Zoonotic acquisition of cutaneous Sporothrix braziliensis infection in the UK.

A veterinarian presented with multiple erythematous tender nodules over his right hand and arm. One month prior to the appearance of the lesions, he had treated a cat imported from Brazil who had ulcerated pustular cutaneous lesions. Despite antibiotic treatment there had been no improvement in his symptoms.Biopsies from the patient were sent for histology, bacterial and fungal culture. Periodic acid-Schiff (PAS) stains showed a PAS positive oval yeast-like micro-organism with surrounding necrosis. Fungal cultures resembling Sporothrix species grew after 18 days with typical appearances seen on direct microscopy; this was confirmed as Sporothrix brasiliensis on 18S PCR. The patient was treated with oral itraconazole.This is a unique case of cutaneous S. brasiliensis acquired from an infected imported cat. S. brasiliensis is a rare pathogen in the UK. This case has clinical relevance due to its unusual aetiology and in raising awareness of rarer infections associated with importation of pets and global travel. Clinicians should be aware of sporotrichosis as a differential diagnosis for cutaneous and extracutaneous infection in patients with a high risk of exposure, as well as the use of appropriate diagnostic tests.

Recurrent strokes in an occult case of recurrent Cutibacterium acnes prosthetic valve infective endocarditis: a case report.

BACKGROUND: Infective endocarditis (IE) is a known but uncommon cause of cardioembolic stroke and there are rare but recognized cases of IE without an inflammatory response. Cutibacterium acnes is an increasingly recognized source of invasive infections, including IE, but diagnosis is challenging due to its low virulence and fastidious nature. CASE SUMMARY: A 47-year-old man presented with a multi-focal stroke suggestive of a cardioembolic source. Outpatient transoesophageal echocardiography (TOE) was concerning for vegetation or thrombus associated with his previous mitral valve repair. He remained clinically well, with no evidence of an inflammatory response and sterile blood cultures. Computed tomography-positron emission tomography (CT-PET) corroborated the TOE findings, however, given the atypical presentation, he was treated for valvular thrombus. Following discharge, he quickly re-presented with further embolic phenomena and underwent emergency mitral valve replacement. Intraoperative findings were consistent with prosthetic valve IE (PVE) and a 6-week course of antibiotics commenced. C. acnes was identified on molecular testing. Eighteen months later, he re-presented with further neurological symptoms. Early TOE and CT-PET were consistent with IE. Blood cultures grew C. acnes after prolonged incubation. Given the absence of surgical indications, he was managed medically, and the vegetation resolved without valvular dysfunction. He continues to be followed up in an outpatient setting. DISCUSSION: In patients presenting with multi-territory stroke, IE should be considered despite sterile blood cultures and absent inflammatory response. C. acnes is an increasingly recognized cause of PVE in this context, often requiring surgical intervention. A high index of suspicion and collaboration with an Endocarditis Team is therefore essential to diagnose and treat.

Endovascular Graft Infection by Neisseria meningitidis: A Rare but Fatal Infection.

Endovascular graft infection is a rare but challenging complication that requires a tailored approach to remove the infected graft and restore the arterial circulation combined with long-term antibiotic therapy. We present a case surgically treated with explant of the graft and reconstruction of the thoracoabdominal aorta. Microbiological investigation revealed growth of Neisseria meningitidis, which is extremely rare in this location, and to our knowledge, has not been previously published in the literature.

Echocardiography in Patients With Infective Endocarditis and the Impact of Diagnostic Delays on Clinical Outcomes.

Infective endocarditis (IE) is associated with high mortality and morbidity. The aim of this study was to investigate the impact of timing of echocardiography on IE complications. We studied 151 consecutive patients with definite IE. Valve destruction was defined as ≥1 of severe regurgitation, cardiac abscess, or fistula. A definitive echocardiogram was the first echocardiogram (transthoracic (TTE) or Transesophageal (TEE)) which identified pathology consistent with IE and further echocardiography was not required for the diagnosis. TTE and TEE were performed within 4 days of admission in 62% and 15% patients respectively. Definitive echocardiography was achieved with TTE in 60% patients and required additional TEE in 40% patients. Significantly more in-patient embolic events occurred when definitive echocardiography was performed late (≥4 days) compared with early (<4 days) (40% vs 14%, p = 0.043). A significantly greater proportion of patients who underwent late definitive echocardiography (≥4 days) required valve surgery (73% vs 56%, p = 0.04). Time to definitive echocardiography (odds ratio [OR] 1.015, p = 0.011), male gender (OR 1.254, p = 0.005) and age (OR 0.992, p = 0.002) were predictors of severe valve destruction. Late definitive echocardiography (OR 1.166, p=0.035) was a predictor of in-patient embolism. In conclusion, time to definitive echocardiography is an important predictor of valve destruction, embolic events, and subsequent valve surgery. Pathways to reduce delays to echocardiography are required in patients with suspected IE.

Invasive shigellosis in MSM.

Shigella flexneri is an emerging pathogen in men who have sex with men (MSM); recent outbreaks related to sexual practices have been noted in this population in the UK and other developed countries. While the majority of cases of shigellosis present with gastroenteritis, some vulnerable patients with underlying immunosuppression can develop complications like bacteraemia and may present atypically as an acute surgical emergency. This case report highlights such a case of S. flexneri bacteraemia in a man who had sex with men.

A geographically-restricted but prevalent Mycobacterium tuberculosis strain identified in the West Midlands Region of the UK between 1995 and 2008.

BACKGROUND: We describe the identification of, and risk factors for, the single most prevalent Mycobacterium tuberculosis strain in the West Midlands region of the UK. METHODOLOGY/PRINCIPAL FINDINGS: Prospective 15-locus MIRU-VNTR genotyping of all M. tuberculosis isolates in the West Midlands between 2004 and 2008 was undertaken. Two retrospective epidemiological investigations were also undertaken using univariable and multivariable logistic regression analysis. The first study of all TB patients in the West Midlands between 2004 and 2008 identified a single prevalent strain in each of the study years (total 155/3,056 (5%) isolates). This prevalent MIRU-VNTR profile (32333 2432515314 434443183) remained clustered after typing with an additional 9-loci MIRU-VNTR and spoligotyping. The majority of these patients (122/155, 79%) resided in three major cities located within a 40 km radius. From the apparent geographical restriction, we have named this the "Mercian" strain. A multivariate analysis of all TB patients in the West Midlands identified that infection with a Mercian strain was significantly associated with being UK-born (OR =  9.03, 95%CI = 4.56-17.87, p<0.01), Black Caribbean (OR = 5.68, 95%CI = 2.96-10.91, p < 0.01) resident in Wolverhampton (OR = 9.29, 95%CI = 5.69-15.19, p < 0.01) and negatively associated with age >65 years old (OR = 0.25, 95% CI = 0.09-0.67, p < 0.01). A second more detailed investigation analyzed a cohort of 82 patients resident in Wolverhampton between 2003 and 2006. A significant association with being born in the UK remained after a multivariate analysis (OR = 9.68, 95% CI = 2.00-46.78, p < 0.01) and excess alcohol intake and cannabis use (OR = 6.26, 95%CI = 1.45-27.02, p =  .01) were observed as social risk factors for infection. CONCLUSIONS/SIGNIFICANCE: The continued consistent presence of the Mercian strain suggests ongoing community transmission. Whilst significant associations have been found, there may be other common risk factors yet to be identified. Future investigations should focus on targeting the relevant risk groups and elucidating the biological factors that mediate continued transmission of this strain.