- Volume 1, Issue 3, 2014
Volume 1, Issue 3, 2014
- Case Report
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- Blood/heart and lymphatics
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A rare case of breakthrough fungal pericarditis due to fluconazole‐resistant Candida auris in a patient with chronic liver disease
More LessIntroduction:Candida pericarditis is a rare clinical entity with a high fatality, primarily attributed to difficulty in diagnosis. Unfortunately, the diagnosis is made post‐mortem in more than 50% of cases, and thus a high index of clinical suspicion is crucial.
Case presentation:We report a rare case of fungal pericardial effusion caused by the recently recognized multidrug‐resistant Candida auris, which was cultured from pericardial fluid, blood, bronchoalveolar lavage and urine of a chronic liver disease patient while on empiric fluconazole therapy. The yeast was misidentified as Candida haemulonii by the VITEK2 commercial identification system, and was confirmed as C. auris by internal transcribed spacer and large ribosomal subunit sequencing. In addition, the VITEK2 AST card erroneously revealed a high amphotericin B MIC (16 µg ml−1) and low caspofungin MIC (0.25 µg ml−1) that did not correlate with results from the reference Clinical and Laboratory Standards Institute (CLSI) microbroth dilution method. Based on VITEK2 MIC data, the patient was administered caspofungin. However, in vitro antifungal susceptibility data for C. auris by the CLSI method exhibited high MICs to fluconazole (64 µg ml−1) and caspofungin MIC (1 µg ml−1) but low MICs to amphotericin B (MIC range, 0.125−0.5 µg ml−1). The patient’s repeat pericardial fluid culture, despite caspofungin therapy for 12 days, grew C. auris and he died on day 13 of therapy.
Conclusion:C. auris is a recently reported agent of fungaemia and deep‐seated infections and is notable for its antifungal resistance. Although early species identification and rapid antifungal susceptibility testing are needed in cases of critical infections, the reporting of rare yeast isolates exhibiting high MICs to antifungals by automated systems needs a cautionary approach.
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Infective endocarditis caused by Bartonella quintana in Greenland
Introduction:Bartonellosis has not been described previously in Greenland. Here, we present a case of infective endocarditis due to Bartonella quintana in a patient living in western Greenland.
Case presentation:A 68‐year‐old man from Disko Island in western Greenland underwent aortic valve replacement because of infective endocarditis. Culture from blood and tissue was negative. PCR of bacterial DNA and DNA sequencing revealed DNA from B. quintana in the valve, and the finding was confirmed by species‐specific PCR.
Conclusion:This case demonstrates the presence of B. quintana in Greenland. The finding emphasizes the importance of testing for unexpected agents when culture fails to identify the cause of a severe disease.
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Linezolid‐resistant S. epidermidis clone ST‐2 isolated from a patient who did not receive any course of oxazolidinone therapy: a case report
Lara Mendes De Almeida, Alexandre Inácio Cruz De Paula, Thaís Guimarães, Mónica Pavez, Andrey Guimarães Sacramento, Liane Constantino Lemos, Laís Carolina Scapolan Ito, Maria Rita Elmor De Araújo, Marta Fumiko Iwasaki, Ana Cristina Gales, Nilton Lincopan, Jorge Luiz Mello Sampaio and Elsa Masae MamizukaIntroduction:Linezolid has excellent activity against multidrug‐resistant Staphylococcus spp. and linezolid resistance has emerged mainly in isolates recovered from patients who are receiving courses of oxazolidinone therapy.
Case presentation:We report a clinical case of bacteraemia caused by a linezolid‐resistant Staphylococcus epidermidis clone ST‐2 with the G2576T mutation in five copies of the 23S rRNA gene (MIC, 32 µg ml−1) isolated from a patient who did not receive any course of oxazolidinone therapy. The S. epidermidis HSPE24‐SP strain was WT for L3, L4 and L22 ribosomal proteins, cfr negative and indistinguishable by PFGE from the clone that circulated at the same time in another tertiary care hospital located in the same city.
Conclusion:This report suggests the inter‐hospital spread of S. epidermidis clone ST‐2 and calls attention to the possibility of isolation of a linezolid‐resistant strain with multiple 23S rRNA mutated copies in an environment under no oxazolidinone selective pressure.
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Isolated cervical cryptococcal lymphadenitis without meningitis in an immunocompetent human immunodeficiency virus‐negative child: a rare case report
More LessIntroduction:Cryptococcal infection is the second most common life‐threatening, opportunistic infection in human immunodeficiency virus (HIV)‐infected individuals after Mycobacterium tuberculosis. Most cryptococcal infections start in the respiratory tract and secondarily involve the central nervous system, skin and bone marrow but rarely disseminate to lymph nodes.
Case presentation:Cases of disseminated cryptococcal lymphadenitis with or without meningitis have been reported in HIV‐infected as well as immunocompetent HIV‐negative individuals. Here, we report a rare case of isolated cervical cryptococcal lymphadenitis without meningitis in an immunocompetent HIV‐negative child diagnosed by fine‐needle aspiration cytology (FNAC) of the involved lymph nodes.
Conclusion:Clinical presentations of extrapulmonary cryptococcosis in HIV‐positive hosts are variable and vague. The present case scenario proves that the same might also be true for HIV‐negative individuals. FNAC is a quick, feasible, economical and reliable method for the diagnosis of cryptococcal lymphadenitis when correlated with microbiological, biochemical and histopathological examinations.
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Recalcitrant coagulase‐negative methicillin‐sensitive Staphylococcus aureus in an extremely low‐birth‐weight pre‐term infant with thrombocytopaenia
Introduction:Infections due to Staphylococcus aureus are cumbersome to treat and control. Virulent S. aureus is commonly coagulase positive, whilst non‐virulent isolates are coagulase negative. Literature on coagulase‐negative variants of S. aureus and their role in clinical disease in neonates is seldom available.
Case presentation:We report a case of an extremely low‐birth‐weight pre‐term infant who had persistent recalcitrant infection with coagulase‐negative methicillin‐sensitive S. aureus, which resulted in clinical sepsis, thrombocytopaenia and persistence in blood cultures for 7 weeks. The API STAPH‐Ident system (Bio‐Merieux) and 16S rRNA gene sequencing were used to confirm identity. Parallel use of blood culture yielded an isolate with the same phenotypic identity.
Conclusion:Prompt identification of uncommon phenotypes of S. aureus also requires the use of appropriate molecular diagnostics to necessitate timely treatment of life‐threatening systemic infections in neonates.
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Two cases of portal vein thrombosis associated with Fusobacterium bacteraemia
More LessThis report presents two cases of Fusobacterium bacteraemia associated with portal vein thrombosis. A 63‐year‐old man with a history of hypercholesterolaemia and nephrolithiasis was admitted to the hospital with fever and abdominal pain. A computed tomography (CT) scan revealed thrombosis of the posterior right portal vein. Blood cultures were positive for Fusobacterium nucleatum. The second case was a 53‐year‐old man with alcoholic steatohepatitis admitted with fever, chills and abdominal pain. A CT scan revealed right portal vein thrombosis and Fusobacterium necrophorum was isolated from his blood cultures. Both patients were successfully treated with intravenous ertapenem 1 g day–1 for 4 weeks with resolution of symptoms. These case reports underscore the importance of considering the diagnosis of portal vein thrombosis in patients with Fusobacterium bacteraemia of unclear aetiology.
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Difficulty with Gordonia bronchialis identification by Microflex mass spectrometer in a pacemaker‐induced endocarditis
More LessIntroduction:This report describes the first case, to the best of our knowledge, of pacemaker‐induced endocarditis due to Gordonia bronchialis.
Presentation:Pacemaker‐induced endocarditis due to G. bronchialis infection was determined in a 92‐year old man. This Gram‐positive bacillus failed to be identified by matrix‐assisted laser desorption/ionization time‐of‐flight mass spectrometry technology, whereas the taxon was indexed in the database. 16S rRNA and rpoB gene sequencing were required to determine the correct strain identity.
Conclusion:Infections caused by G. bronchialis remain a rare phenomenon affecting immunocompromised patients and/or medical device carriers. Molecular tools may be necessary to ensure accurate identification.
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Catheter‐related bloodstream infection caused by Gordonia terrae in a bone‐marrow transplant patient: case report and review of the literature
More LessIntroduction:Gordonia spp. are a rare but recognized cause of bloodstream infections (BSIs), particularly catheter‐related BSIs (CR‐BSI). These infections are mostly associated with long‐term central catheters and occur in immunocompromised patients. Their optimal management is still uncertain due to the paucity of cases.
Case presentation:We describe a case of CR‐BSI by Gordonia terrae in a bone‐marrow transplant patient. Definitive diagnosis of the CR‐BSI was confirmed by using the differential time to positivity of blood cultures. The patient was treated with antibiotic therapy without catheter removal and the infection cleared despite the presence of persistent bacteraemia.
Conclusion:Although in the present case report persistent CR‐BSI bacteraemia by G. terrae cleared without catheter removal, further experience is required to confirm that these infections can, in some cases, be successfully treated while retaining the catheter.
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A case of massive pericardial effusion caused by Mycobacterium simiae
More LessIntroduction:Mycobacterium simiae can cause disseminated infection in human immunodeficiency virus (HIV)‐infected patients, mainly with involvement of pulmonary and reticulo‐endothelial systems. Although this organism is also known to cause infections in non‐HIV‐infected individuals, to our knowledge there has been no report of pericardial effusion caused by M. simiae.
Case presentation:We describe a case report with massive pericardial effusion caused by M. simiae in a non‐HIV‐infected female patient, who presented with complaints of gradually increasing breathlessness and cough over a period of 1 month. Acid‐fast bacilli were isolated from the pericardial effusion and subsequently confirmed as M. simiae by PCR‐RFLP.
Conclusion:In an area where Mycobacterium tuberculosis infection is endemic, clinicians and microbiologists must be aware of the possibility of a non‐tubercular mycobacterial infection that could be misdiagnosed as a tubercular infection.
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- Central nervous system
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A case of cavernous sinus thrombosis caused by Dialister pneumosintes, Slackia exigua and Prevotella baroniae
Introduction:Cavernous sinus thrombosis (CST) is a rare manifestation of cerebral venous thrombosis. We herein describe the first case of CST associated with the oral microbes (Dialister pneumosintes, Slackia exigua and Prevotella baroniae).
Case presentation:An 82‐year‐old previously self‐supported Japanese woman presented with acute onset of impaired consciousness. Computed tomography revealed intracranial haemorrhage complicated with CST. D. pneumosintes, Slackia exigua and P. baroniae were cultivated from two sets of blood cultures and were identified with 16S rRNA sequencing. The patient was successfully discharged after ampicillin–sulbactam treatment, which was performed soon after admission.
Conclusion:To our knowledge, this is the first description of CST caused by D. pneumosintes, Slackia exigua and P. baroniae. CST should be considered in cases of unusual distribution of cerebral haemorrhage.
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Fatal cryptococcal meningitis in a HIV‐seronegative patient with liver cirrhosis
More LessIntroduction:A 41‐year‐old man with a history of alcoholic cirrhosis presented to Patan Hospital in Kathmandu, Nepal, with a severe headache.
Case presentation:Clinical examination found an isolated sixth nerve palsy of the left side with normal blood parameters and a normal brain scan. An initial cerebrospinal fluid analysis found lymphocytosis, with a significantly elevated protein level and reduced glucose. Tubercular meningitis was considered; however, the patient did not improve and a re‐examination of the cerebrospinal fluid confirmed cryptococcal meningitis.
Conclusion:After diagnosis the patient was treated with amphotericin B. Despite all efforts the patient died 5 days later.
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Complicated infection caused by Streptococcus suis serotype 14 transmitted from a wild boar
More LessIntroduction:Streptococcus suis is a zoonotic pathogen transmitted to humans from infected pigs. Nearly all human cases of S. suis are caused by serotype 2 organisms, and meningitis is the best‐documented type of human infection. On rare occasions, S. suis can be transmitted to humans from wild boars.
Case presentation:Here we report a case where S. suis of serotype 14 was transmitted from a wild boar to a previously healthy 63‐year‐old man, causing meningitis, spondylodiscitis, a psoas abscess and a prolonged post‐infectious inflammatory condition. The infection was treated with a long course of β‐lactam antibiotics, but signs of inflammation were relieved only after the addition of corticosteroids. The isolate was found to harbour the virulence‐associated gene sly.
Conclusiuon:S. suis of serotypes other than type 2 can be transmitted to humans from wild boars and the disease may become complicated. Increasing numbers of wild boars in some European countries calls for increased vigilance to this type of infection.
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- Gastrointestinal
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Achromobacter xylosoxidans: a rare pathogen for community‐acquired acute pancreatitis
More LessIntroduction:Achromobacter xylosoxidans is a water‐borne organism that causes healthcare‐associated infections and has been isolated from blood, cerebrospinal fluid, stool, urine, sputum, peritoneal fluid, skin, ear discharge, wounds, abscesses, bone, joints, endocardium and central venous catheters, mostly in immunocompromised patients.
Case presentation:We describe here the rare case of a young immunocompetent alcoholic male admitted with symptoms of acute pancreatitis who failed to improve with conventional management. Blood culture later showed the growth of A. xylosoxidans. The patient improved when he was treated with antibiotics as per the sensitivity report.
Conclusion:Although Achromobacter is rarely isolated from clinical samples, it should never be assumed to be a contaminant as this infection has propensity for progression to fatal bacteraemia, even in apparently healthy individuals.
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Efficacy of Bacillus probiotics in prevention of antibiotic‐associated diarrhoea: a randomized, double‐blind, placebo‐controlled clinical trial
More LessIntroduction:Antibiotic‐associated diarrhoea (AAD) is one of the most common side effects of antibiotic therapy. The main mechanism associated with the development of AAD is significant changes in the composition and quantity of the gut microbiota during the treatment with antibiotics. Probiotic bacteria have been shown to stabilize the gut microbiota and can be used to prevent diarrhoea associated with antibiotic therapy.
Case presentation:We present the results of a single‐centre, randomized, double‐blinded, placebo‐controlled clinical trial. Patients were randomized into three groups: probiotic group 1 received a probiotic containing strains Bacillus subtilis 3 and Bacillus licheniformis 31; probiotic group 2 received a probiotic, containing B. subtilis 3; and the placebo group received an inert composition in vials, formulated to be indistinguishable from the vials with probiotics. Participants received one vial twice a day. Probiotic treatment significantly reduced incidents of AAD in the patients. Among 91 patients in group 1 treated with probiotic mix, nine developed AAD. In group 2, seven patients out of 90 who received only one probiotic strain developed AAD. A considerably higher incidence of AAD was registered in the placebo group – 23 from 90 patients (P<0.001 vs groups 1 and 2). Both probiotics demonstrated a significant effect in the prevention of nausea, bloating, vomiting and abdominal pain.
Conclusion:Treatment with Bacillus probiotics during antibiotic therapy significantly decreased the incidence of AAD and adverse effects related to the use of antibiotics. Both probiotics were well tolerated by the patients without side effects. No significant difference was found in the efficacy of the two probiotics.
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A case of trichurosis in gilts and fattening pigs
More LessIntroduction:Trichuris suis, also called whipworm, is a parasite of the caecum and colon distributed widely and considered as a fairly common parasite in swine. It may be responsible for porcine trichurosis characterized by diarrhoea, anorexia, growth retardation, dehydration, emaciation and anaemia.
Case presentation:This report presents a case of trichurosis diagnosed in a farrow‐to‐finish Belgian pig herd. The infection was associated with severe and persistent diarrhoea, growth retardation, emaciation and/or anaemia in 10 recently purchased gilts and in fattening pigs. In gilts, levamisole [8 mg (kg body weight)−1] administered once per os gave a good clinical response, as diarrhoea resolved in nine gilts out of 10. In parallel, for these nine gilts, the number of eggs of T. suis (g faeces passed)−1 decreased from 12 400 to less than 100 eggs. In fattening pigs, flubendazole (1 mg kg−1) administrated over 5 days in drinking water allowed a reduction in the number of T. suis eggs g−1 and was effective against diarrhoea.
Conclusion:Although most of the time pig whipworm infections are light and asymptomatic, in some cases when large numbers of worms are present, they can cause watery to bloody diarrhoea that can lead to anaemia. This less frequent disease should not be forgotten in the differential diagnosis of persistent diarrhoea in growing pigs.
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First case report of blood and urine cultures positive bacteraemia by Salmonella enterica serotype Choleraesuis from India
More LessIntroduction:Non‐typhoidal Salmonella (NTS) are commonly implicated in causing bacteraemia in infants, the elderly and immunosuppressed individuals in sub‐Saharan African countries. However, NTS bacteraemia in otherwise healthy adults from India has been rarely reported. Here, we report a case of bacteraemia caused by Salmonella enterica serovar Choleraesuis (S. Choleraesuis), isolated simultaneously from the blood and urine of an adult febrile patient from Kolkata, India.
Case Presentation:A middle‐aged man was admitted to a private hospital in Kolkata with clinical suspicion of acute enteric fever on 25 October 2013. His blood report showed neutropenia and mild thrombocytopenia, with an elevated C‐reactive protein level. The Widal test was negative. S. Choleraesuis isolates were grown simultaneously by microbiological culture of blood and urine samples. The patient recovered without complications following antibiotic therapy. On further characterization, both of the S. Choleraesuis isolates showed identical antibiotic‐susceptibility patterns and virulence‐gene, plasmid and PFGE profiles, confirming their clonality (100% similarity).
Conclusion:This is the first report of S. Choleraesuis bacteraemia associated with a human infection in India. The identification and reporting of uncommon Salmonella serovars from various countries are important for understanding the global epidemiology of salmonellosis.
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A case of multiple splenic abscesses due to Enterococcus hirae
More LessIntroduction:Enterococci are prevalent human pathogens that display increasing resistance to antimicrobial agents. Twelve species pathogenic for humans have been described to date, including the most common human isolates, Enterococcus faecalis and Enterococcus faecium. Enterococcus hirae is a known member of the intestinal flora of several domestic animal species but rarely encountered in humans.
Case presentation:We report a case of multiple splenic abscesses caused by E. hirae in an adult patient diagnosed with type 2 diabetes mellitus. The patient responded to combined therapy with antibiotics plus splenectomy.
Conclusion:Only 9 human infections due to E. hirae have been reported in the literature. To our knowledge, this is the first reported case of splenic abscess and septicemia caused by E. hirae.
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Primary peritonitis caused by Raoultella ornithinolytica in a 53‐year‐old man
More LessIntroduction:Raoultella ornithinolytica is a Gram‐negative bacillus. This bacillus was until recently often confused with Klebsiella spp. It is known primarily for causing histamine fish poisoning or scombroid syndrome, and rarely causes human infections. This case report discusses a patient who presented with generalized primary peritonitis due to R. ornithinolytica.
Case presentation:A 53‐year‐old Scandinavian man resident in Botswana, sub‐Saharan Africa, presented to the emergency department shortly after onset of lower abdominal pain and dysuria. He was treated for urinary tract infection and discharged. He came back after 16 h with more severe, generalized abdominal pain and a fever of 38 °C. Abdominal sonography was unremarkable. Examination confirmed peritonitis, particularly marked in the right iliac fossa. He had mild leukocytosis 13.1×109 l−1, a C‐reactive protein level of 372.7 mg l−1 and his serum albumin level was 31 g l−1. He was admitted for parenteral antibiotics, laparoscopic peritoneal lavage and appendectomy. He had 500 ml of free pus in the abdomen with no evident focal source. A pus swab grew R. ornithinolytica. The pathology showed mild early acute appendicitis with severe periappendicitis and suppurative peritonitis. He was discharged home after 7 days of parenteral antibiotics.
Conclusion:R. ornithinolytica infections are rare in humans, but they can be life‐threatening.
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- Oropharyngeal
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Fatal disseminated fusariosis presenting initially as tonsillitis
Introduction:Disseminated fusariosis is a devastating disease in severely immunocompromised patients and is associated with high lethality.
Case presentation:We describe a patient with severe disseminated fusariosis presenting initially as tonsillitis. Fusarium solani was isolated from cultures of the tonsils, skin and blood, while histological evidence for fungal tissue invasion was detected in tissue samples of the tonsils, tongue, oesophagus, lungs, myocardium, intestine, kidney, mediastinal lymphnodes and skin. Susceptibility testing revealed resistance to voriconazole, posaconazole and caspofungin, and susceptibility to amphotericin B. The patient died, despite treatment with amphotericin B, due to multiorgan failure and refractory cardiac arrhythmia.
Conclusion:Tonsillitis was the primary clinical manifestation of disseminated fatal fusariosis in this immunocompromised patient. It is important to know the spectrum of primary manifestations of less commonly encountered moulds in order to guide clinical decisions and early targeted therapy.
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A case of acute epiglottitis caused by Haemophilus influenzae type a in an adult
More LessIntroduction:Prior to the introduction of a paediatric conjugate vaccine in the early 1990s, Haemophilus influenzae serotype b (Hib) was a major cause of childhood meningitis and pneumonia. Since becoming part of national immunization programmes, the Hib conjugate vaccine has been very successful in preventing invasive Hib disease worldwide. However, in the post‐Hib vaccine era, the emergence of invasive disease caused by non‐type b H. influenzae has been reported from several countries. Previous studies by our group found an increased incidence of invasive disease caused by H. influenzae serotype a in Northwestern Ontario, Canada, during 2002–2011. Most of the cases of invasive H. influenzae type a disease occurred in young children.
Case presentation:Our continued surveillance identified a case of epiglottitis caused by H. influenzae type a in a 65‐year old woman. This life‐threatening condition was historically associated with invasive Hib disease in young children but had not previously been reported in association with H. influenzae type a. We describe the clinical presentation of this case as well as characteristics of the H. influenzae type a isolate.
Conclusion:Our findings stress the importance of continued surveillance of H. influenzae in the post Hib‐vaccine era, and point to the significance of H. influenzae type a as a cause of severe invasive disease in countries with a universal paediatric anti‐Hib immunization programme.
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- Respiratory
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HBoV‐1 in pleura of an adult patient in Cologne, Germany
Introduction: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.
Case presentation: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.
Conclusion:HBoV infection can lead to serious disease in adults and can affect also the pleura.
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Diphtheria outbreak in rural North Karnataka, India
More LessIntroduction: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.
Case presentation: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.
Conclusion:This article should provide a wake‐up call for the health administrators for restructuring and strengthening immunization strategies and programmes.
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A severe case of pneumopathy in a duck breeder due to Chlamydia psittaci diagnosed by 16S rDNA sequencing
More LessIntroduction: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.
Case presentation: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.
Conclusion: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.
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Varicella pneumonia associated with spontaneous popliteal arterial thrombosis in an adult: a case study and review of the literature
More LessIntroduction: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.
Case presentation: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.
Conclusions: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.
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Psittacosis domiciliary outbreak associated with monk parakeets (Myiopsitta monachus) in Brazil: need for surveillance and control
More LessIntroduction: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.
Case presentation: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.
Conclusion: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.
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Apnoea, dyspnoea and wheezing in primary lower respiratory infections due to human rhinovirus in Japanese infants
Human rhinovirus (HRV) is generally recognized as a common cold agent, but it can be associated with severe acute respiratory infection and result in illnesses such as pneumonia. Here, we report on manifestations of severe respiratory infection, including apnoea, dyspnoea and wheezing, that might have been due to primary HRV infection, in two Japanese infants. Although both cases had a good outcome, the infants, a 40‐day‐old male and 2‐month‐old male, displayed the aforementioned symptoms with life‐threatening bronchitis and hyperinflation, and received aggressive respiratory care (intubation or oxygen tent). HRV alone was detected in respiratory specimens. Genetic and phylogenetic analysis of the detected HRV revealed strains that are prevalent in various countries (HRV‐A, genotype HRV‐96 and HRV‐C, genotype HRV‐C46). The results suggest that, besides respiratory syncytial virus, primary HRV infection in infants can be associated with severe respiratory symptoms such as apnoea, dyspnoea and wheezing in lower respiratory infections, although these cases may be rare.
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Clinical and microbiological characteristics of Chryseobacterium spp. isolated from neonates in Kuwait
More LessIntroduction: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.
Case presentation: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.
Conclusion:It appears that Chryseobacterium spp. are emerging pathogens for neonates in Kuwait, causing serious systemic infections.
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Extensively drug‐resistant Raoultella planticola carrying multiple resistance genes including blaNDM‐1
More LessIntroduction: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.
Case presentation: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.
Conclusion:These results described the ability of the rare pathogen R. planticola to acquire multiple resistance genes.
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- Soft tissue
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Fatal spontaneous Aeromonas hydrophila myonecrosis and sepsis without antecedent trauma
Introduction: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.
Case presentation: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.
Conclusion: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.
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A case of Panton–Valentine leucocidin toxin‐positive Staphylococcus aureus‐mediated neonatal mastitis
Introduction: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.
Case presentation: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.
Conclusion: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.
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Primary cutaneous cryptococcosis and a surprise finding in a chronically immunosuppressed patient
Introduction: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.
Case presentation: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.
Conclusion: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.
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Intrafamilial spread of a Panton‐Valentine leukocidin‐positive community‐acquired methicillin‐resistant Staphylococcus aureus belonging to the paediatric clone ST5 SSCmecIV
Introduction: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.
Case presentation: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.
Conclusion: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.
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Isolation and identification of Rhizomucor pusillus from rhinofacial mucormycosis in a diabetic patient
More LessIntroduction: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.
Case presentation: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.
Conclusion:Early diagnosis is critical in prevention of morbidity and mortality associated with disease.
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Disseminated Scedosporium apiospermum infection with leprosy responsive to voriconazole
Introduction: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.
Case presentation: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.
Conclusion:Therapy‐resistant cutaneous lesions in chronic diseases such as leprosy should be evaluated for rare opportunistic fungal infections.
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- Urinary tract and reproductive organs
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Coinfection by avirulent Rhodococcus equi and Klebsiella oxytoca as a cause of atypical abortion in a thoroughbred mare
Introduction: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.
Case Presentation: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.
Conclusion: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.
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An unusual case of polymicrobial anaerobic bacteraemia in a male with ureteral calculi
More LessIntroduction: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.
Case presentation: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.
Conclusions: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.
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Recurrent urinary tract infection due to co‐infection with extended spectrum β‐lactamase‐producer uropathogenic Escherichia coli and enteroaggregative E. coli
Introduction: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.
Case presentation: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.
Conclusion: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.
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Epidemic ranaviral disease in imported captive frogs (Dendrobates and Phyllobates spp.), Japan, 2012: a first report
More LessIntroduction: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.
Case presentation: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.
Conclusion: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.
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A rare case of early‐onset neonatal sepsis
More LessIntroduction: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.
Case presentation: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.
Conclusion: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.
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- Case Quiz
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- Blood/heart lymphatics
- Respiratory