Antibacterial activity of methanol extracts of the leaves of three medicinal plants against selected bacteria isolated from wounds of lymphoedema patients.

BACKGROUND: Patients with lymphoedema are at high risk of getting bacterial and fungal wound infections leading to acute inflammatory episodes associated with cellulitis and erysipelas. In Ethiopia, wound infections are traditionally treated with medicinal plants. METHODS: Agar well diffusion and colorimetric microdilution methods were used to determine the antibacterial activity of methanol extracts of the three medicinal plants against Staphylococcus aureus, Streptococcus pyogenes, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Shewanella alage, methicillin-resistant S. aureus ATCC®43300TM, Staphylococcus aureus ATCC25923, Escherichia coli ATCC25922, Klebsiella pneumoniae ATCC700603, and Pseudomonas aeruginosa ATCC37853. RESULTS: The methanol extract of L. inermis leaves showed high activity against all tested bacterial species, which was comparable to the standard drugs. Similarly, the extracts of A. indica showed activity against all tested species though at higher concentrations, and higher activity was recorded against Streptococcus pyogenes isolates at all concentrations. However, the extract of A. aspera showed the lowest activity against all tested species except Streptococcus pyogenes isolates. The lowest minimum inhibitory concentration (MIC) was recorded with the extract of L. inermis against E. coli isolate and S. aureus ATCC 25923. CONCLUSION: Methanol extracts of L. inermis, A. indica, and A. aspera leaves exhibited antimicrobial activity against selected bacterial isolates involved in wound infections, of which the methanol extracts of L. inermis exhibited the highest activity. The results of the present study support the traditional use of plants against microbial infections, which could potentially be exploited for the treatment of wound infections associated with lymphoedema.

Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema.

BACKGROUND: This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema. METHODS: From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis. RESULTS: A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%). CONCLUSIONS: The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.

Bacterial Flora in the Genital Area of Patients with Lower Limb Lymphedema.

Background: Patients with lymphedema, especially those having genital lymphangiectasia, experience repeated cellulitis; however, the causative bacteria are not detected in most cases. In this study, we investigated the composition of genital bacterial flora in patients with lower limb lymphedema to appropriately treat or prevent repeated cellulitis in these patients. Methods and Results: We examined 47 women with lower limb lymphedema. The average age was 58.4 (range 36-80) years. We performed indocyanine green (ICG) lymphography to confirm the presence of genital lymphedema. For each patient, we swab the skin in the genital area. The swabs were applied to aerobic agar plates, incubated, and evaluated to assess bacterial colonization and resistance to antibiotics. We numbered the patients who held the antibiotic-resistant bacteria, especially methicillin-resistant Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus, and extended spectrum ß-lactamase-producing Enterobacteriaceae. Among the 47 patients enrolled, 30 patients (63.8%) had a history of cellulitis accompanied by lymphedema and 31 patients (66.0%) had genital lymphedema diagnosed by ICG lymphography. Among 47 patients, 43 (91.5%) had at least one bacterial strain. Coryneform bacterial species were most commonly detected in 19 patients. Of 29 patients with a history of cellulitis, 9 had antibiotic-resistant bacteria (31.0%). In contrast, of 18 patients with no history of cellulitis, only 2 had antibiotic-resistant bacteria (11.1%) (p = 0.12). Conclusions: The percentage of patients with drug-resistant bacteria was higher among those with a history of cellulitis than among those without it.

Heating and Compression Bandage Treatment Is Effective for Chronic Lymphedema with Dermatolymphangioadenitis-A Case-Controlled Study.

BACKGROUND: To investigate the therapeutic effect of far infrared rays and compression bandaging in the treatment of chronic lymphedema with dermatolymphangioadenitis (DLA). METHODS: Between 2005 and 2013, 106 patients with chronic lymphedema with DLA treated at the Shanghai Ninth People's Hospital were retrospectively reviewed. These patients were divided into an infrared and a bandaging group (80 patients, group 1) and bandaging only group (26 patients, group 2). Outcome measures include DLA frequency, patients' subjective feedback with regards to their symptoms, and the relationship between continuous elastic compression bandaging and relapse of DLA. RESULTS: The frequency of DLA in group 1 and group 2 were significantly reduced after treatment (p = 0.000 and 0.004, respectively). Seventy five percent (60) of patients in group 1 and 19% (5) of patients in group 2 suffered no further episodes of DLA during the follow-up period. In group 1, over 90% of patients reported a subjective improvement in their symptoms and the relapse rate was shown to be lower using elastic compression bandaging when higher pressures were applied. CONCLUSION: Heating with compression bandaging can be an effective treatment strategy to reduce DLA and improve the quality of life for those patients with chronic lymphedema associated with DLA.

Cryptic Bacteria of Lower Limb Deep Tissues as a Possible Cause of Inflammatory and Necrotic Changes in Ischemia, Venous Stasis and Varices, and Lymphedema.

BACKGROUND: Infections and inflammation of the lower limb skin, soft tissues, and vessels are more common than in other body regions. The aim was to determine whether cryptic bacteria dwelling in deep tissues are the cause. METHODS: We performed bacteriologic studies of specimens harvested from arteries of amputated ischemic legs, leg varices, and tissue fluid/lymph and lymphatics in lymphedema. RESULTS: Calf arteries contained isolates in 61% and femoral arteries in 36%, whereas normal cadaveric organ donors' arteries in 11%. Bacterial deoxyribonucleic acid (DNA) was detected in 70%. The majority of isolates belonged to the coagulase-negative staphylococci and Staphylococcus aureus; however, highly pathogenic bacteria were also detected. All were sensitive to all antibiotics except penicillin. Saphenous vein varices contained bacterial cells in 40% and controls 4%; bacterial DNA was found in 69%. The majority of bacteria were S. epidermidis and S. aureus susceptible to all antibiotics except penicillin, Lymph and epifascial lymphatics limb contained bacteria in 60% and 33% samples, respectively and controls in 7%. Most were S. epidermidis susceptible to all antibiotics except penicillin. CONCLUSION: Cryptic bacteria are present in lower limb tissues and may play a pathologic role in surgical site infections. Proper antibacterial prophylaxis should be considered when planning surgical interventions.

Sporotrichoid chromomycosis.

Chromomycosis is a chronic fungal skin infection. It manifests frequently by warty or vegetative lesions in exposed areas, most often secondary to trauma. The diagnosis, nevertheless, is confirmed by the presence of fungi in the mycological examination. In fact, the treatment remains a challenge given its recalcitrant nature.

[Iliofemoral cutaneous mucormycosis with endopelvic extension in an immunocompetent child]. / Mucormycose cutanée ilio-fémorale avec extension endo-pelvienne chez un enfant immunocompétent.

Mucormycosis is a rare opportunistic fungal infection with clinical polymorphism and is rapidly extensive and destructive. It is caused by fungi of the mucorales group in the environment and generally arises in the context of immunosuppression. Often difficult and late, diagnosis is based on mycological and histological examination. We report the case of a 10-year-old patient admitted for a pruritic erythematous scaly eruption located in the right inguinal area associated with satellite lymphadenopathy and lymphedema of the right lower limb. The histological study of the cutaneous biopsy revealed a granulomatous reaction with filaments. The mycological examination of the collection of the cutaneous lesion showed mucorales filaments and a stump of Absidia corymbifera was isolated. Abdomino-pelvic CT showed muscular extension with vascular and ureteral englobement. The diagnosis of cutaneous mucormycosis was made. Immunological investigations were normal. Treatment included itraconazole for 3months followed by IV amphotericin B for 1month, with favorable clinical and radiological progression. Mucormycosis is an uncommon fungal infection whose cutaneous localization is rare. It occurs exceptionally in immunocompetent patients and is clinically manifested by a vesicular and pustular rash progressing to ulceration. The diagnosis is confirmed by mycological and histological studies. Treatment consists of antifungal therapy associated with surgical excision of necrotic and infected tissue.

Endovascular repair of an infected ruptured isolated iliac artery aneurysm combined with congenital lymphedema: report of a case.

PURPOSE: A novel technique using the reversed iliac leg of a Zenith device has been reported. This study reports a complicated isolated iliac artery aneurysm (IIAA) using this novel technique and reviews the relative literature to discuss current treatment modalities. CASE REPORT: A 46-year-old man presented with a mass in the left lower quadrant accompanied by abdominal pain for 60 days. Computer tomography angiography (CTA) revealed a complicated IIAA and a massive retroperitoneal hematoma. Percutaneous puncture and drainage at the hematoma was done. Enterococcus faecium was isolated from the hematoma. The infection was controlled after 2 weeks of drainage and anti-infection treatment. The IIAAs were successfully excluded using the novel technique. The 12-month CTA follow-up was unremarkable. CONCLUSION: Using inverted Zenith device legs is safe and effective even in complicated IIAAs. Further studies are warranted before it can become a widely acceptable definitive treatment option.

Ultrasonography for the monitoring of subcutaneous damage in Mycobacterium ulcerans infection (Buruli ulcer).

We used ultrasonography to evaluate the nature and the extent of subcutaneous damage provoked by Mycobacterium ulcerans (M. ulcerans) and to investigate the possible involvement of the tributary lymph nodes during the various stages of progression of Buruli ulcer. Nineteen patients affected by M. ulcerans infection in Benin, West Africa, were studied. Ultrasonography was performed on all subjects, except one, at the site of nonulcerated lesions and/or at perilesional site. The tributary lymph nodes were also studied in six patients. Ultrasound (US) evaluation was carried out using a 10 MHz linear probe and all lesions were compared with the homologous unaffected controlateral site. The ultrasonography showed relevant alterations at the dermo-hypodermic level, in agreement with histological specimens. In the active forms of the disease, these alterations are characterized by significant oedematous imbibition of the adipose tissue and necrosis (adiponecrosis) that leads to varying irregularities in the echogenicity of the hypodermis, which is generally thicker. In agreement with the clinical examination, the lymph nodes in six patients evaluated, despite their possible histological involvement with necrotic phenomena described in literature in M. ulcerans infection, did not display significant alterations visible by ultrasonography. The US scanning we have performed is the first use of this technique for M. ulcerans infection. We have shown that it can reveal the subcutaneous depth and the peripheral extent of the pathological process and it is particularly useful for monitoring the efficacy of or resistance to antibiotic treatment, especially in extensive ulcero-oedomatose forms. Such monitoring offers also a useful guide to the surgeon allowing the reduction or postponement of the removal of the large cutaneous areas that were carried out until recently.

The effectiveness of long-acting penicillin (penidur) in preventing recurrences of dermatolymphangioadenitis(DLA) and controlling skin, deep tissues, and lymph bacterial flora in patients with "filarial" lymphedema.

Dermatolymphangioadenitis (DLA) is a common and serious complication of so-called "filarial" and bacterial non-filarial lymphedema of the limb, affecting skin, lymphatics and lymph nodes. In our previous studies, we demonstrated that more than 60% of patients revealed presence of bacterial isolates in deep tissues, tissue fluid and lymph from the lymphedematous limbs. The question remained open whether elimination or suppression of bacteria dwelling in lymphedematous tissues by administration of low doses of penicillin for long time periods would prevent recurrence of DLA attacks. In this study, we retrospectively evaluated a self/community-selected group of patients with lymphedema of the lower limbs with respect to the efficacy of long-acting penicillin in preventing episodes of DLA. There were no microfilariae or anti-filarial antibodies detected in the investigated group. The questions we asked were: (a) how effective is the benzathine penicillin in preventing recurrences of DLA attacks and (b) how does its long-term administration influence the bacterial spectrum of leg skin, deep tissues, lymph and lymph nodes and sensitivity to antibiotics. Two randomly selected groups of patients, receiving and not receiving penicillin during the same period of time, were compared. Evidently lower recurrence rate of DLA was observed in the treated group (p < 0.002). There was increased prevalence of cocci and gram-positive bacilli with a concomitant decrease of gram-negative bacilli on the foot and calf skin surface. Simultaneously, decreased prevalence of gram-positive cocci and gram-negative bacilli isolates in limb deep tissues and lymph was seen. No resistance to penicillin and other tested antibiotics developed in isolates from the skin surface, deep tissues and lymph. We conclude that long-lasting penicillin is effective in preventing recurrent DLA attacks.

[Infectious complications of lymphedema]. / Complications infectieuses des lymphoedèmes.

Erysipelas and lymphangitis are frequent complications of lymphedemas (20 to 30%). The most important risk factor for erysipelas is lymphedema since this is a protein rich edema that contributes to the risk of infection. In case of lymphedema the treatment is the usual consensus treatment for erysipelas. A prophylactic treatment with penicillin is requested as soon as the first recurrence. This prophylactic treatment includes skin care, particularly treatment of injuries and intertrigos. Hyperplastic skin leads to maceration and then mycoses. Physiotherapy does not increase the risk for infection. Moreover an infection needs a complex decongestive physiotherapy which decreases risks of recurrence.

[Intertrigo in patients with lower limb lymphedema. Clinical and laboratory correlation]. / Intertrigo em pacientes com linfedema de membro inferior. Correlação clínico-laboratorial.

Cutaneous lesions in the interdigital spaces are commonly seen in lymphedema patients and their prevention and suitable care is one of the cornerstones of any successful treatment, by preventing acute inflammations and additional worsening in limb volume and fibrosis. We obtained swab specimens from the interdigital area from 21 patients followed in the Lymphedema Unit of the Department of Vascular Surgery of the University of São Paulo; thirteen of them had lesions suggestive of tinea pedis. The pathological agent could be identified in 11 out of these 13 patients: fungal infection alone was responsible for seven lesions, Corynebacterium minutissimum for another two and both agents were isolated from two patients. Although two patients had evident clinical lesion of the skin, no fungal or bacterial species could be isolated. From the eight patients without interdigital lesions, Candida and Corynebacterium was found in one. We concluded that clinical examination has a high sensibility (84%) and specificity (91%) but the high prevalence of Corynebacterium minutissimum suggests that adequate treatment should follow careful laboratory examination.