Sigmoido-Cecal Fistula: A Rare Case of Complicated Recurrent Diverticulitis and a Review of the Literature.

BACKGROUND Although diverticular disease is well described and treated in daily clinical practice, there are cases that attract great interest because of their complexity and difficulty in management. Herein, we describe a rare case of colo-colonic fistula-complicated diverticulitis that necessitated urgent surgical intervention. CASE REPORT A 76-year-old female patient with a known history of diverticular disease of the sigmoid colon presented in the Emergency Department for evaluation of left lower quadrant abdominal pain. The clinical and radiological examinations revealed a recurrent episode of acute diverticulitis of the sigmoid colon. However, it was of great interest that we detected a sigmoido-cecal fistula in the abdominal computed tomography (CT). The patient was admitted to the hospital for conservative treatment. After 48 hours, the patient's clinical status deteriorated, with pain aggravation, abdominal distension, bloating, and metallic bowel sounds. The simple abdominal x-ray revealed large-bowel obstruction and the CT demonstrated worsening inflammation of the sigmoid colon. An exploratory laparotomy revealed an inflamed dolichol-sigmoid colon forming a fistulous tract with the cecum and thus, mimicking a closed loop obstruction. The sigmoid colon was transected en bloc with the sigmoido-cecal fistula and a Hartmann's procedure was performed. CONCLUSIONS This case is extremely unusual as the patient presented at the same time two complications of diverticular disease, both obstruction and this rare formation of sigmoido-cecal fistula. It is presented in order to acquaint surgeons with the possibility of an unexpected course of this disease which indeed necessitates an individualized management.

Methicillin-resistant Staphylococcus aureus (MRSA) in slaughtered pigs and abattoir workers in Italy.

Methicillin-resistant Staphylococcus aureus (MRSA) is a pathogen present in the hospital environment (HA-MRSA), in the community (CA-MRSA) and in livestock, including pigs (LA-MRSA). MRSA may enter the human food chain during slaughtering and may infect humans coming into direct contact with pigs or pork products. This study aimed to determine the prevalence and characteristics of MRSA isolated from pigs and workers at industrial abattoirs in southern Italy. A total of 215 pig nasal swabs were screened for the presence of MRSA using PCR. An MRSA isolate was detected from each mecA/nuc PCR-positive sample and characterized by spa-typing, Multi-Locus Sequence Typing, SCC-mec and Panton-Valentine Leukocidin (PVL), and also tested for the production of staphylococcal enterotoxins (SEs). Eighty-one MRSA isolates (37.6%) were obtained from the 215 pig nasal swabs; 37 of these isolates were further characterized, and showed 18 different spa-types and 8 different STs. The most frequently recovered STs were ST398 (CC398-t034, t011, t899, t1939 - 43.2%) followed by ST8 (CC8-t008, t064, t2953, t5270 - 24.3%) and ST1 (CC1-t127, t174, t2207 - 10.8%). Nine MRSA isolates were obtained from the 113 human swabs; the isolates showed 5 different spa-types and 5 different STs, including the novel ST2794 (t159). The most representative STs recovered were ST1 (CC1-t127) and ST398 (CC398-t034) (33.3%). None of the MRSA isolates showed the ability to produce SEs and PVL and all resulted resistant to two or more classes of antimicrobials. This study shows the great genetic diversity of MRSA strains in slaughtered pigs and in abattoir employees in Italy, and clearly demonstrates the need for improved hygiene standards to reduce the risk of occupational and food-borne infection linked to the handling/consumption of raw pork containing MRSA.

Differential protein expression patterns between planktonic and biofilm cells of Salmonella enterica serovar Enteritidis PT4 on stainless steel surface.

In the present study, the proteome of a strain of S. enterica serovar Enteritidis PT4, grown either as biofilm on stainless steel surface or as free-floating (planktonic) in Brain Heart (BH) broth, was investigated in order to detect the strong differences in whole-cell protein expression patterns between the two growth styles. The proteins extracted from both types of cells were subjected to 2-D PAGE, followed by in-gel tryptic digestion, extraction, subsequent MALDI-TOF mass spectrometry (MS) analysis and finally database searches for protein identification. Using this approach, 30 proteins were identified as differentially expressed between the two growth modes on an "on-off" basis, that is, proteins that were detected in one case but not in the other. In particular, 20 and 10 proteins were identified in biofilm and planktonic-grown cells, respectively. The group of proteins whose expression was visible only during biofilm growth included proteins involved in global regulation and stress response (ArcA, BtuE, Dps, OsmY, SspA, TrxA, YbbN and YhbO), nutrient transport (Crr, DppA, Fur and SufC), degradation and energy metabolism (GcvT, GpmA, RibB), detoxification (SseA and YibF), DNA metabolism (SSB), curli production (CsgF), and murein synthesis (MipA). To summarize, this study demonstrates that biofilm growth of S. Enteritidis causes distinct changes in protein expression and offers valuable new data regarding some of the proteins presumably involved in this process. The putative role of these proteins in the maintenance of a biofilm community in Salmonella and other bacteria is discussed.

Unraveling persistent host cell infection with Coxiella burnetii by quantitative proteomics.

The interaction between the immune system and invading bacteria is sufficient to eradicate microorganisms for the majority of bacterial infections, but suppression of the microbicidal response leads to reactivation or chronic evolution of infections and to bacterial persistence. To identify the cellular pathways affected by bacterial persistence, we applied the MS-driven combined fractional diagonal chromatography (COFRADIC) proteomics technique for a comparative study of protein expression in the C. burnetii strains Nine Mile (NM) and its respective strain (NMper) isolated from 18 months persistently infected cell cultures. In total, three different proteome comparisons were performed with the total bacterial proteome, potentially secreted bacterial proteins, and the eukaryotic infected proteome being assessed. Our results revealed that among the 547 identified bacterial proteins, 53 had significantly altered levels of expression and indicated potential metabolic differences between the two strains. Regarding differences in the secreted proteins between both strains and different modulation of the host cell, machineries reflect at least large rearrangements of both bacterial and eukaryotic proteomes during the persistent model of infection when compared to the acute one, which emphasizes that C. burnetii orchestrates a vast number of different bacterial and eukaryotic host cell processes to persist within its host.

The Coxiella burnetii cryptic plasmid is enriched in genes encoding type IV secretion system substrates.

The intracellular bacterial pathogen Coxiella burnetii directs biogenesis of a phagolysosome-like parasitophorous vacuole (PV), in which it replicates. The organism encodes a Dot/Icm type IV secretion system (T4SS) predicted to deliver to the host cytosol effector proteins that mediate PV formation and other cellular events. All C. burnetii isolates carry a large, autonomously replicating plasmid or have chromosomally integrated plasmid-like sequences (IPS), suggesting that plasmid and IPS genes are critical for infection. Bioinformatic analyses revealed two candidate Dot/Icm substrates with eukaryotic-like motifs uniquely encoded by the QpH1 plasmid from the Nine Mile reference isolate. CpeC, containing an F-box domain, and CpeD, possessing kinesin-related and coiled-coil regions, were secreted by the closely related Legionella pneumophila Dot/Icm T4SS. An additional QpH1-specific gene, cpeE, situated in a predicted operon with cpeD, also encoded a secreted effector. Further screening revealed that three hypothetical proteins (CpeA, CpeB, and CpeF) encoded by all C. burnetii plasmids and IPS are Dot/Icm substrates. By use of new genetic tools, secretion of plasmid effectors by C. burnetii during host cell infection was confirmed using ß-lactamase and adenylate cyclase translocation assays, and a C-terminal secretion signal was identified. When ectopically expressed in HeLa cells, plasmid effectors trafficked to different subcellular sites, including autophagosomes (CpeB), ubiquitin-rich compartments (CpeC), and the endoplasmic reticulum (CpeD). Collectively, these results suggest that C. burnetii plasmid-encoded T4SS substrates play important roles in subversion of host cell functions, providing a plausible explanation for the absolute maintenance of plasmid genes by this pathogen.

Proteomic screening for possible effector molecules secreted by the obligate intracellular pathogen Coxiella burnetii.

Coxiella burnetii is a Gram-negative, gamma-proteobacteria with nearly worldwide distribution, and it is the pathogenic agent of Q-fever in man. It is an obligate intracellular parasite that is highly adapted to reside within the eukaryotic phagolysosome. In fact, it is the only known intracellular bacterium that manages to survive and replicate within a fully formed, acidic phagolysosome. C. burnetti possesses a functional Type 4 Secretion System (T4SS), similar to the Dot/Icm system of Legionella pneumophila. Up to date there have been no reports for the effector molecules secreted by Coxiella's T4SS. These are speculated to have quite different roles than the effectors of other intracellular pathogens, since there is no need for phagosomal arrest or escape in the case of Coxiella. In this study, we have investigated the cytoplasm of Vero cells infected with C. burnetti strain Nine Mile Phase II. We have identified by mass spectrometry (ESI-MS/MS) several C. burnetti proteins that bear typical characteristics of effector molecules. Most of the identified proteins were also very alkaline, something which is supportive for a protective strategy that has evolved in this bizarre pathogen against acidic environments.

Analysis of whole cell lysate from the intercellular bacterium Coxiella burnetii using two gel-based protein separation techniques.

Coxiella burnetii, the causative agent of Q fever, is an obligate intracellular gamma-proteobacterium, which replicates within large phagolysosome-like compartments formed in the host cell. The global protein profile of intracellular C. burnetii strain Nine Mile phase II was analyzed by two gel-based approaches coupled to MALDI-TOF MS. Colloidal Coomassie brilliant blue-stained 2-DE gels at the pH range 3-10 resolved over 600 protein spots and 125 spots in doubled-SDS-PAGE gels. Mass spectra obtained for each trypsin-digested protein-spot were compared to the C. burnetii genome database, and a total number of 185 different C. burnetii proteins were identified by both techniques. 2-DE in combination with MALDI-TOF MS, as a high-throughput method, allowed the identification of 172 proteins. On the other hand, the application of doubled-SDS-PAGE allowed the identification of 38 proteins, with some of them being very alkaline and membrane proteins not identified in the 2-DE approach. Most identified proteins were predicted to be involved in metabolism and biosynthesis. Several identified proteins are speculated to have a distinct and vital role in the pathogenesis and survival of C. burnetii within the harsh phagolysosomal environment.