Botryomycosis

Adamantinoma associated with botryomycosis: the first report of this rare association after trauma

A 27-year-old man presented with swelling and inflammation of his right tibia, which had been present for nearly 3 years. It apparently was associated with an injury that was sustained to the right leg when it was struck against a tree stump, which had led to immediate swelling. There were no other symptoms and no history of fever or weight loss. The right tibia was swollen to twice the size of the left and the skin was indurated with numerous crusted lesions and some sinus-like areas, but no ulceration of the skin surface was apparent. We report for the first time to our knowledge a unique case of both botryomycosis and adamantinoma in the right tibia of the same patient at an area of previous trauma. Pathologists, clinicians and radiologists should be aware that both lesions can occur together. Although both botryomycosis and adamantinoma usually have a history of trauma, as in our patient, a causal relationship will need more cases to establish a possible link.

Bacterial Infections

In Osier’s time, bacterial pneumonia was a dreaded event, so important that he borrowed John Bunyan’s characterization of tuberculosis and anointed the pneumococcus, as the prime pathogen, “Captain of the men of death.”1 One hundred years later much has changed, but much remains the same. Pneumonia is now the sixth most common cause of death and the most common lethal infection in the United States. Hospital-acquired pneumonia is now the second most common nosocomial infection.2 It was documented as a complication in 0.6% of patients in a national surveillance study,3 and has been reported in as many as 20% of patients in critical care units.4 Furthermore, it is the leading cause of death among nosocomial infections.5 Leu and colleagues6 were able to associate one third of the mortality in patients with nosocomial pneumonia to the infection itself. The increase in hospital stay, which averaged 7 days, was statistically significant. It has been estimated that nosocomial pneumonia produces costs in excess of $500 million each year in the United States, largely related to the increased length of hospital stay.

Cutaneous botryomycosis of the cervicofacial region

BACKGROUND

Botryomycosis is a rare, chronic, bacterial infection of insidious onset involving the integument or viscera that often mimics actinomycosis or a deep fungal infection. The pathogenesis is thought to be a symbiotic relationship between the host and the infecting organism.

METHODS

Case report of a patient with a chronic infection involving the cervicofacial region diagnosed as cutaneous botryomycosis arising from a chronic osteomyelitis of the mandible. The diagnosis was based on the chronicity of the infection along with the identification of botryomycotic (bacteria-containing) granules on histopathologic examination. Special stains excluded fungi and mycobacterium. Cultures identified the offending bacteria, and antibiotic therapy was initiated on the basis of the sensitivities, resulting in resolution of this chronic infectious process. A review of the English language literature revealed that this is the first case of cutaneous botryomycosis arising from a chronic osteomyelitis of the mandible.

RESULTS

Medical therapy proved curative at 14 months follow-up. Surgery was performed for diagnostic purposes only.

CONCLUSIONS

Botryomycosis is exceedingly rare in the head and neck, and consideration of this entity in the differential diagnosis is critical to the diagnosis. The mainstay of therapy is medical with surgery reserved for biopsy and/or excision of persistent disease. Published 2001 John Wiley & Sons, Inc.

Fatal mural endocarditis and cutaneous botryomycosis after heart transplantation

Fatal mural endocarditis and botryomycosis occurred concurrently in a 62-year-old women 4 months after orthotopic heart transplantation. Subsequent to mild mitral regurgitation, infection developed on a left atrial thrombus and was complicated by cerebral embolization. Simultaneously, skin nodules manifested on both forearms. Histologic examination revealed typical aspects of early evolving botryomycosis with massive infiltration of the dermis and hypodermis by necrotic granulomas framed by grains of Gram-positive coccoid forms. Bacteria were decorated by a nonspecific polyclonal antibody to Mycobacterium bovis.

Botryomycosis: improved therapy for a difficult infection

Botryomycosis is a chronic bacterial granulomatous disease often involving the skin and subcutaneous tissue. Head and neck involvement is rare. Botryomycosis presents with clinical and histological features similar to actinomycosis or mycetoma, but the causative organism is usually Staphylococcus aureus. Microscopically the organisms appear to be encapsulated in granules, which are thought to protect them from the effects of standard courses of antibiotics. Botryomycosis usually requires surgical intervention for cure. Major debilitating surgery has been required for most patients, because the infection has been unresponsive to seemingly appropriate medical therapy. We present an 8-month-old male with periorbital botryomycosis. Surgical specimens for diagnosis were obtained, but complete resection would have created debilitating functional and cosmetic defects. The lesion failed to respond to nafcillin alone or combination therapy with hyperbaric oxygen, but showed slow, steady improvement with long-term clindamycin. The patient has been disease free for more than 4 years, with minimal scarring and no functional impairment. Prolonged medical therapy for botryomycosis may be a viable alternative to the traditionally recommended surgical resection, thereby reducing cosmetic and functional morbidity.

Cutaneous botryomycosis

We report four cases of cutaneous botryomycosis. The predisposing factors included alcoholism, diabetes, and trauma. Clinically, the patients had nodules, suppurative plaques, or ulcers. In two cases, Staphylococcus aureus was cultured. In one case Neisseria species was cultured and in another a coagulase-negative Staphylococcus and Corynebacterium species were the only organism cultured. All patients responded to systemic antibiotic therapy.

Botryomycosis of the oral cavity

Botryomycosis is a bacterial infection characterized histologically by granules containing bacteria. Usually there is surrounding granulomatous inflammation with occasional extension into muscle or bone. While there are several hypotheses regarding the pathogenesis of botryomycosis, the exact mechanism is unclear. Botryomycosis has been associated with a variety of aerobic and anaerobic bacteria, usually endogenous flora and low virulence organisms. Oral lesions appear to be uncommon despite continuous exposure to endogenous oral flora. Treatment should include surgical excision and antibiotic therapy.

Cutaneous botryomycosis in a patient with acquired immunodeficiency syndrome

A patient with acquired immunodeficiency syndrome presented with multiple pruritic papules and nodules over the trunk and extremities. Biopsy specimens from two of these lesions contained granules within abscesses of the papillary dermis. There were numerous gram-positive cocci within the granules. Culture of one lesion failed to produce growth. A mouse inoculated with tissue from a lesion revealed no evidence of sepsis or organ involvement. The skin lesions showed no obvious response to systemic antimicrobial therapy but gradually resolved after treatment had been discontinued. Such lesions should be clinically distinguished from other cutaneous manifestations of acquired immunodeficiency syndrome, such as Kaposi's sarcoma.

Botryomycosis

Botryomycosis is a subacute or chronic bacterial infection, which is characterized by a granulomatous response and granules in which the microorganisms are embedded by a hyaline matrix. It may be caused by several pyogenic bacteria. The mechanism of granule formation is not understood. Treatment is with surgical drainage or resection, whenever possible, and prolonged use of the appropriate antibiotics.

Immunologic abnormalities in botryomycosis. A case report with review of the literature

Botryomycosis in an uncommon chronic bacterial infection that mimics fungal disease clinically and histologically. Microscopically the hallmark of the disease is the presence of fungus-like granules in which the causative organism is embedded. A patient with typical cutaneous botryomycosis is presented, along with the immunologic abnormalities discovered on laboratory examination. The botryomycosis literature is reviewed, with special emphasis on the immunologic status of the host. Additional studies of the causative organism and cell-mediated immunity in the host in future patients with botryomycosis may help to further elucidate the pathogenesis of this most interesting disease.

Anaerobic botryomycosis

Botryomycosis ofthe liver developed in a patient receiving corticosteroid therapy. The botyromycosis was caused by Propionibacterium acnes, which grew only anaerobically. The patient was successfully treated medically and at followup is asymptomatic.

Botryomycosis: a complication of extensive follicular mucinosis

A case of extensive follicular mucinosis, without evidence of lymphoma and present for 9 years, was complicated by cutaneous botryomycosis which initially resembled sporotrichosis. Scanty Staphylococcus aureus was cultured with difficulty. No immunodeficiency could be demonstrated, and the importance of a local factor (namely follicular mucinosis) in the production of the characteristic histological reaction of botryomycosis is emphasized.