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A 58-year-old man with a history of diabetes mellitus and end-stage renal disease acquired pneumonia with acute respiratory failure during his stay in an intensive care unit (ICU). Empirical antimicrobial therapy with ceftazidime and vancomycin was initiated, and imipenem replaced ceftazidime 2 days later due to the patients pulmonary condition failed to improve. However, within 5 days, pulmonary consolidation rapidly progressed to necrotizing pneumonia complicated by lung abscess, empyema, pyopneumothorax, and tension pneumothorax, leading to the patient's death. After the patient had died, all bacterial isolates from cultures of pleural effusion, blood, and tracheal aspirate were identified as Enterobacter cloacae (E. cloacae), which was susceptible to imipenem but resistant to ceftazidime. E. cloacae should be considered in the differential diagnosis of complicated necrotizing pneumonia with lung abscess, empyema, pyopneumothorax, and tension pneumothorax. Carbapenem therapy should be immediately initiated until the pathogen in such rapidly progressive ICU-acquired pneumonia is confirmed. Increased awareness among physicians regarding E. cloacae-induced complicated necrotizing pneumonia acquired in ICUs could enable earlier detection and appropriate antimicrobial therapy for this invasive disease.

Staphylococcus lugdunensis, a strain of coagulase–negative staphylococci, is part of the normal flora of human skin but can cause multiple infections at various sites. This microorganism has emerged as a major human pathogen. However, no study has reported primary lung abscess caused by S. lugdunensis. A 54-year-old alcoholic man without relevant past medical history was admitted because of primary lung abscesses. Empirical amoxicillin/clavulanate therapy was initially administered; however, the patient had persistent pleuritic chest pain and fever. He subsequently underwent resection of the lung abscess and removal of exudative pleural effusion on the fourth hospital day. Histopathologic examination confirmed the diagnosis of lung abscess, and colonies of gram-positive bacteria were identified. The culture specimen from the abscess was positive for S. lugdunensis, which was susceptible to amoxicillin/clavulanate, cefazolin, ciprofloxacin, clindamycin, erythromycin, oxacillin, teicoplanin, tetracycline, and vancomycin. Following resection and 3 weeks of amoxicillin/clavulanate therapy, the patient eventually recovered well without relapse. This case report is the first to describe S. lugdunensis as a cause of primary lung abscess; this microorganism should be considered a potential monomicrobial pathogen in primary lung abscess.

A 68-year-old woman with end-stage renal disease was started on regular hemodialysis with a tunneled cuffed catheter through the right internal jugular vein for 2 months. She entered our emergency department with complaints of fever, shortness of breath, and chest pain of 2 days duration. On arrival, she was febrile, tachycardic, tachypneic, and had a normal blood pressure. No erythema, swelling, heat, or tenderness was observed at the insertion site of the dialysis catheter. No abnormal breath sounds or audible heart murmurs were detected. Oxygen saturation was 88 % while breathing room air. The electrocardiogram revealed sinus tachycardia. Laboratory examination revealed leukocytosis, thrombocytopenia, and elevated C-reactive protein. An initial chest radiograph (Fig. 1) showed multiple ill-defined opacities in the right lung and the tip of the dialysis catheter was placed in the right atrium (RA). Based on the clinical manifestations and chest radiographic findings, a dialysis catheter-related infection with septic pulmonary embolism (SPE) was suspected. The patient was treated with empirical vancomycin. Contrastenhanced computed tomography (CT) (Fig. 2a–c) performed after dialysis catheter removal revealed that the thrombi were in the superior vena cava (SVC), RA, right ventricle (RV), and right interlobar pulmonary artery branch. CT findings on lung window setting (Fig. 3a–d) showed different types of SPE. A transthoracic echocardiography revealed a 45 9 26 mm thrombus within the RA, which was attached to the wall of the atrium, and protruded into the RV (Fig. 2d). The RA and RV were of normal size. Mild tricuspid regurgitation and mild pulmonary hypertension (estimated pulmonary artery systolic pressure 32 mmHg) were detected. Anticoagulation therapy was initiated. The catheter tip culture and three pairs of blood cultures were positive for oxacillin-sensitive Staphylococcus aureus. Based on radiographic evidence of thrombi and positive blood culture results, the diagnoses of septic thrombophlebitis of the SVC, septic thrombosis of the RA with pulmonary embolism (PE), and SPE were confirmed. In a previous study, approximately 12.5 % of patients exhibit thrombus at the tip of catheter within 6–8 weeks of catheter insertion, and all thrombi are found in those patients with the catheter tip position in the RA, in contrast to none in those with the catheter tip position in the SVC [1]. The likely mechanism of thrombus formation at this location is related to friction of the catheter on the atrial endocardium [2, 3]. The endothelial damage induced by trauma results in platelet aggregation and thrombus formation [4]. An adherent infected thrombus in the RA may become dislodged, and lead to PE and SPE. Great diversity of SPE can be found in CT findings, including a feeding vessel sign, nodules with or without cavities, pleural effusions, peripheral wedge-shaped opacities, patchy ground-glass opacities, lung abscesses, and focal consolidations [5]. A chest radiograph can assist in diagnosis of this disease, as seen in the present case. A possible diagnosis of dialysis catheter-related SPE from a chest radiograph may & Deng-Wei Chou choudw@gmail.com

OBJECTIVES: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential.

An endemic outbreak of melioidosis developed in southern Taiwan following a flood caused by a typhoon in July 2005. A total of 27 patients were diagnosed with the acute and indigenous form of pulmonary melioidosis. Parapneumonic pleural effusions were noted on chest X-rays in six patients. Thoracentesis was done in three patients and all revealed lymphocyte predominance in differential cell count. Burkholderia pseudomallei was isolated in the pleural effusion in one of them. All three patients survived after antibiotic treatment. Lymphocytic pleural effusion is generally seen in tuberculosis or malignancy. However, our findings suggest that melioidosis should be considered in the differential diagnosis of lymphocytic pleural effusion.

A 58-year-old woman without diabetes or other immunocompromising diseases presented to the emergency department with a fever and progressive deterioration of consciousness of 2 days duration. She had been bedridden for a month because of major depression. On examination, she was comatose, febrile, tachycardic, tachypneic, and hypotensive. Extensive bruising was present over the trunk, and she had an 8-cm sacral pressure ulcer (Stage IV, The National Pressure Ulcer Advisory Panel). Neither cutaneous blisters nor crepitation was noted. The remainder of the physical examination was unremarkable. Laboratory examination showed a leukocytosis, thrombocytopenia, elevated C-reactive protein, and a prolonged coagulation time. A plain radiograph of the kidney ureter bladder (Fig. 1a) indicated gas formations over the soft tissues of the bilateral hips and the pelvic regions, which suggested necrotizing soft tissue infections (NSTIs). These findings were confirmed through a computed tomography (CT) scan of the abdomen and pelvis (Fig. 1b–f). The diagnosis of NSTIs of the thighs, buttocks, and pelvis caused by a pressure ulcer was made. Broad-spectrum antibiotics and surgical debridement were performed immediately. NSTIs were confirmed through histopathologic examination. A delay in diagnosis of NSTIs leads to delayed surgical debridement, and the patient’s condition may deteriorate and result in death [1]. Clinical characteristics that facilitate the process of identifying NSTIs include: pain disproportionate to the appearance of the lesion, tense edema, skin discoloration, blisters, bullae, necrosis, and crepitus [2]. However, this patient was an exception to the rule because she was both comatose, and did not exhibit any cutaneous symptoms, rendering the diagnosis difficult. Diagnosing NSTIs in the gluteal area and pelvis is challenging when pathognomonic physical findings are not available, and a plain radiograph is sometimes valuable. This case highlights the importance of an early and accurate interpretation of a plain radiograph when the typical ‘‘normal’’ gas formations are not normally located or distributed. This specific finding may be missed even by experienced radiologists and emergency physicians, which decreases the patient’s survival chances. These lesions might be incorrectly identified as bowel loops when cutaneous lesions are absent, missing the diagnosis. A CT scan should follow the plain radiograph, if one is able to think of the entity and institute a search for its presence, and to confirm the diagnosis and assess the extent of the NSTIs. A CT scan can show the spatial relationships between the NSTIs and the surrounding structures, and even reveal the routes of spread of this disease. This case is valuable because lesions in the thighs, buttocks, and pelvis were clearly identified, and the extension of the lesions into the & Shu-Chen Han han520719@gmail.com

Prototheca wickerhamii, an environmental alga, rarely causes human infections. We present a case of Prototheca wickerhamii cutaneous and systemic infections in an 85-year-old male with adrenal insufficiency. This organism was identified by morphological features and microbiological tests. The patient was successfully treated with ketoconazole.

Background/PurposeIn recent years, the number of cases of melioidosis has increased substantially in Taiwan. However, there have been no publications specifically studying patients who have bacteremic melioidosis in Taiwan. This study aimed to determine the clinical characteristics and outcome of patients with bacteremic melioidosis in Taiwan.MethodsWe retrospectively reviewed the records of 30 patients (mean age, 65 years) with blood culture-confirmed melioidosis who were managed at Tainan Municipal Hospital between June 2004 and January 2007. Nineteen out of 30 patients were identified within 1 month after Typhoon Haitang struck in mid-July 2005. A comparison of demographic characteristics, underlying conditions, biochemistry results, and clinical presentations between survivors (n = 21) and non-survivors (n = 9) was analyzed.ResultsUnderlying conditions were identified in 90% of patients, diabetes mellitus being the commonest (50%). The most common site of infection was the lung (70%), followed by the genitourinary tract (13.3%), peritoneum (6.7%), meninges (3.3%), skin (3.3%), and aorta (3.3%). There were also 20% of cases without a primary site of infection being identified. Twenty percent of patients had multiple sites of infection. The number of bacteremic melioidosis with pneumonia was significantly higher in the posttyphoon outbreak (p = 0.001). Comparing survivors and non-survivors, there were no significant differences in age, gender, underlying conditions, and presence of pneumonia. Significant differences were evident in elevated serum creatinine (p = 0.038) and pH (p = 0.004). Fifty-six percent (5/9) of deaths occurred within 48 hours after presentation to hospital and 67% (6/9) of deaths occurred in the posttyphoon outbreak. Patients with septic shock (p < 0.001), acute renal failure (p = 0.013), and respiratory failure (p = 0.001) had significantly higher mortality. The in-hospital mortality rate was 27% and the relapse rate was 14%.ConclusionThe lungs were the most common site of infection in patients with bacteremic melioidosis and rapidly progressive community-acquired pneumonia (CAP) was the major cause leading to mortality. Patients with septic shock, acute renal failure, and acute respiratory failure had a much higher mortality rate. Typhoon Haitang was associated not only with higher numbers of cases and deaths but also with pneumonic presentations. Locally adapted guidelines need to be developed for the treatment of CAP in an endemic area of melioidosis in southern Taiwan and after extreme weather events such as typhoons or heavy rains.