A rare case of a prostatic abscess, bacteremia and chronic granulomatous disease associated with Klebsiella pneumoniae.

Chronic granulomatous disease (CGD) is a primary immunodeficiency disease characterized by severe recurrent infections such as pneumonia, liver and skin infections. However, prostatic abscesses are rare as only two cases have been reported thus far. We present the case of a 41-year-old patient with CGD who was admitted to the hospital with fever and subsequently, Klebsiella pneumoniae was identified on blood culture. Abdominal computed tomography revealed a prostatic abscess. He improved with intravenous antibiotics and drainage of the abscess. After he was taken off the intravenous antibiotics and started on an oral agent, he was discharged from the hospital. We confirmed a reduction in the prostatic abscess size and continued the antibiotic therapy for 52 days. A prostatic abscess is an uncommon disease being diagnosed at a median age of 49 years. Sometimes it is discovered in patients with fever of unknown origin and might be considered as an infection site of CGD patients.

Posttransplant complications in adult recipients of intestine grafts without bowel decontamination.

BACKGROUND: Selective digestive decontamination is commonly used to decrease lumenal bacterial flora. Preoperative bowel decontamination may be associated with a lower wound infection rate but has not been shown to decrease risk of intra-abdominal abscess or lower leak rate for enteric anastomoses. Alternatively, the decontamination disrupts the normal flora of the gastrointestinal tract and may affect normal physiology, including immunologic function. This study reports complication rates of an intestine transplant program that has never used bowel decontamination. METHODS: All adult patients who underwent intestine transplant from 2003 to 2015 at a single center were reviewed. Posttransplant complications included intra-abdominal abscess, enteric fistula, and leak from the enteric anastomosis. Viral, fungal, and bacterial infections in the first year after transplant are reported. RESULTS: There were 184 adult patients who underwent deceased donor intestine transplant during the study period. Among these patients, 30% developed an infected postoperative fluid collection, 4 developed an enteric fistula (2%), and 16 had an enteric or anastomotic leak (8%). The rate of any bacterial infection was 91% in the first year, with a wound infection rate of 25%. Fungal infection occurred in 47% of patients. Rejection rates were 55% at 1 y for isolated intestine patients and 17% for multivisceral (liver inclusive) patients. CONCLUSIONS: Among this population of intestine transplant patients in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. Bowel decontamination provides no identifiable benefit in intestine transplantation.

Retrospective review of laparoscopic versus open surgery in the treatment of appendiceal abscess in pediatric patients: Laparoscopic versus open surgery for appendiceal abscess.

Laparoscopic appendectomy (LA) has become well accepted, but the role of LA for appendicitis upon presentation with an abscess remains undefined. This study was to assess the postoperative recovery and complications following LA in pediatric patients with appendiceal abscess in comparison with open appendectomy (OA).We conducted a retrospective review of patients presented with appendiceal abscess between 2005 and 2016. Propensity score matching (PSM) was conducted to adjust for any potential selection bias for the surgical approaches. In 108 matched patients, operative outcomes and surgical complications were evaluated based on LA or OA.The patients with LA experienced prompt postoperative gastrointestinal function recovery, like first bowel movement (risk ratio [RR], 0.52; 95% confidence interval [CI], 0.44-0.69; P < .001), so spend the lower mean length of hospitalization (RR, 0.53; 95% CI, 0.41-0.76; P < .001) in comparison with patients with OA. Furthermore, the immunologic and inflammatory variable white blood cell (WBC) (RR, 0.56; 95% CI, 0.46-0.73; P < .001) and C-reactive protein (CRP) (RR, 0.58; 95% CI, 0.43-0.86; P = .011) on postoperative days (POD) 5 was reduced in patients undergone LA compared with that of OA. A lower overall postoperative complication rate, including surgical wound infection (odds ratio [OR], 0.38; 95% CI, 0.18-0.81; P = .008) and incision dehiscence (OR, 0.06; 95% CI, 0.01-0.45; P < .001) was noted in patients with LA compared with OA.LA was feasible and effective for appendicitis upon presentation with an abscess and associated with beneficial clinical effects, such as postoperative gastrointestinal function recovery and reduced postoperative complications. LA should be seriously considered as the first line procedure of choice.

Safety and Efficacy of Anti-TNFα Treatment in Crohn's Disease Patients with Abdominal Abscesses.

BACKGROUND/AIMS: It is estimated that up to 30% of CD patients develop abdominal abscesses; the management of active luminal CD in such patients represents a clinical challenge. The aim of this study is to assess the safety of biologics in patients with Crohn's disease and abdominal abscesses treated with percutaneous drainage and/or broad-spectrum antibiotics. METHODOLOGY: We performed a retrospective review of the clinical charts of consecutive Crohn's disease patients with abdominal abscesses treated with anti-TNFα therapy attended in our institution. RESULTS: 12 patients were finally included in the study. All were treated with broad-spectrum antibiotic and biological therapy (anti-TNF); indication of anti-TNFα therapy was moderate to severe activity of CD in all of them. Percutaneous drainage of the abscess was performed in 7 of the 12 patients. No complications were observed during a mean follow-up of 37,8 (16-71) months, including abscess volume increase, enterocutaneous fistula, soft tissue infections, bacteraemia, or need for emergency surgery. CONCLUSIONS: In addition to conventional treatment, the use of anti-TNFα therapy in Crohn's disease patients with abdominal abscesses seems to be safe. Usefulness of this approach has to be validated in larger cohorts.

Effects of tissue plasminogen activator in experimentally induced peritonitis.

BACKGROUND: We aimed to evaluate the microbiological and immunological effects of tissue plasminogen activator (tPA) in a rat model of peritonitis. METHODS: Twenty-four male Wistar albino rats were divided equally into three groups. Peritonitis and thereafter laparotomy and partial omentectomy were performed in all rats. The control group (C) had no further treatment. The antibiotics group (A) received metronidazole and ceftriaxone. The antibiotic and tPA group (A+T) received the same antibiotics as well as tPA. For microbiological and immunological analysis, blood samples were obtained at the 24th hour, and peritoneal fluid samples were obtained at the 24th and 72nd hours. On the fifth day after surgery, all rats were sacrificed, and the macroscopic findings of the peritoneal cavity were recorded. RESULTS: The mean number of intraperitoneal abscesses was significantly higher in the control group and the lowest in the two treatment group (A+T). The levels of cytokines were not significantly different between groups. Giving tPA reduced the number and sizes of the abscesses with no significant difference in inflammatory response. CONCLUSION: In this experimental peritonitis model, it can be postulated that tPA decreased abscess formation without exaggerating the inflammatory response.

Iliopsoas coccidioidomycotic abscess with associated intra-abdominal extension in an immunocompetent patient.

Exposure to the fungal pathogen Coccidioides immitis in normal hosts causes primarily self-limited pulmonary disease. We report a case of an immunocompetent patient who developed a Coccidioides-associated iliopsoas abscess with rare intra-abdominal dissemination at least one decade after primary exposure in an area endemic for this fungus.

Splenic abscess caused by Lactobacillus paracasei.

Splenic abscess is relatively uncommon. Infections caused by lactobacilli, which are usually one of the constituents of normal flora of human gut and vagina, are also very uncommon. Here we report a case of splenic abscess caused by Lactobacillus paracasei. We performed a literature review for this rare entity. Immunocompromised status of the patient, who had uncontrolled diabetes, could have contributed to the pathogenesis of this rare disease.

Neutrophil extracellular traps contain calprotectin, a cytosolic protein complex involved in host defense against Candida albicans.

Neutrophils are the first line of defense at the site of an infection. They encounter and kill microbes intracellularly upon phagocytosis or extracellularly by degranulation of antimicrobial proteins and the release of Neutrophil Extracellular Traps (NETs). NETs were shown to ensnare and kill microbes. However, their complete protein composition and the antimicrobial mechanism are not well understood. Using a proteomic approach, we identified 24 NET-associated proteins. Quantitative analysis of these proteins and high resolution electron microscopy showed that NETs consist of modified nucleosomes and a stringent selection of other proteins. In contrast to previous results, we found several NET proteins that are cytoplasmic in unstimulated neutrophils. We demonstrated that of those proteins, the antimicrobial heterodimer calprotectin is released in NETs as the major antifungal component. Absence of calprotectin in NETs resulted in complete loss of antifungal activity in vitro. Analysis of three different Candida albicans in vivo infection models indicated that NET formation is a hitherto unrecognized route of calprotectin release. By comparing wild-type and calprotectin-deficient animals we found that calprotectin is crucial for the clearance of infection. Taken together, the present investigations confirmed the antifungal activity of calprotectin in vitro and, moreover, demonstrated that it contributes to effective host defense against C. albicans in vivo. We showed for the first time that a proportion of calprotectin is bound to NETs in vitro and in vivo.

[Evaluation of severity of immune disorders and prognosis of the development of pyo-septic complications in patients with emergency surgery pathology].

Any lesion in organism, causing the development of inflammation, is followed by changed work of the immune system that is extremely important for prognosis of the course of the pathological process. The adequate compensation-defense reaction was estimated using well-known immunological tests and normal reaction of the immune system was determined to be different from the pathological reaction, especially in patients in critical state. The adequate reaction of the immune system is characterized by mild leukocytosis, two-three fold increase of the spontaneous HCT test, normal or moderately pronounced indices of the cellular and humoral links of immunity. The markers of the formation of secondary immune incompetence are not only decreased but also extremely increased indices of immunogram at early terms of the disease.

Corticosteroids but not infliximab increase short-term postoperative infectious complications in patients with ulcerative colitis.

BACKGROUND: Recent reports suggest that the preoperative use of infliximab (IFX) increases postoperative infectious complications in patients with ulcerative colitis (UC). Therefore, we determined the impact of IFX on postoperative infectious complications. METHODS: A consecutive group of 141 UC patients (41% female, median age 39.8 years) undergoing (procto)colectomy was studied. Postoperative infectious complications were compared between 22 patients who received IFX within 12 weeks prior to (procto)colectomy (IFX group) and 119 patients who did not (control group). Short-term infectious complications, consisting of anastomotic leaks, pelvic abscesses, wound infections, and nonsurgical site infections, were recorded within 30 days after primary surgery. RESULTS: At primary surgery there was no significant difference in gender, disease extent, smoking behavior, body mass index, and concomitant medication (including corticosteroids) between the groups. Patients in the IFX group less often underwent restorative proctocolectomy without defunctioning ileostomy (9% versus 34%, P = 0.022), had a significantly shorter median (interquartile range, IQR) disease duration (2.7 [1.2-8.6] versus 5.9 [2.6-13.0] years, P < 0.036) and a significantly higher C-reactive protein level at primary surgery (51.7 [9.9-103.6] versus 19.1 [7.5-42.6] mg/L, P = 0.023). There was no short-term mortality. A moderate-to-high dose of corticosteroids (>or=20 mg methylprednisolone for >or=2 months, odds ratio 5.19 [95% confidence interval [CI]: 1.72-15.66], P = 0.003) and a restorative proctocolectomy without defunctioning ileostomy (odds ratio 6.45 [95% CI: 2.12-19.64], P = 0.001) were independent predictors of short-term postoperative infectious complications. CONCLUSION: Corticosteroids and a restorative proctocolectomy without defunctioning ileostomy, but not IFX, are associated with an increased risk of short-term postoperative infectious complications in UC.

Genital tuberculosis as the cause of tuboovarian abscess in an immunosuppressed patient.

BACKGROUND: Although tuberculosis (TB) is a major health problem worldwide, primary extrapulmonary tuberculosis (EPTB), and in particular female genital tract infection, remains a rare event. CASE REPORT: A 35-year-old human immunodeficiency virus (HIV) seropositive woman of African descent with lower abdominal pain and fever of two days duration underwent surgery due to left adnexal mass suggesting pelvic inflammatory disease. The surgical situs showed a four quadrant peritonitis, consistent with the clinical symptoms of the patient, provoked by a tuboovarian abscess (TOA) on the left side. All routine diagnostic procedures failed to determine the causative organism/pathogen of the infection. Histopathological evaluation identified a necrotic granulomatous salpingitis and specific PCR analysis corroborated Mycobacterium tuberculosis (M. Tb). Consequently, antituberculotic therapy was provided. CONCLUSION: In the differential diagnosis of pelvic inflammatory disease, internal genital tuberculosis should be considered. Moreover, physicians should consider tuberculous infections early in the work-up of patients when immunosuppressive conditions are present.

Retroperitoneal abscess perforating into the thoracic cavity in an immunocompromised host.

A 71-year-old man with a retroperitoneal abscess caused by a ureteral stone was successfully treated by retroperitoneal drainage. He was considered to be at high risk of infection because of his bedridden state (resulting from a post-cerebral infarction and malignant rheumatoid disease) and steroid administration for the rheumatoid disease. He also had an empyema adjacent to the retroperitoneal abscess. This was thought to be separate from the retroperitoneal abscess because it did not resolve after the retroperitoneal drainage. Thoracic cavity drainage was undertaken, after which the empyema disappeared. The drainage fluid contained pus, similar to the fluid from the retroperitoneal drainage. Escherichia coli organisms were cultured from both drainage fluids. There were no signs of recurrence on computed tomography (CT) imaging. In conclusion, we report a case of retroperitoneal abscess perforating into the thorax, successfully treated by retroperitoneal and thoracic cavity drainage in an immunocompromised host. CT was a very effective imaging modality for this diagnosis, and we recommend early drainage of abscess in immunocompromised patients.

CD4+ T cells mediate abscess formation in intra-abdominal sepsis by an IL-17-dependent mechanism.

Abscess formation associated with intra-abdominal sepsis causes severe morbidity and can be fatal. Previous studies have implicated T cells in the pathogenesis of abscess formation, and we have recently shown that CD4(+) T cells activated in vitro by zwitterionic capsular polysaccharides from abscess-inducing bacteria such as Staphylococcus aureus and Bacteroides fragilis initiate this host response when transferred to naive rats. In this study, we show that mice deficient in alphabetaTCR-bearing T cells or CD4(+) T cells fail to develop abscesses following challenge with B. fragilis or abscess-inducing zwitterionic polysaccharides, compared with CD8(-/-) or wild-type animals. Transfer of CD4(+) T cells from wild-type mice to alphabetaTCR(-/-) animals reconstituted this ability. The induction of abscesses required T cell costimulation via the CD28-B7 pathway, and T cell transfer experiments with STAT4(-/-) and STAT6(-/-) mice demonstrated that this host response is dependent on STAT4 signaling. Significantly higher levels of IL-17, a proinflammatory cytokine produced almost exclusively by activated CD4(+) T cells, were associated with abscess formation in Th2-impaired (STAT6(-/-)) mice, while STAT4(-/-) mice had significantly lower levels of this cytokine than control animals. The formation of abscesses was preceded by an increase in the number of activated CD4(+) T cells in the peritoneal cavity 24 h following bacterial challenge. Confocal laser-scanning microscopy analysis revealed that CD4(+) T cells comprise the abscess wall in these animals and produce IL-17 at this site. Administration of a neutralizing Ab specific for IL-17 prevented abscess formation following bacterial challenge in mice. These data delineate the specific T cell response necessary for the development of intra-abdominal abscesses and underscore the role of IL-17 in this disease process.

Delayed clearance of intraabdominal abscesses caused by Candida albicans in tumor necrosis factor-alpha- and lymphotoxin-alpha-deficient mice.

The role of endogenous tumor necrosis factor-alpha (TNF) and lymphotoxin-alpha (LT) in a model of intraabdominal Candida sepsis and abscess formation was investigated. Significantly more abscesses were observed in TNF/LT double knockout (TNF(-/-)LT(-/-)) mice, compared with that in wild-type (TNF(+/+)LT(+/+)) mice. Outgrowth of Candida in abscesses of TNF(-/-)LT(-/-) mice was 10-fold increased on day 14 and 60-fold increased on day 21 of infection. The interleukin-10rcolon;interferon-gamma ratio, measured in supernatants of stimulated splenocytes, shifted from 131 for TNF(-/-)LT(-/-) mice and 13.9 for TNF(+/+)LT(+/+) mice on day 8 to 0.11 for TNF(-/-)LT(-/-) mice and 11.66 for TNF(+/+)LT(+/+) mice on day 14 of infection. The diminished host resistance is explained by an impaired extracellular killing capacity of granulocytes and a delayed development of a T helper 1 response in TNF(-/-)LT(-/-) mice. In conclusion, TNF and LT are critical to the stimulation of effector cells that leads to elimination of Candida from abscesses.

Interleukin-10 protects against lethality of intra-abdominal infection and sepsis.

The aim of this study was to determine whether interleukin-10 would alter locally derived and systemic proinflammatory cytokine expression and protect from the lethality of cecal ligation and puncture. Three groups of Sprague-Dawley rats were used. Group 1 underwent cecal manipulation. Groups 2 and 3 underwent cecal ligation and puncture. Group 2 received intraperitoneal saline injections beginning 1 hour after cecal ligation and puncture and every 3 hours thereafter for 24 hours. Group 3 received intraperitoneal interleukin-10 one hour after cecal ligation and puncture and every 3 hours thereafter. Animals were killed at 6 and 24 hours after cecal ligation and puncture or sham operation. Serum tumor necrosis factor-alpha (TNF-alpha) levels were determined by enzyme-linked immunosorbent assay. TNF-alpha messenger RNA expression was determined by reverse transcriptase-polymerase chain reaction using Beta-actin as the internal standard. There was a twofold increase (P <0.001) in TNF-alpha mRNA in the liver at 6 and 24 hours after cecal ligation and puncture when compared to rats treated with interleukin-10. There was a twofold increase (P <0.05) in TNF-alpha mRNA in the lung observed only at 24 hours after cecal ligation and puncture when compared to rats treated with interleukin-10. Serum levels of TNF-alpha were elevated at 6 hours in control animals, and this effect was abolished by the administration of interleukin-10. There was no difference in mortality rates at 6 hours (0% for all groups); however, at 24 hours 57% (4/7) mortality was observed in group 2 vs. 0% (0/20) in groups 1 and 3. Interleukin-10 given after the onset of cecal ligation and puncture protects against the lethality of intra-abdominal sepsis.

Effect of molecular size on the ability of zwitterionic polysaccharides to stimulate cellular immunity.

The large-molecular-sized zwitterionic capsular polysaccharide of the anaerobe Bacteroides fragilis NCTC 9343, designated polysaccharide (PS) A, stimulates T cell proliferation in vitro and induces T cell-dependent protection against abscess formation in vivo. In the present study, we utilized a modification of a recently developed ozonolytic method for depolymerizing polysaccharides to examine the influence of the molecular size of PS A on cell-mediated immunity. Ozonolysis successfully depolymerized PS A into structurally intact fragments. PS A with average molecular sizes of 129.0 (native), 77.8, 46.9, and 17.1 kDa stimulated CD4+-cell proliferation in vitro to the same degree, whereas the 5.0-kDa fragment was much less stimulatory than the control 129.0-kDa PS A. Rats treated with 129.0-kDa, 46.9-kDa, and 17.1-kDa PS A molecules, but not those treated with the 5.0-kDa molecule, were protected against intraabdominal abscesses induced by challenge with viable B. fragilis. These results demonstrate that a zwitterionic polysaccharide as small as 22 repeating units (88 monosaccharides) elicits a T cell-dependent immune response. These findings clearly distinguish zwitterionic T cell-dependent polysaccharides from T cell-independent polysaccharides and give evidence of the existence of a novel mechanism for a polysaccharide-induced immune response.

Inflammatory processes in a murine model of intra-abdominal abscess formation.

Abscess formation has been viewed as a host defense strategy to contain the spread of infection. However, abscesses are also serious and life-threatening manifestations of persisting microbial infection. The initiation of abscess formation, both clinically and experimentally, involves the release of bacteria and an abscess-potentiating agent (e.g., fecal fiber or an analog) into a sterile site, with host defense mechanisms being unable to eliminate the infecting organisms. Abscess formation is aided by a combination of factors that share a common feature: impairment of phagocytic killing and hence clearance of microorganisms. These include bacterial virulence factors (e.g., capsule formation, succinic acid production); complement activation by the abscess potentiating agent; fibrin deposition; and microbial sequestration within abscess neutrophils. Recruitment of cells into the peritoneal cavity follows mast cell activation in the pathogenesis of infection: histamine and tumor necrosis factor alpha can be detected in the peritoneal cavity within minutes of challenge with an abscess-inducing mixture. However, the role of mast cells in host defense is made less clear by the finding of diminished abscess formation (but no mortality or increased morbidity) in mast-cell-depleted mice. This may indicate that mast cell products have a role in not only the initiation of an inflammatory response but also the promotion of fibrin deposition and abscess formation.

IL-2 mediates protection against abscess formation in an experimental model of sepsis.

Little is known regarding the mechanism by which T cells control intraabdominal abscess formation. Treating animals with polysaccharide A (PS A) from Bacteroides fragilis shortly before or after challenge protects against abscess formation subsequent to challenge with different abscess-inducing bacteria. Although bacterial polysaccharides are considered to be T cell-independent Ags, T cells from PS A-treated animals mediate this protective activity. In the present study, we demonstrate that CD4+ T cells transfer PS A-mediated protection against abscess formation, and that a soluble mediator produced by these cells confers this activity. Cytokine mRNA analysis showed that T cells from PS A-treated animals produced transcript for IL-2, IFN-gamma, and IL-10, but not for IL-4. The addition of IL-2-specific Ab to T cell lysates taken from PS A-treated animals abrogated the ability to transfer protection, whereas the addition of Abs specific for IFN-gamma and IL-10 did not affect protection. Finally, administration of rIL-2 to animals at the time of bacterial challenge prevented abscess formation in a dose-dependent manner. These data demonstrate that PS A-mediated protection against abscess formation is dependent upon a CD4+ T cell-dependent response, and that IL-2 is essential to this immune mechanism.