- Volume 1, Issue 3, 2014

The human bocavirus is associated with respiratory tract infections and has been shown to infect virtually all age groups. However, the majoritiy of HBoV infections is observed in children, on the one hand because this group of patients receives a broader diagnostics, on the other hand because up to the age of five years all people have passed the primary infection and developed antibodies. Thus, there is limited knowledge about the HBoV infection in adults.

A case of persistent pleural effusion associated with an infection with human bocavirus (HBoV) is reported. To the best of our knowledge, this is the first case in which HBoV has been found in the pleura during an active infection in an adult patient.

HBoV infection can lead to serious disease in adults and can affect also the pleura.

The global incidence of diphtheria remained steady during 2007–2011 after a steady decline of over 95 % from 1980 to 2006. This was largely due to a resurgence of the disease in India, which alone accounted for 71–83 % of the total cases reported worldwide.

This article describes the identification of an outbreak of diphtheria in two very remote villages of northern Karnataka in South India in May 2011 and detection of further cases in as many as seven nearby villages in the 6 months that followed, which resulted in at least three deaths. The ineffectiveness of the Universal Immunization Programme in its present form in reaching the remote villages is highlighted, and one case of diphtheria with a non‐toxigenic strain of Corynebacterium diphtheriae, which is very rare in India and has the potential to upset eradication strategies, is documented.

This article should provide a wake‐up call for the health administrators for restructuring and strengthening immunization strategies and programmes.

Psittacosis is a zoonotic infectious disease contracted from birds and caused by Chlamydia psittaci, an obligate intracellular pathogen. In humans, the symptoms of the disease range from inapparent illness to systemic illness with severe pneumonia.

A severe case of atypical pneumonia requiring extra‐corporeal membrane oxygenation in a duck breeder is described. Because of the critical urgency of the case described here, and without any clear identification of the pathogen during the first days of hospitalization, treatment had to be adjusted daily. While conventional clinical methods failed to identify the causative agent, C. psittaci was finally identified using broad‐range 16S rDNA PCR analysis performed on a sample of broncho‐alveolar fluid.

Owing to the non‐specific clinical signs of psittacosis, early identification of cases of the disease remains a challenge. C. psittaci should be sought in patients presenting severe acute respiratory distress syndrome without any evidence of other infectious causes and especially when exposure to birds or bird products is reported. PCR is a very useful method to help identify fastidious organisms of this kind.

Chickenpox is generally a childhood exanthematic benign self‐limited disease. In contrast, most complications and fatal cases occur among adults, which is the group that suffers less commonly from this disease. The frequency of chickenpox in adults is increasing worldwide, together with the associated complications, mainly varicella pneumonia, which can lead to death. The incidence of other complications such as peripheral artery thrombosis is much lower but can cause important morbidity.

We report the case of a 63‐year‐old male smoker, who was otherwise previously healthy, who was admitted to the Emergency Department with chickenpox and varicella pneumonia with respiratory insufficiency requiring mechanical ventilation and intensive care unit admission. During hospitalization, the patient developed spontaneous popliteal artery thrombosis that finally led to transfemoral amputation.

Varicella pneumonia and peripheral artery thrombosis are two of the known complications of chickenpox. Both complications seem to be much more frequent in men with an active smoking habit. Clinicians should be aware of these complications in order to recognize them promptly and provide adequate treatment.

Psittacosis is a bacterial infection of humans caused by Chlamydia psittaci and can lead to severe pneumonia that is potentially fatal if not treated. Many psittacosis cases occur after exposure to infected birds, frequently parakeets, cockatiels, parrots and macaws. Despite the fact that psittacosis is the most important zoonosis transmitted by pet birds, the disease is probably underdiagnosed due to diagnosis difficulties and lack of notification.

Here, we described a psittacosis domiciliary outbreak related to monk parakeets (Myiopsitta monachus) acquired from illegal trade, resulting in seven people with severe atypical pneumonia and six hospitalizations.

Campaigns to raise awareness could increase the general degree of attentiveness to human psittacosis. Furthermore, focusing efforts on markets to regulate, or in some cases eliminate, the trade in wildlife could provide a cost‐effective approach to decrease the risks of disease for humans.

Generally considered to be part of the environmental flora, Chryseobacterium spp. have been reported to cause infection in humans, albeit rarely. The clinical significance of these organisms remains to be fully established, despite being isolated from patients, especially neonates, and immunocompromised subjects.

We present a study of 10 isolates of Chryseobacterium spp. cultured from blood and endotracheal secretions of neonates in two hospitals, Farwaniya Hospital (FH) and Maternity Hospital (MH), Kuwait, identified using the Phoenix or Vitek 2 system from April to November 2012. The clinical features of the patients were assessed, and antimicrobial susceptibilities of the isolates were performed by disk diffusion test and Etest. Molecular identification of bacteria was done by 16S rRNA gene sequencing and fingerprinting by random amplified polymorphic DNA (RAPD). Patients suffered from sepsis, pneumonia or other clinical conditions. Two strains of Chryseobacterium indologenes and eight strains of Chryseobacterium meningosepticum (now Elizabethkingia meningosepticum) were cultured from clinical samples from FH and MH, respectively. Both C. indologenes and six of the C. meningosepticum strains were isolated from endotracheal secretions, and two of the latter were from blood. Identification of isolates was confirmed by 16S rRNA gene sequencing. All isolates were multidrug resistant and eight were metallo‐β‐lactamase positive. Five patterns of Chryseobacterium spp. were identified by RAPD.

It appears that Chryseobacterium spp. are emerging pathogens for neonates in Kuwait, causing serious systemic infections.

Raoultella planticola is an uncommon pathogen rarely associated with clinical infections. Previous studies showed that most R. planticola isolates were sensitive to cephalosporins, aminoglycosides, fluoroquinolones and carbapenems, and no extensively drug‐resistant (XDR) strains have been reported.

In this study, an XDR R. planticola strain, RP01, was isolated from a Chinese patient with multiple chronic diseases. Antimicrobial susceptibility testing showed that RP01 was resistant to almost all clinically available antibiotics except tigecycline. PCR and sequencing revealed the presence of blaNDM‐1 , encoding a metallo‐β‐lactamase with hydrolysing activity against carbapenems. Further genomic sequencing and ResFinder analysis identified 20 resistance genes, encoding resistance to β‐lactams, aminoglycosides, sulfonamides, tetracycline, fluoroquinolones, trimethoprim and fosfomycin.

These results described the ability of the rare pathogen R. planticola to acquire multiple resistance genes.

Aeromonas hydrophila is implicated in a wide spectrum of skin and soft‐tissue infections, ranging from cellulitis to life‐threatening necrotizing fasciitis and myonecrosis. Most reported cases of fulminant A. hydrophila necrotizing soft‐tissue infections occur following a history of trauma sustained in an aquatic environment. However, fatal Aeromonas myonecrosis and gas gangrene without antecedent trauma, underlying liver disease, malignancy or immunosuppression has rarely been reported in the literature.

A 50‐year‐old woman who underwent elective percutaneous transluminal coronary angioplasty became acutely ill with septic shock and adult respiratory distress syndrome, on post‐operative day 3. She developed severe oedema, blistering and gangrenous patches in the right lower limb. She died on post‐operative day 3 despite intensive care. A. hydrophila was cultured from the blister fluid, two blood cultures and tissue. An inspection of the hospital water supply was negative for A. hydrophila, and hence the origin of the A. hydrophila could not be ascertained.

Post‐operative Aeromonas infection is rare but very serious, and requires particularly vigilant monitoring. The mortality of Aeromonas necrotizing soft‐tissue infections where the microorganism is simultaneously isolated from blood culture is documented to be extremely high. In all cases of rapidly progressive necrotizing infections, A. hydrophila should be kept in mind and a fluoroquinolone/aminoglycoside should be added to the surgical and medical management. The microbiology laboratory should be alert in dealing with Gram‐negative, β‐haemolytic isolates so that an oxidase or deoxyribonuclease screen is performed to differentiate A. hydrophila from microbiologically similar organisms.

Neonatal mastitis is an inflammatory condition of the breast frequently associated with Staphylococcus aureus. While Panton–Valentine leucocidin (PVL), a B‐pore‐forming cytotoxin, is commonly associated with enhanced virulence in community‐acquired methicillin‐resistant S. aureus isolates, this is the first report to our knowledge of neonatal mastitis caused by PVL‐positive S. aureus.

A 20‐day‐old full‐term female neonate presented with bilateral mastitis, complicated by bilateral abscess formation. PVL toxin‐positive S. aureus was cultured from aspirates of both breasts. All family members, none of whom presented with symptoms of infection, and, specifically, maternal vaginal samples proved negative for PVL‐positive S. aureus. Successful resolution involved surgical drainage and clindamycin therapy.

While PVL toxin‐positive S. aureus has previously been implicated in bovine and ovine mastitis, there may now be a need for vigilance with respect to human incidence. Due to PVL‐mediated tissue necrosis, breast abscess formation and poor response to conventional antimicrobial therapy should, perhaps, be a cause for suspicion of PVL‐bearing S. aureus and expediting of appropriate therapy to avoid potential for long‐term consequences such as abnormal breast development.

Primary cutaneous cryptococcosis is a rare form of cryptococcosis occurring after direct inoculation of Cryptococcus spp. yeast cells through skin injury and equally affects immunocompetent and immunocompromised individuals.

We report a case of a 61‐year‐old man who presented with an 8‐month history of an ulcerative lesion on a finger, which was refractory to antimicrobials, following injury with a plant thorn. The patient had a medical history of myasthenia gravis and had been undergoing treatment with pyridostigmine and intermediate doses of prednisolone for more than 30 years. A skin‐lesion culture was positive for Cryptococcus neoformans var. neoformans, which was molecularly confirmed and typed as serotype D, mating‐type α, genotype AFLP2/VNIV. Histopathology revealed a diffuse type of inflammation, with many yeasts consistent with Cryptococcus spp. The serum cryptococcal antigen was positive at a titre of 1 : 32. Radiological investigation excluded disseminated disease but revealed the incidental presence of a clear cell renal cell carcinoma. The tumour was considered to be an additional factor of immunosuppression and could justify the histological findings. The patient was treated with 200 mg fluconazole twice daily, underwent surgical removal of the mass and received treatment with sunitinib, a receptor protein‐tyrosine kinase inhibitor. At the 4 month follow‐up, he had a remarkable clinical improvement. A year after, he remained symptom free and tolerated the anti‐tumour therapy well.

The patient presented here had no evidence of a disseminated cryptococcal infection despite two concurrent causes of cellular immunity defect and a positive antigen titre.

Community‐acquired methicillin‐resistant Staphylococcus aureus (CA‐MRSA) is increasingly recognized as an important pathogen. Panton–Valentine leukocidin (PVL)‐producing CA‐MRSA constitutes a public health concern because it can be responsible for severe, progressive necrotizing skin, soft‐tissue and pulmonary infections.

We describe a case of recurrent transmission of PVL‐producing ST5, staphylococcal cassette chromosome mec type IV MRSA (paediatric clone) from an asymptomatic nasal carrier to his family causing severe skin and soft‐tissue infections in the mother and children. Nasal application of mupirocin in the carrier was successful for prevention of new infections.

Recurrent skin infections are often not taken into account but may represent a serious threat if caused by a PVL‐producing MRSA strain. Family members of MRSA carriers are in danger of transmission. Characteristics of currently circulating CA‐MRSA strains require closer surveillance. Identification and decolonization of carriers is important to reduce the risk of spread into the community.

Mucormycosis is usually an invasive mycotic disease caused by fungi in the class Mucormycetes. It often occurs in immunocompromised patients but sporadic cases without apparent immune impairment have been described.

Here we report a case of rhinofacial mucormycosis due to Rhizomucor pusillus in a 55‐year‐old diabetic female. She presented with diabetic ketoacidosis and nasal obstruction, nasal discharge and right‐sided cheek swelling following sinus surgery, which had been performed at a private hospital 1 month previously. Endoscopic biopsy was performed and the sample was sent for histopathological examination and KOH wet mount, which showed broad, pauci‐septate hyphae with right‐angle branching. The tissue was inoculated onto Sabouraud dextrose agar and white mycelial growth was obtained which turned grey with age. Morphological identification confirmed it as Rhizomucor pusillus. In vitro antifungal susceptibility testing was performed by means of the microbroth dilution method according to CLSI Approved Standard M38‐A. The isolate was found to be susceptible to amphotericin B, itraconazole and posaconazole but resistant to voriconazole and echinocandins. Functional endoscopic sinus surgery was performed and local necrotic tissue was debrided. The patient was put on liposomal amphotericin B, with a successful outcome.

Early diagnosis is critical in prevention of morbidity and mortality associated with disease.

Scedosporium apiospermum is a significant emerging fungus causing potentially life‐threatening infections in poor immune responders. Scedosporiosis may complicate chronic diseases such as leprosy rarely presenting with fungaemia and extensive cutaneous lesions resistant to treatment.

An elderly female presented with numerous red, painful, pustules over distal extremities spanning 2 months. Fever and numbness of hands and feet were associated features. A past history of a fall 3 years previously traumatizing the lower back followed by joint pains and self‐medication with steroids were antecedent factors as well as uncontrolled diabetes. She was a case of lepromatous leprosy released from multidrug therapy, the period ahead of which was interspersed with episodes of erythema nodosum leprosum. Examination revealed multiple erythematous nodulo‐plaques, pus‐filled bullae and hyperpigmented verrucous plaques over limbs with black skin discoloration and puckered scars over the right thigh and buttocks. Imaging showed sclerosis of pelvic bones and wedge compression of the lumbosacral spine. Direct microscopy of pus demonstrated branched, septate, hyaline hyphae and closely septate swollen cells in periodic acid–Schiff‐stained tissue sections. S. apiospermum isolated in cultures of pus and blood depicted fungaemia and this was further substantiated by echocardiographic visualization of echogenic nodules on the anterior mitral leaflet. A transient favourable response on itraconazole 200–400 mg daily was followed by the emergence of new lesions. Parenteral voriconazole at 4–6 mg kg−1 followed by oral treatment at 400 mg daily showed satisfactory improvement. The final outcome remained obscure as the patient was lost to follow‐up.

Therapy‐resistant cutaneous lesions in chronic diseases such as leprosy should be evaluated for rare opportunistic fungal infections.

The majority of abortions in mares are associated with placental infections caused by opportunistic bacteria. Rhodococcus equi is widespread in the environment of stud farms and Klebsiella oxytoca is found on the mucosal surfaces of horses. Both can occasionally cause placental infection and abortion in mares. To the best of our knowledge, however, there have been no reports of R. equi and K. oxytoca coinfection in mares experiencing placentitis and abortion. The present report describes an uncommon case of abortion caused by R. equi and K. oxytoca coinfection in a thoroughbred mare in Brazil, in which the virulence profile of R. equi was investigated.

A 6‐year‐old thoroughbred mare, in her first pregnancy, showed increased uteroplacental junction and suspected placentitis on transabdominal ultrasound. The mare aborted a 10‐month‐old female fetus. A field necropsy was performed and hydrallantois was diagnosed.

Although we isolated an avirulent strain of R. equi, coinfection of R. equi and K. oxytoca in the placenta and uterus probably potentiated the pathogenic effect of these micro‐organisms, resulting in abortion.

We describe an unusual case of anaerobic bacteraemia caused by Fusobacterium gonidiaformans and Peptoniphilus asacchacrolyticus, both commensal organisms normally found within human oropharyngeal, gastrointestinal and genitourinary tracts.

One week following a routine colonoscopy with polypectomy, a 65‐year‐old male with renal calculi was admitted with a 3‐day history of severe abdominal pain and chills. He required urgent placement of a percutaneous nephrostomy tube. Urine cultures were negative but blood cultures were positive for Fusobacterium gonidiaformans and Peptoniphilus assachacrolyticus.

We hypothesized that, following his colonoscopy, the patient developed transient bacteraemia with commensal gut organisms. In the setting of multiple ureteral calculi, this transient bacteraemia became a clinically significant infection, manifesting as acute ureterolithiasis with concurrent bloodstream infection. The routine collection of blood for anaerobic culture led to pathogen identification and appropriate antimicrobial therapy.

Urinary tract infections (UTIs) are the most common bacterial infections in women of all ages. The emergence of resistance to newer classes of antibiotics, including third generation cephalosporins, has limited the drug choices for treatment of UTI. We report here a recurrent UTI due to co‐infection with multiple‐antibiotic‐resistant (MAR) Escherichia coli pathotypes.

A 73‐year‐old woman with diabetes mellitus type 2 presented with fever, nausea, vomiting, burning sensation, painful and frequent urination. She was diagnosed with recurrent UTI (RUTI) due to co‐infection with pansensitive enteroaggregative E. coli (EAEC) and MAR extended spectrum β‐lactamase (ESBL)‐producing uropathogenic E. coli (UPEC) and treated with azithromycin and levofloxacin (each for 10 days). Unfortunately, she did not respond. Plasmid profile analysis showed that the MAR E. coli strain harboured multiple plasmids including ∼38 and ∼80 MDa plasmids. PCR for detection of β‐lactamase genes showed that the isolate was negative for blaTEM, blaSHV, blaOXA and blaCTX‐M. To the best of our knowledge, this is the first report of co‐infection with an EAEC and MAR ESBL‐producer UPEC in Bangladesh.

We recommend that all pathotypes of E. coli as well as the other more common uropathogens should be considered in the diagnosis of RUTI and multiple antibiotics should be prescribed only in severe conditions.

Ranavirus infection is associated with mass die‐off and population decline in amphibians worldwide, and is listed by the World Organization for Animal Health (OIE) as a notifiable disease under the Aquatic Animal Health Code. Work is ongoing to control the spread of ranavirus, because this agent is considered an emerging pathogen of amphibians. In Japan, ranaviral diseases have been detected at each episode of die‐off of wild bullfrog juveniles since 2008. However, ranaviral disease has not been found in captive anurans.

Epidemic and lethal ranaviral disease in captive Dendrobates and Phyllobates species imported from the Netherlands is reported. Poison dart frogs of three genera were imported from the Netherlands in March 2012. Disease and death were noted approximately 10 days after importation. Fifty‐three adults of five species died in about 1 month, including frogs that had been kept previously. Microscopic examination revealed necrosis and intracytoplasmic basophilic inclusion bodies in the parenchyma of multiple organs. Electron microscopy showed cytoplasmic ranavirus‐like particles within haematopoietic cells of the kidney. These particles were icosahedral, with a diameter of approximately 144 nm. Thirty‐three of 41 dead frogs showed positive PCR results for the major capsid protein gene of Ranavirus. The sequence obtained from five frogs was identical and did not match the registered sequence of any ranavirus.

This is the first report, to our knowledge, of ranaviral disease in imported anurans of the family Dendrobatidae and genera Phyllobates and Dendrobates in Japan.

Capnocytophaga sputigena is a capnophilic Gram‐negative bacillus normally residing intra‐orally in humans, and may be associated with opportunistic infections in the immunocompromised. A case of early‐onset neonatal sepsis is described, which has only rarely been reported as a cause of premature birth and neonatal septicaemia.

This case report focuses on the rare presentation of a microbe, Capnocytophaga sputigena, causing pre‐term labour, early neonatal septicaemia and maternal chorioamnionitis. To the best of our knowledge, it is the first case report of such a presentation in New Zealand. This case helps to demonstrate the contrast between the stormy clinical course in the newborn and the silent asymptomatic presentations in the mother.

Capnocytophaga spp. normally reside in the human oral cavity and have been associated with the pathogenesis of periodontal disease. They have also been reported in wounds in humans inflicted by animal bites, and in a wide spectrum of opportunistic infections in the immunocompromised. Only rarely have Capnocytophaga spp. been attributed as a cause associated with pre‐term birth, early neonatal septicaemia or chorioamnionitis.