Melioidosis presenting with mediastinal lymphadenopathy masquerading as malignancy: a case report

<p>Abstract</p> <p>Introduction</p> <p>Melioidosis, endemic in Thailand and in the Northern Territory of Australia is an emerging infectious disease in India which can present with varied forms. A case of melioidosis, presenting as a rare anterior mediastinal mass which can masquerade as malignancy or tuberculosis, is described here. With treatment, our patient initially showed an increase in the size of mediastinal node and development of new submandibular node.. To the best of our knowledge, this phenomenon has not been documented in the literature and the same is highlighted in this case report. </p> <p>Case Presentation</p> <p>A 43-year-old Asian man with diabetes presented with fever, loss of appetite, weight loss for one month and painful swelling below his left mandible for five days. An examination revealed an enlarged left submandibular lymph node and bilateral axillary lymph nodes. A chest X-ray showed mediastinal widening. Computed tomography of his thorax showed a lobulated heterogeneously enhancing anterior mediastinal mass encasing the superior vena cava suggestive of malignancy. An excision biopsy of the lymph node showed granulomas suggestive of tuberculosis but bone marrow culture and lymph node aspirate culture grew <it>Burkholderia pseudomallei</it>. He was treated with parenteral ceftazidime and amoxicillin-clavulanic acid. During the course of treatment, he developed an enlargement of the submandibular lymph node on the opposite side. It gradually subsided with the continuation of therapy orally with a combination of cotrimoxazole and doxycycline for six months. A repeat computed tomography chest scan showed resolution of the mediastinal mass.</p> <p>Conclusion</p> <p>Melioidosis can present as a mediastinal mass that mimics tuberculosis or malignancy. During the initial phase of treatment of melioidosis, the appearance of new lymph nodes or an increase in the size of the existing lymph nodes does not mean treatment failure. Inexperienced clinicians may consider this as treatment failure and may switch treatment. To the best of our knowledge, this is the first report documenting this phenomenon in melioidosis cases.</p

Implications of environmental and pathogen-specific determinants on clinical presentations and disease outcome in melioidosis patients.

BackgroundMelioidosis is gaining recognition as an emerging infectious disease with diverse clinical manifestations and high-case fatality rates worldwide. However, the molecular epidemiology of the disease outside the endemic regions such as northeast part of Thailand and northern Australia remains unclear.Methodology/principal findingsClinical data and B. pseudomallei isolates obtained from 199 culture-confirmed cases of melioidosis diagnosed during 2006-2016 in South India were used to elucidate the host and pathogen specific variable virulence determinants associated with clinical presentations and disease outcome. Further, we determined the temporal variations and the influence of ecological factors on B.pseudomallei Lipopolysaccharide (LPS) genotypes causing infections. Severe forms of the disease were observed amongst 169 (85%) patients. Renal dysfunction and infection due to B.pseudomallei harboring BimABm variant had significant associations with severe forms of the disease. Diabetes mellitus, septicemic melioidosis and infection due to LPSB genotype were independent risk factors for mortality. LPSB (74%) and LPSA (20.6%) were the prevalent genotypes causing infections. Both genotypes demonstrated temporal variations and had significant correlations with rainfall and humidity.Conclusion/significanceOur study findings suggest that the pathogen specific virulence traits under the influence of ecological factors are the key drivers for geographical variations in the molecular epidemiology of melioidosis

Hospital Acquired Bloodstream Infection by Multi Drug Resistant Organisms-Alarming and Challenging Issue in the Intensive Care Units at Present Era

Hospital-acquired bloodstream infections (BSIs) cause high mortality in the intensive care units (ICUs) compared to wards. Furthermore, the isolation of multidrug resistant (MDR) organisms in ICUs add to the gravity of the condition making the treatment a bigger challenge. The present study was aimed to evaluate the prevalence, spread, and the possible MDR organisms contributing to ICU-acquired BSI & the source of the secondary BSI in the ICUs. A prospective study was conducted in four ICU of tertiary teaching hospital over a period of six months. Patient that developed features of BSI within 48 hours after hospital admission were included in the present study Blood culture was performed by an automated BacT/ALERT®3D system. The source of secondary BSI was identified by analysing culture results for the samples other than blood. These samples were taken within 48 hours of the patient’s blood culture test being positive. A total of 50 patients (25%) had an ICU acquired bloodstream infection. Out of 50 patients, 74% of them had bacterial etiology. Thirty one patients (62%) among them developed multidrug resistant bacteraemia. Fifty six percent of Gram negative bacilli were multi drug resistant. The resistance to carbapenem was 42%. The most common MDR Gram negative isolate was identified as Klebsiella pneumoniae (n=12; 38.7%,) and the most common source was pulmonary infection (26.7% (n=12). 42% of isolates in our study were carbapenem resistant suggesting the need for a proper antibiotic policy in the ICUs. Prolonged stay in the ICU with mechanical ventilation was the critical risk factor and ICU mortality was high (38%)

Mid-Regional Pro-Adrenomedullin (MR-proADM) as a Biomarker for Sepsis and Septic Shock: Narrative Review

WOS: 000447923900041PubMed ID: 30177659Early identification and diagnosis of sepsis and septic shock is vitally important; despite appropriate management, mortality and morbidity rates remain high. For this reason, many biomarkers and screening systems have been investigated in accordance with the precision medicine concept. A narrative review was conducted to assess the role of mid-regional pro-adrenomedullin (MR-proADM) as a biomarker for sepsis and septic shock. Relevant studies were collected via an electronic PubMed, Web of Science, and The Cochrane Library search. The review focused on both diagnosis and prognosis in patients with sepsis and septic shock and specifically in subpopulations of patients with sepsis and septic shock with burns or malignant tumors. No exclusion criteria regarding age, sex, intensive care unit admission, follow-up duration, or co morbidities were used so as to maximize sensitivity and due to lack of randomized controlled trials, opinion paper and reviews were also included in this review. A total of 22 studies, one opinion paper, and one review paper were investigated. MR-proADM levels were found to be useful in assessing patients' initial evolution and become even more useful during follow-up with increased area under curve values in the mortality prognosis by exceeding values of 0.8 in the data shown in several studies. These results also improve along with other biomarkers or severity scores and especially correlate with the organ failure degree. The results of this study indicate that MR-proADM is a good biomarker for the diagnosis and prognosis of sepsis and septic shock patients as well as for organ failure. Although several publications have discussed its role as a biomarker for pneumonia, its value as a biomarker for sepsis and septic shock should now be assessed in randomized controlled trials and more collaborative prospective studies with larger patient samples.CIBERES; Fondos FEDER, Institudo de Salud Carlos III; Madrid, Spain; European Society of Clinical Microbiology and Infectious Diseases, Basel, SwitzerlandThis research was supported in part by CIBERES, Fondos FEDER, Institudo de Salud Carlos III; Madrid, Spain and an Observership Grant from the European Society of Clinical Microbiology and Infectious Diseases, Basel, Switzerland

Prevalence of Clinical Periodontitis and Putative Periodontal Pathogens among South Indian Pregnant Women

In view of recent understanding of the association of periodontal infections and adverse pregnancy outcomes, the present investigation was undertaken to study the periodontal infections among 390 asymptomatic pregnant women and to find an association of bacterial etiologies with the disease. Prevalence of gingivitis was 38% and clinical periodontitis was 10% among the study population. Subgingival plaque specimens were subjected to multiplex PCR targeting ten putative periodontopathogenic bacteria. Among the periodontitis group, high detection rates of Porphyromonas gingivalis (56%), Prevotella nigrescens (44%), Treponema denticola (32%), and Prevotella intermedius (24%) were noted along with significant association with the disease (P<0.05)

Antifungal Susceptibility Patterns, In Vitro Production of Virulence Factors, and Evaluation of Diagnostic Modalities for the Speciation of Pathogenic Candida from Blood Stream Infections and Vulvovaginal Candidiasis

Candida spp. have emerged as successful pathogens in both invasive and mucosal infections. Varied virulence factors and growing resistance to antifungal agents have contributed to their pathogenicity. We studied diagnostic accuracy of HiCrome Candida Differential Agar and Vitek 2 Compact system for identification of Candida spp. in comparison with species-specific PCR on 110 clinical isolates of Candida from blood stream infections (54, 49%) and vulvovaginal candidiasis (56, 51%). C. albicans (61%) was the leading pathogen in VVC, while C. tropicalis (46%) was prominent among BSIs. HiCrome Agar and Vitek 2 Compact had good measures of agreement (κ) 0.826 and 0.895, respectively, in comparison with PCR. We also tested these isolates for in vitro production of proteinase, esterase, phospholipases, and biofilms. Proteinase production was more among invasive isolates (P=0.017), while phospholipase production was more among noninvasive isolates (P=0.001). There was an overall increase in the production of virulence factors among non-albicans Candida. Identification of clinical isolates of Candida up to species level either by chromogenic agar or by Vitek 2 Compact system should be routinely done to choose appropriate therapy

Epidemiology of sepsis and risk factors for mortality in intensive care unit: a hospital based prospective study in South India

Objective: The present study was aimed at elucidating the epidemiology of sepsis, with a special emphasis on identifying the common bacterial aetiology, proportion of infections caused by multi-drug resistant (MDR) bacteria, and risk factors associated with 28-day mortality at a university hospital in South India. Methods: A prospective study was undertaken from January 2017 to March 2018. Adult patients with the diagnosis of sepsis requiring intensive care unit (ICU) care were recruited. Baseline clinical, epidemiological, and laboratory data were recorded, and their association with 28-day mortality was assessed using logistic regression models. Results: 400 subjects with a qSOFA score ≥2 at the time of ICU admission were included in the study. The mean age was 55.7 ± 16.6 years, and 69% were males. The mean SOFA score at the time of admission was 9.9 ± 2.7. Bacterial aetiology of sepsis was established in 53.5% of cases and 24% were caused by MDR pathogens. Carbapenem resistance was observed in 37% of the Gram-negative isolates. Escherichia coli (34.1%) was the leading pathogen. Overall, the 28-day mortality in ICU was 40%. 38% died within 48 h of ICU admission. Hypertension and SOFA > 9, male gender, and baseline-creatinine values >2.4 mg/dl were risk factors for mortality. Conclusions: Male gender, hypertension, SOFA > 9, and increased creatinine were identified as the predictors for mortality. Infectious aetiology remained undetected in nearly half of the cases using routine microbiology culture methods. Mortality within the first 48 h of admission to ICU is high and prompts the need for increasing awareness about early sepsis diagnosis in community health care settings

Risk Factors for Preterm Birth and Low Birth Weight Among Pregnant Indian Women: A Hospital-based Prospective Study

Objectives: The present study was undertaken to study the maternal risk factors for preterm birth (PTB) and low birth weight (LBW) with a special emphasis on assessing the proportions of maternal genitourinary and periodontal infections among Indian women and their association with adverse pregnancy outcomes. Methods: A hospital-based prospective study comprising 790 pregnant women visiting the obstetrics clinic for a routine antenatal check-up was undertaken. Once recruited, all study participants underwent clinical and microbiological investigations for genitourinary infections followed by a dental check-up for the presence of periodontitis. The study participants were followed up until their delivery to record the pregnancy outcomes. Infectious and non-infectious risk factors for PTB and LBW were assessed using univariate and multivariate Cox regression analysis. Independent risk factors for PTB and LBW were reported in terms of adjusted relative risk (ARR) with the 95% confidence interval (CI). Results: Rates of PTB and LBW in the study population were 7.6% and 11.4%, respectively. Previous preterm delivery (ARR, 5.37; 95% CI, 1.5 to 19.1), periodontitis (ARR, 2.39; 95% CI, 1.1 to 4.9), Oligohydramnios (ARR, 5.23; 95% CI, 2.4 to 11.5), presence of Nugent’s intermediate vaginal flora (ARR, 2.75; 95% CI, 1.4 to 5.1), gestational diabetes mellitus (ARR, 2.91; 95% CI, 1.0 to 8.3), and maternal height <1.50 m (ARR, 2.21; 95% CI, 1.1 to 4.1) were risk factors for PTB, while periodontitis (ARR, 3.38; 95% CI, 1.6 to 6.9), gestational hypertension (ARR, 3.70; 95% CI, 1.3 to 10.8), maternal height <1.50 m (ARR, 2.66; 95% CI, 1.3 to 5.1) and genital infection during later stages of pregnancy (ARR, 2.79; 95% CI, 1.2 to 6.1) were independent risk factors for LBW. Conclusions: Our study findings underscore the need to consider screening for potential genitourinary and periodontal infections during routine antenatal care in developing countries