Nasal myiasis in an intensive care unit linked to hospital-wide mouse infestation

A large city hospital experienced an infestation of mice combated in part by broadcasting poisoned baits. Months later there was an invasion of flies into the hospital, and 2 comatose patients in an intensive care unit contracted nasal maggots. Adult flies were trapped and maggots removed from the nares of the second patient. These were identified as the green blowfly (Phaenicia sericata). Recent downsizing of hospital personnel had led to the unintended and unrecognized loss of housekeeping services in the canteen food storage areas. A mouse infestation of the hospital occurred, with the epicenter in the canteen area. This was initially addressed by scattering poisoned bait and using rodent glue boards. The result of such treatment was the presence of numerous mouse carcasses scattered throughout the building attracting the green blowfly. Adult gravid female flies trapped in the new intensive care unit (where mice were not present) laid eggs in the fetid nasal discharge of 2 comatose patients. Live trapping of mice and removal of carcasses led to an abatement of the fly infestation. The cause-and-effect nature of the mouse carcasses and flies was underscored a year later when an outbreak of P. sericata occurred in the operating department and was linked to the presence of mouse carcasses on glue boards not removed the previous fall. Hence, the disruption or loss of 1 vital link in hospital organization (in this case, housekeeping support) may lead to an unintended and bizarre outcome.

Role of inflammatory mediators in resistance and susceptibility to pneumococcal infection

Variations in the host response during pneumonia caused by Streptococcus pneumoniae in susceptible (CBA/Ca) and resistant (BALB/c) inbred mouse strains were investigated. Significant differences were detected in survival time, core body temperature, lung-associated and systemic bacterial loads, mast cell numbers, magnitude and location of cytokine production, lung disruption, and ability of isolated lung cells to release the cytokine tumor necrosis factor (TNF) alpha in vitro. Overall, the results indicate that the reduced capacity of CBA/Ca mice to induce rapid TNF activity within the airways following infection with S. pneumoniae may be a factor in their elevated susceptibility to pneumococcal pneumonia.

Case report. Fatal rhinocerebral zygomycosis due to Rhizopus oryzae

A case of rhinocerebral zygomycosis due to Rhizopus oryzae, arising after trauma in a 53-year-old diabetic man, is reported. Diagnosis was based on histological and mycological examination. Fragments of the colonies were observed by scanning electron microscopy. This is the first case diagnosed in Tuscany.

Streptococcus pneumoniae causes experimental meningitis following intranasal and otitis media infections via a nonhematogenous route

Using two different animal models of Streptococcus pneumoniae infection, we have demonstrated that this organism is able to spread to the central nervous system and cause meningitis by bypassing the bloodstream. Following respiratory tract infection induced via intranasal inoculation, bacteria were rapidly found in the bloodstream and brains in the majority of infected mice. A similar pattern of dissemination occurred following otitis media infection via transbullar injection of gerbils. However, a small percentage of animals infected by either route showed no bacteria in the blood and yet did have significant numbers of bacteria in brain tissue. Subsequent experiments using a galU mutant of S. pneumoniae, which is impaired in its ability to disseminate to the bloodstream following infection, showed that this organism is able to spread to the brain and cerebrospinal fluid. These results demonstrate that, unlike many bacterial pathogens that cause meningitis, S. pneumoniae is able to do so independent of bloodstream involvement upon different routes of infection. This may address the difficulty in treating human infections caused by this organism.

Fatal rhino-orbito-cerebral mucormycosis in an apparently normal host: case report and literature review

Fungal infections of the central nervous system (CNS) are fortunately rare but remain challenging problems occurring mostly in immunocompromised individuals, with protean manifestations, unpredictable course and unfavorable outcome in many cases despite aggressive neurosurgical intervention and recent antifungal drugs. Rhino-orbito-cerebral mucormycosis is a potentially lethal opportunistic fungal infection with rapid progression and high mortality. Its pathogenic nature becomes evident when the patient's general resistance is compromised. We present a case of an invasive rhino-orbito-cerebral mucormycosis in an apparently normal adult who initially developed mild paranasal sinusitis and later developed status epilepticus and despite an aggressive management died. Interesting clinical, neuroimaging and histological findings are described, and the possibility of fatal mucormycosis in an apparently normal host is highlighted.

Presumably entomophthoramycosis in an HIV-infected patient: the first in Thailand

The authors reported the case of a symptomatic HIV-infected woman with a slowly progressive infiltrative lesion which invaded in and around the nasal cavity over a 6-month period. Physical examination showed erythematous to violaceous plaques at the nasal and malar areas. Swelling of the inferior turbinate was noted in the right nare. Skin biopsy of the involved area revealed multiple nonseptate, broad, thin-walled hyphae within giant cells and granulomata. Entomophthoramycosis was diagnosed based on clinical features and histopathology. She was treated with intravenous amphotericin B for two weeks, followed by oral itraconazole 400 mg daily. At six months there was complete resolution of all lesions.

Rhinocerebral mucormycosis in an 11-year-old boy

A patient with diabetic ketoacidosis admitted for treatment developed features characteristic of rhinocerebral mucormycosis, confirmed by histopathologic examination, is presented. The patient had been experiencing symptoms of diabetes for one month before presentation to the hospital in state of diabetic ketoacidosis. Within a few days of admission he developed mucormycosis of the nasal cavity and the orbit which extended to the brain very fast and resulted in death. High index of suspicion form the clinical presentation in an immunocompromised patient, especially, one with diabetic ketoacidosis, is suggested to effect early intervention.

Successful treatment of rhinocerebral zygomycosis using liposomal nystatin

We describe a case of successful treatment of rhinocerebral mucormycosis in a patient with multiple myeloma. Therapeutic strategies used included liposomal amphotericin, hyperbaric oxygen, GM-CSF and liposomal nystatin.

[Rhinocerebral mucormycosis: apropos of 4 new Tunisian cases]

Mucormycosis is a rare opportunistic infection but a fulminant disease. We report the 4 first cases of rhinocerebral mucormycosis diagnosed in Sfax region (Tunisia). They occurred in insulin dependent diabetes and developed varying clinical manifestations from facial cellulites to ocular and cerebral extension. The diagnosis of mucormycosis was not initially evoked, but confirmed tardively by anatomopathologic and mycologic examinations. The evolution was favourable in 2 cases by administration of amphotericine B associated with extensive surgical debridement and correction of the diabetes. Two patients had a fatal outcome. This infection has a severe prognosis and necessitates early diagnosis.

Do oral flora colonize the nasal floor of patients with oronasal fistulae?

OBJECTIVE

To determine if oral bacteria colonize the cleft nasal floor in patients with unilateral oronasal fistula when compared with the unaffected nasal floor and whether the results obtained would be of benefit in assessing oronasal fistulae in the clinic.

DESIGN

Prospective study of 26 patients with cleft palate and unilateral oronasal fistula. Microbiological culture swabs were taken from the mouth and nasal floors of patients. The unaffected nasal floor was used as a control. Bacterial isolates were identified and compared in the laboratory by a senior microbiologist.

MAIN OUTCOMES MEASURE

A significant growth of oral bacteria from the cleft nasal floor when compared with the unaffected nasal floor.

RESULTS

Four patients were excluded because no growth was found on any culture plate. In the remaining 22 cases, a light growth of oral flora was found in the cleft nasal floor in only 3 patients. No statistical correlation between culture of oral bacteria and the cleft nasal floor could be found (p =.12).

CONCLUSIONS

The relative lack of colonization of the cleft nasal floor by oral bacteria may reflect poor transmission of bacteria through the fistula, competition with commensal nasal flora, or an inability of oral bacteria to survive in a saliva-depleted area. The investigation is not helpful in the assessment of oronasal fistulae in the clinic.

Entomophthoramycosis by Conidiobolus coronatus. Report of a case successfully treated with the combination of itraconazole and fluconazole

Rhinoentomophthoramycosis caused by Conidiobolus coronatus in a 61-year old woman was unsuccessfully treated during 8 years with all the antifungals available in the Brazilian market, including potassium iodide for 1 month, sulfamethoxazole plus trimethoprim for 2 months, amphotericin B, total dose of 1130 mg, cetoconazole, 400 mg/day for 6 months, fluconazole, 200 mg/day, for at least 2 months and, itraconazole, 400 mg/day for 2 months, followed by 200 mg/day for 4 more months. Complete clinical and mycological cure was achieved using itraconazol 400 mg/day in association with fluconazol 200 mg/day during 24 months. After cure she was submitted to plastic surgery to repair her facial deformation. Today she remains clinically and mycologically cured after 59/60 months (5 years!) without any specific antifungal. We thus suggest the use of the combination of itraconazole and fluconazole as an additional option for the treatment of this mycosis.

Usefulness of computed tomography and magnetic resonance in fulminant invasive fungal rhinosinusitis

Fulminant invasive fungal rhinosinusitis is an aggressive, destructive process most commonly affecting the immunocompromised host. Although frequently fatal, prognosis is related directly to early recognition and aggressive treatment. Various reports advocate computed tomography (CT) scanning as the study of choice in evalucating suspected invasive fungal disease, reserving magnetic resonance imaging (MRI) for select cases. Others report lack of correlation between CT and surgical or pathological findings. Our aim wasq to investigate the usefulness of CT and MR in the diagnosis of invasive fungal rhinosinusitis. We retrospectively reviewed four cases of biopsy-proven invasive disease. Correlations between radiographic, endoscopic, and surgical findings were investigated. Rhizopus species were detected in three cases and mixed Mucor and Aspergillus species in another. Superimposed bacterial sinusitis was confirmed in all cases. CT findings were nonspecific, revealing pansinusitis; no bone destruction or intracranial extension was noted. Mild orbital cellulitis was noted in one case. Anterior rhinoscopy revealed nonviable tissue in two patients. Nasal endoscopy later confirmed tissue ischemia in a third patient, whereas a final patient had normal findings on both exams. Nonspecific findings resulted in delay of diagnosis by 48-72 hours in two patients with presumed bacterial sinusitis. MR revealed intracranial extension in two patients and better represented intraoperative findings. In conclusion, CT findings in invasive fungal rhinosinusitis may be nonspecific and underestimate extent of disease. A high index of suspicion and early endoscopic examination with biopsy are mandatory for evaluation. MRI may better represent disease progression and should be considered early.

Recovery of anaerobic bacteria from 3 patients with infection at a pierced body site

We describe 3 adolescents who developed infections due to anaerobes at pierced body sites: the nipple, the umbilicus, and the nasal septum. Anaerobes (Prevotella intermedia and Peptostreptococcus anaerobius) were recovered from pure culture of specimens obtained from 1 patient with nipple infection and were mixed with aerobic bacteria in cultures of specimens obtained from 2 patients (Streptococcus aureus, Peptostreptococcus micros, and Prevotella melaninogenica were recovered from a patient with nasal septum infection, and Bacteroides fragilis and Enterococcus faecalis were recovered from a patient with umbilical infection). The infection resolved in all patients after removal of the ornaments and use of antimicrobial drug treatment.

Ultrastructural pathology of nasal and tracheal mucosa of rabbits experimentally infected with Pasteurella multocida serotype D:1

Sixteen 8- to 9-week-old Pasteurella multocida-free New Zealand White rabbits were divided into two equal groups. The first group was inoculated intranasally with P multocida serotype D:1 strain and the second group that was inoculated with phosphate-buffered saline (PBS) only was used as a control group. Pasteurella multocida was isolated from the nasal cavity of all infected rabbits in group 1 and from tracheal swabs of seven rabbits in this group. Four rabbits in group 1 died with clinical signs of septicaemia, two rabbits had mucopurulent nasal discharge and pneumonic lesions and the other two did not show any clinical signs or gross lesions. The ultrastructural changes detected were deciliation or clumping of cilia of ciliated epithelium, cellular swelling, vacuolation and sloughing. The subepithelial capillaries showed congestion, intravascular fibrin deposition, platelets aggregation and endothelial injury. Pasteurella multocida was observed attached to the injured endothelial cells. Heterophils, mast cells, vacuolated monocytes and macrophages infiltrated the lamina propria and between the degenerated epithelial cells.

[Mucormycosis: a classical infection with a high mortality rate. Report of 5 cases]

Mucormycosis is an infection caused by fungi in the Mucorales order, of which the most relevant family is Mucoraceae, which includes the Rhizopus, Mucor and Absidia genera. It is a severe infection which involves diabetic patients with ketoacidotic decompensation and immunosuppressed patients. We report here five cases (four with rhino-cerebral forms) attended at our hospital in the last ten years. Three patients had diabetes, one was infected with the human immunodeficiency virus, and the other was on a programme of peritoneal dialysis due to renal failure. The most relevant clinical manifestation was the presence of the necrotic lesion in three of the four patients with rhinocerebral involvement (two in the palate, one in the nasal mucosa). Two patients died as a result of the direct infection a few days after diagnosis. In summary, mucormycosis is an infection with a low prevalence but still maintaining a high mortality rate. An early diagnosis is essential and thereby a high index of clinical suspicion is required in patients with predisposing factors.

Rhinocerebral zygomycosis in childhood acute lymphoblastic leukaemia

The hazards associated with invasive candidiasis and aspergillosis in oncology patients are well recognised. These conditions typically present late in treatment, often after prolonged or recurrent episodes of neutropenia. We report the occurrence of Absidia corymbifera infection causing rhinocerebral zygomycosis in two children with acute lymphoblastic leukaemia, early in the induction phase of treatment and within a 3-month interval, in the same oncology unit. The initial presentation of facial pain was rapidly followed by the development of cranial nerve palsies, cavernous sinus thrombosis, diabetes insipidus, seizures and death within 9 days of symptom onset, despite aggressive management with high-dose liposomal amphotericin (Ambisome), surgical debridement and local instillation of amphotericin solution. These cases highlight the need for awareness of zygomycosis as a potentially lethal fungal infection that can present even with short duration exposure to the usual risk factors. Their occurrence within a limited time period raises questions as to the relative importance of environmental exposure. The failure of medical and surgical intervention to impact on the course illustrates the need to develop appropriate preventative strategies which may have to incorporate measures to reduce the environmental exposure of susceptible patients.

Cutaneous alternariosis in a cat

A 10-year-old male domestic shorthaired cat had a chronic, slowly enlarging subcutaneous mass on the right side of its nose. At the time of presentation, the nasal airflow was severely impeded on the affected side. The cat had been treated medically with various drugs. Oral itraconazole had been the most effective in reducing the size of the mass, but had caused hepatotoxicity and had to be withdrawn. The mass was finally removed surgically, and a diagnosis of granulomatous cellulitis caused by Alternaria alternata (phaeohyphomycosis) was established, based on histopathology and fungal isolation. There has been no recurrence of the lesion after 21 months and the cat remains clinically well at the time of writing. Subcutaneous phaeohyphomycosis caused by A alternata has not, to the authors' knowledge, been previously described in small domestic animals in the UK.

Mucor endophthalmitis

PURPOSE

To report on a case of type 2 diabetes, with eyelid gangrene and endophthalmitis as a presenting manifestation of rhino-orbito-cerebral mucormycosis.

RESULTS

CECT head showed proptosis, mucosal thickening in the ethmoid sinus and hypodense lesions in the frontal and occipital lobes. Vitreous tap showed right angle branched aseptate hyphae consistent with mucormycosis.

CONCLUSIONS

A diabetic patient presenting with sudden loss of vision, eyelid gangrene and endophthalmitis, involvement by an angio-invasive fungus-like mucormycosis is an important consideration.

Extra-laryngeal head and neck tuberculosis

OBJECTIVE

Extra-laryngeal head and neck tuberculosis is exceptional. Therefore, a retrospective multicenter study in patients with head and neck tuberculosis, excluding solitary lymphadenitis and laryngeal locations was carried out.

METHODS

We reviewed the patients with these features and tuberculosis confirmation by culture and/or histologic granuloma with presence of acid-fast bacilli (AFB).

RESULTS

We found 16 patients with the following locations: eight in oral cavity and/or pharynx, four in ear, two in salivary glands, one in nose and one in frontal sinuses. The average duration of symptoms was 11.5 months. Purified protein derivative (PPD) was positive (> 10 mm) in all but one patient in whom it was performed (six of seven). Except tuberculous otitis, which occured without reactive lymphadenitis, this was present in 50% of the rest (six of the 12). In all cases a biopsy was required for diagnosis. Only in four patients, all with pharyngeal locations, was coincident pulmonary tuberculosis confirmed. One patient with tuberculous otitis developed meningitis and died; three additional patients (two with otitis) were cured but with sequelae; the evolution of the remaining patients was satisfactory with medical therapy.

CONCLUSIONS

Extra-laryngeal head and neck tuberculosis has a slow course. The diagnosis is difficult due to the common absence of lung involvement and the usual requirements for biopsy procedures. The outcome is usually favorable with antituberculous drugs alone although in tuberculous otitis there are possibilities of complications.

[Long-term survival in rhino-mucormycosis after conservative treatment]

OBJECTIVE/METHODS

We describe a case of rhino-mucormycosis, in a 52-year-old male, with diabetes mellitus type 2, III cranial nerve palsy and blindness due to obliteration of central retinal artery and vein of the right eye The patient was treated with anfotericin B and necrotic tissues exeresis of nasal and paranasal (ethmoidal, maxillar and esfenoidal) sinuses, without orbital exenteration.

RESULTS/CONCLUSIONS

After a follow up of five years, no type of relapse was detected, but neovascular glaucoma developed.

[The results and characteristics of the mupirocin (Bactroban) sanative treatment of intranasal Staphylococcus carriers in a large hospital]

The action of mupirocin as a nasal ointment (Bactroban) was studied on intranasal carriers of the hospital staphylococcal strains. The study included 37 medical workers from different and mainly problem units of the large general hospital. The tolerability of the ointment was good. After the Bactroban use no complications of the patients were recorded. The efficacy of Bacroban by the microbiological criteria in total amounted to 100 per cent. The eradication of methicillin resistant Staphylococcus aureus (MRSA) was observed in 93 per cent of the cases. A decrease of the level of the nasal passages dissemination by MRSA and methicillin resistant coagulase-negative staphylococci (MRSC) up to such low titers as 100 and 90 per cent was stated. No difference in the action of Bactroban on MRSA, MSSA and MRSC was noted. The bacteriological monitoring for 3 to 4 months revealed a change of the staphylococcal strains in 94 per cent of the cases, recolonization by the same staphylococcal strain in 19 per cent, recolonization by some another staphylococcal strains in 33 per cent and no recolonization in 14 per cent. A stable decrease of staphylococcal strains was possible with simultaneous Bactroban sanitation of all the bacterial carriers of the hospital or its isolated unit.

Nasal carriage and antibiotic resistance of Staphylococcus aureus isolates from hospital and non-hospital personnel in Abha, Saudi Arabia

The prevalence of nasal carriage of Staphylococcus aureus, antibiograms and prevalence of methicillin-resistant S. aureus (MRSA) were studied in 1999 among healthy hospital and non-hospital personnel in Abha, Saudi Arabia. S. aureus was isolated from 26.1% of 299 adults in the community and 25.4% of 279 hospital personnel. No isolate was resistant to vancomycin. Antibiotic resistance rates, for all other antibiotics tested except cephalothin, were significantly higher for strains from hospital personnel (P values < 0.001-0.04) compared to non-hospital adults. The antibiograms were also compared with those of 140 clinical isolates. The rates of resistance of the inpatient strains to all the antibiotics tested were significantly higher than those of hospital nasal carrier strains (P < 0.001-0.05). MRSA was isolated, respectively, from 5.1% and 18.3% of non-hospital and hospital carriers; MRSA carriage rates were 1.3% and 4.7%, respectively, for non-hospital and hospital carriers, and 61% of S. aureus isolates from infected patients were MRSA. Only 8% of non-hospital but 44% of hospital carrier strains were multiply resistant (P < 0.001). Multiple resistance among inpatient strains (89%) was significantly higher than that among hospital nasal strains (44%) (P < 0.001). Such rates of multiple resistance and endemic MRSA prevalence among healthy carriers (11%) at a much higher rate than those reported in the literature should raise concern in a region with unrestricted availability of antibiotics.

[A trial of the use of mupirocin in the nasal carriage of Staphylococcus aureus in medical personnel]

Many hospital-acquired purulent diseases and wound infections are due to multiresistant hospital strains of Staphylococcus aureus. The role of S. aureus nasal carriage in development of wound infections due to autoinfection is confirmed. Not only inpatients but also hospital staff can be highly colonized with coagulase positive staphylococci. The S. aureus persistence in hospital personnel results in distribution of the microorganisms in the environment. Therefore, detection of S. aureus carriers without signs of the infection among the hospital personnel and eradication of the pathogen make it possible to control outbreaks of S. aureus infection in hospitals. Clinical efficacy of nasal ointment of mupirocin in the treatment of S. aureus carriers among the intensive care personnel of the N. N. Blokhin Cancer Research Center was evaluated. S. aureus nasal carriage was diagnosed in 17 (26 per cent) out of 65 persons. All the isolates were susceptible to oxacillin. 5-7 days after discontinuation of the mupirocin nasal ointment use eradication of S. aureus was stated in 100 per cent of the cases. The effect was still observed in 94 per cent of the cases in 1 month, in 76 per cent of the cases in 5-6 months and in 60 per cent of the cases in 8-9 months. It is believed that mupirocin nasal ointment (Bactroban) is convenient to use, low toxic and highly active in the treatment of persons with S. aureus nasal carriage.

Entomophthoromycosis of the nose and paranasal sinus

A case of entomophthoromycosis of the nose and paranasal sinus is presented. To our knowledge, this is the youngest patient reported with this infection. Though the clinical picture mimicked a malignancy, histopathology clinched the diagnosis of entomophthoromycosis. The lesions resolved completely with oral potassium iodide.