[Post-traumatic pulmonary aspergilloma]. / Aspergillome pulmonaire sur corps étranger résiduel post-traumatique. Diagnostic et prise en charge.

INTRODUCTION: Aspergillomas occur due to colonization of a pre-existing pulmonary, bronchial or pleural cavity by Aspergillus spp. Often asymptomatic, this pathology can reveal itself by recurrent haemoptysis or when bacterial superinfections occur. Aspergillomas occurring in post-traumatic cavities are rare and their management is poorly codified. CASE REPORT: A child suffered from a chest wound at the age of 13 years. Two years later, investigation of recurrent haemoptysis revealed a residual pneumatocele in the right lower lobe colonized by Aspergillus spp. Initial treatment with systemic azole antifungals was unsuccessful because of digestive and ophthalmological intolerance. Surgical treatment by right lower lobectomy was finally decided on by the multidisciplinary team. This revealed an intrabronchial foreign body of vegetal type with cellulosic reinforcement, causing a polymorphic granulomatous reaction around, and associated with a proliferation of filamentous fungi including Aspergillus fumigatus. Surgery was followed by liposomal amphotericin B treatment for three weeks with a favourable outcome. CONCLUSIONS: This clinical case illustrates the benefits of surgical management of post-traumatic aspergillomas, even in children, in order to eradicate the aspergillus implant and to remove any foreign body to prevent recurrence.

Filler Nodules: Inflammatory or Infectious? A Review of Biofilms and Their Implications on Clinical Practice.

BACKGROUND: The numbers of minimally invasive cosmetic procedures performed in the United States have steadily increased each year. Concurrently, the rates of filler complications have also increased. Delayed filler reactions and granulomas have recently been attributed to biofilm infections. OBJECTIVE: The biology and pathogenesis of biofilms, and their diagnosis, treatment, and prevention will be discussed. METHODS: The relevant and recent literature on delayed filler reactions and biofilms was reviewed. RESULTS: Increasing evidence implicates biofilm infections in the pathogenesis of delayed filler reactions. Therapeutic and preventative measures can be taken to minimize the occurrence of these potentially devastating consequences of dermal fillers. CONCLUSION: Awareness of biofilm infections is key in the assessment of filler reactions in order to ensure timely and accurate diagnosis and treatment.

Streptococcus sanguinis isolated from filler granuloma: Successful treatment with incision and drainage.

Filler granuloma is considered to be the result of delayed immune responses; growing evidence suggests that they may be secondary to biofilm formation. Dermal filler is technically a foreign body, and as the development of newer generations of dermal fillers lengthens their duration, it is possible that there is also an increased risk of biofilm formation. Here, we present a case report of a patient with Streptococcus sanguinis isolated from a filler granuloma, suggestive of biofilm formation. This case demonstrates the effective use of antibiotics after incision and drainage on antibiotic resistant biofilm.

Unusual ocular presentations of ocular phaeohyphomycosis.

PurposePhaeohyphomycosis are melanin-containing fungi that rarely infect the eye. We describe three cases of ocular infection with some unusual clinical features.MethodsSeries of three case reports describing three different presentations of phaeohyphomycosis of the eye, their histopathology, and management.ResultsCase 1 mimicked an inflamed conjunctival naevus and was excised on this basis, revealing a conjunctival retention cyst containing pigmented fungal hyphae. Case 2 showed a wooden foreign body incidentally associated with pigmented fungal hyphae, which required treatment with topical antifungal therapy. Case 3 clinically was thought to be a perforated uveal melanoma and comprised an extensive plaque of pigmented fungal hyphae over ulcerated cornea.ConclusionThe pigmented melanin containing hyphae of phaeohyphomycosis mimicked melanocytic lesions in two cases and was an incidental finding in the context of a surface foreign body.

Are bacterial growth and/or chemotaxis increased by filler injections? Implications for the pathogenesis and treatment of filler-related granulomas.

BACKGROUND: As microbial agents have been associated with late adverse effects related to fillers antibiotic treatment has been envisaged. OBJECTIVE: To determine whether biomaterials favor bacterial growth and/or attract bacteria. METHODS: Hyaluronic acid, semi-permanent fillers, such as calcium hydroxylapatite, and permanent fillers, such as polyalkylimide/polyacrylamide, were used. Experiments were performed with Escherichia coli, strain HVH-U47. Bacteria were transferred to Sven-Gard agar to test mobility. Striae of this bacterial strain with a MacFarland 1 turbulence pattern were seeded from a spot of inoculated biomaterial using Müller-Hinton medium. The chemoattractive properties of the biomaterials were analyzed 10 days after inoculation. Bacterial growth over the biomaterial and in-depth growth were assessed as well. RESULTS: Semi-permanent fillers did not stimulate bacterial growth but they allowed bacterial colonization over the filler. Permanent acrylic compounds neither presented chemoattractant properties nor showed bacterial growth over the biomaterial. Similar results were obtained when performing in-depth cultures. CONCLUSIONS: Permanent and semi-permanent fillers did not facilitate bacterial growth when flagellated E. coli HVH-U47 was used. Our results do not argue in favor of antibiotics as the mainstay of therapy in late granulomas related to permanent fillers. In the case of resorbable/semi-permanent fillers, more studies are needed before recommending antibiotic therapy.

Detection of bacteria by fluorescence in situ hybridization in culture-negative soft tissue filler lesions.

BACKGROUND: Adverse reactions to polyacrylamide gel occur as swellings or nodules, and controversy exists whether these are due to bacterial infection or an autoimmune reaction to the filler. OBJECTIVES: Biopsies from culture-negative long-lasting nodules after injection with different types of polyacrylamide gel were examined with a combination of Gram stain and fluorescence in situ hybridization. RESULTS: Bacteria were detected in biopsies from seven of eight patients. They inhabited gel and intervening tissue and tended to lie in aggregates. CONCLUSION: This study supports the assumption that infection with bacteria in aggregates causes culture-negative late adverse reactions to polyacrylamide gel, suggesting a biofilm environment.

Deficiency of IL-12p40 subunit determines severe paracoccidioidomycosis in mice.

Paracoccidioidomycosis, the major systemic mycosis in Latin America, is caused by the thermally dimorphic fungus Paracoccidioides brasiliensis. To investigate the role of interleukin (IL)-12 in this disease, IL-12p40-/- deficient mice (IL-12p40-/-) and wild type mice (WT) were infected intravenously with viable yeast cells of P. brasiliensis 18 isolate. We found that, unlike WT mice, IL-12p40-/- mice did not control fungal proliferation and dissemination and succumbed to infection by day 21 after inoculation. Additionally, IL-12p40-/- mice presented a higher number of granulomas/mm2 in lung tissue than WT mice, and showed unorganized granulomas containing high numbers of yeast cells. Moreover, IL-12p40-/- mice did not release detectable levels of IFN-gamma, but they produced high levels of IL-10, as well as IgG1 antibody. Additionally, splenocytes from both infected IL-12p40-/- and WT mice exhibited a suppressed Con-A-induced T cell proliferative response. Our findings suggest that the IL-12p40 subunit mediates resistance in paracoccidioidomycosis by inducting IFN-gamma production and a Th1 immune response.

Multiple granulomas in three squirrel monkeys (Saimiri sciureus) caused by Mycobacterium microti.

Mycobacterium microti, a member of the Mycobacterium tuberculosis complex, causes tuberculosis in small rodents and occasionally in other mammals including man. Three adult male squirrel monkeys, two with a history of lethargy, weakness and stridor and one with paralysis of the hind legs, were presented for necropsy. One of the two lethargic animals showed multiple granulomas in the mesentery, mesenteric lymph nodes, lung, liver, kidneys and spleen, while the other showed granulomas only in the lung. The animal with paralysis of the legs had an abscess-like lesion in the skeletal muscle of the neck, granulomas in the mesenteric and mediastinal lymph nodes, and a fracture of the thirteenth thoracic vertebra with severe lesions of the spinal cord. Histologically the granulomas showed typical features of tuberculous granulomas, i.e., central necrosis surrounded by epithelioid cells, multinucleated giant cells, inflammatory cells and a border of connective tissue. Ziehl-Neelsen stain demonstrated sporadic acid-fast bacilli within the granulomas, these organisms being identified as M. microti by microbiological and molecular methods.

Clinicopathologic analysis of 15 explanted hydroxyapatite implants.

PURPOSE: To report the clinical findings, treatment, outcomes, and histopathologic findings in patients with suspected orbital implant infection requiring implant removal. METHODS: Retrospective, observational case series of 14 patients (15 hydroxyapatite orbital implants) undergoing implant removal from September 1994 through December 2002. Patient age, type of surgery, implant type, symptoms, treatment, histopathology of implant, and follow-up course were analyzed. RESULTS: Of the 14 patients, 7 were female and 7 were male. The mean age at explantation was 42 years. The most common symptoms were discharge and socket tenderness. The most common signs were conjunctival inflammation (edema, hyperemia), discharge, and recurrent pyogenic granuloma. Clinical evidence of infection was documented in 13 patients. Histopathologic assessment of the 15 explanted implants showed acute inflammation and necrosis (abscess) with identification of microorganisms (5 patients), acute inflammation and necrosis without identification of microorganisms (4 patients), chronic inflammation with identification of microorganisms (1 patient), chronic inflammation without identification of microorganisms (3 patients), and a predominant foreign body granulomatous response without identification of microorganisms (2 patients). Osseous metaplasia was seen in 10 implants. Prompt resolution of symptoms and signs occurred in all but one case. CONCLUSIONS: The clinical course of porous orbital implant infection may be prolonged, and the early symptom of recurrent discharge, a common problem for implant recipients, may delay diagnosis. Implant infection should be suspected when there is persistent conjunctival inflammation and discharge after implant placement despite antibiotic therapy, discomfort on implant palpation, and recurrent pyogenic granuloma (indicative of implant exposure). Implant removal is usually required in these cases. If orbital pain (not necessarily related to implant palpation) is the main complaint, without signs of conjunctival inflammation and with or without discharge, one should consider other reasons for the symptoms.

Localization of satratoxin-G in Stachybotrys chartarum spores and spore-impacted mouse lung using immunocytochemistry.

Satratoxin-G (SG) is the major macrocyclic trichothecene mycotoxin produced by Stachybotrys chartarum (atra) and has been implicated as a cause of a number of animal and human health problems including pulmonary hemorrhage in infants. However, there is little understanding where this toxin is localized in the spores and mycelial fragments of this species or in the lung impacted by SG-sequestered spores. The purpose of this study was to evaluate the distribution of SG in S. chartarum spores and mycelium in culture, and spore-impacted mouse lung in vivo, using immunocytochemistry. SG was localized predominately in S. chartarum spores with moderate labelling of the phialide-apex walls. Labelling was primarily along the outer plasmalemma surface and in the inner wall layer. Only modest labelling was observed in hyphae. Toxin localization at these sites supports the position that spores contain the highest satratoxin concentrations and that the toxin is constitutively produced. In impacted mouse lung, highest SG labelling was detected in lysosomes, along the inside of the nuclear membrane in nuclear heterochromatin and RER within alveolar macrophages. Alveolar type II cells also showed modest labelling of the nuclear heterochromatin and RER. There was no evidence that the toxin accumulated in the neutrophils, fibroblasts, or other cells associated with the granulomas surrounding spores or mycelial fragments. These observations indicate that SG displays a high degree of cellular specificity with respect to its uptake in mouse lung. They further indicate that the alveolar macrophages play an important role in the sequestration and immobilization of low concentrations of the toxin.

A case of anaerobic abscessed hydroxyapatite orbital implants.

The purpose of this report is to document an unusual case of implant infection in a patient who had undergone enucleation and hydroxyapatite orbital implant surgery. A 32-year-old woman presented with chronic orbital discomfort and discharge following a history of hydroxyapatite orbital implant surgery at another hospital 4 years previous. She exhibited profuse discharge with a yellow, creamy color and marked conjunctival chemosis. Granulation tissue was noted on the central conjunctival surface. Following the removal of the conjunctival granulation tissue, a central 3x5 mm conjunctival dehiscence was present with exposure of the hydroxyapatite implant. A culture of purulent drainage emanating from the exposed implant showed a growth of Clostridium acetobutylicum. Removal of the orbital implant was done. The implant was noted to be filled with pus. This case suggests that anaerobic infection may be suspected when the granulation tissue is observed and a discharge with a foul odor is found.

Identification of Mycobacterium marinum in sea-urchin granulomas.

BACKGROUND: Sea-urchin granuloma is a chronic granulomatous reaction arising after injury with sea-urchin spines. Classified as an allergic foreign-body type of granuloma, it is believed to be a delayed-type reaction to an as yet unidentified antigen. In a clinicopathological study, 50 biopsy specimens from 35 patients diagnosed as having sea-urchin granuloma caused by Paracentrotus lividus, we found different inflammatory patterns that in some cases suggested a mycobacterial infection. OBJECTIVES: To investigate and identify mycobacterial DNA in formalin-fixed and paraffin-embedded skin biopsy specimens diagnosed as sea-urchin granulomas. METHODS: A search combining polymerase chain reaction amplification using Mycobacterium genus-specific primers, and subsequent restriction enzyme analysis enabling identification to the species level, was performed in 41 samples. RESULTS: Amplification of a 924-bp DNA fragment encoding mycobacterial 16S rRNA gene was positive in eight biopsy specimens from seven patients (21%). M. marinum-specific restriction patterns were identified in three samples. CONCLUSIONS: Although further controlled studies are necessary, from these data it would appear that mycobacteria may play a pathogenic role in some cases of sea-urchin granuloma.

Longterm survival in acute rhinocerebral mucormycosis with giant cell arteritis and foreign body granulomas.

A case of rhinocerebral mucormycosis occurring in a 41-year-old man with insulin-treated diabetes mellitus is reported. Microscopically, biopsy samples obtained from the left ethmoid and middle turbinate sinuses contained fungi that formed mycotic granulomas associated with multinucleate giant cell arteritis. The multinucleate giant cells contained broad, infrequently septate hyphase consistent with mucormycosis. The patient received surgical debridement with extenteration of the left orbit, and intravenous liposome-encapsulated amphotericin B. After 12 months, examination of the patient revealed complete healing. Multinucleate giant cell granulomas and arteritis are only exceptionally associated with rhinocerebral mucormycosis, but these histologic findings may be correlated with a progressive disease with better prognosis.

Adverse effects of bone wax in surgery of the orbit.

The goal of this article is to establish the incidence and scope of adverse reactions to bone wax in a large orbital surgical series. We report two patients with bone wax granulomas of the orbit as a remote surgical complication. These are the first reported cases of adverse reactions to bone wax in the ophthalmic literature. A chart review was conducted on all patients from the University of British Columbia Orbit Clinic that had surgery with temporary or permanent removal of orbital bone. Two patients with bone wax granulomas were identified. In one case, intraoperative cultures grew Staphylococcus aureus, confirming that the wax may indeed act as a nidus for infection. No cases of pseudoarthrosis have occurred. This syndrome of chronic granulomatous giant cell foreign body inflammation has characteristic clinical, radiologic, and histopathologic features. The literature regarding adverse reactions to bone wax is reviewed, and specific implications for orbital surgery are discussed.

Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a long-term light and electron microscopic follow-up study.

Light and electron microscopy were used to analyze nine therapy-resistant and asymptomatic human periapical lesions, which were removed as block biopsies during surgical treatment of the affected teeth. The cases that required surgery represented about 10% of all of the cases which received endodontic treatment and root fillings during the period 1977 to 1984. These cases revealed periapical lesions when they were examined 4 to 10 yr after treatment. The biopsies were processed for correlated light and electron microscopy. Six of the nine biopsies revealed the presence of microorganisms in the apical root canal. Four contained one or more species of bacteria and two revealed yeasts. Of the four cases in which bacteria were found, only in one biopsy could they be found by light microscope. In the other three specimens, the bacterial presence could be confirmed only after repeated electron microscopic examination of the apical root canal by serial step-cutting technique. Among the three cases in which no microorganisms could be encountered, one showed histopathological features of a foreign body giant cell granuloma. These findings suggest that in the majority of root-filled human teeth with therapy-resistant periapical lesions, microorganisms may persist and may play a significant role in endodontic treatment failures. In certain instances such lesions may also be sustained by foreign body giant cell type of tissue responses at the periapex of root-filled teeth.