Endocarditis and Ureaplasma urealyticum osteomyelitis in a hypogammaglobulinemic patient. A case report and review of the literature

Immunocompromised teenager with meningitis caused by Ureaplasma parvum

Infection in the immunocompromised patient is often challenging on multiple levels. It can be difficult to distinguish between manifestations of the underlying disease, infection or malignancy. Symptoms may be vague or even absent, deviations in the common inflammatory parameters discrete, imaging findings scarce and the causative microbe may be a true pathogen as well as opportunistic. Here, we report an immunosuppressed female in her late teens with a purulent meningitis due to Ureaplasma parvum-a very rare cause of infection in the central nervous system of adults. We wish to highlight the relevance of intracellular pathogens and the need to actively search for these microbes, especially when response to broad-spectrum antibiotic treatment is absent. Furthermore, we emphasise the need for adequate molecular microbial diagnostics in search of microbes that are difficult to identify by culture and where serology and antigen tests may be absent or unreliable due to immune suppression.

Metagenomic next-generation sequencing restores the diagnosis of a rare infectious complication of B cell depletion

A 45-year-old female patient receiving rituximab for B cell non-Hodgkin follicular lymphoma presented unexplained recurrent fever, abdominal discomfort, and pollakiuria. We performed shotgun metagenomic sequencing from peri-kidney collection that identified a co-infection with Mycoplasma hominis and Ureaplasma urealyticum. The patient recovered with sequelae after appropriate antibiotic treatment was given.

Droplet digital PCR (ddPCR) for the detection and quantification of Ureaplasma spp

BACKGROUND

Ureaplasma spp. are associated with various infectious diseases in females, but there is still limited evidence regarding whether they are related to nonspecific cervicitis. The aim of this study was to develop and evaluate a digital droplet PCR (ddPCR) assay for the detection and quantification of Ureaplasma spp. in cervical swabs.

METHODS

A total of 267 non-specific cervicitis (NSC) patients and 195 asymptomatic females were included in this study. We produced standard curves for Ureaplasma spp. to evaluate the analytical performance of the ddPCR assay. Then, we detected and quantified the bacterial load of Ureaplasma spp. in cervical swabs.

RESULTS

The prevalences of U. parvum were 37.8% (101/267) and 29.7% (58/195),  U. urealyticum were 9.0% (24/267) and 8.7% (17/195) in the NSC group and control group, respectively. In addition, the median copy number of U. parvum was 2.5 × 10⁴ copies/ml (n = 101) in the NSC group and 9.2 × 10³ copies/ml (n = 58) in the control group. The U. parvum load in the NSC group was significantly higher than that in the asymptomatic individuals (P < 0.001). whereas the median load of U. urealyticum was 8.4 × 10³ copies/ml (n = 24) and 1.4 × 10³ (n = 17) copies/ml in the two groups, respectively, , the difference was not statistically significant (P = 0.450).

CONCLUSIONS

Our study is the first to develop a droplet digital PCR (ddPCR) method for the detection and quantification of Ureaplasma spp. in clinical samples, and the method has excellent analytical performance and a wide range of clinical application prospects.

[Clinical implications of the genus Mycoplasma]

Dentro del género Mycoplasma, las especies que tradicionalmente se han relacionado con cuadros infecciosos han sido principalmente M. pneumoniae, M. genitalium, M. hominis o U. urealyticum. Sin embargo, existen otras muchas que están implicadas y, que muchas veces, son desconocidas para los profesionales sanitarios. El objetivo de esta revisión es identificar todas las especies del género Mycoplasma que se han aislado en el hombre y determinar su participación en la patología infecciosa humana.

Ureaplasma urealyticum disseminated multifocal abscesses in an immunocompromised adult patient: a case report

BACKGROUND

Ureaplasma urealyticum is a fastidious bacteria which lacks a cell wall. Extragenital infections are rare in immunocompetent adults. There are few literature reports of perinephric abscess. We present a case of non-resolving multifocal "culture-negative" abscesses in a hypogammaglobulinemic adult female due to U. urealyticum.

CASE PRESENTATION

66-year-old female with a one-week history of fever, malaise and new right hip and leg pain. Past medical history was notable for chronic pancytopenia secondary to in remission B cell follicular lymphoma, ESRD on intermittent hemodialysis with bilateral nephrostomy tubes and Crohn's. CT abdomen/pelvis revealed a small left perinephric hematoma and proximal right femur fluid collection. Persistent right thigh pain led to additional ultrasound with anterior thigh collection and CT revealed an irregular rim-enhancing fluid collection in the left posterior pararenal space. Antimicrobial therapy included ertapenem and vancomycin followed by meropenem, trimethoprim-sulfamethoxazole, daptomycin and metronidazole in setting of persistent culture-negative results and clinical deterioration. Following detection of U. urealyticum by 16S rDNA PCR in both left pararenal and right trochanteric bursa abscesses doxycycline was started. Despite this, the patient died four days later.

CONCLUSIONS

Disseminated infection by U. urealyticum has been documented in immunocompromised adult patients with few reports of perinephric abscess. We propose that ascending genitourinary route led to perinephric abscess. The multiple disseminated fluid collections make it highly suspicious for hematogenous spread given the lack of radiographic enhancement to suggest contiguous spread. Diagnosis and treatment of U. urealyticum-disseminated infection is extremely challenging as culture is laborious and not routinely performed. Furthermore, the lack of cell wall renders beta-lactams and vancomycin ineffective and therefore requirement for "atypical" coverage. Early diagnosis and treatment are key to prevent further complications and death.

Diagnosis and treatment of mycoplasmal septic arthritis: a systematic review

PURPOSE

Septic arthritis caused by Mycoplasma is rare. The diagnosis and effective treatment of mycoplasmal septic arthritis remains a serious problem for clinicians. The aim of this systematic review was to document the available evidence on the diagnosis and treatment methods for mycoplasmal septic arthritis and to provide guidance for clinicians.

METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched in December 2018.The searches were limited to the English language. Article screening and data extraction and compilation were conducted by two independent reviewers. All the included studies were assessed using the Methodological Index for Non-randomized Studies (MINORS) tool.

RESULTS

There was a total of 33 articles including 34 cases of mycoplasmal septic arthritis and eight of them were periprosthetic joint infection (PJI). Twenty-four patients (70.6%) were immunocompromised, and the synovial fluid white blood cell (WBC) count was significantly lower in the immunocompromised group than in the immunocompetent group (48,527 × 10⁶/L vs. 100,640 × 10⁶/L; P = 0.009). The traditional culture method took longer, and the positivity rate was lower than that of nucleic acid testing (50% vs. 100%; P = 0.016). Only 19.2% (5/26) of patients treated with empiric antibiotics were relieved of symptoms, while 82.4% (28/34) of patients achieved satisfactory results after being treated with antibiotics against Mycoplasma.

CONCLUSION

The possibility of mycoplasmal septic arthritis should be considered if patients with joint infections have a history of immunocompromised, repeated negative cultures, and poor empiric antibiotic treatment results. The rational use of nucleic acid testing technologies can help in the clinical diagnosis and treatment of mycoplasmal septic arthritis.

Invasive Ureaplasma Infection in Patients Receiving Rituximab and Other Humoral Immunodeficiencies-A Case Report and Review of the Literature

Ureaplasma species are small, fastidious bacteria that frequently colonize the lower reproductive tract of asymptomatic hosts. These organisms have been well described to cause chorioamnionitis, neonatal infection, and urethritis, and to a lesser degree surgical site infection and infection in transplant recipients. Outside of these settings, invasive Ureaplasma infections are rare. We describe the case of a young woman receiving rituximab for multiple sclerosis who presented with fever and bilateral renal abscesses due to Ureaplasma spp., which was successfully treated with oral doxycycline. We searched the literature for cases of invasive Ureaplasma infection and found a patient population that predominates with humoral immunodeficiency, either congenital or iatrogenic. Diagnostic and therapeutic interventions are discussed.

Brain abscess caused by Ureaplasma urealyticum in an adult patient

Ureaplasma urealyticum is a fastidious bacterium usually residing in the female genitourinary tract. We present an exceedingly complicated case of a brain abscess secondary to mastoiditis by U. urealyticum in an adult hypogammaglobulinemic patient after rituximab treatment 3 years earlier.

Osteoarticular infectious complications in patients with primary immunodeficiencies

PURPOSE OF REVIEW

To describe the incidence and management of various infectious arthritides in selected primary immunodeficiency states.

RECENT FINDINGS

Joint complications have been a well recognized finding in patients with primary immunodeficiencies for many years. Many are clearly infectious in etiology, but other apparently noninfectious joint abnormalities similar to rheumatoid arthritis have been shown to be due to an underlying infectious trigger. In humoral immunodeficiencies such as common variable immunodeficiency and X-linked agammaglobulinemia, bacterial organisms are the most common causes of infectious arthritis, but mycoplasmas and ureaplasmas are also of particular importance. In nonhumoral immunodeficiencies, noninfectious inflammatory arthritides are more prevalent, although microbiologic organisms have been reported in some cases of arthritis. Lack of appropriate culturing techniques and documentation of infectious agents may underestimate the prevalence of low-virulence infections in these patients.

SUMMARY

Infectious arthritis is a significant comorbidity associated with primary immunodeficiencies and can be the presenting feature for some patients. Prompt examination for common as well as atypical organisms is not only important for the treatment but also crucial to the understanding of the exact etiology of arthritides as a whole in these disorders.

Infective endocarditis complicating rituximab (anti-CD20 monoclonal antibody) treatment in an SLE patient with a past history of Libman–Sacks endocarditis: a case for antibiotic prophylaxis?

We report a 54 year old female whose successful treatment of cerebral lupus with rituximab was complicated by the development of streptococcus intermedius, on valves damaged by Libman-Sacks endocarditis more than 20 years previously.