Edwardsiella tarda bacteraemia--complicated by acute pancreatitis and pyomyoma

Spontaneous Ruptured Pyomyoma in a Nulligravid Female: A Case Report and Review of the Literature

Introduction

Pyomyoma, or suppurative leiomyoma, is a rare complication of uterine fibroids. It occurs most commonly in the setting of pregnancy, the immediate postpartum period, or postmenopausal status. It may also arise after recent uterine instrumentation, after uterine artery embolization, or in immunocompromised patients. The most likely cause of pyomyoma is vascular compromise followed by bacterial seeding from direct, hematogenous, or lymphatic spread. Diagnosis is difficult, as the condition is rare, presents with vague symptoms, and is difficult to identify on imaging. Definitive diagnosis is only possible with surgery. Pathology shows a degenerating fibroid with hemorrhage, necrosis, cystic degeneration, and/or inflammatory change. Cultures of the pus contained within often show polymicrobial infection.

Case Presentation

Our patient is a 24-year-old nulligravid female who presented with a surgical abdomen, fever, hypotension, and leukocytosis. She had no significant prior medical or surgical history, no history of uterine instrumentation, and no history of pelvic infection; she was not currently sexually active at the time of presentation. She was taken to the operating room, where she underwent diagnostic laparoscopy. This showed a ruptured pyomyoma originating in the left broad ligament. She then underwent laparoscopic myomectomy. She was transferred to the ICU intubated; she slowly recovered on IV antibiotics and was discharged home on postoperative day 10.

Discussion

Pyomyoma is a rare condition and is even rarer in premenopausal patients without recent history of pregnancy or uterine instrumentation. This demonstrates an unusual case of spontaneous pyomyoma in the absence of risk factors, other than a history of known fibroids. Pyomyoma should be considered as a diagnosis in patients with sepsis, history of fibroids, and no other identifiable source of infection.

Maternal peripartum septic shock caused by intrauterine infection with Edwardsiella tarda: A case report and review of the literature

Edwardsiella tarda (E. tarda) is a rare pathogen in humans, especially during the peripartum period. Only a few cases of fatal neonatal infection with E. tarda have been reported. Herein, we describe a case of maternal septicemia caused by E. tarda following peripartum chorioamnionitis. The mother developed septic shock, disseminated intravascular coagulation and a post-cesarean wound hematoma with abscess. Her condition improved with multidisciplinary therapy including blood transfusion, antimicrobial agents, recombinant thrombomodulin and surgical debridement. E. tarda was isolated from the maternal blood, cesarean wound and neonatal skin, pharynx and gastric fluid. This case demonstrates that peripartum infection with E. tarda is a rare but life-threatening condition, not only for the neonate but also for the mother.

Large uterine pyomyoma in a perimenopausal female: A case report and review of 50 reported cases in the literature

Pyomyoma is a rare complication, which withoug antibiotics or surgical intervention, may cause sepsis and mortality. The present study reported a case of large uterine pyomyoma in a perimenopausal female. A 53-year-old multigravida woman was referred to the Department of Obstetrics and Gynecology (Wakayama Medical University, Wakayama, Japan) due to progressive abdominal distension. The patient presented with anemia gravis, severe inflammatory reaction and cachexia. Computed tomography revealed a large unilocular mass, 50 cm in size, with an irregular surface and thickened wall, occupying the entire abdomen. Following antibiotic medication, the patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Intraoperative findings demonstrated a solid tumor arising from the back of the uterine body. A total of 12 liters of purulent, malodorous fluid was drained from the tumor. The resected mass was 50 cm in size and 13.5 kg in weight. Cultures of the pus revealed the presence of Streptococcus agalactiae. Pathological findings revealed suppurative leiomyoma with no malignancy. Large pyomyoma is difficult to distinguish from a gynecological malignant tumor types, particularly in perimenopausal women with non-specific clinical presentation. Although pyomyoma is a benign tumor, care must be taken to discriminate these from large abdominal tumors.

Pyomyoma after abortion: Uterus conserving surgery is possible to maintain fertility. Case report

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If initial treatment of endometritis is unsuccessful consider a differential diagnosis of a pyomyoma.

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We can maintain patient’s fertility with a myomectomy and future pregnancy can be possible.

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The post abortion period is a risk factor for pyomyoma even in cases of spontaneous miscarriage.

Introduction

Pyomyoma is a rare complication associated with high rates of morbidity and mortality.

Presentation of case

We report the case of a 28-year-old nulligravida patient presenting pyomyoma following a spontaneous abortion at fourteen weeks and four days. Fourteen days following spontaneous miscarriage she was referred to the hospital with abdominal pain and fever. An antibiotic treatment was initiated. However, after ten days, the patient’s condition deteriorated and a decision for an emergency laparotomy made. The pyomyoma was successfully resected and the patient’s postoperative recovery was uneventful. A new pregnancy was confirmed two years later.

Discussion

The diagnosis of pyomyoma can be difficult but surgical treatment is often indicated. Performing a prompt myomectomy avoids the need for hysterectomy, preserving future fertility.

Conclusion

Pregnancy is possible following uterine sparing treatment of pyomyoma.

Edwardsiella tarda bacteremia. A rare but fatal water- and foodborne infection: Review of the literature and clinical cases from a single centre

BACKGROUND

Edwardsiella tarda bacteremia (ETB) can be a fatal disease in humans.

OBJECTIVES

To determine the significant risk factors associated with death caused by ETB, and to examine the geographical, seasonal, environmental and dietary factors of the disease.

METHODS

A retrospective, observational, case control study was performed. The PubMed MEDLINE and Japanese Medical Abstract Society (www.jamas.or.jp) databases were searched for ETB case reports and meeting abstracts. In additon, retrospective chart reviews of patients with ETB at the Tokyo Women's Medical University Hospital (Tokyo, Japan) were conducted to evaluate the risk factors associated with death using multivariate analyses.

RESULTS

The literature search yielded 46 publications, comprising 72 cases from the English (n=30), French (n=1), Spanish (n=1) and Japanese (n=14) literature. Five cases at the Tokyo Women's Medical University Hospital were also included. Of the included 77 cases, the mean age was 61 years and 39% of patients were female; 77.2% of the cases occurred between June and November, and 45.5% were reported in Japan. Dietary factors (raw fish/meat exposure) were reported for 10.4% of patients and 12.9% reported environmental (ie, brackish water) exposure. The overall mortality rate was 44.6%; however, this rate increased to 61.1% for ETB patients with soft tissue infections. Liver cirrhosis was determined to be an independent risk factor associated with death (OR 12.0 [95% CI 2.46 to 58.6]; P=0.00213) using multivariate analyses.

DISCUSSION

To our knowledge, the present analysis was the first and largest multi-language review of ETB. Clinical characteristics of ETB resemble those of Aeromonas, typhoid fever and Vibrio vulnificus infections, in addition to sharing similar risk factors.

CONCLUSION

ETB should be categorized as a severe food- and waterborne infection, which results in high mortality for patients with liver cirrhosis.

Temperature-dependent expression of virulence genes in fish-pathogenic bacteria

Virulence gene expression in pathogenic bacteria is modulated by environmental parameters. A key factor in this expression is temperature. Its effect on virulence gene expression in bacteria infecting warm-blooded hosts is well documented. Transcription of virulence genes in these bacteria is induced upon a shift from low environmental to a higher host temperature (37°C). Interestingly, host temperatures usually correspond to the optimum for growth of these pathogenic bacteria. On the contrary, in ectothermic hosts such as fish, molluscs, and amphibians, infection processes generally occur at a temperature lower than that for the optimal growth of the bacteria. Therefore, regulation of virulence gene expression in response to temperature shift has to be modulated in a different way to that which is found in bacteria infecting warm-blooded hosts. The current understanding of virulence gene expression and its regulation in response to temperature in fish-pathogenic bacteria is limited, but constant extension of our knowledge base is essential to enable a rational approach to the problem of the bacterial fish diseases affecting the aquaculture industry. This is an interesting issue and progress needs to be made in order to diminish the economic losses caused by these diseases. The intention of this review is, for the first time, to compile the scattered results existing in the field in order to lay the groundwork for future research. This article is an overview of those relevant virulence genes that are expressed at temperatures lower than that for optimal bacterial growth in different fish-pathogenic bacteria as well as the principal mechanisms that could be involved in their regulation.

Surgical wound infection, tuboovarian abscess, and sepsis caused by Edwardsiella tarda: case reports and literature review

Edwardsiella tarda is a freshwater pathogen that may cause mild to invasive infections with high mortality in humans. We describe two patients with serious E. tarda infections. The first patient was a woman with a tuboovarian abscess (TOA) and bilateral salpingitis requiring surgical resection and drainage. Her hospital course was complicated by a postoperative wound infection. TOA fluid as well as surgical wound culture revealed pure growth of E. tarda resistant to several antibiotics. The second patient was a man with a bloodstream E. tarda infection and cholangitis who recently traveled to Ecuador. He presented with hypoxia and further workup revealed choledocholithiasis and common bile duct benign polyps. Both patients made a full recovery.

Investigation of EscA as a chaperone for the Edwardsiella tarda type III secretion system putative translocon component EseC

Edwardsiella tarda is an important Gram-negative enteric pathogen affecting both animals and humans. It possesses a type III secretion system (T3SS) essential for pathogenesis. EseB, EseC and EseD have been shown to form a translocon complex after secretion, while EscC functions as a T3SS chaperone for EseB and EseD. In this paper we identify EscA, a protein required for accumulation and proper secretion of another translocon component, EseC. The escA gene is located upstream of eseC and the EscA protein has the characteristics of T3SS chaperones. Cell fractionation experiments indicated that EscA is located in the cytoplasm and on the cytoplasmic membrane. Mutation with in-frame deletion of escA greatly decreased the secretion of EseC, while complementation of escA restored the wild-type secretion phenotype. The stabilization and accumulation of EseC in the cytoplasm were also affected in the absence of EscA. Mutation of escA did not affect the transcription of eseC but reduced the accumulation level of EseC as measured by using an EseC-LacZ fusion protein in Ed. tarda. Co-purification and co-immunoprecipitation studies demonstrated a specific interaction between EscA and EseC. Further analysis showed that residues 31-137 of EseC are required for EseC-EscA interaction. Mutation of EseC residues 31-137 reduced the secretion and accumulation of EseC in Ed. tarda. Finally, infection experiments showed that mutations of EscA and residues 31-137 of EseC increased the LD(50) by approximately 10-fold in blue gourami fish. These results indicated that EscA functions as a specific chaperone for EseC and contributes to the virulence of Ed. tarda.

Sonographic appearance of a postpartum pyomyoma with gas production

Pyomyoma or suppurative leiomyoma is a potentially fatal complication of uterine leiomyomas. It is a rare condition with only a small number of reported cases since the era of antibiotics, and the descriptions of its sonographic appearance has been limited. We present a case of a pyomyoma associated with gas production, including a brief review of the reported sonographic features.

EscC is a chaperone for the Edwardsiella tarda type III secretion system putative translocon components EseB and EseD

Edwardsiella tarda is a Gram-negative enteric pathogen that causes disease in both humans and animals. Recently, a type III secretion system (T3SS) has been found to contribute to Ed. tarda pathogenesis. EseB, EseC and EseD were shown to be secreted by the T3SS and to be the major components of the extracellular proteins (ECPs). Based on sequence similarity, they have been proposed to function as the 'translocon' of the T3SS needle structure. In this study, it was shown that EseB, EseC and EseD formed a protein complex after secretion, which is consistent with their possible roles as translocon components. The secretion of EseB and EseD was dependent on EscC (previously named Orf2). EscC has the characteristics of a chaperone; it is a small protein (13 kDa), located next to the translocators in the T3SS gene cluster, and has a coiled-coil structure at the N-terminal region as predicted by coils. An in-frame deletion of escC abolished the secretion of EseB and EseD, and complementation of DeltaescC restored the export of EseB and EseD into the culture supernatant. Further studies showed that EscC is not a secreted protein and is located on the membrane and in the cytoplasm. Mutation of escC did not affect the transcription of eseB but reduced the amount of EseB as measured by using an EseB-LacZ fusion protein in Ed. tarda. Co-purification studies demonstrated that EscC formed complexes with EseB and EseD. The results suggest that EscC functions as a T3SS chaperone for the putative translocon components EseB and EseD in Ed. tarda.

Regulation of a type III and a putative secretion system in Edwardsiella tarda by EsrC is under the control of a two-component system, EsrA-EsrB

Edwardsiella tarda is a gram-negative enteric pathogen that causes hemorrhagic septicemia in fish and gastro- and extraintestinal infections in humans. A type III secretion system (TTSS) and a putative secretion system (EVP) have been found to play important roles in E. tarda pathogenesis. Our previous studies suggested that the TTSS and EVP gene clusters were regulated by a two-component system of EsrA-EsrB. In the present study, we characterized another regulator, EsrC, which showed significant sequence similarity to the AraC family of transcriptional regulators. Mutants with in-frame deletions of esrC increased the 50% lethal doses in blue gourami fish, reduced extracellular protein production, and failed to aggregate. Complementation of esrC restored these three phenotypes. Two-dimensional gel electrophoresis showed that EsrC regulated the expression of secreted proteins encoded by the TTSS (such as EseB and EseD) and EVP (EvpC) gene clusters. The expression of esrC required a functional two-component system of EsrA-EsrB. EsrC in turn regulated the expression of selected genes encoded in TTSS (such as the transcriptional unit of orf29and orf30, but not esaC) and genes encoded in the EVP gene cluster. The present study sheds light on the regulation of these two key virulence-associated secretion systems and provides greater insight into the pathogenic mechanisms of this bacterium.

Structural characterization of the O-polysaccharide antigen of Edwardsiella tarda MT 108

Edwardsiella tarda, a Gram-negative bacterium, is an important cause of hemorrhagic septicemia in fish and also of gastro- and extraintestinal infections in humans. The lipopolysaccharide produced by the fish pathogenic strain E. tarda MT 108 was isolated and the structure of its antigenic O-polysaccharide component determined by the application of chemical analyses, high-resolution 1D and 2D nuclear magnetic resonance spectroscopy, and mass spectrometry. The polysaccharide was found to be a polymer of a repeating pentasaccharide unit composed of 2-acetamido-2-deoxy-D-glucose (D-GlcNAc), 2-acetamido-2-deoxy-D-galactose (D-GalNAc), D-galactose (D-Gal), L-rhamnose (L-Rha), D-galacturonic acid (D-GalA) and (2S,3R)-threonine (1:1:1:1:1:1) having the structure: [structure: see text].

Functional genomics approach to the identification of virulence genes involved in Edwardsiella tarda pathogenesis

Edwardsiella tarda is an important cause of hemorrhagic septicemia in fish and also of gastro- and extraintestinal infections in humans. Here, we report the identification of 14 virulence genes of pathogenic E. tarda that are essential for disseminated infection, via a genome-wide analysis. We screened 490 alkaline phosphatase fusion mutants from a library of 450,000 TnphoA transconjugants derived from strain PPD130/91, using fish as an infection model. Compared to the wild type, 15 mutants showed significant decreases in virulence. Six mutants had insertions in the known virulence-related genes, namely, fimA, gadB, katB, pstS, pstC, and ssrB. Some mutants corresponded to known genes (astA, isor, and ompS2) that had not been previously shown to be involved in pathogenesis, and three had insertions in two novel genes. In vivo infection kinetics experiments confirmed the inability of these attenuated mutants to proliferate and cause fatal infection in fish. Screening for the presence of the above-described virulence genes in six virulent and seven avirulent strains of E. tarda indicated that seven of the genes were specific to pathogenic E. tarda. The genes identified here may be used to develop vaccines and diagnostic kits as well as for further studying the pathogenesis of E. tarda and other pathogenic bacteria.

Myonecrosis caused by Edwardsiella tarda: a case report and case series of extraintestinal E. tarda infections

Edwardsiella tarda is an unusual human pathogen. It is primarily associated with gastrointestinal disease, although recent reports of extraintestinal disease are broadening the current understanding of the clinical spectrum of E. tarda. A series of 11 cases of extraintestinal E. tarda infection is presented, including the first reported case of myonecrosis in an immunocompetent patient. Wound infections were the most common manifestation, and 3 of 5 patients with infected wounds had been exposed to a marine environment. One patient had bacteremia, and the remaining 5 patients developed abscesses that required surgical drainage. Four patients had E. tarda isolated in pure culture, including the patient with myonecrosis. Although it is often difficult to ascertain the contribution of E. tarda to infection when it is isolated as part of a mixed culture, this case series suggests that E. tarda is singularly capable of causing limb- and life-threatening infections.