Chest wall abscess due to Prevotella bivia

Chest wall abscess due to Prevotella bivia 1 first-author 1 2 3 4 corresp ‡Corresponding Author ‡Corresponding Author †E-mail:luh572001@yahoo.com.tw †E-mail:luh572001@yahoo.com.tw luh572001@yahoo.com.tw Department of Medicine, Chia-Yi Christian Hospital, Chia-Yi City 60002, Taiwan, China Department of Medicine, Chia-Yi Christian Hospital, Chia-Yi City 60002, Taiwan, China Laboratory Medicine, Chia-Yi Christian Hospital, Chia-Yi City 60002, Taiwan, China Laboratory Medicine, Chia-Yi Christian Hospital, Chia-Yi City 60002, Taiwan, China Department of Surgery, St Martin DePorres Hospital, Chia-Yi City 60069, Taiwan, China Department of Surgery, St Martin DePorres Hospital, Chia-Yi City 60069, Taiwan, China Bioinformational Institute, National Chiao-Tung University, Shinchu City 30010, Taiwan, China Bioinformational Institute, National Chiao-Tung University, Shinchu City 30010, Taiwan, China Prevotella bivia is associated with pelvic inflammatory disease. A 77-year-old man developed a rapidly growing chest wall abscess due to P . bivia within days. He underwent surgical resection of the infected area; his postoperative course was uneventful. This is the first case of chest wall abscess due to P . bivia infection. Its correct diagnosis cannot be underestimated because fulminant infections can occur in aged or immunocompromised patients if treated incorrectly. Prompt, appropriate surgical management, and antibiotic therapy affect treatment outcome. Prevotella bivia Chest wall abscess Resection Reconstruction CASE REPORT 1 A 77-year-old male Taiwanese retired farmer experienced a left, anterior chest wall soreness followed by a rapidly growing mass lesion in the infraclavicular area within two weeks. He had no history of major trauma in the previous year. He developed and was nourished moderately. He experienced no anorexia or body weight loss recently. He had no major medical disease such as diabetes mellitus, cardiovascular disease, or renal disease. He smoked 1.5 packs of cigarettes per day, but did not drink alcohol or chew betal nuts. He did not take any medicine or herbal drugs regularly in the last few years. At the onset of pain, he took medicines for pain relieve only. However, his chest pain worsened and a rapidly growing mass of greater than 10 cm in diameter was noted locally within 2 weeks. The overlying skin looked erythematous and tense, and felt warm to the touch. On examination in the clinic, the patient had a painful, protruding mass of 10 cm in diameter in the left upper parasternal area, with overlying skin discoloration and local heat on palpation (Fig. 1 1 ). He also had a low-grade fever of 38.0 °C. He had no cervical lymphadenopathy or venous engorgement. His breathing sounds were vesicular in both lung fields. Laboratory data revealed leukocytosis (white blood cell count was 18 330 mm −3 ) with shift to the left (neutrophils ratio in white blood cell count was 85.5%). Chest roentgenography revealed an opaque mass shadow in the left upper medial lung field, just under the left clavicle. Chest computed tomography (CT) showed a soft tissue mass measuring 10 cm in diameter, with enhanced wall and central low density just anterior to the left border of the sternum (Fig. 2 2 ). Infectious lesion was impressed because local heat and redness were noted. This mass grew rapidly even though continuous parenteral antibiotics with the first to the second generation cephalosporins were treated. Focal cortical breakthrough of the sternum suggested a contiguous spread. A 2.3-cm fibrocalcified lesion in the left upper lung was also incidentally found, which was probably an old tuberculosis lesion. The patient underwent surgery to remove this lesion since it had been refractory to be under control. We resected all of the infected tissue en bloc with some of the overlying skin, and curetted the necrotic bone and soft tissue of the underlying thoracic cage. Tissues and fluids were collected during the surgery for further cultures for aerobes, anaerobes, fungi, and mycobacteria. The pathology examination revealed that the specimen consisted of one mass with overlying skin, measuring 10 cm×8 cm×6 cm (Fig. 3 3 ). The sections of the specimen showed skin tissue with acute and chronic inflammatory cell infiltration, granulation tissue, fibrosis, necrotic cellular debris, and aggregation of degenerative leukocytes. Gram and periodic acid-Schiff (PAS) stains failed to demonstrate microorganism in the specimens examined. The tissue and pus culture revealed abundant growth of anaerobic gram-negative rods, which were classified as Prevotella bivia . P . bivia was isolated on supplemented blood agar plates containing Brucella agar, L-cysteine, hemin, and vitamin K 1 ; it was an obligate anaerobic. The isolate was classified as P . bivia using the Crystal Anaerobe ID kit (Becton Dickinson Diagnostic Systems, Baltimore, Maryland, USA). It did not grow in the presence of bile nor did it hydrolyze esculin. The bacterial organism was susceptible to ampicillin/sulbactam, clindamycin, cefmetazole, cefoxitin, and metronidazole as examined by agar dilution antimicrobial susceptibility testing for minimum inhibitory concentrations of antibiotics based on criteria defined by the Clinical and Laboratory Standards Institute (NCCLS, 2004 2004 ). The infection was effectively controlled postoperatively by parenteral treatment and then oral amoxicillin/clavulanate treatment. The patient was discharged uneventfully 11 d later. Small areas of necrosis on the skin edges were noted but healed into granulation tissue shortly thereafter, as seen during later follow-up visits to the clinic. DISCUSSION 1 Prevotella belongs to one of the major genera of anaerobic, gram-negative rods (Finegold, 1995 1995 ). P . bivia , a member of the non-pigmented group, is predominantly associated with infections in the female urogenital tract, presenting as endometritis, pelvic inflammatory disease, or peri-rectal or anal abscess (Jousimies-Somer, 1997 1997 ). This infection also increases the risk of preterm delivery in pregnant women (Strömbeck et al., 2007 2007 ). Some rare locations of P . bivia infection, such as bones/joints, nail bed, male external genitalia, oral cavity, and endocardium, are reported (Alegre-Sancho et al., 2000 2000 ; Riesbeck, 2003 2003 ; Nalmas et al., 2007 2007 ; Schindl and Schön, 1999 1999 ; Kentos et al., 1994 1994 ). Infection manifesting as a large chest wall abscess was not previously reported in the literature. Other species of Prevotella ( P . oralis and P . ruminicola ) can result in lung abscesses in human immunodeficiency virus (HIV)-infected patients (Marcos Sánchez et al., 2003 2003 ). P . bivia is isolated from infectious tissues or fluids as the only pathogen or in association with other pathogenic microorganisms (Nalmas et al., 2007 2007 ; Falagas and Siakavellas, 2000 2000 ). Other anaerobes, such as Bacteroides or Porphyromonas species, Gardnerelia vaginalis , and Streptococcus constellatus , were reported to be associated with P . bivia in mixed anaerobic infections (Nalmas et al., 2007 2007 ; Falagas and Siakavellas, 2000 2000 ). On the contrary, some of the vaginal normal flora, such as Lactobacillus species, inhibited the growth of P . bivia (Atassi et al., 2006 2006 ). P . bivia usually results in low-virulence infections in the female urogenital tract. An experimental study showed that it invades epithelial cells, but induces weak pro-inflammatory responses (Strömbeck et al., 2007 2007 ). In cases of preterm labor induced by P . bivia infection, the mechanism could be related to the increased prostaglandin formation (Puapermpoonsiri et al., 1997 1997 ). In our patient, the infection in the chest wall was rapid and fulminant. Although severe and systemic infections can be caused in immunocompromised hosts (Nagy et al., 1995 1995 ), our patient was well and immunocompetent. We postulated that the behavior of P . bivia differs by site of infection. An animal study in a mouse subcutaneous infection model revealed that P . bivia needed to be mixed with other bacteria, such as E . coli or Peptostreptococcus spp., to start an effective initial infection; then, the P . bivia became the predominant organism in the chronic abscess (Citron et al., 2005 2005 ). We believe that our patient was an example of this model of the P . bivia infection, because P . bivia was the only isolated organism in the infected tissue and fluid of our patient. Most P . bivia is β-lactamase positive (Kuzucu et al., 2004 2004 ), although the positive rate is lower than that for other anaerobes such as Bacteroides (Herrak et al., 2007 2007 ). P . bivia are susceptible to clindamycin, amoxicillin/clavulanate, metronidazole, and imi-penam (Riesbeck, 2003 2003 ; Stein et al., 2007 2007 ; Citron et al., 2005 2005 ). In our patient, P . bivia isolated from the chest wall was sensitive to amoxicillin/clavulanate, which was administered postoperatively and achieved satisfactory results. The common infectious agents on the chest wall are Mycobacterium tuberculosis , Actinomyces sp., fungi, and other aerobes and anaerobes (Kuzucu et al., 2004 2004 ; Herrak et al., 2007 2007 ; Lin et al., 2007 2007 ; Luh et al., 2007 2007 ). Chest wall abscesses caused by P . bivia have not been reported previously. Our patient’s infection could have arisen from the bony chest wall instead of from the lung parenchyma or skin. Nonetheless, his lung lesion was old and seemed unrelated to the chest wall abscess. The overlying skin of the abscess, in spite of erythematous change, was intact without defects or draining sinuses. The precise mechanism of this infection remains unclear. In summary, we report the first case of chest wall abscess due to P . bivia infection. Its correct diagnosis cannot be underestimated because fulminant infections can occur in aged or immunocompromised patients if treated incorrectly. Prompt, appropriate surgical management, and antibiotic therapy affect treatment outcome. References JJ Alegre-Sancho , X Juanola , FJ Narvaez , D Roig-Escofet . Septic arthritis due to Prevotella bivia in a patient with rheumatoid arthritis . Joint Bone Spine , 2000 . 67 228 - 229 . 10875323 . Septic arthritis due to Prevotella bivia in a patient with rheumatoid arthritis F Atassi , D Brassart , P Grob , F Graf , AL Servin . Lactobacillus strains isolated from the vaginal microbiota of healthy women inhibit Prevotella bivia and Gardnerella vaginalis in coculture and cell culture . FEMS Immunol Med Microbiol , 2006 . 48 ( 3 ): 424 - 432 . 17059467 DOI: 10.1111/j.1574-695X.2006.00162.x http://doi.org/10.1111/j.1574-695X.2006.00162.x . Lactobacillus strains isolated from the vaginal microbiota of healthy women inhibit Prevotella bivia and Gardnerella vaginalis in coculture and cell culture DM Citron , KL Tyrrell , YA Warren , H Fernandez , CV Merriam , EJ Goldstein . In vitro activities of tinidazole and metronidazole against Clostridium difficile , Prevotella bivia and Bacteroides fragilis . Anaerobe , 2005 . 11 ( 6 ): 315 - 317 . 16701592 DOI: 10.1016/j.anaerobe.2005.04.005 http://doi.org/10.1016/j.anaerobe.2005.04.005 . In vitro activities of tinidazole and metronidazole against Clostridium difficile, Prevotella bivia and Bacteroides fragilis ME Falagas , E Siakavellas . Bacteroides , Prevotella , and Porphyromonas species: a review of antibiotic resistance and therapeutic options . Int J Antimicrob Agents , 2000 . 15 ( 1 ): 1 - 9 . 10856670 DOI: 10.1016/S0924-8579(99)00164-8 http://doi.org/10.1016/S0924-8579(99)00164-8 . Bacteroides, Prevotella, and Porphyromonas species: a review of antibiotic resistance and therapeutic options SM Finegold . Overview of clinically important anaerobes . Clin Infect Dis , 1995 . 20 ( Suppl. 2 ): 205 - 207 . 7548607 . Overview of clinically important anaerobes L Herrak , Y Msouger , Y Ouadnouni , M Bouchikh , A Benosmane . Pulmonary actinomycosis with chest wall fistula formation . Rev Mal Respir , 2007 . 24 ( 3 Pt 1 ): 349 - 352 . 17417174 . Pulmonary actinomycosis with chest wall fistula formation H Jousimies-Somer . Recently described clinically important anaerobic bacteria: taxonomic aspects and update . Clin Infect Dis , 1997 . 25 ( Suppl. 2 ): S78 - S87 . 9310640 . Recently described clinically important anaerobic bacteria: taxonomic aspects and update A Kentos , S Motte , C Nonhoff , F Jacobs , JM de Smet , E Serruys , JP Thys . Prevotella bivia as an unusual cause of endocarditis . Eur J Clin Microbiol Infect Dis , 1994 . 13 ( 2 ): 142 - 145 . 8013486 DOI: 10.1007/BF01982187 http://doi.org/10.1007/BF01982187 . Prevotella bivia as an unusual cause of endocarditis A Kuzucu , O Soysal , H Günen . The role of surgery in chest wall tuberculosis . Interact Cardiovasc Thorac Surg , 2004 . 3 ( 1 ): 99 - 103 . 17670188 DOI: 10.1016/S1569-9293(03)00192-0 http://doi.org/10.1016/S1569-9293(03)00192-0 . The role of surgery in chest wall tuberculosis MS Lin , WL Lin , SP Luh , TC Tsao , TC Wu . Pulmonary actinomycosis: a case undergoing resection through video-assisted thoracic surgery (VATS) . J Zhejiang Univ Sci B , 2007 . 8 ( 10 ): 721 - 724 . 17910114 DOI: 10.1631/jzus.2007.B0721 http://doi.org/10.1631/jzus.2007.B0721 . Pulmonary actinomycosis: a case undergoing resection through video-assisted thoracic surgery (VATS) SP Luh , JD Hsu , YS Lai , SW Chen . Primary tuberculous infection of breast: experiences of surgical resection for aged patients and review of literature . J Zhejiang Univ Sci B , 2007 . 8 ( 8 ): 580 - 583 . 17657861 DOI: 10.1631/jzus.2007.B0580 http://doi.org/10.1631/jzus.2007.B0580 . Primary tuberculous infection of breast: experiences of surgical resection for aged patients and review of literature F Marcos Sánchez , I Albo Castaño , F Arbol Linde , J Celdrán Gil . Lung abscess caused by Prevotella oralis and Prevotella ruminicola in an HIV-positive patient . Ann Intern Med , 2003 . 20 164 - 165 . . Lung abscess caused by Prevotella oralis and Prevotella ruminicola in an HIV-positive patient E Nagy , I Szóke , M Gacs , K Csiszár . Resistance to beta-lactam antibiotics and beta-lactamase production of Bacteroides , Porphyromonas and Prevotella strains . Acta Microbiol Immunol Hung , 1995 . 42 287 - 299 . 8548202 . Resistance to beta-lactam antibiotics and beta-lactamase production of Bacteroides, Porphyromonas and Prevotella strains S Nalmas , E Bishburg , T Chan . Streptococcus constellatus and Prevotella bivia penile abscess . Scientific World Journal , 2007 . 7 ( 10 ): 1631 - 1633 . 17982605 . Streptococcus constellatus and Prevotella bivia penile abscess NCCLS (National Committee for Clinical Laboratory Standards) Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria , 2004 . 6th Ed. : Wayne, PA National Committee for Clinical Laboratory Standards , Approved Standard (M11-A6) . Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria S Puapermpoonsiri , K Watanabe , N Kato , K Ueno . In vitro activities of 10 antimicrobial agents against bacterial vaginosis-associated anaerobic isolates from pregnant Japanese and Thai women . Antimicrob Agents Chemother , 1997 . 41 2297 - 2299 . 9333068 . In vitro activities of 10 antimicrobial agents against bacterial vaginosis-associated anaerobic isolates from pregnant Japanese and Thai women K Riesbeck . Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological diagnosis is crucial . J Clin Microbiol , 2003 . 41 ( 10 ): 4901 - 4903 . 14532256 DOI: 10.1128/JCM.41.10.4901-4903.2003 http://doi.org/10.1128/JCM.41.10.4901-4903.2003 . Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological diagnosis is crucial AH Schindl , H Schön . Foot infection with Prevotella bivia , P . oralis and P . loescheii after wound licking . J Med Microbiol , 1999 . 48 109 9920135 . Foot infection with Prevotella bivia, P. oralis and P. loescheii after wound licking GE Stein , S Schooley , KL Tyrrell , DM Citron , EJ Goldstein . Human serum activity of telithromycin, azithromycin and amoxicillin/clavulanate against common aerobic and anaerobic respiratory pathogens . Int J Antimicrob Agents , 2007 . 29 39 - 43 . 17189093 DOI: 10.1016/j.ijantimicag.2006.08.041 http://doi.org/10.1016/j.ijantimicag.2006.08.041 . Human serum activity of telithromycin, azithromycin and amoxicillin/clavulanate against common aerobic and anaerobic respiratory pathogens L Strömbeck , J Sandros , E Holst , P Madianos , U Nannmark , P Papapanou , I Mattsby-Baltzer . Prevotella bivia can invade human cervix epithelial (HeLa) cells . APMIS , 2007 . 115 ( 3 ): 241 - 251 . 17367470 DOI: 10.1111/j.1600-0463.2007.apm_512.x http://doi.org/10.1111/j.1600-0463.2007.apm_512.x . 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