Successful treatment of post-neurosurgical intracranial Mycoplasma hominis infection using gatifloxacin

Bilateral decompressive craniotomy complicated by postoperative mycoplasma hominis epidural empyema and meningitis: A case report

RATIONALE

Postoperative intracranial mycoplasma hominis infection was a rare complication. Timely diagnosis was difficult due to its growth characteristics and nonspecific clinical symptoms.

PATIENT CONCERNS

A 52-year-old man underwent bilateral decompressive craniotomy for severe traumatic brain injury. On the seventeenth day after surgery, the patient developed an unexplained high fever. Empirical anti-infective therapy was ineffective, and the fever persisted. In addition, viscous pus oozed from the head incision. Empiric therapy was still ineffective, the fever persisted, and the culture result was negative. The lumbar puncture pressure was 150 mmH2O and the cerebrospinal fluid white blood cell count was 3600 × 106/L, suggesting an intracranial infection.

DIAGNOSES

Culture growth morphologically consistent with mycoplasma species was obtained from multiple specimens (scalp incision fluid and cerebrospinal fluid) and the identification of mycoplasma hominis was confirmed by 16S rDNA sequencing.

INTERVENTION

Targeted anti-infective therapy (Minocycline), change of fresh wound dressing, and continued lumbar cerebrospinal fluid drainage.

OUTCOME

At the 3-month follow-up, the patient was still in the rehabilitation department of the local hospital for treatment, but there were no symptoms of intracranial infection.

LESSONS

Neurosurgeons should carefully examine postoperative incisions and be aware of the possibility of mycoplasma infection during clinical management.

Diagnosis of Mycoplasma hominis Meningitis with Metagenomic Next-Generation Sequencing: A Case Report

Background

Mycoplasma hominis meningitis is a rare postoperative complication of neurosurgery. Accurate and early diagnosis of M. hominis remains challenging because of the limitations of traditional detection methods. Metagenomic next-generation sequencing (mNGS) is an advanced technique with high sensitivity and specificity for identifying infectious pathogens; however, its application in diagnosing M. hominis meningitis has not been widely studied.

Case Presentation

We report the case of a 61-year-old man who presented with fever and headache after neurosurgical treatment for a cerebral hemorrhage. Empiric antibiotic therapy was ineffective. Traditional culture of pathogens and serological testing yielded negative results, but M. hominis was detected in the cerebrospinal fluid by mNGS. After further verification by polymerase chain reaction (PCR), the patient's clinical treatment was adjusted accordingly. With targeted antibiotic intervention, the patient's symptoms were effectively alleviated, and clinical indicators returned to normal levels. Furthermore, the abundance of M. hominis decreased significantly compared to the initial mNGS reading after targeted treatment, indicating that the infection caused by M. hominis was effectively controlled.

Conclusion

Using mNGS, we found that M. hominis may be a candidate causative agent of meningitis. The technique also has the advantage of timeliness and accuracy that traditional cultures cannot achieve. A combination of mNGS with PCR is recommended to identify pathogens in the early stages of infectious diseases to administer targeted clinical medication.

A Case Report of Mycoplasma hominis Subdural Empyema Following Decompressive Craniotomy, and a Review of Central Nervous System Mycoplasma hominis Infections

Background

Mycoplasma hominis is a small cell-wall-free organism, part of the normal microbiota of the genitourinary tract. It is rarely involved in extragenital infections, mainly joint, surgical-site, and respiratory infections.

Methods

We describe a case of M. hominis subdural empyema and lower limb surgical site infections, following decompressive craniotomy, after traumatic brain and extremities injury. In addition, a literature review of 34 cases M. hominis CNS infections was done.

Results

Our case depicts a 25-years old patient who developed subdural empyema and surgical site infections in his cranium and fibula. Both sites were cultured, and small pinpoint colonies grew on blood agar. MALDI-TOF MS identified M. hominis. Simultaneously 16S-rDNA PCR from CSF detected M. hominis. Antimicrobial treatment was switched to doxycycline with improvement. Literature review revealed 21 adults and 13 pediatric cases of M. hominis CNS infection. Risk factors in adults were head trauma, neurosurgery, or post-partum period.

Conclusions

Based upon the literature reviewed, we postulate that adult patients with head trauma or neurosurgical procedure, rarely are infected either through direct contamination during the trauma, or by undergoing urgent, urinary catheterization, and may experience distant infection due to translocation of M. hominis into the bloodstream. In such cases diagnosis is delayed due to difficulties in growing and identifying the bacteria. Empiric antimicrobials are usually not effective against mycoplasmas. These factors contributed to the mortality in adult cases (15%). Our rare case highlights the necessity of combining classical microbiology routines with advanced molecular techniques to establish a diagnosis in complicated cases.

Mycoplasma hominis meningitis after operative neurosurgery: A case report and review of literature

BACKGROUND

Mycoplasma hominis (M. hominis), which causes central nervous system infections in adults, is very rare. It is also relatively difficult to culture mycoplasma and culturing requires special media, resulting in a high rate of clinical underdiagnosis. Therefore, clinicians often treat patients based on their own experience before obtaining pathogenic results and may ignore infections with atypical pathogens, thus delaying the diagnosis and treatment of patients and increasing the length of hospital stay and costs.

CASE SUMMARY

A 44-year-old man presented to the hospital complaining of recurrent dizziness for 1 year, which had worsened in the last week. After admission, brain magnetic resonance imaging (MRI) revealed a 7.0 cm × 6.0 cm × 6.1 cm lesion at the skull base, which was irregular in shape and had a midline shift to the left. Based on imaging findings, meningioma was our primary consideration. After lesion resection, the patient had persistent fever and a diagnosis of suppurative meningitis based on cerebrospinal fluid (CSF) examination. The patient was treated with the highest level of antibiotics (meropenem and linezolid), but the response was ineffective. Finally, M. hominis was detected by next-generation metagenomic sequencing (mNGS) in the CSF. Therefore, we changed the antibiotics to moxifloxacin 0.4 g daily combined with doxycycline 0.1 g twice a day for 2 wk, and the patient had a normal temperature the next day.

CONCLUSION

Mycoplasma meningitis after neurosurgery is rare. We can use mNGS to detect M. hominis in the CSF and then provide targeted treatment.

Iatrogenic Ventriculitis Due to Mycoplasma Hominis: A Case Report and Review of the Literature

BACKGROUND Mycoplasma hominis, which rarely causes infection after neurosurgical procedures, is a small free-living organism, belonging to the genus Mycoplasma. M. hominis lacks a rigid cell wall and cannot be clearly visualized by routine light microscopy. Thus, it is challenging to diagnose infections caused by this pathogen. Here, we report a case of Mycoplasma hominis causing iatrogenic ventriculitis secondary to extraventricular drain. CASE REPORT A 25-year-old man who was a victim of a road traffic accident developed M. hominis ventriculitis secondary to extraventricular drain. Despite a delay in the diagnosis due to the difficulty of identifying M. hominis, the patient was successfully treated with intravenous ciprofloxacin 400 mg for 14 days. CONCLUSIONS The findings of this case report, coupled with a thorough review of the literature, demonstrate the pathogenic potential of M. hominis. Particularly in developing countries, in which laboratories may have limited access to advanced technologies, such rare infectious diseases remain major diagnostic challenges.

Postoperative Mycoplasma hominis brain abscess: keep it in mind!

A temporal lobe abscess was diagnosed in a 57-year-old man. A urethral catheter had been inserted 12 days earlier, just prior to clot evacuation of a subacute haematoma secondary to an arterio-venous malformation. Fever persisted despite debridement and treatment with meropenem and vancomycin. Gram stains of operative samples showed no bacteria. Extended cultures grew pinpoint colonies after 5 days. Meanwhile, sequencing of bacterial 16S rDNA from operative specimens had identified Mycoplasma hominis; the bacterial colonies were subsequently similarly identified. The patient responded promptly following addition of oral doxycycline 100 mg two times per day. There is a growing literature of similar cases. Transient bacteraemia, following urinary catheterisation, with seeding of existing sites of inflammation is the proposed explanation. Urethral carriage of M. hominis is 15% and catheterisation is a common procedure. Mycoplasma hominis maybe more common than appreciated, especially as the need for extended cultures makes a correct diagnosis less likely.

Meningitis in a Chinese adult patient caused by Mycoplasma hominis: a rare infection and literature review

Background

Mycoplasma hominis, a well known cause of neonatal infection, has been reported as a pathogen in urogenital infections in adults; however, central nervous system (CNS) infections are rare. We report here the first case of M. hominis meningitis in China, post neurosurgical treatment for an intracerebral haemorrhage in a 71-year-old male.

Case presentation

We describe a 71-year-old man who developed M. hominis meningitis after neurosurgical treatment and was successfully treated with combined azithromycin and minocycline therapy of 2 weeks duration, despite delayed treatment because the Gram stain of cerebrospinal fluid (CSF) yielded no visible organisms. The diagnosis required 16S rDNA sequencing analysis of the cultured isolate from CSF. Literature review of M. hominis CNS infections yielded 19 cases (13 instances of brain abscess, 3 of meningitis, 1 spinal cord abscess and 1 subdural empyema each). Delay in diagnosis and initial treatment failure was evident in all cases. With appropriate microbiological testing, antibiotic therapy (ranging from 5 days to 12 weeks) and often, multiple surgical interventions, almost all the patients improved immediately.

Conclusions

Both our patient findings and the literature review, highlighted the pathogenic potential of M. hominis together with the challenges prompted by rare infectious diseases in particular for developing countries laboratories with limited diagnostic resources.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1885-4) contains supplementary material, which is available to authorized users.

Neonate with Mycoplasma hominis meningoencephalitis given moxifloxacin

Mycoplasma hominis is a commensal organism in the genitourinary tract that can cause life-threatening CNS infections in neonates after intrauterine infection or through vertical transmission during birth. We present a case of an 11-day-old neonate presenting with fever and supporting laboratory evidence of a CNS infection. No systemic maternal infection or maternal genitourinary tract infection occurred at the time of delivery. Empirical treatment was initiated, consisting of amoxicillin, cefotaxime, and aciclovir. After clinical deterioration, 16S ribosomal DNA PCR in cerebrospinal fluid detected M hominis, antibiotic treatment was switched to moxifloxacin, and pharmacokinetic data were obtained. This Grand Round illustrates the challenges that exist in the diagnosis and treatment of M hominis meningoencephalitis: bacterial cultures are often negative and recommended empirical antimicrobials do not provide adequate antimicrobial coverage. Optimal antimicrobial treatment regimens for M hominis meningoencephalitis are unknown. Although we describe successful treatment of a neonate with a complicated M hominis meningoencephalitis with moxifloxacin, caution with fluoroquinolone monotherapy (including moxifloxacin) has to be taken into account because resistance to fluoroquinolones has previously been described.

Fatal nosocomial meningitis caused by Mycoplasma hominis in an adult patient: case report and review of the literature

Meningitis due to Mycoplasma hominis in adults is rarely described, with only three cases having been reported to date. A case of fatal meningitis in a 39-year-old patient after a neurosurgical procedure for a subarachnoid haemorrhage is reported herein. Identification and treatment were significantly delayed because of the rarity of the aetiology and difficulty identifying this organism with the routinely used conventional methods, such as Gram staining and agar growth on standard agar plates. Clinical procedures and the treatment of 'culture-negative' central nervous system infections is a real challenge for clinical microbiologists and clinicians, and M. hominis has to be considered as a potential, although very uncommon, pathogen.

Postoperative Mycoplasma hominis infections after neurosurgical intervention

OBJECT

Mycoplasma hominis is a rare cause of infection after neurosurgical procedures. The Mycoplasma genus contains the smallest bacteria discovered to date. Mycoplasma are atypical bacteria that lack a cell wall, a feature that complicates both diagnosis and treatment. The Gram stain and some types of culture media fail to identify these organisms, and typical broad-spectrum antibiotic regimens are ineffective because they act on cell wall metabolism. Mycoplasma hominis commonly colonizes the genitourinary tract in a nonvirulent manner, but it has caused postoperative, postpartum, and posttraumatic infections in various organ systems. The authors present the case of a 17-year-old male with a postoperative intramedullary spinal cord abscess due to M. hominis and report the results of a literature review of M. hominis infections after neurosurgical procedures. Attention is given to time to diagnosis, risk factors for infection, ineffective antibiotic regimens, and final effective antibiotic regimens to provide pertinent information for the practicing neurosurgeon to diagnose and treat this rare occurrence.

METHODS

A PubMed search was performed to identify reports of M. hominis infections after neurosurgical procedures.

RESULTS

Eleven cases of postneurosurgical M. hominis infection were found. No other cases of intramedullary spinal cord abscess were found. Initial antibiotic coverage was inadequate in all cases, and diagnosis was delayed in all cases. Multiple surgical interventions were often needed. Once appropriate antibiotics were started, patients typically experienced rapid resolution of their neurological symptoms. In 27% of cases, a suspicious genitourinary source other than urinary catheterization was identified.

CONCLUSIONS

Postoperative M. hominis infections are rarely seen after neurosurgical procedures. They are typically responsive to appropriate antibiotic therapy. Mycoplasma infection may cause prolonged hospitalization and multiple returns to the operating room due to delay in diagnosis. Early clinical suspicion with appropriate antibiotic coverage could help prevent these significant complications.

Diagnosis and antimicrobial therapy of Mycoplasma hominis meningitis in adults

Meningitis in adults due to infection with Mycoplasma hominis is rarely reported. Here, we document the third case of M. hominis meningitis in an adult individual, developed upon neurosurgery following a subarachnoid haemorrhage. Our findings are noteworthy, because the presence of M. hominis in cerebrospinal fluid cannot be identified by standard culturing, Gram-staining, or matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Importantly, however, 16S rDNA sequencing did lead to an unambiguous diagnosis and guided successful antimicrobial therapy. Based on our present findings and a review of the respective literature, we conclude that M. hominis should be considered as a candidate causative agent of infections of the central nervous system following neurosurgical procedures, especially if there is no response to standard antimicrobial therapy, and routine culturing yields negative results.

Mycoplasma hominis brain abscess presenting after a head trauma: a case report

Introduction

Mycoplasma hominis brain abscess is a rare occurrence, and treatment is not well defined. The mechanism by which M. hominis infects sites outside the genitourinary tract, including the central nervous system, is unclear.

Case presentation

We report the case of a 40-year-old Somali man who sustained a traumatic brain injury that required initial neurosurgical hematoma evacuation and that subsequently was complicated by a hospital-acquired M. hominis brain abscess. Our patient was successfully treated with neurosurgical debridement and an antibiotic course of intravenous doxycycline.

Conclusions

Head trauma or neurosurgical procedures or both might be a predisposing factor for this type of infection.