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Background: Hemorrhagic fever with renal syndrome (HFRS) is a viral, natural focal infection that is currently relevant for many countries of the world and ranks high among zoonotic viral infections in the Russian Federation. The purpose of our work was to present the main stages of the discovery and study of HFRS: from registration of the first clinical cases of the disease by military doctors in the east of our country to the current level of research. Materials and methods: We analyzed scientific literature devoted to the discovery of HFRS and further studies of this natural focal disease. Results: The discovery of many natural focal infections that are still relevant today in the Russian Federation coincided with the beginning of the rapid exploration and development of the Far East in the 1930s. Long-term studies of Soviet and foreign scientists helped systematize knowledge about viral etiology, clinical picture, pathophysiology, and pathomorphology of hemorrhagic nephrosonephritis and isolate the Hantaan virus, the etiological agent of HFRS (Lee HW, 1978). World famous Soviet virologists A.A. Smorodintsev and M.P. Chumakov, local scientists, doctors, and employees of the Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing made a significant contribution to the research into etiology, terminological consistency, epidemiology, and epizootology of HFRS. Conclusion: At present, the study of various aspects of hantavirus infections is one of the main tasks of the Research Institute of Epidemiology and Microbiology named after G.P. Somov. The research continues to establish the mechanisms of functioning of the natural foci of orthohantaviruses at different phases of the population cycles of their main carriers and in different landscape zones of the Russian Far East. A search for new species of orthohantaviruses, their natural reservoirs, and novel antiviral biologically active substances of natural and synthetic origin against orthohantaviruses is going on.

Periodontitis is one of the most common human chronic inflammatory diseases and about 11% of adults develop its clinicalsigns. Untreated periodontitis ultimately leads to inflammation and destruction of the periodontium leading to the lossof the teeth. Periodontitis is considered as a dental focal infection. The foci can influence other diseases in different areasof the body through different pathways. Diseases and conditions such as cardiovascular disease, diabetes mellitus,rheumatoid arthritis, gastric ulcer, pregnancy complications and respiratory diseases such as aspiration pneumonia andchronic obstructive pulmonary disease (COPD) have been proven to be affected by the condition of the periodontium.COPD is an inflammatory disease characterized by progressive deterioration of pulmonary function and increasingairway obstruction, including chronic bronchitis and emphysema. It has a worldwide prevalence in adults at the age of40 years or older in about 9%–10%, and it is currently the third leading cause of death worldwide. In addition, the incidenceand mortality of COPD are continually increasing. An observational study found that 97% of a COPD cohort hadat least one other comorbidity, with 50% having at least four. This impacts the health care costs of COPD patients withmultiple comorbidities that are 4,7 times higher than those with no comorbidity.As periodontitis and COPD are both chronic, progressive conditions characterized by neutrophilic inflammation withsubsequent proteolytic destruction of connective tissue, it has been proposed that they share common pathophysiologicprocesses. Several mechanisms have been proposed to explain the association of periodontal disease and COPD. Assummarized by the European Federation of Periodontology and American Academy of Periodontology (EFP/AAP), COPDinflammatory status may be modified either by aspiration of bacteria from the oral cavity and/or haematogenous disseminationof inflammatory mediators and plaque organisms from periodontal pockets. The present review of literature aimsto investigate the potential connection between periodontal disease and COPD.

Palmoplantar pustulosis is a chronic inflammatory disorder characterized by sterile pustules predominantly involving the palms and soles. Palmoplantar pustulosis has many similar aspects to psoriasis, either plaque and pustular type, namely familial occurrence between palmoplantar pustulosis and psoriasis, the appearance of the Köbner phenomenon, joint involvement, and nail involvement. Pustular psoriasis is classified into generalized and localized types, and there are a number of papers regarding palmoplantar pustulosis as an acral variant of localized pustular psoriasis. Many Japanese dermatologists consider palmoplantar pustulosis to be a distinct entity from pustular psoriasis, and the coexistence of palmoplantar pustulosis and psoriasis is rare. However, outside Japan, palmoplantar pustulosis is often considered to be palmoplantar psoriasis or palmoplantar pustular psoriasis, and extra-palmoplantar lesions are also considered to be psoriasis. The purpose of the current review is to compare the similarities and differences between palmoplantar pustulosis and generalized/localized pustular psoriasis. Japanese patients with palmoplantar pustulosis have a close relationship with focal infection, and the associated bone-joint manifestation exclusively involves the anterior chest wall. Furthermore, pediatric occurrence of palmoplantar pustulosis is extremely rare, and difference of genetic background between palmoplantar pustulosis and psoriasis has also been reported. Treatment of focal infection often results in dramatic effects on both cutaneous lesions and joint pain of palmoplantar pustulosis. Those findings suggest that palmoplantar pustulosis should be separately considered from either palmoplantar psoriasis or palmoplantar pustular psoriasis. The clinicopathological features and therapeutic approach of both diseases are discussed.

Introduction and objectives Cardiac device-related infections (CDRI) may be life-threatening and require early and accurate diagnosis. The aims of this study were to analyze the performance of positron emission tomography-computed tomography (PET/CT) in suspected CDRI, to assess changes to the initial diagnosis, and to identify a clinical subgroup deriving the greatest benefit from this imaging modality. Methods Retrospective study including patients evaluated by PET/CT for suspected CDRI from 2011 to 2018. We assessed PET/CT performance and the agreement between the initial, post-PET and definitive diagnoses. We also assessed changes in the diagnosis, depending on initial clinical suspicion, to identify patients deriving the greatest benefit from PET/CT. Results We included 44 patients. The prevalence of endocarditis was 57%. The sensitivity and specificity of PET/CT for the diagnosis of infective endocarditis were 0.84 and 0.95, respectively. Post-PET diagnosis improved the initial diagnosis by 45%. PET/CT correctly reclassified 57% of patients with initial suspicion of generator pocket infection by detecting lead infection. Conclusions PET/CT showed high diagnostic performance in suspected of CDRI and significantly improved the conventional diagnostic approach, especially in patients with initial suspicion of focal infection.

Gram-negative bacteremia secondary to focal infection such as skin and soft-tissue infection, pneumonia, pyelonephritis, or urinary tract infection is commonly encountered in hospital care. Current practice guidelines lack sufficient detail to inform evidence-based practices. Specifically, antimicrobial duration, criteria to transition from intravenous to oral step-down therapy, choice of oral antimicrobials, and reassessment of follow-up blood cultures are not addressed. The presence of bacteremia is often used as a justification for a prolonged course of antimicrobial therapy regardless of infection source or clinical response. Antimicrobials are lifesaving but not benign. Prolonged antimicrobial exposure is associated with adverse effects, increased rates of Clostridioides difficile infection, antimicrobial resistance, and longer hospital length of stay. Emerging evidence supports shorter overall duration of antimicrobial treatment and earlier transition to oral agents among patients with uncomplicated Enterobacteriaceae bacteremia who have achieved adequate source control and demonstrated clinical stability and improvement. After appropriate initial treatment with an intravenous antimicrobial, transition to highly bioavailable oral agents should be considered for total treatment duration of 7 days. Routine follow-up blood cultures are not cost-effective and may result in unnecessary healthcare resource utilization and inappropriate use of antimicrobials. Clinicians should incorporate these principles into the management of gram-negative bacteremia in the hospital.

BACKGROUND Dental focal infection-induced ventricular and spinal canal empyema is an extremely rare, severe, acute disease that is clinically associated with extremely high morbidity and mortality. Traditional cerebrospinal fluid (CSF) bacterial culture is time-consuming, with a low positive rate, which frequently results in severe irreversible consequences. The next-generation sequencing technique is an emerging pathogenic microorganism detection method that can obtain results in a short time with high accuracy, thus providing great assistance in the clinical diagnosis and treatment of this disease. CASE SUMMARY This paper reports a rare case of dental focal infection-induced ventricular and spinal canal empyema. During the course of treatment at a local hospital, the patient had negative results from repeated CSF bacterial cultures and was empirically given vancomycin treatment. After transfer to our hospital, the next-generation sequencing technique was adopted to determine that the pathogenic microorganisms were multiple anaerobic infectious bacteria derived from the oral cavity. The antibiotic therapeutic scheme was adjusted in a timely manner, and the ventricular and spinal canal inflammation was also controlled. However, the antibiotics that had been applied at the local hospital were not able to cover all pathogenic microorganisms, which resulted in irreversible injury to the brain stem, finally leading to patient death. CONCLUSION Dental focal infection-induced ventricular and spinal canal empyema is an extremely rare, severe, acute disease with high morbidity and mortality. Any delay in diagnosis and treatment will result in irreversible consequences. The early application of the next-generation sequencing technique can obtain results in a short time and clarify a diagnosis. Appropriate antibiotic treatment combined with suitable surgical intervention is the key to managing this disease.

OBJECTIVES: This study aimed to determine the burden of sepsis with focal infections in the resource-limited context of Indonesia and to propose national prices for sepsis reimbursement.METHODS: A retrospective observational study was conducted from 2013-2016 on cost of surviving and non-surviving sepsis patients from a payer perspective using inpatient billing records in four hospitals. The national burden of sepsis was calculated and proposed national prices for reimbursement were developed.RESULTS: Of the 14,076 sepsis patients, 5,876 (41.7%) survived and 8,200 (58.3%) died. The mean hospital costs incurred per surviving and deceased sepsis patient were US$1,011 (SE ± 23.4) and US$1,406 (SE ± 27.8), respectively. The national burden of sepsis in 100,000 patients was estimated to be US$130 million. Sepsis patients with multifocal infections and a single focal lower-respiratory tract infection (LRTI) were estimated as being the two with the highest economic burden (US$48 million and US$33 million, respectively, within 100,000 sepsis patients). Sepsis with cardiovascular infection was estimated to warrant the highest proposed national price for reimbursement (US$4,256).CONCLUSIONS: Multifocal infections and LRTIs are the major focal infections with the highest burden of sepsis. This study showed varying cost estimates for sepsis, necessitating a new reimbursement system with adjustment of the national prices taking the particular foci into account.

There are over 850,000 people living with dementia in the UK and this figure is expected to rise to over a million by 2021. Increasingly, oral healthcare professionals in primary care will see more patients affected by dementia at varying stages of the disease, and it is therefore crucial that they have a basic understanding of the disease and how these patients can be managed in a primary care environment. The first article in this series of two provides a definition of dementia and describes the symptoms of the disease along with the key issues related to oral health, such as oral pain. Oral pain can have far reaching consequences, but identifying it can be problematic, particularly in the latter stages of the disease. This article will therefore cover how to diagnose pain in patients with dementia. Information is also provided about how to make dental surgeries more ‘dementia friendly’.

Abstract: Billions of microorganisms can be found in the oral cavity, from which bacteria are the most frequent. More than 600 bacterial species can be isolated. Most of them are harmless, moreover, some species prove themselves to be specifically useful. However, in the case of a weakened immune status or inappropriate oral hygiene, they may cause many types of soft and hard tissue disorders. Caries and periodontal diseases are the most common bacterial diseases of the oral cavity. In both cases, the dental biofilm gives rise to the disorder, which is caused by the insufficient oral hygiene. Dental caries are mainly caused by cariogenic streptococci and lactobacilli. In the case of serious periodontal diseases, anaerob parodonto-pathogen microorganisms play the major role. Untreated caries may result in the necrosis of the pulp, which can cause an inflammation expanding towards the parodontium. This can be characterized as a focal infection, like the untreated periodontal pockets. Dental foci may have lots of systemic consequences such as cardiovascular diseases, diabetes, pneumonia, arthritis, preterm birth and alopecia areata. When these diseases occur, dental foci should always be considered. The professional plaque control and chlorhexidine rinsing before the proposed surgeries have an outstanding role in the prevention of ventilator-associated pneumonia. Oral cancer is multicausal; more and more researchers are analyzing the role of certain bacteria in the carcinogenesis of oral cancer. In addition to the mentioned clinical aspects, we are planning to describe the relatively rare, but diverse and diagnostically challenging bacterial soft tissue disorders in another publication. Orv Hetil. 2019; 160(19): 739–746.

Background Correctly identifying anaerobic bloodstream infections (BSIs) is difficult. However, a new technique, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), enables more accurate identification and appropriate treatment. Anaerobic BSIs identified by MALDI-TOF MS were retrospectively analyzed to determine the clinical and microbiological features and patient outcomes based on the anaerobic genera or group. Methods Medical records of patients with anaerobic BSIs were used to conduct a single-center retrospective cohort study from January 2016 to December 2020 in Nagoya, Japan. Multivariate logistic regression analysis was performed to determine the independent risk factors for in-hospital mortality. Results Of the 215 patients with anaerobic BSIs, 31 had multiple anaerobic organisms in the blood culture, including 264 total episodes of anaerobic BSIs. Bacteroides spp. were isolated the most (n = 74), followed by gram-positive non-spore-forming bacilli (n = 57), Clostridium spp. (n = 52), gram-positive anaerobic cocci (GPAC) (n = 27), and gram-negative cocci (n = 7). The median patient age was 76 years; 56.7% were male. The most common focal infection site was intra-abdominal (36.7%). The in-hospital mortality caused by anaerobic BSIs was 21.3%, and was highest with Clostridium spp. (36.5%) and lowest with GPAC (3.7%). Age, solid tumors, and Clostridium spp. were independent risk factors for in-hospital mortality. Conclusions We identified current anaerobic BSI trends using MALDI-TOF MS and reported that mortality in patients with anaerobic BSIs patients was highest with Clostridium spp. infections.

BACKGROUND Rapid detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in hospitals is essential for early isolation and treatment. However, false positive test results can have adverse consequences for patient safety. CASE PRESENTATION A man in his eighties was admitted to hospital with fatigue and new-onset gait and balance difficulties, without fever or symptoms of focal infection, but with elevated C-reactive protein. On admission, he tested positive on screening for SARS-CoV-2 using a fully automated rapid reverse transcription polymerase chain reaction (RT-PCR) test. He was placed together with two patients with confirmed COVID-19 infection in cohort isolation. Due to very low exposure risk and nonspecific symptoms, the primary and multiple subsequent test swabs were analysed using RT-PCR analyses guided by laboratory personnel, and all gave negative results. The patient had several risk factors for developing severe COVID-19 illness, but fortunately he remained COVID-19 negative on repeated tests. INTERPRETATION The case presentation highlights the danger of false-positive SARS-CoV-2 test results, and the importance of interpreting a diagnostic test in the context of pretest probability and test accuracy. It also underlines the risk of using cohort isolation instead of individual isolation.

Objective Patients with severe infection or sepsis require fast identification of the focus and prompt eradication. This study aims at investigating the role of body computed tomography (CT) and identifying outcome predictors in a general ward setting of patients with obscure infection. Methods We retrospectively identified 196 consecutive body CTs acquired in 179 patients with obscure infection, i.e. severe infection or sepsis from general wards with unclear focus, over 12-months in the year 2018. Reports were extracted using a full-text search in the radiological information system (RIS) of a large university medical center. CT reports were classified according to diagnostic confidence of the reader (i.e. certain, likely, possible, no focus), and correlated with clinical and laboratory parameters. The discharge diagnosis was set as the diagnostic reference standard. Contingency tables were prepared for statistical analysis with Chi-squared test amongst other analyses and the calculation of AUC statistics. Results In 133 out of 196 (67.9 %) body CTs from general wards with severe infection or sepsis, body CT identified an infectious focus. 90 % of the infections were located in the chest, abdomen, and genitourinary tract, in descending order. In 76.5 % (150 of 196) of examinations, CT correctly predicted the final infectious source. The positive predictive value (PPV) of a CT-detected focus was 84.2 % (95 % CI 79.0%–88.3%). A high diagnostic confidence of the reader resulted in a PPV of 96.4 % (95 % CI 87.4%–99.1%) while a low confidence resulted in a PPV of 63.3 % (95 % CI 48.2%–76.3%). Conclusion In patients with obscure infection treated in general wards, body CT detects the infectious source with a high positive predictive value. Focus detection accuracy highly depends on the diagnostic confidence of the CT reader.

The aim of this study was to comprehensively review our experience with odontogenic infections in the head and neck region requiring treatment at a national referral center. We retrospectively reviewed 85 patients treated at the Chair and Clinic of Maxillofacial Surgery of the University Hospital in Wrocław between January 2018 and June 2019. We excluded patients with nonondontogenic infections or other than purulent clinical forms of dentivitis in the head and neck region. Several demographic, clinicopathological, and treatment variables were assessed. The majority of patients were men who were referred for inpatient treatment by a dentist or family doctor, presented to the Hospital Emergency Ward (SOR) by themselves, or transported to the SOR by paramedics SOR from their home or another hospital. All patients were treated in accordance with the current guidelines for head and neck region odontogenic infections. An incision was made and the abscess was drained. The odontogenic cause was removed followed by the collection of tissue for microbiological examination. The course of infection was monitored by means of laboratory parameters such as leukocyte counts and c-reactive protein levels. Odontogenic infections in the head and neck region are a persistent and common problem. Rapid, accurate diagnosis and treatment minimizes the risk of life-threatening complications, shortens the hospitalization period, and lowers treatment costs.

Dental focal infections are extraoral manifestations caused by oral pathogens. Pathological oral conditions, such as periapical inflammation and periodontitis, can cause bacteremia. Dissemination of oral pathogens to nonoral sites can subsequently cause infections in extraoral tissues and organs. Cardiovascular infections and brain abscesses are the most common of these. The course of such infections can be lethal. In order to improve patient care, a closer collaboration between dental and medical caregivers is necessary.Dentale focale infecties zijn extraorale ontstekingen die worden veroorzaakt door orale pathogenen. Orale aandoeningen als periapicale ontsteking of parodontitis kunnen bacteriëmie veroorzaken. Disseminatie van orale pathogenen kan vervolgens leiden tot infecties in extraorale organen en weefsels. Hierbij komen cardiovasculaire infecties en hersenabcessen het meest frequent voor. Dergelijke infecties kunnen levensbedreigend verlopen. Om de patiëntenzorg te kunnen verbeteren is intensievere samenwerking tussen tandheelkundige en geneeskundige zorgverleners noodzakelijk.

Background/Purpose To present clinical and laboratory features, treatment options, and outcome in patients with brucellar testicular infection and to compare them with analogous in brucellar patients without testicular involvement. Methods Thirty four brucellar patients with testicular infection treated in two general hospitals in the Republic of Macedonia, during the period 1998–2009, were retrospectively analyzed. Their clinical and laboratory characteristics were compared with analogous in 364 male brucellar patients without testicular infection, who were treated at the same hospitals during the same time period. Results Brucellar testicular infection was evident in 34 (8.5%) out of 398 male patients with brucellosis. The median age of the patients was 46.5 years. In all patients testicular involvement was presented as an acute form with a median duration of 5 days (range, 2–14 days) prior to diagnosis. Twenty-three of the patients had at least one other simultaneous focal infection. After starting with the treatment testicular infection lasted a median 10 days, range 7–21 days. Brucellar patients with testicular infection when compared with other brucellar patients more frequently manifested fever (97% vs. 61%), concomitant spondylitis (32% vs. 16%), and urinary system involvement (12% vs. 2%). Also, the relapse rate in patients with testicular involvement was significantly higher (24% vs. 9%). Conclusion In endemic regions brucellosis should be taken into consideration in any patient with testicular infection. Brucellar testicular involvement is usually characterized with a severe acute clinical presentation and a high percentage of relapses which entails the need of timely recognition and proper treatment duration of at least 60 days.

OBJECTIVE To further characterize clinical characteristics, etiologic factors, associated disorders, and treatment of palmoplantar pustulosis (PPP). PATIENTS AND METHODS We conducted a retrospective review of patients with PPP at Mayo Clinic between January 1, 1996, and December 31, 2013. RESULTS Of 215 patients with PPP identified, 179 (83%) were female, and the mean age at onset was 45.3 years. Most patients (n=165, 77%) were current or former smokers. At diagnosis, 15 patients (7%) had an anxiety diagnosis and 9 (4%) had an infection. Nineteen cases (9%) were drug induced. Comorbid conditions included thyroid disease in 18 patients (8%), gluten sensitivity in 3 (1%), and type 2 diabetes mellitus in 21 (10%). In all, 194 patients (90%) received topical corticosteroids, 55 (26%) received phototherapy, and 54 (25%) received systemic agents. CONCLUSION More than three-fourths of the patients in this study had a history of smoking, which is considered a triggering or aggravating factor for PPP. Regarding comorbid conditions, gluten sensitivity and thyroid disease were found less frequently than previously reported in the literature. Treatment regimens and responses in this cohort varied considerably.

Both metal allergy and dental focal infection have been considered as causative factors for palmoplantar pustulosis, and several case reports described that the skin lesions were ameliorated after dental metal removal or dental infection control. However, limited data are available to evaluate the association of these factors with disease severity of palmoplantar pustulosis. This study is designed to analyze the clinical outcome of 85 palmoplantar pustulosis patients after dental infection control (n = 70), tonsillectomy (n = 6) and dental metal removal (n = 9). More than half of the patients (63%, 44/70) showed positive clinical outcome after dental infection control. The skin lesions of all patients with tonsillitis were improved after tonsillectomy (100%, 6/6). On the other hand, one-third of patients (33%, 3/9) showed positive response after dental metal removal. These results suggest that focal infection is more closely associated with palmoplantar pustulosis than dental metal allergy. According to our findings, palmoplantar pustulosis patients should be preferentially examined for focal infections.

A 69-year-old woman with orbital cellulitis secondary to odontogenic Streptococcus constellatus was transferred to the authors' institution for surgical management of infection refractory to intravenous antibiotics. She underwent debridement with preservation of the globe, recovering full motility. Visual recovery was limited by optic nerve ischemia. This case supports the importance of urgent surgical drainage in necrotizing orbital infections secondary to odontogenic Streptococcus constellatus.

Background Descending necrotizing mediastinitis is life-threatening and extends into the deep cervical fascia including the pretracheal, perivascular and retrovisceral, and prevertebral spaces. Deep cervical and paratracheal drainage via a transcervical approach prevents the spread of infection into the deep mediastinum. It is effective for local neck drainage and important in the primary treatment of descending necrotizing mediastinitis. Transthoracic mediastinal drainage is also effective for treating this condition. Methods Nine patients with descending necrotizing mediastinitis were treated by deep cervical and paratracheal drainage via a transcervical approach at our institution from April 2007 to December 2017. Four patients with diagnoses of extensive descending necrotizing mediastinitis had progressive extension of abscesses into the lower mediastinum, below the level of the carina. The other five had localized descending necrotizing mediastinitis with infection in the upper mediastinum above the level of the carina. Results All 9 patients (4 with extensive and 5 with localized descending necrotizing mediastinitis) initially underwent deep cervical and paratracheal drainage via a transcervical approach, and all recovered. Two of the patients with extensive infection required no additional surgical intervention. Conclusions Fluid collections in the deep cervical fascia must be drained urgently. Deep cervical and paratracheal drainage via a transcervical approach effectively controls all types of descending necrotizing mediastinitis, and it is less invasive than transthoracic approaches via thoracotomy. However, a thoracotomy for mediastinal drainage must be considered if infection is not controlled by transcervical drainage. Thoracic surgeons and otolaryngologists must plan efficacious treatment before surgical procedures for descending necrotizing mediastinitis.

Non-typhoidal Salmonella (NTS) spp. causes about 40% of all infective aortitis and it is characterized by high morbidity and mortality. Human infection occurs by fecal-oral transmission through ingestion of contaminated food, milk, or water (inter-human or zoonotic transmission). Approximately 5% of patients with NTS gastroenteritis develop bacteremia and the incidence of extra-intestinal focal infection in NTS bacteremia is about 40%. The organism can reach an extra-intestinal focus through blood dissemination, direct extension from the surrounding organs and direct bacterial inoculation (e.g. invasive medical procedures). Medical and surgical interventions are both needed to successfully control the infection. Here, we report a case of abdominal sub-renal aortitis caused by Salmonella enterica serovar Enteritidis in an 80-year-old man.

Salmonella in a breast abscess is uncommon, and Salmonella paratyphi A causing breast abscess is a rare entity. It has been reported post immunosuppression. We report here a 35-year-old woman with breast abscess caused by S. paratyphi A without obvious enteric fever-like symptoms. The case was managed with combined surgical and medical approach to treat the aetiology and focal infection.

Palmoplantar pustulosis (PPP) is a chronic inflammatory disorder characterized by sterile pustules predominantly involving the palms and soles. The purpose of this review was to describe the characteristics of Japanese PPP patients as PPP is frequently observed within the Japanese population. Most Japanese dermatologists consider PPP a distinct entity, and co-existence of PPP and psoriasis is rare; however, outside Japan, PPP is often considered to be palmoplantar psoriasis, and an extra-palmoplantar lesion associated with PPP is considered to be psoriasis. PPP frequently develops or exacerbates following focal infections such as tonsillitis, odontogenic infection, and sinusitis, either with or without arthralgia. Pustulotic arthro-osteitis (PAO) is a major comorbidity of PPP, most often affecting the anterior chest wall. In Japanese patients, PAO is frequently seen, whereas cases of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome with symptoms other than PPP and sternocostoclavicular joint pain are extremely rare. A difference in incidence depending on race suggests that different genetic backgrounds may be responsible for susceptibility to these disorders. The treatment of focal infections often results in dramatic effects on cutaneous lesions, as well as joint pain. The characteristics of Japanese patients with PPP are female predominance, mostly smokers, rare co-existence with psoriasis, frequent association with PAO, almost no accompanying celiac disease, and closely associated with focal infection. PPP should be separately considered from palmoplantar psoriasis.

The article deals with problems of diagnostics and therapy of purulent and inflammatory pathology of ENT-organs. The authors consider major reasons of acute focal infection of ENT-organs as well as factors contributing to inflammation chronization. The article provides data on the most popular causative agents of purulent and inflammatory ENT-organs diseases, peculiarities of microbe biocenoses of ENT-organs in normal conditions and in case of concomitant diseases, issues of rational antibacterial therapy are considered with use of short high-dosage courses of antimicrobial drugs.

PURPOSE: Data on the systemic dissemination in Staphylococcus aureus bloodstream infection (SAB) remain sparse. We investigated the timing and the sequence of clinical symptoms, diagnostic confirmation, and occurrence of multiple infective foci in relation to three major infective foci.METHODS: From 2006 to 2011, all adult patients with first-time SAB in Cologne and Freiburg, Germany were followed prospectively. The study was restricted to patients with short-term central venous catheter (CVC)-related SAB, vertebral osteomyelitis (VO), and infective endocarditis (IE). The collection date of the first positive blood culture was used as reference point for determining time to onset of clinical symptoms, microbiological findings, imaging results compatible with focal infection, and occurrence of additional infective foci.RESULTS: We included 266 patients with first-time SAB. Among patients with CVC-related SAB, clinical onset, collection of the first positive blood culture, and microbiological confirmation almost coincided. In contrast, among patients with VO or IE, the onset of clinical symptoms most often preceded the collection of the first positive blood culture, and imaging and microbiological confirmation were most frequently obtained subsequent to the SAB diagnosis. CVC-related SAB was infrequently associated with further foci (n = 15/15.5%). Conversely, more than one infective focus was observed in 44 (56.4%) patient with VO and 68 (64.8%) patients with IE.CONCLUSIONS: The sequence of clinical symptoms, diagnostic confirmation, and occurrence of multiple infective foci varied considerably with different infective foci in SAB. Based on these results, we propose a pragmatic and evidence-based terminology for the clinical course of SAB and suggest the terms "portal of entry", "infective focus", "multiple infective foci", and "dominant infective focus".

Solid organizing hepatic abscess is a rare form of focal infection, which needs differentiation from benign and malignant solid masses. We report a case of a 30-year-old man with a solid organizing hepatic abscess, diagnosed by imaging andex juvantibuscriteria. CT and MRI findings are presented and role of DWI is outlined. Noninvasive diagnosis of a solid organizing hepatic abscess is possible in the appropriate clinical setting; percutaneous or surgical biopsy may be indicated in equivocal cases.

A cerebral abscess (focal infection of brain parenchyma) carries a high mortality and morbidity. Iatrogenic cerebral abscesses are less common and make up 10% of all cases. The presence of a cerebral abscess can rarely improve a patient’s prognosis and quality of life, however this case illustrates an abscess and its treatment following a prolonged course of antibiotics leading to resolution of a severe psychotic disorder. This is a case report of a 32-year-old female inpatient at a psychiatric hospital with a long-standing history of congenital hydrocephalus, cerebral palsy and organic delusional disorder who developed an iatrogenic cerebral abscess after insertion of an implantable intracranial pressure monitoring device. After receiving treatment of 6 weeks of intravenous meropenem the patient’s mental condition rapidly improved, she became stable and euthymic and was discharged home. The patient has since had no delusions or hallucinations and is living independently at home.

Acute focal bacterial nephritis (AFBN) is a rare, acute focal infection of the renal parenchyma without liquefaction. The pathogenesis is thought to be due to hematogenous infection or ascending infection from the lower urinary tract. Escherichia coli has been the major pathogen isolated in prior cases, but other Gram-negative enteric pathogens and Staphylococcus aureus have been reported as well. It is well described in children and adults with diabetes and organ transplantation, but has not been previously reported in healthy adults. We report a case of an immunocompetent adult female who presented with a methicillin-resistant Staphylococcus aureus bacteremia after a skin and soft tissue infection that resulted in AFBN.

Keratin-specific immune responses in tonsils may be associated with the pathogenesis of pustulosis palmaris et plantaris (PPP). Evaluation of keratin-specific immune responses in tonsils might be useful to predict the effectiveness of tonsillectomy for patients with PPP.The aim of the present study was to clarify the role of keratin-specific immune responses in the pathogenesis of PPP in tonsils. It has been reported that anti-keratin antibodies in serum were higher in patients with PPP and decreased after tonsillectomy, indicating that anti-keratin antibodies might be generated in tonsils.In order to demonstrate the presence of keratin-specific immune responses in tonsils, the numbers of keratin-specific antibody-forming cells (AFCs) in tonsillar and peripheral blood lymphocytes were examined by enzyme-linked immunospot assay. The prognosis of PPP was compared after tonsillectomy.The numbers of keratin-specific IgM and IgG AFCs in tonsils and of IgG AFCs in peripheral blood were significantly increased in patients with PPP. The numbers of keratin-specific IgG AFCs in peripheral blood correlated positively with tonsil and serum IgG antibodies specific to keratin. Our data show that a good prognosis in patients with PPP depended on the numbers of keratin-specific IgG and IgM AFCs in peripheral blood and the levels of keratin-specific IgG antibodies in serum being significantly decreased 6 months after tonsillectomy.

Odontogenic abscess can become an orbital cellulitis, causing potentially serious intracranial and orbital complications. The full clinical complications from odontogenic orbital cellulitis in a pediatric patient are rarely seen daily in hospital emergency departments. Thus, odontogenic orbital cellulitis still remains a rarity, resulting in a medical challenge. With this in mind, this study aimed to describe a case of periorbital and orbital cellulitis resulting from odontogenic origin in a 6-year-old patient who was successfully treated by performing intravenous antibiotic administration combined with surgical drainage.

Non-typhoidal Salmonella, particularly Salmonella enterica serovar typhimurium is food borne pathogen causing mild self-limiting diarrhoea in healthy adults. It can occasionally cause extraintestinal focal infection in susceptible patients. Salmonella, as the aetiological agent of osteomyelitis and septic arthritis is rare and has been mostly reported in patients with sickle cell disease or thalassaemia. We report a case of septic arthritis by Salmonella typhimurium in an immunocompromised patient who was successfully treated following timely isolation and identification of the aetiological agent.

The possibility of a connection between oral infection and systemic health was suggested already during the nineteenth century [1] and a discussion on the oral focal infection theory continued, a d...

Introduction: Cervical necrotizing fasciitis is a rare but very severe infection that affects the soft‑tissues of the cephalic extremity. Cervical necrotizing fasciitis most frequently occurs secondarily to inflammatory odontogenic disorders and represents the most severe infection of maxillofacial spaces, with a high lethal potential.Materials and Methods: In this study, we selected 55 patients with confirmed cervical necrotizing fasciitis of odontogenic origin, treated in the Clinic of Oral and Maxillofacial Surgery in Cluj‑Napoca during January 1996-December 2012.Results: In the majority of cases, the disease evolved without the presence of associated systemic disorders (60% [45.49- 72.69]), the rest of the patients having 1-4 types of systemic disorders; type 2 diabetes mellitus was the most frequent type of underlying systemic disorder. From the appearance of the first symptoms until the presentation for treatment, a time interval of 2-30 days elapsed. During this time period, 78.18% (95% confidence interval [CI] [65.49 89.06]) of the patients received antibiotic treatment, but without results. Mandibular molars were the most frequent starting point of the disease, and the submandibular space was the first affected by the disease, 47.27% (95% CI [32.76-61.79]). Bacteriological exams showed that facultatively aerobic/anaerobic G + bacteria were the most frequently identified (72.22% [58.21-83.60]).Conclusion: The odontogenic lesions of the lower molars, complicated by submandibular space infections, are the most frequent starting point of odontogenic cervicofacial necrotizing fasciitis. Delayed surgical treatment and strict antibiotic therapy play an important role in favoring the development of odontogenic necrotizing fasciitis.Keywords: Head and neck infections, necrotizing fasciitis, odontogenic infection

Aim To study the aetiology of bloodstream infections (BSI) in children 0–17 years, the influence of age and underlying co-morbidity on BSI rate, distribution of pathogens and outcome; and to provide data on antimicrobial susceptibility patterns. Methods A retrospective population-based study. Data on blood cultures were collected at yearly intervals during 1998–2008. Information about risk factors, focal infection and outcome was retrieved from the patient charts. Results We identified 1097 BSI. The incidence of BSI was 0.4/1000. The age-specific incidence was 2.3/1000 in neonates (0–28 days old) and 0.2/1000 in the age group 6–17 years. Staphylococcus aureus was the most common pathogen. The number of species causing BSI in previously healthy children was lower compared with children with co-morbidity. Most children requiring intensive care had a serious underlying illness. Antimicrobial resistance was rare and did not influence outcome. The case-fatality rate was 14.4% in neonates, 5.4% in children with co-morbidity and 1.7% in previously healthy children. Conclusion Mortality from BSI is low, and a limited spectrum of pathogens is isolated from previously healthy children compared with children with co-morbidity. When choosing empirical therapy for suspected BSI, age and presence of risk factors should be taken into account.

Background/PurposeNontyphoidal Salmonella (NTS) is a crucial pathogen in immunocompromised patients, especially those with connective tissue disease (CTD) and corticosteroid or immunosuppressant therapy. The aim of this study is to identify the clinical characteristics and outcomes of patients with CTD and NTS bacteremia, and the clinical variations between systemic lupus erythematosus (SLE) and other CTDs.MethodsDuring a 15-year study period, from 1994 to 2009, NTS bacteremia patients were reviewed from the database of clinical microbiology laboratory. Medical records were reviewed for clinical information and only patients with underlying CTD were included.ResultsFrom 1994 to 2009, there were 299 patients with NTS bacteremia. Forty-six (15.4%) patients had certain connective tissue diseases, and SLE was the major CTD, accounting for 73.9% (34) of 46 patients. In comparison with patients without CTD, the patients with CTD were younger (p

The purpose of this investigation was to analyze epidemiological patterns, clinical features and the management of odontogenic infections in patients undergoing treatment in a dental emergency outpatient care unit.A retrospective analysis of 58 161 case records of patients presenting to an emergency outpatient unit in Hamburg, Germany between 2000-2007 was performed. From this pool, patients with odontogenic infections were identified using an ICD-10 code, analyzing age, gender, medical co-morbidities, duration of pain, ratio of infiltrates/abscesses, affected teeth, management of infection and administered antibiotics.Of the 58 161 patients, 5357 (9.2%) were identified as having odontogenic infections, with 2689 (50.2%) inflammatory infiltrates and 2668 (49.8%) abscesses. Mean age was 34.8 ± 16.8 years. As the primary site of odontogenic infection, the most significantly affected teeth were the maxillary and mandibular first molars. Patients in age-group 20-29 years (25.1%) utilized the emergency care unit more frequently than other age groups. Clindamycin was the most frequently administered antibiotic.Early recognition, diagnosis and management of odontogenic infections are requisite for avoiding or minimizing the development of potential complications. Strategies and evidence-based protocols should be developed within the dental ambulatory care sector, advancing interdisciplinary cooperation between general dentists and oral or maxillofacial surgeons.

Numerous hypotheses have been suggested to explain the cause of sudden unexpected infant death, including infection. As part of the autopsy, routine ancillary investigations are performed, including blood/bile tandem mass spectrometry (TMS) primarily for detection of metabolic disease. The aim of this study was to evaluate and assess TMS derived acylcarnitine profiles to determine whether infectious deaths were associated with characteristic profiles. As part of a retrospective study including >2,500 pediatric autopsies at a single specialist centre over a 14 year period, acylcarnitine profiles were reviewed. Using multiple linear regression, standardised residuals were prepared and findings compared between different cause of death groups, including unexplained, focal infection, microbiological infection and accidental injuries. 415 blood samples from SUDI autopsies were identified. Statistically significant differences in TMS profiles were identified between those dying of infection and the unexplained SUDI group, including changes in free carnitine, short chain acylcarnitines and octanoylcarnitine. Cases with microbiological infection diagnosed only from postmortem cultures did not show any significant difference from the unexplained group. Postmortem TMS profiling identifies SUDI deaths which are associated with histological evidence of infection, and an acylcarnitine profile suggesting perturbation of oxidative metabolism. Such findings raise the possibility that more comprehensive TMS profiling may offer additional diagnostic clues beyond screening for metabolic disorders, and may contribute to determination of mode of death.

Oral infections commonly originate from an odontogenic source in adults and from tonsil and lymphatic sources in children. Odontogenic infections arise from advanced dental caries or periodontal disease. Oral trauma, radiation injury, chemotherapy mucositis, salivary gland infection, lymph node abscess, and postoperative infection are potential nonodontogenic sources of infections that could potentially be life threatening. This article reviews the serious nature and potential danger that exists from oral infection and the antibiotics available to treat them are reviewed. Successful treatment requires an understanding of the microflora, the regional anatomy, the disease process, the treatment methods available, and interdisciplinary team collaboration.

Corneal allograft rejection is known to have many risk factors, including ocular infection and inflammation. Although not reported in the literature, local nonocular inflammation may also have the ability to incite a graft reaction. We report 2 cases, one with dental inflammation and the other with a facial abscess, with simultaneous corneal transplant rejection. Possible pathophysiology and a review of the literature are given.

We document the aetiology of community-acquired bacteraemia in sickle-cell disease (SCD) patients and present clinical aspects of 11 cases of Salmonella bacteraemia. Prospective computerized records of all significant bacteraemic episodes presenting to our institution from 1969 to 2008 were analysed. Additional clinical information was drawn from hospital medical records. Six thousand three hundred and sixty-nine community-acquired bacteraemic episodes were documented, with 66 occurring in SCD patients. Salmonella species were the third most frequently isolated organism in SCD patients; 18% of bacteraemias in SCD patients were caused by Salmonella species vs 3% in non-SCD patients (p < 0.0001). Moreover, the proportion of community-acquired Salmonella bacteraemic episodes caused by non-Typhi species was significantly higher in SCD compared to other patients (p = 0.0015). Focal infection was identified in 7 of the 11 cases of Salmonella bacteraemia in SCD patients, with bone and joint accounting for 6 of these. Infection may have been acquired during travel to the tropics in 4 patients. Our study supports the view that SCD patients are particularly susceptible to Salmonella infection. These infections frequently require multiple surgical interventions and prolonged hospital stays. SCD patients should be advised to pay particular attention to food hygiene while travelling to the tropics.

Background/objectives: Nowadays, intracranial abscess is a rare complication of acute rhinosinusitis. The consequent orbital and intracranial complications of acute rhinosinusitis are rare but must be mutually excluded in complicated rhinosinusitis even when proper surgical and medical treatment tend to efficiently heal the orbital complication. Methods: We report a case of a patient who primarily revealed symptoms of orbitocellulitis as a complication of odontogenous rhinosinusitis. Proper diagnostic and therapeutical measures were undertaken to manage the disease immediately after stationary admission. We strongly rely on a literature review and recommendations on diagnosis and treatment of this possibly lethal complication in the discussion. Results: Two weeks after an inconspicuous healing period, hemiparesis due to formation of an intracranial abscess developed. An emergency situation revealed the unusual character of the clinical situation. In a literature review concerning intracranial complication after acute rhinosinusitis, we demonstrate the complexity of this complication. We indicate the predisposing factors, diagnostic measures and treatment strategy. Conclusion: The possible role of underlying mechanisms of intracranial abscess formation is discussed. The correct indication of imaging methods and accurate evaluation of diminutive symptoms are essential. We recommend performing a complementary CT of the brain or MRI, even when a previous CT scan of the orbit/paranasal sinuses reveals no cerebral pathology, to avoid or minimize the number of future patients with consecutive orbital and intracranial complications of acute rhinosinusitis.

BACKGROUND: Well-appearing young infants with focal bacterial infections present to the emergency department (ED) and are often admitted for a sepsis evaluation of blood, urine, and spinal fluid. However, the risk of concomitant systemic infections (CSI) in this population is not well reported, specifically comparing febrile to afebrile infants. We hypothesized that afebrile, well-appearing infants under two months of age with a defined focal bacterial infection on exam have a very low risk of CSI. METHODS: This retrospective study was conducted at an urban, academic, tertiary care pediatric hospital ED on patients seen from January 2000-December 2005. Eligible infants were less than 60 days of age, well-appearing on exam, and with normal-for-age vital signs who presented with a focal bacterial infection on exam. Exclusion criteria included immunodeficiency, indwelling catheter, previous admission for bacterial infection, or current use of systemic antibiotics. Main study outcome was risk of CSI in febrile and afebrile groups. RESULTS: One hundred ninety seven patients were included in the study population. Of these, 39 were febrile and 158 were afebrile. Four patients had a documented CSI: one case of S. pneumoniae bacteremia and three cases of E. coli urinary tract infection. Of these 4 infants, 3 were febrile (7.7% CSI risk) and 1 was afebrile (0.6%). Febrile infants had a significantly higher risk of CSI (OR 13.1, 95% CI 1.3, 129.5). CONCLUSIONS: CSI is very uncommon in afebrile, well-appearing infants under 60 days of age with a focal bacterial infection. Journal of Hospital Medicine 2010;5:76–82. © 2010 Society of Hospital Medicine.

Summary The differential diagnoses of tarsal joint infection, fractur e and peritarsal focal infection are of particularimportance in practice. The objective of the present report is to provide additional clinical data to assist in the understanding of one of these conditions. The haematological parameters, clinical signs, treatment and outcome of 10 cases of severe lameness associated with peritarsal infection are reviewed. All horses had a significant rise in rectal temperature. The majority of cases (6/10) had haematological changes consistent with acute bacterial infection on the day of first examination. In the remaining cases these changes were not apparent on a blood sample taken on the first examination, but became so after24 h. Nine out of 10 cases made a complete recovery on a regimen of i.v. antibiotic therapy, in conjunction with administration of nonsteroidal anti-inflammatory drugs and repeated forced exercise. One case developed osteomyelitis of the third and fourth metatarsal bones, but made a full recovery in due course. It is concluded that, in the majority of cases, prompt treatment with antibiotic therapy, analgesics and forced exercise results in complete resolution of the condition.

Bacteriospermia requiring medical treatment were diagnosed in more than 70% of the subfertile patients who had since 1988 attended the gynecological clinic at the RWTH hospital in Aachen. In 23% of all cases specific treatment with antibiotics did not reduce the concentrations of bacteria in sperma. Thirty-six patients with bacteriospermia resistant to antibiotic therapy were then subjected to dental examination. A high incidence of potential dental foci was found in all patients. In a test group of 18 patients these sources of potential infection were eliminated. Between dental operations and therapy swabs were taken to determine bacterial levels and bacteriological composition. It could be demonstrated that the bacterial spectrum of the intraoral samples was almost identical with the spermiograms. Six months following completion of dental treatment a further spermiogram analysis was carried out. In the test group about two thirds of the spermiograms proved sterile. Spermatological parameters, such as motility, density and morphology, had also clearly improved. In the control group the findings of the spermiogram remained poor. This study indicates that a direct causal relationship exists between bacterial colonies (dental foci) and therapy-resistant bacteriospermia which probably leads to subfertility.

Early diagnosis and aggressive antimicrobial and surgical treatment are essential to successfully treat extensive cervico-mediastinal abscesses of odontogenic origin. Patient management should be performed by experienced clinicians well trained in managing possible complications. We recommend close clinical and radiological postoperative follow-up investigations with early surgical re-intervention if necessary.While neck infections affecting the perimandibular space have a high prevalence and their clinical aspects have repeatedly been discussed, further spread of the inflammation and life-threatening situations have rarely been described. The objective was to determine clinical, diagnostic, and therapeutic aspects of severe neck infections of odontogenic origin. Emphasis was placed on grave descending deep neck space infections, sometimes resulting in mediastinitis as a life-threatening complication.We reviewed 10 patients with severe odontogenic abscesses treated during an 8-year interval in a single center.The submandibular space was the most frequently encountered location of deep neck space infections. Mediastinitis was found in five patients. The most frequent causative bacteria were Streptococcus and Bacteroides species. All patients underwent intravenous antibiotic treatment and surgical therapy. Mediastinotomy was inevitable in five cases and thoracotomy in one case. All patients survived.

Purpose To describe a small series of patients with odontogenic orbital cellulitis and review the visual outcomes of such patients reported in the scientific literature. Methods Review of medical records and the scientific literature. Measured parameters included gender, age, days to presentation and surgery, the need for surgical intervention(s), sinus and orbital involvement on CT imaging, and pathogens involved. Results Current cases and review of the scientific literature resulted in 24 patients with odontogenic orbital cellulitis and adequate examinations for statistical analysis. Twelve of 24 patients had preserved vision (final vision better than 20/70), whereas 11 of 24 patients had vision loss (final vision of light perception or no light perception). Analysis of data showed no statistical correlation between visual loss and age (p = 0.81), days to clinical presentation (p = 0.45), days to surgical exploration (p = 0.96), sinus radiographic involvement (p = 0.50), orbital radiographic findings (p = 0.19), or type of bacterial infection (Gram-positive aerobic vs. anaerobic organisms), (p = 0.31 and p = 0.50 respectively). Male gender, the need for surgical drainage, and multiple surgical procedures performed correlated statistically with loss of vision (p = 0.05, p = 0.03, and p = 0.02, respectively). Conclusions Multiple case reports have demonstrated that orbital cellulitis from an odontogenic source can result in devastating visual loss. Male gender, the need for surgical drainage, and multiple surgical procedures correlated statistically with severity of visual loss.

A case of suspicious breast mass due to Salmonella enterica serotype Paratyphi A in a non-lactating, diabetic female is being described. The infection was successfully treated with a combination of surgical drainage and antibiotic treatment. This case highlights the fact that a focal Salmonella infection involving the breast should be considered as a rare differential diagnosis for breast malignancy and submission of specimens for microbiological analysis may be helpful in establishment of an accurate diagnosis and management.

Woman, 68 years old came to hospital with chief complain trismus and dysphagia. She was in a good condition with physical examination and standard laboratory test reveal normal value. The neurologist found multiple parese of cranial nerve (V, VII, IX, X, XI). After further examination include electromedic test and head ct scan with contrast the neurologist did not find any abnormality that may explain her symptoms. The patient then consulted to the internist with suspect of local tetanus infection because of focal infection in her dental caries. The patient is then treated with antibiotics, convultion inhibitor agent, also given tetanus immunoglobulin. During the treatment, her symptoms improved. There were no other severe complication. Patient was returning home on the ninth day of hospitalisation and ready for her dentist appointment.Keywords : Trismus, dysphagia, parese, tetanus, tetanus imunoglobulin

Background Most cases of cerebral venous thrombosis (CVT) have non-infective causes. Infective CVT, though less common, often results in a catastrophic outcome. The distinctive clinical characteristics of infection-associated CVT (IACVT) and non-infection-associated CVT (NIACVT) would facilitate early detection and proper management. Objective To compare the characteristics of IACVT and NIACVT. Methods All patients with CVT admitted to Songklanagarind Hospital between January 2002 and December 2013 with the ICD10 codes I636, I676, O225 and G08 were identified and recruited. We compared the clinical presentations, neuroimaging results and hospital outcomes for patients with IACVT and those with NIACVT. We analysed the differences using descriptive statistics. Additionally, for patients with IACVT, we described the primary sites of infection, associated CVT, host immune status and microbiological results. Results Twenty of the 83 patients with CVT (24.1%) had IACVT. Male gender (70.0% vs 34.9%) and pre-existing diabetes mellitus (35.0% vs 4.8%) were significantly more prevalent in the IACVT than the NIACVT group. Additionally, cavernous sinus thrombosis predominated in IACVT (80.0% vs 11.1%), whereas focal neurological syndrome was more common among patients with NIACVT (50.8% vs 15.0%). Paracranial infections, mostly sinusitis and orbital cellulitis, were common primary infections (80.0%) among patients with IACVT. Lastly, fungus was a devastating causative pathogen in IACVT—five of six patients with fungal infection had intracranial complications. Conclusions Cavernous sinus thrombosis is a distinctive clinical presentation of IACVT, whereas focal neurological syndrome is a hallmark feature of NIACVT. Paracranial fungal infections are highly virulent and frequently associated with intracranial complications.

A 65-year-old man was admitted to our hospital with edema and renal dysfunction. He had received a diagnosis of psoriatic arthritis at 50 years of age. As a renal biopsy showed IgA nephropathy (IgAN), bilateral tonsillectomy was performed, and one course of steroid pulse therapy with an oral steroid and mizoribine were subsequently administered. The patient's proteinuria gradually reduced in association with an improvement in the renal function. In addition, the rash and arthralgia were ameliorated. In this case, adding treatment for chronic epipharyngitis accelerated the curative effects, and focal infection therapy consisting of immunosuppressive drugs was effective for both IgAN and psoriatic arthritis.

Robertson and colleagues’ review of severe acute dental infections rightly mentions the disparities in access to dental healthcare “disproportionately affecting the poor.”1 Poverty is associated with increased oral cancers and infections. Poorer people are more likely to smoke, have higher dietary sugar intake, and delay attending dental services because of previously having had to pay. All of these factors …