decreases in the viability of all microorganisms were observed for biofilms exposed to PDI mediated by MB dye. Reductions (log₁₀) of single-species biofilms were greater (2.32–3.29) than the association of biofilms (1.00–2.44). Scanning electron microscopy micrographs suggested that lethal photosensitization occurred predominantly in the outermost layers of the biofilms. The results showed that PDI mediated by MB dye, might be a useful approach for the control of oral biofilms.     

Urinary tract infection caused by <Emphasis Type="Italic">Haemophilus influenzae</Emphasis> and <Emphasis Type="Italic">Haemophilus parainfluenzae</Emphasis> in children

There are few reports on urinary tract infections caused by Haemophilus influenzae or Haemophilus parainfluenzae in children. The true incidence is not known, since bacteria of Haemophilus species do not grow in standard urine culture media. With the objective of investigating the occurrence and character of urinary tract infections (UTIs) caused by Haemophilus bacteria in children, we searched the files of our UTI clinic. Over a 24-year period 36 children with Haemophilus spp. bacteriuria were identified out of a total of more than 5,000 UTI episodes. There was a significant gender difference in that Haemophilus influenzae dominated in girls and Haemophilus parainfluenzae in boys. With one exception, all children had important urinary tract abnormalities, such as malformation, gross reflux or bladder dysfunction. Permanent renal damage was seen in 25. We conclude that growth of Haemophilus bacteria in urine is associated with serious urinary tract abnormalities. The inability of bacteria of the Haemophilus species to grow in standard media commonly used for culture of uropathogens suggests that the true frequency of these strains as a cause of urinary tract infections is underestimated.