Key Clinical MessagePrimary cutaneous mucormycosis due to Saksenaea vasiformis is a rare clinical manifestation and the actual number of the disease condition is underestimated due to lack of sporulation in the absence of molecular diagnosis. Combination therapy of antifungal and repetitive debridement is mandatory in curing the patients.
Burkholderia cepacia complex (BCC) is an opportunistic pathogen in immunocompromised patients and well distributed in the natural environment. Nosocomial outbreaks of BCC are due to contaminated solutions and medical devices. However, in Sri Lanka, there have been no nosocomial outbreaks of BCC reported in the past. We report here an outbreak investigation of bacteraemia due to BCC in the wards and ICUs of the National Hospital of Sri Lanka (NHSL) during the period of August 14 th 2017 to September 13 th 2017 which an extensive investigation traced to a contaminated nebulizer solution of a particular brand of ipratropium bromide. The blood culture isolates from the patients with bacteraemia and from the particular nebulizer solution were found to be identical and confirmed as BCC. There had been outbreaks in other hospitals with the same organism in the recent past but they were not able to find the common source for the outbreak. The incident was reported officially to the relevant authorities and other hospitals, and an alternative agent for the use of nebulization was strongly recommended to prevent further cases immediately.
BackgroundBacteremia following Staphylococcus aureus is a serious clinical condition which is often associated with distant metastatic infections. One of the most dreaded complications of Staphylococcus aureus bacteremia is infective endocarditis. Cloxacillin is a common antibiotic prescribed for suspected staphylococcal infections and confirmed methicillin-sensitive Staphylococcus aureus infections. Prolonged use of cloxacillin may lead to neutropenia.Case presentationA 38-year-old Sinhalese man presented to Teaching Hospital Kurunegala, Sri Lanka, complaining of a 3-week history of fever; he was found to have a pansystolic murmur over the apex of his heart. He had leukocytosis with predominant neutrocytosis. His C-reactive protein was 231 mg/l and erythrocyte sedimentation rate was 100 mm/first hour. Transthoracic two-dimensional echocardiography revealed prolapsed mitral valve with 7 × 13 mm vegetation over the posterior mitral valve. On the following day, three blood cultures became positive and were subsequently identified as Staphylococcus aureus. Intravenously administered cloxacillin 3 g 6 hourly was started. Following day 24 of intravenously administered cloxacillin, our patient developed high spike fever. His total white blood cells were: 990/mm3 with 34% neutrophils and 22% eosinophils. His hemoglobin concentration was 9.5 g/dL and platelet count remained normal (202 × 106/mm3). His C-reactive protein was 78 mg/l, erythrocyte sedimentation rate was 95 mm/first hour, and he was otherwise comfortable, showing no signs of sepsis beside the high grade fever. His serum was negative for filarial and Toxoplasma antibodies while stool was negative for oocytes and amoebic cysts. Further, his serum was negative for dengue virus, Epstein–Barr virus, cytomegalovirus, and hepatitis B antibodies. He was clinically well on day 6 after stopping cloxacillin with 44% neutrophils and 18% eosinophils. His C-reactive protein and erythrocyte sedimentation rate became normal, and there was no further plan for cardiothoracic intervention or administration of antimicrobials. He was discharged from hospital and remained well 6 months later.ConclusionThis case report signifies the potential fatal adverse effect of cloxacillin in methicillin-sensitive Staphylococcus aureus infections. Leukopenia is associated with prolonged use of high doses of cloxacillin. In addition to transthoracic two-dimensional echocardiography and inflammatory markers, sequential white blood cells and differential counts would help clinicians to assess the prognosis of patients with infective endocarditis.
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