Dysbiotic salivary microbiota in dry mouth and primary Sjögren's syndrome patients.

OBJECTIVES: Primary Sjögren's syndrome (pSS) is an autoimmune disease characterized by reduced lacrimal and salivary secretion. Sicca symptoms together with fatigue and musculoskeletal pain can significantly reduce the patients' quality of life. Furthermore, low salivary secretion may disrupt the oral microbial homeostasis. The aim of this study was to compare the salivary microbiota from pSS patients with patients with sicca symptoms not fulfilling the classification criteria for pSS (non-SS), and with healthy controls without sicca complaints. METHODS: Pellets from centrifuged chewing-stimulated whole saliva from pSS patients (n = 15), non-SS sicca patients (n = 15) and healthy controls (n = 15) were prepared. DNA was extracted and analyzed by 16S rRNA gene sequencing. The acquired sequencing data were performed using the human oral microbiome database (HOMD). RESULTS: We detected 42, 45, and 34 bacterial genera in saliva samples from pSS patients, non-SS sicca patients, and healthy controls, respectively. The most abundant genera in all samples were Prevotella, Veillonella, Streptococcus, and Haemophilus. At species level Streptococcus intermedius, Prevotella intermedia, Fusobacterium nucleatum subsp. vincentii, Porphyromonas endodontalis, Prevotella nancensis, Tannerella spp., and Treponema spp. were detected in the samples from pSS and non-SS only, while Porphyromonas pasteri was mostly found among the healthy controls. CONCLUSION: Our study indicated dysbiosis in the salivary microbiota from pSS and non-SS patients compared to healthy controls. Additionally, the results showed that the salivary microbiome in the pSS group differed significantly from the non-SS group.

Pediatric Humeral Osteomyelitis.

BACKGROUND: Osteomyelitis is a common problem among the pediatric population. The humerus is the most commonly affected bone in the upper limb; however, there are relatively few series in the literature. This article retrospectively reviews a large number of cases of pediatric humeral osteomyelitis. We aim to further define the disease and its clinical course to aid in improved treatment. METHODS: A 10-year retrospective review was performed of clinical records of pediatric humeral osteomyelitis at the 2 children's orthopaedic departments in the Auckland region. The Osteomyelitis Database was used to identify all cases between 1997 and 2007 at Starship Children's Hospital, and 1998 and 2008 at Middlemore's Kidz First Hospital. RESULTS: Forty-nine patients were identified. Sixty-one percent were male with an average age of 4.2 years. Maori and Pacific Islanders were overrepresented. Seventy-eight percent were not using the limb, 70% complained of pain. Only 55% were febrile. White cell count, erythrocyte sedimentation rate, and C-reactive protein raised in 73%, 74%, and 79% of cases, respectively. X-ray, bone scintigraphy, and particularly magnetic resonance imaging were useful in radiologic diagnosis. Blood and tissue cultures revealed Staphylococcus aureus as the most common organism; there were 2 cases of community-acquired methicillin-resistant S. aureus. The distal humerus was more commonly affected. Fifty-three percent required surgery. Antibiotic therapy averaged 2.7 weeks intravenous and 2.6 weeks of oral therapy. There were 7 cases with adjacent septic arthritis, which had higher inflammatory markers. Major complications included 2 multiorgan failure and 1 growth disturbance. CONCLUSIONS: Humeral osteomyelitis can be diagnosed with an appropriate history, clinical examination, and investigations. One should be aware of concurrent septic arthritis and be prepared to treat this urgently. Those children with septic arthritis were not using the limb and had higher inflammatory markers. Treatment with intravenous and oral antibiotics and surgical debridement/washout if indicated can lead to good clinical outcomes with minimal complications. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Intracortical haematogenous osteomyelitis.

We present an unusual case of haematogenous osteomyelitis in the diaphysis of the tibia of an adult leading to a subacute presentation with an extracortical abscess. Fluid from the abscess grew methicillin resistant Staphylococcus aureus (MRSA) on culture; MRSA with the same antibiogram had been grown from the patient's blood seven years earlier following a bowel resection. Drainage of the abscess and curettage of the bone lesion together with appropriate antibiotic therapy led to resolution of the osteomyelitis.

Infections with the tick-borne bacterium "Candidatus Neoehrlichia mikurensis" mimic noninfectious conditions in patients with B cell malignancies or autoimmune diseases.

BACKGROUND: Candidatus Neoehrlichia mikurensis is a newly discovered noncultivatable bacterium spread among ticks and rodents in Europe and Asia that can infect humans, particularly immunocompromised patients. METHODS: We compiled clinical and laboratory data from 11 patients with hematological malignances or autoimmune diseases who were diagnosed with Candidatus N. mikurensis infection in Europe 2010-2013. Both published (6) and unpublished cases (5) were included. RESULTS: The patients had a median age of 67, were mostly male (8/11), and resided in Sweden, Switzerland, Germany, and the Czech Republic. All but one had ongoing or recent immune suppressive treatment and a majority were splenectomized (8/11). Less than half of them recalled tick exposure. The most frequent symptoms were fever (11/11), localized pain afflicting muscles and/or joints (8/11), vascular and thromboembolic events (6/11), that is, deep vein thrombosis (4), transitory ischemic attacks (2), pulmonary embolism (1), and arterial aneurysm (1). Typical laboratory findings were elevated C-reactive protein, leukocytosis with neutrophilia, and anemia. Median time from onset of symptoms to correct diagnosis was 2 months. In at least 4 cases, the condition was interpreted to be due to the underlying disease, and immunosuppressive therapy was scheduled. All patients recovered completely when doxycycline was administered. CONCLUSIONS: Candidatus N. mikurensis is an emerging tick-borne pathogen that may give rise to a systemic inflammatory syndrome in persons with hematologic or autoimmune diseases that could be mistaken for recurrence of the underlying disease and/or unrelated arteriosclerotic vascular events. Awareness of this new pathogen is warranted among rheumatologists, hematologists, oncologists, and infectious disease specialists.

Unusual presentations of osteoarticular tuberculosis in two paediatric patients.

Tuberculosis is a universal mimicker and thus could be a differential diagnosis of any osteolytic lesion. Bone biopsy is crucial in these cases for culture and histological proof of tuberculous infection. This is a case report of two paediatric patients with unusual presentations of tuberculosis. One patient presented with knee pain and had imaged findings of an osteolytic lesion at the epiphysis. Interval scan showed spread of the lesion through the physis to the metaphyseal region. The second patient presented with hip pain and an osteolytic lesion of the acetabulum. He was subsequently found to have involvement of the brain and spine as well. Both patients were diagnosed with tuberculosis by bone biopsy for culture and pathological examination. They were treated successfully with antituberculous medications without chronic sequelae. These two patients showed that early recognition and prompt treatment are critical for management of tuberculosis to avoid chronic sequelae.