Case Report: Coral Reef Pathogen Aspergillus sydowii Causing Black Grain Mycetoma

Mycetoma is an infrequent subcutaneous infection caused by true fungi (eumycetoma) or aerobic actinomycetes (actinomycetoma). We report the case of a 62-year-old man with eumycetoma involving the left foot and ankle. Skin biopsy revealed black-brown grains, and in culture, a white colony fungus grew at day 8. Molecular sequencing using ITS1-ITS4 primers identified the species as Aspergillus sydowii. The patient was treated with itraconazole 200 mg twice daily and terbinafine 250 mg daily for 8 months, with complete response and no recurrence after 2.5 years of follow-up. Aspergillus sydowii is a saprotrophic fungus that rarely causes skin or nail disease. No cases of eumycetoma caused by this agent have been previously reported. As its geographic distribution continues to expand, it may increasingly be recognized as a cause of human disease.

Tuberculous ankle versus pyogenic septic ankle arthritis: a retrospective comparison

Ankle tuberculosis (TB) manifests with varying symptoms and is easily confused with pyogenic septic ankle arthritis. In this study, all patients with either ankle TB or pyogenic septic ankle arthritis who were admitted to a medical center in southern Taiwan between May 1986 and October 2006 were reviewed retrospectively to identify risk factors for ankle TB. Compared with the 42 patients with culture-confirmed pyogenic septic ankle arthritis, the 26 patients with ankle TB (12 definitive, 5 probable, and 9 possible) were significantly more likely to have evidence of TB on chest radiographs (50 versus 10%; P<0.01), a history of trauma (58 versus 17%; P<0.01), presentation with sinus discharge (50 versus 12%; P<0.01), duration of symptoms of more than 3 months (69 versus 12%; P<0.01), a leukocyte count of <10,000/μL (58 versus 29%; P=0.03), and C-reactive protein of <5 mg/dL (42 versus 17%; P=0.03). Evidence of TB on chest radiographs was identified as an independent risk factor for ankle TB (odds ratio=35.1; 95% confidence interval=1.6‒779.8; P=0.02) by multiple logistic regression analysis. Awareness of these factors is essential for the accurate and timely diagnosis of ankle TB.

Clinical experience with daptomycin treatment of foot or ankle osteomyelitis: a preliminary study

We retrospectively reviewed 25 patients with foot or ankle osteomyelitis reported to a registry who were treated with daptomycin. The patients' clinical experience was analyzed and described at a median dose of 6 mg/kg (range, 4-6.2 mg/kg) and a median duration of 38 days (range, 6-59 days). Twenty-three patients received daptomycin as secondary or tertiary therapy, primarily for not responding to their prior antibiotic therapy (n = 15). Concomitant antibiotics were given to 11 patients, mostly for Gram-negative and/or anaerobic coverage. Methicillin-resistant Staphylococcus aureus was the most common pathogen overall (15 of 25 patients). The median followup interval was 9 weeks (range, 0.5-77 weeks). Outcomes at the end of therapy were 16 patients' symptoms resolved, eight patients improved, and one patient did not respond to therapy; at followup, 19 patients' symptoms resolved, three patients improved, and three patients did not respond to therapy. Ongoing antibiotics were given to 52% of patients for a minimum of 8 days (median, 30 days; range, 8-232 days). Four patients with an implant (all removed) were successfully treated. Daptomycin appears promising for foot and ankle osteomyelitis caused by Gram-positive bacteria. Prospective, controlled clinical trials of daptomycin for osteomyelitis are warranted.

Chlorhexidine provides superior skin decontamination in foot and ankle surgery: a prospective randomized study

Feet are prone to bacterial contamination. We hypothesized that chlorhexidine scrub and isopropyl alcohol paint provide superior local flora reduction than povidone-iodine scrub and paint. Patients with intact, uninfected skin having clean elective foot and ankle surgery were prospectively enrolled and randomly assigned to skin preparation with povidone-iodine (Group 1) or chlorhexidine scrub and isopropyl alcohol paint (Group 2). Culture swabs (aerobic, anaerobic, acid fast, fungus, and routine antibiotic sensitivity) were taken from all web spaces, nail folds, toe surfaces, and proposed surgical incision sites. One-hundred twenty-seven patients were enrolled (mean age, 46 years; range, 16-85 years). Sixty-seven patients were assigned to Group 1; 60 patients were assigned to Group 2. In Group 1, 53 of 67 patients (79%) had positive cultures; in Group 2, 23 of 60 patients (38%) had positive cultures. These data indicate that chlorhexidine and alcohol provide better reduction in bacterial carriage than povidone-iodine. Based on these data, we recommended chlorhexidine as the surgical preparatory agent for the foot and ankle.

LEVEL OF EVIDENCE

Therapeutic study, Level I-1a (significant difference). See the Guidelines for Authors for a complete description of levels of evidence.

Preoperative skin preparation of the foot and ankle: bristles and alcohol are better

BACKGROUND

The most efficient way to prepare the skin for foot and ankle surgery is unknown. In recent studies, >70% of aerobic bacterial cultures of specimens taken from the nail folds following skin preparation with povidone-iodine were positive. The goal of the current study was to determine the effect of isopropyl alcohol on the eradication of bacteria from the nails and skin of the normal foot and ankle. In addition, the effect of using a bristled brush rather than sponges to scrub the foot was investigated.

METHODS

Four skin-preparation techniques were studied in two sets of twenty-five volunteers. In phase I of the study, the right foot and ankle of each member of the first set of volunteers was prepared with method 1, which consisted of a two-stage povidone-iodine scrub and paint with use of soft sponges. The left foot and ankle was prepared with method 2, which consisted of method 1 as well as an additional pre-wash with 70% isopropyl alcohol. In phase II, the right foot and ankle of each member of the second set of volunteers was prepared with method 3, which consisted of a povidone-iodine scrub and paint with use of a bristled brush to scrub the foot. The left side was prepared with method 4, which consisted of an alcohol scrub and paint with use of a bristled brush to scrub the foot. At the end of the preparation process, specimens for aerobic bacterial cultures were obtained from the hallucal nail fold, interdigital web spaces, and anterior aspect of the ankle. Cultures were interpreted as positive or negative, and the results were also assessed quantitatively.

RESULTS

The rates of positive cultures of the nail-fold specimens were 76% and 80% after methods 1 and 2 (soft sponges) and 76% and 12% after methods 3 and 4 (bristled brush). The reduction in the percentage of positive cultures with method 4 was highly significant (p < 0.001). Cultures of the specimens from the web spaces showed a significant difference in the rates of positive results between methods 1 and 2 (36% and 8%, p < 0.05) but no significant difference between methods 3 and 4 (12% and 0%, p = 0.25). The rates of positive cultures of specimens from the anterior aspect of the ankle were consistently low (< or = 4% for all methods). Quantitative analysis of positive cultures demonstrated significant reductions (p < 0.01) in heavy growth when bristled brushes had been used, both with povidone-iodine and isopropyl alcohol.

CONCLUSIONS

The use of isopropyl alcohol and the use of a bristled brush both have beneficial effects on the skin-preparation process before foot and ankle surgery. In the current investigation, the most effective technique was the use of isopropyl alcohol in conjunction with scrubbing with a bristled brush. Merely washing the foot with alcohol-soaked sponges provided limited benefit to the web spaces only.

Mycotic osteomyelitis due to Scedosporium Apiospermum: MR imaging-pathologic correlation

Mycotic osteomyelitis is rare and occurs in immunocompromised patients after inoculation of the pathogen at a penetrating trauma site. Mycotic osteomyelitis due to Scedosporium Apiospermum is extremely rare, with only 13 cases of septic arthritis reported previously. Ours is only the third case of S. apiospermum osteomyelitis in an immunocompromised patient and the only patient with a histopathologic diagnosis from an amputation specimen. Recognition of this pathogen may be delayed due to insidious onset and negative joint fluid cultures, often requiring synovial or bone biopsies to establish the diagnosis. Delay in appropriate treatment may result in disseminating infection or even death.

Disease severity in a murine model of lyme borreliosis is associated with the genotype of the infecting Borrelia burgdorferi sensu stricto strain

The pathogenicity of Borrelia burgdorferi sensu stricto clinical isolates representing 2 distinct ribosomal DNA spacer restriction fragment-length polymorphism genotypes (RSTs) was assessed in a murine model of Lyme disease. B. burgdorferi was recovered from 71.5% and 26.6% of specimens from mice infected with RST1 and RST3 isolates, respectively (P<.0001). The average ankle diameter and histologic scores for carditis and arthritis were significantly higher after 2 weeks of infection among mice infected with RST1 isolates than among those infected with RST3 isolates (P<.001). These clinical manifestations were associated with larger numbers of spirochetes in target tissues but not with the serum sensitivity of the individual isolates. Thus, the development and severity of disease in genetically identical susceptible hosts is determined mainly by the pathogenic properties of the infecting B. burgdorferi isolate. The RST1 genotype is genetically homogeneous and thus may represent a recently evolved clonal lineage that is highly pathogenic in humans and animals.

Isolated tuberculosis of talus without ankle and subtalar joint involvement

This case has been reported because of its rarity and atypical clinical presentation. An 8-year-old boy presented with a gradually increasing swelling localised on the antero-medial aspect of the foot haemogram, erythrocyte sedimentation rate (ESR), Mantoux and X-ray chest were normal. An irregular lytic lesion of the talus was seen on the x-ray of the affected part. Ziehl Nelson staining of the aspirated fluid revealed acid-fast bacilli. Material obtained after curettage and bone grafting was sent for histopathological examination which confirmed the diagnosis of tuberculosis. Post operatively a below knee cast was given for 12 weeks and anti tubercular treatment was given for 20 months. At the end of the treatment patient had full and painless motion at the ankle and subtalar joint. The lytic lesion had healed on X-ray.