Recent update in diagnosis and treatment of human pythiosis.

Human pythiosis is an infectious condition with high morbidity and mortality. The causative agent is the oomycete microorganism Pythium insidiosum. The pathogen inhabits ubiquitously in a wet environment, and direct exposure to the pathogen initiates the infection. Most patients with pythiosis require surgical removal of the affected organ, and many patients die from the disease. Awareness of pythiosis among healthcare personnel is increasing. In this review, we summarized and updated information on the diagnosis and treatment of human pythiosis. Vascular and ocular pythiosis are common clinical manifestations. Recognition of the typical clinical features of pythiosis is essential for early diagnosis. The definitive diagnosis of the disease requires laboratory testing, such as microbiological, serological, molecular, and proteomic assays. In vascular pythiosis, surgical intervention to achieve the organism-free margin of the affected tissue, in combination with the use of antifungal drugs and P. insidiosum immunotherapy, remains the recommended treatment. Ocular pythiosis is a serious condition and earliest therapeutic penetrating keratoplasty with wide surgical margin is the mainstay treatment. Thorough clinical assessment is essential in all patients to evaluate the treatment response and detect an early sign of the disease recurrence. In conclusion, early diagnosis and proper management are the keys to an optimal outcome of the patients with pythiosis.

Vascular pythiosis of carotid artery with meningitis and cerebral septic emboli: A case report and literature review.

Vascular Pythiosis caused by Pythium insiodiosum rarely involves carotid artery. A case of concealed ruptured pseudoaneurysm of the carotid artery with neck abscesses, and cerebral septic emboli is described. Patient presented with large pulsatile neck mass that failed to response to surgery, antifungals and immunotherapeutic vaccine. Residual unresectable disease leads to death in the patient. Pythiosis should be considered as a differential diagnosis of head and neck infection.

Clinicopathological features and outcomes of pythiosis.

OBJECTIVES: Vascular pythiosis is a life-threatening infection caused by the oomycete Pythium insidiosum. This article reports the clinical presentation, serodiagnosis, pathology, and outcomes seen at the authors' institution. METHODS: The cases of patients with proven vascular pythiosis at Ramathibodi Hospital, Mahidol University, Bangkok, Thailand from January 2006 to December 2016 were analyzed retrospectively. RESULTS: Thirteen patients were analyzed, eight of whom had underlying thalassemias. Of the remaining five patients, one had aplastic anemia, one had myelodysplasia, one had acute leukemia, one had cirrhosis, and one had alcoholism. Neutropenic patients showed a rapid clinical deterioration. Atypical presentations including carotid arteritis, aneurysm, brain abscess, and stroke occurred in the non-thalassemic patients. Serology yielded positive results in all cases, with a rapid turnaround time. Serology has the advantage of providing a presurgical diagnosis, which allows prompt surgery and clinical cure to be achieved. Pathology revealed a neutrophilic response in the acute phase and a later shift to granuloma. Immunotherapy in combination with itraconazole and terbinafine was given. The amputation rate was 77%, and disease-free surgical margins were achieved in five cases (38%). The mortality rate was 31%. CONCLUSIONS: This study highlights new aspects of pythiosis, such as the unusual host, clinical presentation, serology as a marker for rapid diagnosis, histopathology, and outcomes. Early recognition of the disease with prompt multimodality treatment may improve survival.

A case report of Tubo-ovarian abscess caused by Burkholderia pseudomallei.

BACKGROUND: Melioidosis, the disease caused by Burkholderia pseudomallei is endemic in the Northeastern part of Thailand, South-East Asia, and Northern Australia. The pelvic involvement of disease is rare even in an endemic area. Therefore, we describe in this report the clinical presentation, management, and outcome of the patient with primary tubo-ovarian abscess due to melioidosis. CASE PRESENTATION: A 31-year-old Thai cassava farmer woman presented with fever and abdominal pain at left lower quadrant for one month. She also had pain, swelling, and redness of the genitalia without any ulcer. She had odorless whitish vaginal discharge. The pelvic examination revealed excitation pain on the left side of her cervix. Transvaginal ultrasonography revealed a large left tubo-ovarian abscess size 9.4 × 4.8 cm located at anterior of the uterus. Urgent exploratory laparotomy revealed left hydrosalpinx with a large amount of pus. The pus culture grew Burkholderia pseudomallei. The computer tomography of the abdomen revealed multiple hepatosplenic abscesses. The patient underwent left salpingo-oophorectomy and pus drainage. The pathological examination of excised left adnexa revealed chronic and acute suppurative inflammation with necrotic tissue. She was given intravenous ceftazidime for one month, and her clinical symptom improved. She was diagnosed with type 2 diabetes mellitus at this visit and treated with insulin injection. She continued to take oral co-trimoxazole for 20 weeks. The final diagnosis was disseminated melioidosis with left tubo-ovarian abscess and hepatosplenic abscesses in a newly diagnosed morbidly obese diabetic patient. CONCLUSION: Burkholderia pseudomallei should be considered as the causative organism of gynecologic infection among patient with risk factor resided in an endemic area who do not respond to standard antibiotics. The pus culture from the site of infection is the only diagnostic method of pelvic melioidosis, appropriate antibiotics, and adequate surgical drainage were the components of the successful outcome.

Prevalence and Outcome of Disseminated Varicella Zoster Infection Post Kidney Transplantation.

OBJECTIVE: Varicella zoster (VZV) is a potentially life-threatening infection after kidney transplantation (KT) but data on the incidence and outcome of late KT VZV infection is limited. MATERIAL AND METHOD: A retrospective study of disseminated VZV infection (D-VZV) in post KT patients was conducted between 2003 and 2013. Acyclovir prophylaxis was given routinely for six months after KT Statistical analyses were performed by SPSS software version 17.0. RESULTS: Prevalence of D-VZV was 2% [22/1,032 patients]. Patients median age were 40 (21-67) years old and 12 (55%) were male. Timing of the infection was mostly (68.2%) late (> 1 year) post KT The majority of maintenance immunosuppressive drug included prednisolone (95.5%), cyclosporine (77.3%), mycophenolate (68.2%). Two (9.1%) had a recent VZV exposure and four (18%) received intensified immunosuppression before the diagnosis. Common clinical presentations were lymphopenia (54.5%), generalized vesicular rash (50%), and multi-dermatomal distribution (50%) while liver involvement was infrequent (9.1%). None had pneumonitis or neurological involvement. All cases received systemic acyclovir with the median duration of 14 (3-31) days. One had received IVIG for fulminant hepatitis. Immunosuppressive drug/s was reduced in 59%. Median duration of hospitalization was seven (3-37) days. None of patients died. The median follow-up duration was 1939 (IQR 804-2440) days. Recurrent infection was uncommon (4.5%). Secondary prophylaxis was given only in one patient with fulminant VZV hepatitis. CONCLUSION: Incidence of D-VZV post KT was low. Treatments with intravenous acyclovir and reduction of immunosuppression without the use of VZV IgG provided favorable outcome in resource-limited settings.

Disseminated Mycobacterium Simiae with Pelvic Malakoplakia in an AIDS Patient.

Malakoplakia in an acquired immunodeficiency syndrome (AIDS) patient with disseminated Mycobacterium simiae infection presented with a large pelvic mass that caused organ dysfunction from mimicking a tumor. Malakoplakia is a rare, chronic granulomatous abnormal host response toward infectious agents, presenting as a tumor-like lesion. This is the first report of pelvic malakoplakia after disseminated M. simiae infection in an AIDS patient.