Case 1: A 70 year old immunocompetent woman presenting with 4 weeks of generalized body weakness and gram positive bacilli that grew on 4 culture bottles on admission.
Taken from: http://www.easynotecards.com/uploads/977/95/69c3b13a_13a8788d737__8000_00000081.jpg
1. The gram positive bacilli in this case was later identified as Bacillus sp. (not anthracis). The same blood cultures also showed growth of methicillin-susceptible Staphylococcus aureus and Staphylococcus hominis.
2. Let's review the different clinically important gram positive bacilli (look here). Our laboratory routinely reports branching filamentous organisms (BFO). It is important to note that some gram positive bacilli are also AFB positive. As you can see from the diagram, the clinically significant gram positive bacilli are diverse and are responsible for a wide spectrum of illnesses.
3. Can Bacillus (not athracis) cause clinically significant infection? The answer is yes. Bacillus cereus is known to cause serious endophthalmitis. It has also been reported as a cause of endocarditis (see here, kuddos to our very own Ben Thomas). Bacillus bacteremia have been reported among intravenous drug users, preterm neonates, and those with long-term indwelling catheters.
Case 2: A 14 year old boy presenting with acute frontal head swelling and pain, rhinorrhea, cough, fever, and post-nasal discharge secondary to Streptococcus angionosus Pott's puffy tumor.
Taken from: http://www.asnr2.org/neurographics/8/3/68/What%27s%20in%20a%20Name_files/slide0029_image128.jpg
1. Pott's puffy tumor refers to frontal bone subperiosteal abscess associated with frontal bone osteomyelitis. It occurs as a complication of frontal sinusitis or trauma. Most patients with Pott's puffy tumor are immunocompetent. All patients present with frontal head swelling. Complications include intracranial extension (80%) and orbital cellulitis (30%).
2. Common etiologic agents for Pott's puffy tumor include Streptococcus (pneumoniae, angionosus, Group A), Staphylococcus (aureus usually), and anaerobes (Fusobacterium, Propionebacterium). Cultures can be polymicrobial or sterile as well.
3. Streptococcus angionosus group (once known as Streptococcus milleri) include Streptococcus angionosus, Streptococcus intermedius, and Streptococcus constellatus. They have a characteristic butterscotch smell on culture media. They are associated with abscess formation.
Case 3: This is a management case
A 22 year old man with paraplegia presenting with sepsis secondary to osteomyelitis and soft tissue infection from multi-drug resistant organisms (vancomycin-resistant Enterococcus; methicillin-susceptible Staphylococcus aureus; Pseudomonas aeruginosa susceptible only to colistin, amikacin, gentamicin, and tobramycin; and Candida lusitaniae)
1. The main point that was emphasized is that, management of chronic osteomyelitis in paraplegic patients is very challenging and one that requires a multidisciplinary approach. Antibiotics alone will not be sufficient.
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