A systemic review of the role of enterotoxic Bacteroides fragilis in colorectal cancer

Enterotoxigenic Bacteroides fragilis (ETBF) has received significant attention for a possible association with, or causal role in, colorectal cancer (CRC). The goal of this review was to assess the status of the published evidence supporting (i) the association between ETBF and CRC and (ii) the causal role of ETBF in CRC. PubMed and Scopus searches were performed in August 2021 to identify human, animal, and cell studies pertaining to the role of ETBF in CRC. Inclusion criteria included the use of cell lines, mice, exposure to BFT or ETBF, and detection of bft. Review studies were excluded, and studies were limited to the English language. Quality of study design and risk of bias analysis was performed on the cell, animal, and human studies using ToxRTools, SYRCLE, and NOS, respectively. Ninety-five eligible studies were identified, this included 22 human studies, 24 animal studies, 43 cell studies, and 6 studies that included both cells and mice studies. We found that a large majority of studies supported an association or causal role of ETBF in CRC, as well as high levels of study bias was detected in the in vitro and in vivo studies. The high-level heterogeneity in study design and reporting made it difficult to synthesize these findings into a unified conclusion, suggesting that the need for future studies that include improved mechanistic models, longitudinal in vitro and in vivo evidence, and appropriate control of confounding factors will be required to confirm whether ETBF has a direct role in CRC etiopathogenesis.

Fusobacterium nucleatum and Bacteroides fragilis detection in colorectal tumours: Optimal target site and correlation with total bacterial load

Background

Mucosal infiltration by certain bacterial species may contribute to the development and progression of colorectal cancer (CRC). There is considerable variation in reported detection rates in human CRC samples and the extent to which bacterial infiltration varies across regions of the primary tumour is unknown. This study aimed to determine if there is an optimal site for bacterial detection within CRC tumours.

Methods

Presence of target bacterial species was assessed by quantitative real-time PCR (qPCR) in 42 human CRC tumours. Abundance in primary tumour regions, normal epithelium and at metastatic sites was investigated in an expanded cohort of 51 patients. Species presence/absence was confirmed by diversity profiling in five patients. Correlation with total bacterial load and clinicopathological features was assessed.

Results

Fusobacterium nucleatum and Bacteroides fragilis were detected in tumours from 43% and 24% of patients, respectively (17% positive for both species). The optimal detection site was the tumour luminal surface (TLS). Patients testing positive at the TLS frequently tested negative at other sites, including central tumour and invasive margin. F. nucleatum was detected at a higher frequency in tumour versus normal epithelium (p < 0.01) and was associated with more advanced disease (p = 0.01). Detection of both species correlated with total bacterial load. However, corroboration of qPCR results via diversity profiling suggests detection of these species may indicate a specific microbial signature.

Conclusions

This study supports a role for F. nucleatum in CRC development. Presence of F. nucleatum and B. fragilis varies across primary tumour regions, with the TLS representing the optimal site for bacterial detection.

Colonization with enterotoxigenic Bacteroides fragilis is associated with early-stage colorectal neoplasia

BACKGROUND

Enterotoxigenic Bacteroides fragilis (ETBF) is a toxin-producing bacteria thought to possibly promote colorectal carcinogenesis by modulating the mucosal immune response and inducing epithelial cell changes. Here, we aim to examine the association of colonic mucosal colonization with ETBF and the presence of a range of lesions on the colonic neoplastic spectrum.

METHODS

Mucosal tissue from up to four different colonic sites was obtained from a consecutive series of 150 patients referred for colonoscopy. The presence and relative abundance of the B. fragilis toxin gene (bft) in each tissue sample was determined using quantitative PCR, and associations with clinicopathological characteristics were analysed.

FINDINGS

We found a high concordance of ETBF between different colonic sites (86%). Univariate analysis showed statistically significant associations between ETBF positivity and the presence of low-grade dysplasia (LGD), tubular adenomas (TA), and serrated polyps (P-values of 0.007, 0.027, and 0.007, respectively). A higher relative abundance of ETBF was significantly associated with LGD and TA (P-values of < 0.0001 and 0.025, respectively). Increased ETBF positivity and abundance was also associated with left-sided biopsies, compared to those from the right side of the colon.

CONCLUSION

Our results showing association of ETBF positivity and increased abundance with early-stage carcinogenic lesions underlines its importance in the development of colorectal cancer, and we suggest that detection of ETBF may be a potential marker of early colorectal carcinogenesis.

[Spontaneous renal forniceal rupture with suspicious ovarian mass]

Extravasation of urine following rupture of the renal fornix is a rare complication mostly caused by obstruction secondary to distal ureteric stones. This 35-year-old woman was referred with back pain. Her CT scan revealed rupture of the renal fornix secondary to a pelvic mass. Laparoscopy subsequently confirmed this to be an ovarian abscess. We report the first case of spontaneous renal forniceal rupture secondary to pelvic inflammatory disease.

Clinical diagnostic accuracy of suspected sources of bacteremia and its effect on mortality

BACKGROUND

Although much has been written about bacteremia, evidence of the clinical diagnostic accuracy of bacteremia sources in the absence of microbiological results and the impact of diagnostic accuracy on mortality is scarce.

METHODS

This is a retrospective study of bacteremia episodes over a 2-year period at a general hospital in Madrid. Congruence analyses between clinically presumed and definite sources, acquisition, causative organism, empirical treatment and progression to death were performed.

RESULTS

The study included 323 bacteremia episodes. Clinicians' diagnostic accuracy was higher for gastrointestinal (88.8%; 95% CI: 79%-84%), respiratory (93.9%; 95% CI: 79%-99%) and urinary tract sources (83.6%; 95% CI: 75%-89%) and lower for skin and soft tissues (77.2%; 95% CI: 54%-92%) and, notably, intravascular sources (56%; 95% CI: 39%-71%). Overall, a non-significant (3.45%; 95% CI: -0.6%-13.5%, p=0.47) increase in mortality was observed in the incorrectly suspected bacteremia source group. Mortality related to a definitive source was significantly higher when an intravascular origin was not suspected, resulting in a 26% increase in mortality (95% CI: 1%-52%, p=0.03). Differences in mortality related to inaccurate source assumptions were non-significant when the definitive bacteremia sources were gastrointestinal, urinary, respiratory, skin and soft tissues or unknown. Mortality in the group receiving appropriate empirical antimicrobial treatment was 10.6% compared with 19.7% mortality in the group receiving inappropriate empirical antimicrobial treatment (OR 2; 95% CI: 1.01-4.25).

CONCLUSIONS

The diagnostic accuracy of bacteremia sources is high in all but intravascular sources. A non-suspected intravascular source and inappropriate empirical treatment are related to a higher mortality.

A clinical case of Fournier gangrene

OBJECTIVE

To present a case of Fournier gangrene and the specific surgical therapy

CASE PRESENTATION

A 71-year old patient with a two days history of pain in the perineal region, swelling, developing necrosis and foul-smelling lesions was examined in emergency settings. The swelling of subcutaneous plane involved the flank regions, mainly on the left side. The investigations were performed (full blood count, blood urea, electrolytes, coagulation profile). A Fournier gangrene was diagnosed and surgery performed under general anesthesia. Broad spectrum antibiotics were given concomitantly. The first surgical procedure consisted in surgical debridement and excision of all the necrotic tissue. Cultures were taken. We performed counter incisions bilaterally on both flanks. The communication through the fascial planes was clearly demonstrated, especially on the left side. A loop colostomy was also performed. Multiple re-excisions were further employed. Due to a precarious evolution, the patient were on mechanical ventilation for 13 days. Inotrope medication was given for a total of 19 days and, the antibiotherapy adapted to the antibiogram (Bacterioides eggerthii was identified). The reconstruction of the perineum was later performed and, after 3 months, the colostomy was closed in good conditions without further complications.

CONCLUSION

Early recognition and aggressive surgical excision are mandatory for success in patients with Fournier gangrene. Colonic diversion can be very useful if employed from the beginning.

Spondylodiscitis complicated by an epidural abscess and meningitis caused by Bacteroides fragilis

Bacteroides fragilis is a rare causative agent of spondylodiscitis. The pathophysiology of B. fragilis in spondylodiscitis remains largely unclear because of its rare occurrence. We herein report a case of spondylodiscitis complicated by an epidural abscess and meningitis; B. fragilis was detected in the blood of the patient. Moreover, the patient had a splenic abscess that was confirmed on magnetic resonance imaging. The patient completely recovered with antimicrobial therapy alone.

[Endotoxin production in members of the Bacteroides fragilis group in relation to colorectal cancer humans]

BACKGROUNDS

Members of the Bacteroides fragilis group are the most frequently isolated anaerobic bacteria causing a wide range of severe anaerobic infections. In spite of the high frequency of their occurrence, their presence in clinical specimens is underestimated or even disregarded. The article warns of the severity of these anaerobic pathogens, particularly if detected in clinical samples from the abdominal area. It was hypothesized that there is a correlation between the presence of the bacteria in patients preferring high-meat diet and cancers of the small intestine and especially the colon and rectum [10]. Endotoxins of the bacteria contribute to weakening the patient's immune system damaged by cancer and play a significant role in the progression of small intestine and colon cancer.

MATERIAL AND METHODS

Endotoxin production was determined in 140 strains of the Bacteroides fragilis group (B. fragilis, B. thetaiotaomicron, B. distasonis, B. vulgatus) isolated from patients with 7 cancerous and non-cancerous diseases (5 strains of each type of Bacteroides spp. for each diagnosis), using the Pyrosate LAL (limulus amoebocyte lysate) assay.

RESULTS

A statistically significant difference in the production of endotoxins isolated from strains of the Bacteroides fragilis group was found between cancerous and non-cancerous diseases.

CONCLUSIONS

All four bacterial species produced significantly more endotoxins in cancer than in non-cancerous diseases, with the lowest production in skin abscess (F2,134 = 170, p < 0.0001). Statistically significant differences in the production of endotoxins were also found between the individual members of the Bacteroides fragilis group. B. fragilis and B. vulgatus produced significantly more of (twice as much) endotoxin than B. distasonis and B. thetaiotaomicron (post hoc t-tests, p < 0.00001).

Periodontitis associated with Chediak-Higashi syndrome in a young African American male

BACKGROUND

Chediak-Higashi syndrome (CHS) is a rare autosomal recessive genetic disease. The primary defect is abnormal granule formation in the cells secondary to a mutation of a lysosomal trafficking regulator protein. CHS patients have immune system abnormalities, bleeding abnormalities, and multiple infections including periodontitis.

METHODS

A 13-year-old African American male presented with severe gingival inflammation, generalized gingival bleeding, and tooth looseness. Comprehensive dental, medical and laboratory evaluations were performed.

RESULTS

All teeth exhibited excessive mobility. The gingival tissues were swollen and bled easily. Most sites had probing depth in excess of 10 mm. Dental radiographs showed advanced generalized alveolar bone loss. Areas of skin depigmentation were noted. Blood smear showed presence of intracellular large granules in white blood cells. Platelet function was altered. Gingival histopathology showed an intense chronic inflammatory cell infiltrate and presence of numerous filamentous bacteria. Subgingival microbiological culture showed the presence of Porphyromonas gingvalis, Prevotella intermedia and Tannerella forsythia. Based on the periodontal, medical and laboratory findings a diagnosis of CHS was established. Because of the advanced periodontal condition and the risk of fatal bacterial infections, exodontias were performed. Because of platelet abnormalities the patient developed postoperative bleeding complications that required management with coagulation factor 7.

CONCLUSIONS

Advanced periodontitis is an important symptom of CHS and may be the first step in the diagnosis of the condition. Due to the weakened immunity of CHS patients, periodontal management is usually unsuccessful. Tooth extractions are recommended to eliminate the periodontal problems and reduce the risk of fatal bacterial infections.

Thigh infection and subcutaneous emphysema: an emergency, review of literature and case discussion

Thigh infection associated with local emphysematous signs on presentation to the emergency room should alert the medical staff at once of potential complication associated with it. The infection may be associated with underlying bowel pathology and has a high mortality rate. Hence, emergency treatment should be instituted. We discuss a case with this uncommon presentation, treatment administered and relevant literature.

Bacteroides fragilis bacteremia associated with vertebral osteomyelitis in a sickle cell patient

Osteomyelitis and septic arthritis are serious complications of sickle cell disease which occur at rates of 18% and 7%, respectively. In two small studies of osteomyelitis in sickle cell patients, the most common causative organisms were Salmonella spp. and Staphylococcus spp. Anaerobic infection is uncommon. Here, we report an 18-year-old girl with sickle cell disease and suspected spontaneous vertebral osteomyelitis due to Bacteroides fragilis. The diagnosis was based on multiple positive blood cultures. Despite extensive investigation, the port of entry could not be determined. The patient responded well to a four-week therapy with metronidazole, without the need for surgical debridement.

Bacteroides (Parabacteroides) distasonis splenic abscess in a sickle cell patient

Splenic abscess is not an uncommon complication of patients with sickle-cell disease. Here we describe an 18 year-old boy with sickle cell disease and left upper quadrant abdominal pain. Computerized axial tomography revealed left sided free flowing pleural effusion and splenomegaly with liquefaction and possible gas formation. The splenic fluid grew an unusual organism known as Bacteroides distasonis. The patient received antimicrobial therapy and underwent a splenectomy with full recovery. The spleen was cystically infarcted and measured 22 x 16 x 5 cm. The capsule was thickened and covered by fibrinous exudate. Histopathologic examination of the spleen showed complete necrosis with reparative fibrosis. This case presents an unusual cause of splenic abscess due to Bacteroides distasonis with a subacute to chronic course. The presence of fever and left sided pleuritic chest pain in patients with sickle cell disease should raise the suspicion of splenic abscess.

A Schloffer tumor treated 27 years after appendectomy

Most complications of appendectomy occur in the early postoperative period. A 51-year-old woman presented to our hospital with abdominal fullness and a painful mass in the right lower abdomen. The painful mass was related to a scar from an appendectomy performed 27 years previously; some earlier episodes of pain had occurred after the operation. A tender mass 7 cm in diameter was palpable, extending from the appendectomy scar toward the umbilical region. Findings of abdominal ultrasonography and computed tomography were consistent with an abdominal wall abscess, which was excised. At operation, a thick-walled abscess was seen to extend from the appendectomy scar toward the umbilicus, and from within abdominal wall muscles to the preperitoneal fat; it did not communicate with any intra-abdominal organ. Bacteroides fragilis was isolated from the abscess contents. Pathologic examination revealed diffuse infiltration by inflammatory cells including neutrophils and plasma cells, with inflammation spreading into surrounding muscles. Our patient's findings indicate that the abdominal wall abscess (so-called Schloffer tumor) resulted from persistent inflammation following the appendectomy performed 27 years previously. Since treatment of Schloffer tumor is not difficult once the diagnosis is made, physicians and surgeons should be aware of Schloffer tumor as a possible late complication of appendectomy.

Retroperitoneal infection complicated by bacterial meningitis and ventriculitis with secondary brainstem infarction

INTRODUCTION

Retroperitoneal abscesses have been previously reported to cause infectious meningitis. Cerebral infarction is a known complication of basilar meningitis.

SUMMARY OF CASE

We present a case where a comatose patient with a known retroperitoneal abscess was diagnosed via Magnetic Resonance Imaging (MRI) with extensive brainstem infarction secondary to basilar meningitis.

Intramedullary spinal cord abscess complicating thoracic spondylodiscitis caused by Bacteroides fragilis

Intramedullary spinal cord abscess associated with infectious spondylodiscitis is a rare entity. The case of a 66-year-old man with an intramedullary spinal cord abscess complicating thoracic spondylodiscitis is presented. The patient was unable to ambulate independently due to weakness of the legs. MR imaging showed findings suggestive of infectious spondylodiscitis at the T5-T6 level associated with epidural and intramedullary spinal cord abscesses. Biopsy of the intervertebral disc was performed and Bacteroides fragilis was isolated. Antibiotic therapy was instituted, and MR imaging of the thoracic spine was performed 6 weeks after the initiation of treatment, showing resolution of the epidural and intramedullary spinal cord abscesses.

Pylephlebitis Associated with Acute Infected Choledocholithiasis

Pylephlebitis, also called septic thrombophlebitis of the portal vein, is a life-threatening complication of intra-abdominal infection. Although rare, it remains a less recognized entity with a high rate of mortality. We present a 66-year-old man with acute infected choledocholithiasis complicated with Bacteroides fragilis bacteremia. The contrast-enhanced computed tomography scan of the abdomen showed nearly total thrombotic occlusion of the left portal vein. The comprehensive studies for hypercoagulation disorders all yielded negative results. After endoscopic extraction of bile duct stones and broad-spectrum antibiotic therapy, the patient recuperated with complete recanalization of the occluded portal vein. To our knowledge, pylephlebitis associated with acute infected choledocholithiasis has never been reported. This report details the clinical features, radiographic findings, pathogenesis, and treatment of this distinctly unusual manifestation. Early identification of pylephlebitis and underlying intra-abdominal infection can be achieved by exquisite imaging studies with raised awareness in the clinical setting. Eradication of infectious foci and judicious administration of antimicrobials are essential to reduce the catastrophic morbidity and mortality of pylephlebitis.

Treatment of rheumatoid arthritis with ornidazole: a randomized, double-blind, placebo-controlled study

The aim of our study was to evaluate the clinical efficacy, safety, and tolerability of ornidazole in patients with rheumatoid arthritis (RA). This was 3 months, randomized, double-blind,placebo-controlled study. A total of 160 patients with active RA were randomly assigned to receive 1,000 mg ornidazole (n = 53), 500 mg ornidazole (n = 55), or placebo (n = 52). A significantly greater percentage of patients treated with 1,000 mg ornidazole met the American College of Rheumatology 20% improvement criteria (achieved an ACR20 response) at 3 months compared with patients who received placebo (62.0 vs. 32.4%; P < 0.001). Greater percentages of patients treated with 1,000 mg ornidazole also achieved ACR50 responses (38.3 vs. 10.9%; P < 0.001) and ACR70 responses (19.6 vs. 1.2%; P < 0.001) compared with patients who received placebo. Ornidazole treatment was also associated with significant reductions in pain and duration of morning stiffness, significant improvement in the quality of life and both the physician's and patient's global assessments, and significant reductions in disease activity as assessed by objective laboratory measures (erythrocyte sedimentation rate and C-reactive protein level). Ornidazole was well tolerated. There were no dose-limiting toxic effects. In this 3-month-trial ornidazole was safe, well tolerated, and associated with improvement in the inflammatory symptoms of RA.

The distribution of the bft alleles among enterotoxigenic Bacteroides fragilis strains from stool specimens and extraintestinal sites

Enterotoxigenic Bacteroides fragilis (ETBF) has been implicated in diarrhoeal illness in animals and humans. Recent data suggest that ETBF is associated with flares of inflammatory bowel disease. Toxigenicity is attributed to expression of a toxin referred to as fragilysin, which stimulates fluid accumulation in ligated intestinal segments and alter the morphology of human intestinal cells. Three different isoforms or variants of the enterotoxin gene, designated bft-1, bft-2, and bft-3, have been identified. In this study we investigated the distribution of bft alleles among ETBF strains in stool specimens from patients with colon cancer (n: 31), the control patients (n: 8) and extraintestinal sources (n: 15). We used restriction fragment length polymorphism analysis of the PCR-amplified enterotoxin gene and sequencing the PCR-product to detect the isoforms of bft gene. Among the stool strains, bft-1 was found to be more common than bft-2; as it was detected 27 of 31 strains from colon cancer patients and 7 of 8 control strains. The bft-1 isoform was also found in almost all isolates from extraintestinal sites. No bft-3 subtype was detected among all tested strains.

Transobturator tape erosion associated with leg pain

A 39 year-old vaginal multipara status postpubovaginal sling in 2002 and a transobturator tape procedure in 2004 presented with persistent stress incontinence and vaginal polypropylene mesh erosion. Ten days later, she presented to the emergency room with severe right groin pain, difficulty walking, fever, and chills. She described shooting pain originating from the right inguinal ligament radiating down her right leg anteriorly. Although her neurologic examination was normal, palpation of the right obturator internus muscle reproduced her pain. MRI clearly revealed the course of the mesh tape through the obturator muscles and marked increase in the size of the right adductor and obturator internus muscles, apparently compressing the adjacent neurovascular fascicle. The patient was taken to the operating room where the polypropylene tape was easily removed through the vaginal erosion. Mesh cultures were positive for bacteroides fragilis. She experienced complete symptom resolution within 1 week of tape removal.

Dysgonomonas capnocytophagoides bacteraemia in a neutropenic patient treated for acute myeloid leukaemia

Dysgonomonas capnocytophagoides, formerly known as CDC group DF-3, is an opportunistic pathogen associated with diarrhoea and very rarely bacteraemia. We report a case of D. capnocytophagoides found in blood cultures from a severely neutropenic patient treated for acute myeloid leukaemia. The isolate was found resistant to penicillin, cephalosporins, meropenem, aminoglycosides and ciprofloxacin, and susceptible to ampicillin, tetracycline, chloramphenicol, clindamycin and trimethoprim-sulphamethoxazole. It was identified using conventional phenotypic testing but remained unidentified by the automated identification system (Vitek-2) as this system did not contain DF-3 or D. capnocytophagoides in its database.

Levofloxacin plus metronidazole administered once daily versus moxifloxacin monotherapy against a mixed infection of Escherichia coli and Bacteroides fragilis in an in vitro pharmacodynamic model

Moxifloxacin has been suggested as an option for monotherapy of intra-abdominal infections. Recent data support the use of a once-daily metronidazole regimen. The purpose of this study was to investigate the activity of levofloxacin (750 mg every 24 h [q24h]) plus metronidazole (1,500 mg q24h) compared with that of moxifloxacin (400 mg q24h) monotherapy in a mixed-infection model. By using an in vitro pharmacodynamic model in duplicate, Escherichia coli and Bacteroides fragilis were exposed to peak concentrations of 8.5 mg of levofloxacin/liter q24h, 32 mg of metronidazole/liter q24h, and 2 mg for moxifloxacin/liter q24h for 24 h. The activities of levofloxacin, metronidazole, moxifloxacin, and levofloxacin plus metronidazole were evaluated against E. coli, B. fragilis, and E. coli plus B. fragilis. The targeted half-lives of levofloxacin, metronidazole, and moxifloxacin were 8, 8, and 12 h, respectively. Time-kill curves were analyzed for time to 3-log killing, slope, and regrowth. Pre- and postexposure MICs were determined. The preexposure levofloxacin, metronidazole, and moxifloxacin MICs for E. coli and B. fragilis were 0.5 and 1, >64 and 0.5, and 1 and 0.25 mg/liter, respectively. Levofloxacin and moxifloxacin achieved a 3-log killing against E. coli and B. fragilis in all experiments, as did metronidazole against B. fragilis. Metronidazole did not decrease the starting inoculum of E. coli. The area under the concentration-time curve/MIC ratios for E. coli and B. fragilis were 171.7 and 85.9, respectively, for levofloxacin and 26 and 103.9, respectively, for moxifloxacin. Levofloxacin plus metronidazole exhibited the fastest rates of killing. The levofloxacin and moxifloxacin MICs for B. fragilis increased 8- to 16-fold after the organism was exposed to moxifloxacin. No other changes in the postexposure MICs were found. Levofloxacin plus metronidazole administered once daily exhibited activity similar to that of moxifloxacin against the mixed E. coli and B. fragilis infection. A once-daily regimen of levofloxacin plus metronidazole looks promising for the treatment of intra-abdominal infections.

Enterotoxigenic Bacteroides fragilis-associated diarrhea in children 0-2 years of age in rural Bangladesh

The burden of enterotoxigenic Bacteroides fragilis (ETBF)-related diarrhea was determined in a birth cohort of 252 children in rural Bangladesh. Isolation rates of ETBF in stool and risk factors for acquisition of ETBF and disease were established. Of 382 B. fragilis-positive specimens, 14.4% of the strains found in them produced enterotoxin, as determined by a tissue-culture assay. The overall isolation rate of ETBF was 2.3% (40/1750) from diarrheal specimens and 0.3% (15/5679) from nondiarrheal specimens collected throughout the 2 years of the study (P < .001). ETBF was isolated from 20.3% (40/197) of the B. fragilis-positive diarrheal specimens and from 8.1% (15/185) of the B. fragilis-positive nondiarrheal specimens (P < .001) and was significantly associated with acute diarrheal disease in children > or = 1 year of age (P = .0001). The diarrheal illness was mild in nature. In conditional multivariate analyses that examined environmental and host risk factors, the presence of livestock in the household area was linked to the acquisition of ETBF (chickens, P < .05; cows, P = .06). ETBF was found to be a small but significant contributor to diarrheal disease in this rural community. Improved management of livestock may be useful for the prevention of ETBF infection.

Inflammatory smears--is there a correlation between microbiology and cytology findings?

Cervical smear results reporting the presence of inflammation are regularly encountered by smeartakers, yet the significance of this finding is not clear. We wished to evaluate whether the presence of inflammation on smear test was associated with a higher incidence of lower genital tract infection. A retrospective review was carried out on women attending our colposcopy unit for their first visit during 2001. Results of 256 women were available for analysis. Evidence of inflammation was found in 9.7% of smears. Genital tract infection was found in 29.2% of women overall. Infection with more than one micro-organism was present in 8.9 percent. Forty eight percent of women having inflammatory changes on smear test had genital tract infection. This compared with 27.3% of women whose smear tests showed no evidence of inflammation. Prevalence of infection with Chlamydia trachomatis, Candida, Bacteroides and Gardnerella vaginalis was higher in the inflammatory smear group. This study shows that women with an inflammatory smear are more likely to harbour genital tract infection than women whose smear shows no evidence of inflammation. Chlamydia infection in particular has long-term fertility consequences through its potential to cause asymptomatic tubal damage: it was present in a substantial proportion of women with inflammation on smear (20%). Screening for lower genital tract infection via high vaginal swab and either intracervical swab or urinary screening for Chlamydia infection should be carried out in all women with smear tests reporting the presence of inflammation.

Septic thrombophlebitis of the portal and superior mesenteric veins as a complication of appendicitis: report of a case

Pylephlebitis is extremely rare and associated with high mortality, even in this modern era. It usually occurs secondary to infection in the region drained by the portal systems or in the structure contiguous to the portal vein. We report a case of septic thrombophlebitis of the portal and superior mesenteric veins (SMV) with multiple liver abscesses caused by acute appendicitis with an abscess of the mesoappendix. We performed appendectomy and successfully removed the thrombi using a Fogarty catheter. Postoperative histopathological examination confirmed a diagnosis of appendicitis and septic thrombophlebitis of the portal vein and SMV. The patient recovered completely with appropriate medical and surgical treatment.

Allograft replacement of common iliac artery mycotic aneurysm caused by Bacteroides fragilis vertebral spondylitis--a case report

Mycotic aneurysm secondary to vertebral spondylitis is a rare but life-threatening pathology with high mortality and morbidity. The authors describe a successfully treated case of mycotic aneurysm of the common iliac artery complicated with vertebral spondylitis in a 74-year-old man. Under midline laparotomy, complete debridement of the infected tissues, in-situ replacement of the common iliac artery with cryopreserved aortic allograft, and iliac bone autotransplantation and omentopexy to fill the debrided cavity were performed. The postoperative course was uneventful, and he remains well 3 years after his operation without persistent infection or allograft rejection.

Cellulite nécrosante périnéale révélant un adénocarcinome rectal

We report one case of rectal cancer disclosed by a perineal cellulitis in a diabetic woman. This infrequent association has a bad prognosis. Diagnosis is mainly clinical. Treatment is urgent with large spectrum antibiotic therapy, surgical debridement, colostomy and hyperbaric oxygen if available. Surgical treatment of the rectal cancer can be done immediately or delayed.

Treatment of portal vein septic thrombosis by infusion of antibiotics and an antifungal agent into portal vein and superior mesenteric artery: a case report

A 44-year-old man was hospitalized because of right-sided abdominal pain and fever. On admission, he presented spike fever, jaundice, and renal failure. Abdominal ultrasonography and computed tomography showed extensive thrombus in the portal vein. Anaerobic bacteria were identified in arterial and portal blood cultures. Based on these findings, septic thrombosis of the portal vein was diagnosed. Intraportal infusion of antibiotics, urokinase and an antifungal agent, followed by infusion of antimicrobials, urokinase, and heparin into the superior mesenteric artery resulted in marked improvement of symptoms and signs. Diverticulitis of the ascending colon was later found to be the underlying disease. In the follow-up, there were no signs of recurrent disease.

Thrombosis and infection: a case of transient anti-cardiolipin antibody associated with pylephlebitis

Infections with Bacteroides species have been noted to occur in association with cases of thrombophlebitis. This association has led to the speculation that the microorganisms themselves may contribute to the pathogenesis of thrombus formation through elaborated enzymes, including heparinases, or by interactions between the clotting cascade and the unique structure of the Bacteroides lipopolysaccharide. Anti-phospholipid antibodies have been linked with hypercoagulable states and thrombus formation. Although a number of infections have been associated with the transient production of anti-cardiolipin antibodies, the effect the antibodies may have in contributing to thrombus formation is not well understood. The occurrence of Bacteroides species infection with transient anti-cardiolipin antibody has not been previously reported.

A case of 'circling seizures' and an intratumoral abscess

We describe a case of a 38-year-old woman who presented with 'circling' seizures and was found to have an intracranial mass with features consistent with a meningioma. Three weeks prior to her presentation she underwent an uncomplicated vaginal hysterectomy. However, after discharge to home she developed a 4-day history of fever, chills and night sweats that eventually resolved. She underwent surgical removal of her intracranial mass without difficulty but intra-operative pathology showed features of acute cerebritis at the margins of the tumor. Further sectioning of the mass revealed evidence of an intratumoral abscess. Culture of the meningioma revealed heavy growth of Bacteroides fragilis. The patient was treated with intravenous antibiotics, discharged home in excellent health and has had no recurrence of seizures. In our case report we will review the historical literature on the incidence and features of intratumoral abscess. Although it is considered a rare event, our case demonstrates both common and unique features about this occurrence and highlights an unusual chain of events in the natural history of the patient's meningioma and the way in which it became clinically apparent.

Tension pneumopericardium caused by positive pressure ventilation complicating anaerobic pneumonia

A 22-year-old man was admitted with pneumonia. He was immediately intubated and positive pressure ventilation was initiated. Blood and sputum cultures showed Bacteroides fragilis and Corynebacterium sp., which were treated with metronidazole and clindamycin. Three weeks later his blood pressure suddenly dropped with an elevation of the central venous pressure. Chest X-ray revealed a pneumopericardium. A parasternal mediastinotomy with partial pericardiectomy was immediately performed. On opening the pericardium his blood pressure normalised. The patient gradually recovered and six weeks after admission he was extubated. Two weeks later he was discharged. A pneumopericardium without previous thorax trauma is very rare and early recognition is imperative because a tension pneumopericardium with cardiac tamponade may develop, as happened in this case. A tension pneumopericardium has to be treated with immediate pericardiocentesis followed by partial pericardiectomy to avoid recurrence.

Bacteroides fragilis bacteremia associated with portal vein and superior mesentery vein thrombosis secondary to antithrombin III and protein C deficiency: a case report

Hypercoagulability is one of the causes of portal vein and superior mesentery vein thrombosis. We report a case of Bacteroides fragilis bacteremia associated with portal vein and superior mesentery vein thrombosis secondary to antithrombin III and protein C deficiency. The patient presented with high fever for more than 3 weeks. Abdominal sonography revealed a liver cyst of 1.7 cm in diameter over segment 4 and a renal stone of 0.7 cm in size over the lower portion of the right kidney but no evidence of hydronephrosis. Elevation of liver enzymes was also noted. Intermittent fever was noted despite treatment with ceftriaxone and doxycycline. On Day 15 of hospitalization, blood culture revealed B. fragilis, which prompted further investigation of the source of intraabdominal and pelvic infection. Abdominal computed tomography revealed portal vein and superior mesentery vein thrombosis. Endoscopic studies of the gastrointestinal tract showed no tumor or diverticulum. Study of coagulation factors disclosed deficiency of antithrombin III and protein C. Clinicians should remain aware of the need to promptly search for a portal or mesentery vein thrombosis in cases of Bacteroides bacteremia of unknown origin.

The relationship between the presence of periodontopathogenic bacteria in saliva and halitosis

OBJECTIVE

To evaluate the association between the presence of periodontal pathogenic bacteria in saliva and halitosis in mouth air.

DESIGN

Cross-sectional microbiological and clinical oral examination of adult patients.

SUBJECTS

101 adult patients (25 males, 76 females) who attended the Preventive Dentistry and Breath Odour Clinic of Kyushu Dental College. Their average age was 50.0+/-13.5 years old (mean +/- SD).

SETTING

The subjects were classified into three groups: halitosis subjects with a probing depth (PD) > or = 4mm (P group), halitosis subjects without PD > or = 4mm (H group), and non-halitosis subjects without PD > or = 4mm (C group).

METHODS

All subjects received a periodontal examination. Volatile sulphur compounds (VSC: hydrogen sulphide and methyl mercaptan) were measured using gas chromatography. The presence of Bacteroides forsythus, Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans and Prevotella intermedia in the saliva was detected by polymerase chain reaction.

RESULTS AND CONCLUSION

The presence of B. forsythus, P. gingivalis and P. intermedia influenced the production of VSC. Specifically, the presence of B. forsythus in subjects with periodontitis was strongly correlated to the concentration of VSC in mouth air.

Primary psoas abscess. Report of three cases

BACKGROUND

Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians.

PATIENTS AND METHODS

We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36-51 years were admitted with fever, abdominal pain and a palpable tender mass.

RESULTS

The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor.

CONCLUSIONS

A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.

Synergy of Bacteroides fragilis and Escherichia coli in the induction of KC gene expression in mouse peritoneal tissues

B. fragilis induces cytokine expression, which can serve as a host signal leading to inflammatory reaction and abscess formation in the peritoneal cavity. We assessed the hypothesis that enteric bacteria may alter the B. fragilis-induced expression of KC genes in mouse peritoneal tissues (MPT). After C57BL/6 mice were inoculated with abscess-forming mixture containing B. fragilis in the presence or absence of E. coli, RNA was extracted from MPT. Expression of KC mRNA was quantified using reverse-transcription polymerase chain reaction and standard RNA. KC and TNFalpha proteins were measured by enzyme-linked immunosorbent assay. KC mRNA in MPT was upregulated following inoculation of B. fragilis and this was paralleled by increased KC protein secretion. When the mice were co-infected with E. coli and B. fragilis intraperitoneally, there was a synergistic increase in the expression of KC of MPT. Co-infection with L. acidophilus and B. fragilis downregulated KC mRNA expression, but co-infection with E. faecalis and B. fragilis synergistically increased KC expression in the infected MPT. Inhibition of TNFalpha production could downregulate KC expression in mixed infected MPT. These results suggest that enteric bacteria may significantly affect the KC signal produced by the host peritoneal cavity in response to B. fragilis infection.

Bacteroides fragilis vertebral osteomyelitis secondary to anal dilatation

STUDY DESIGN

A case report of anaerobic vertebral osteomyelitis after anal dilatation.

OBJECTIVES

To present a patient with monomicrobial anaerobic vertebral osteomyelitis secondary to a previously undescribed source of infection.

SUMMARY OF BACKGROUND DATA

A 17-year-old boy presented with low back pain 3 months after anal dilatation.

METHODS

Physical examination, technetium-99m bone scan, plain radiograph, CT, and MRI studies of the lumbar spine were used to clinically diagnose lumbar osteomyelitis. Culture material from the involved disc was positive for Bacteroides fragilis.

RESULTS

The patient recovered after 8 weeks of treatment with oral metronidazole.

CONCLUSIONS

Bacteroides fragilis hematogenous osteomyelitis is a rare entity. This is the first reported case of such disease after anal dilatation.

Isolated septic arthritis of a lumbar facet joint

This is a report of an isolated septic arthritis of a lumbar facet joint where the infectious agent was Bacteroides sp. and where an early diagnosis was made using MRI.

Contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis

STUDY DESIGN

A case report.

OBJECTIVES

To report and discuss a case of contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis, so that investigators and practitioners may avoid the diagnostic and therapeutic pitfalls associated with pyogenic vertebral spondylitis and aortic disease.

SUMMARY OF BACKGROUND DATA

Pyogenic vertebral spondylitis is a rare disorder that may have serious consequences, including death, if it is not diagnosed promptly and treated effectively. The association of pyogenic vertebral spondylitis with infection of the aorta is a rare but potentially fatal condition that requires prompt diagnosis and aggressive surgical and medical therapy. To our knowledge, this is the first report of a contained rupture of the aneurysm of common iliac artery case associated with pyogenic vertebral spondylitis resulting from an infection with Bacteroides fragilis,although Salmonellae infections are commonly associated with vertebral osteomyelitis and lesions of the contiguous aorta.

METHODS

A 60-year-old man with chronic lower back pain began to experience a severe pain and had increased difficulty in walking. An MRI scan showed an increased signal in the L4-L5 disc space and an abscess extending into the spinal canal. The presumptive diagnosis was infective spondylitis. While performing a CT-guided needle biopsy, an unexpected contained rupture of the aneurysm of common iliac artery was discovered.

RESULTS

A wide resection of all infected tissue, including the right common iliac artery and bony lesions, was performed in combination with antimicrobial therapy. A cryopreserved aortic allograft was used to reconstruct the artery, and an iliac strut graft was used to fill the debrided vertebral cavity. The patient's postoperative recovery was uneventful.

CONCLUSION

The coexistence of pyogenic vertebral spondylitis and lesions of the aorta is rare, but may be lethal if not diagnosed promptly and treated effectively. Even if a patient's condition is stable and the hematocrit is normal, it is important to consider the possibility of a contained rupture of a mycotic abdominal aneurysm in all patients with vertebral osteomyelitis who have acute episodes of unusual severe back pain. CT is sometimes more beneficial than MRI in the identification and characterization of contained rupture of aneurysms.

Necrotizing fasciitis in Crohn's disease

We report a case of a 34-year-old woman, presenting initially with anaemia followed by sacro-iliac pain, and subsequently found to have necrotizing fasciitis complicating Crohn's disease where the organisms were introduced via a fistulous tract. It is perhaps surprising that this is not a more common complication of fistulating Crohn's disease, but we believe this is the first case report of this particular complication.