Favorable outcome of amphotericin B treatment of zygomycotic necrotizing fascitis caused by Apophysomyces elegans

A 45‐year‐old man was referred from a primary health care center to our hospital in November 2005 with features of necrotizing fascitis of the right shoulder and upper back. He had been admitted to the previous hospital following an injury, sustained in an accident, while driving a tractor. He was treated for fracture of the right clavicle followed by wound debridement of the right shoulder at the health center. Examination of the wound in our hospital revealed a large, 15 × 15 cm, raw area over the upper back, extending to the right upper arm and shoulder. The wound was grossly infected with slough and purulent discharge. The margin of the wound was indurated. No other abnormality was detected on general examination, except for the fracture of the clavicle. Laboratory investigation revealed a hemoglobin level of 7.5 g/dL and a total leukocyte count of 19,600/mm³, with a differential count of 82% polymorphs, 16% lymphocytes, and 2% eosinophils. The blood glucose was 80 mg%, blood urea 36 mg/dL, and serum creatinine 0.9 mg/dL. Culture of a sample of tissue from the wound yielded a mixture of Escherichia coli, which was sensitive to imipenem, cefoperazone/sulbactam, and amikacin, and resistant to ampicillin, gentamicin, cefazolin, cefotaxime, ticarcillin, ofloxacin, amoxyclavulanic acid, and ciprofloxacin, together with a multidrug‐resistant Pseudomonas aeruginosa, which was sensitive to imipenem only. As the patient had features of impending septicemia, he was managed with daily cleaning of the wound, with intravenous imipenem 500 mg eight hourly. Seven days later, the wound showed pockets of white cheesy material extruding out as strands. Microscopic examination of scrapings from this cheesy material showed broad aseptate hyphae suggestive of a zygomycete ( Fig. 1 ). A culture of the tissue on Sabouraud's dextrose agar (SDA) yielded a white fluffy growth after 48 h of incubation at both 25 °C and 37 °C ( Fig. 2a ). The microscopic morphology of the fungus stained with lactophenol cotton blue revealed broad, ribbon‐like, aseptate hyphae. Sporulation was very poor on the routine SDA medium. Stimulation of sporulation was attempted on 1% water agar. 1 After 1 week of incubation, sporulation occurred, and microscopy revealed a sporangiophore measuring around 200–300 µm in length, arising at right angles with a septate basal segment, or foot cell, as it is called. The sporangia were multispored, small (20–50 µm in diameter), typically pyriform in shape, and with hemispherical columellae. The apophysis was funnel shaped ( Fig. 2b ). The fungus was identified as A. elegans on the basis of these characteristic features.

Figure 1 Open in figure viewer PowerPoint Photomicrograph of 10% KOH mount showing broad aseptate hyphae together with tissue debris (magnification, ×400)     

Rare indolent zygomycosis caused by subcutaneous Saksenaea vasiformis infection

We report an immunocompetent male child with chronic, indolent subcutaneous limb infection akin to basidiobolomycosis, but was shown by PCR method to be caused by a mucoralean fungus Saksenaea vasiformis. Treatment with oral potassium iodide solution was effective. This finding highlights the consideration of treatment decision according to the phenotypic severity as opposed to species identified.     

Surgical site infection caused by Aeromonas hydrophila presenting as necrotizing soft tissue infection after esophagectomy

Several virulence factors of Aeromonas such as hemolysin, proteases and lipases have been characterized. The relationship between these virulence factors and disease remains unclear. A 71-year-old man underwent thoracoscopic esophagectomy, lymph node dissection and Roux-en-Y reconstruction for esophageal cancer. On postoperative day 1, redness around the wound on the thoracic abdominal wall gradually enlarged and necrosis became apparent with septic shock. Necrotizing soft tissue infection was suspected and emergency surgical debridement was performed. Blood and wound cultures were positive for Aeromonas hydrophila. The strain was found to have hemolytic activity, proteolytic activity and extremely high elastolytic activity. In addition, the strain actively produced elastolytic metalloprotease, which may contribute to extensive tissue necrosis.     

Necrotizing subcutaneous infection by Streptococcus agalactiae

Necrotizing soft tissue infections constitute some of the most potentially threatening infections that may be acquired in the community or in the hospital milieu as they are associated with a high mortality rate. In most cases they are produced by Streptococcus pyogenes. We report a case of a necrotizing soft tissue infection caused by Streptococcus agalactiae (group B beta hemolytic streptococcus) that involved the leg of an elderly man with chronic lymphatic leukemia and diabetes mellitus. The lesions notably improved after initiating intravenous antibiotic treatment with amoxicillin-clavunate and clindamycin.     

注射“溶脂针”致面部多发皮下结节、囊肿一例

1临床资料 患者,女,22岁。双侧面颊、下颌多发结节、囊肿2个月。患者于2个月前为＂面部塑形＂在个人美容工作室于双面颊及双下颌皮下注射＂溶脂针＂（具体成份不详）,共2支,分别为10 mL和5 mL（图1）,注射点达10余处,5天后局部出现豌豆至蚕豆大紫红色皮下结节,皮温高、触之质韧、轻压痛,未予重视。后结节逐渐增大,部分形成囊肿,表面张力大,红肿、疼痛加重,遂就诊于当地医院,疑为＂皮肤感染＂,先后予口服抗生素及静脉输注盐酸莫西沙星注射液8天（具体剂量不详）,效果不佳。     

Cutaneous infection caused by Serratia marcescens

An 86-year-old woman presented with a chronic granulomatous skin lesion on the dorsal aspect of her left hand. Histologic examination showed pseudoepitheliomatous hyperplasia and a dense dermal infiltrate largely composed of lymphocytes and histiocytes. Abscess formation and fibroblastic proliferation were also present. Use of Fite, Giemsa, and periodic acid-Schiff stains did not show specific organisms. The gram-negative bacillus Serratia marcescens was the only microorganism isolated from all cultures performed. Trimethoprim-sulfamethoxazole, 960 mg every 12 hours for 20 days (orally), was given and resulted in complete disappearance of the lesion and negative culture findings. Cutaneous infection by S marcescens may represent a distinctive entity, whose clinical and possible pathogenic features are presented here.     

Cutaneous infection caused by Salmonella typhi

Salmonella typhi is a flagellated, gram-negative bacillus belonging to the family Enterobacteriaceae responsible for typhoid fever, which is a prolonged bacteraemic, systemic illness with minimal, at least initially, diarrhoea. Localized infection is a not uncommon complication of salmonella septicaemia, particularly occurring in immunocompromised patients. However, salmonella localization to the skin presenting as cutaneous ulceration is regarded as a rare event. We report a unique case of such a presentation as the sole clinical manifestation of infection with S. typhi and highlight the possible salmonella aetiology for unusual cutaneous lesions in individuals coming from endemic areas.     

Skin infection caused by Mycobacterium avium

A patient with skin infection due to Mycobacterium avium is reported. A 9–year–old female had 10 subcutaneous nodules and two ulcers on the abdomen and legs. She had no medical history of systemic disease, skin disease or immunosuppressive therapy. Cultures of a biopsy specimen and of aspirated seropurulent fluid in nodules showed acid–fast bacteria, identified as M. avium by the DNA–DNA hybridization method. We treated her with a combination of surgery and the antibiotics, cycloserine, isoniazid and clarithromycin.     

Disseminated subcutaneous nodules caused by Pseudallescheria boydii in an atopic patient

We present a 40-year-old woman with atopic dermatitis and multiple purulent subcutaneous nodules of 20 years' evolution. The biopsy material was cultured and revealed Pseudallescheria boydii. The patient was treated with oral itraconazole for 4 months and incision and drainage of the lesions. Afterwards the patient remained asymptomatic and no new lesions were detected.     

Persistent subcutaneous Scedosporium apiospermum infection

We report the case of a 52-year-old male heart transplant recipient with a persistent localized subcutaneous infection by Scedosporium apiospermum. This form differs from the most common mycetoma by the absence of granules. The patient showed multiple nodules on the right hand that were surgically removed. Concomitantly, he received oral itraconazole, but the infection persisted for two years, and several surgical interventions were necessary to eradicate the infection. Our case demonstrates that a medical approach alone may be not sufficient to cure this fungal infection.