Antimicrobial Selection for the Treatment of Clinical Mastitis and the Efficacy of Penicillin Treatment Protocols in Large Estonian Dairy Herds

Clinical mastitis (CM) is the most common microbial disease treated in dairy cows. We analyzed the antimicrobial usage in cows with CM (n = 11,420) in large dairy herds (n = 43) in Estonia. CM treatment data were collected during a 12-month study period. The antimicrobial usage was observed during the 21 days from the initiation of treatment, and the incidence of antimicrobial-treated CM was calculated for each study herd. The effect of intramammary (IMM), systemic, and combined (systemic and IMM) penicillin treatment of CM on the post-treatment somatic cell count (SCC) was analyzed using the treatment records of 2222 cows from 24 herds with a mixed multivariable linear regression model. The median incidence of antimicrobial-treated CM was 35.8 per 100 cow-years. Procaine benzylpenicillin and marbofloxacin were used in 6103 (35.5%, 95% CI 34.8–36.2) and 2839 (16.5%, 95% CI 16.0–17.1) CM treatments, respectively. Post-treatment SCC was higher after IMM penicillin therapy compared to systemic or combination therapy. Treatment of CM usually included first-choice antimicrobials, but different antimicrobial combinations were also widely used. The effect of procaine benzylpenicillin to post-treatment SCC was dependent on the administration route, cow parity, and days in milk. Further studies should evaluate the factors affecting veterinarians’ choice of antimicrobial used in the treatment of CM.

Neurosyphilis Presenting As Status Epilepticus, Successively Hemiparesis And Aphasia

Background: Neurosyphilis can occur anytime and present with a myriad of symptoms. Lissauer form of General Paresis Insane (GPI) is rare. We can learn more about this form of GPI through this case report.Case Presentation: The patient presented as status epilepticus, successively as hemiparesis and aphasia, which may be considered as the Todd's paresis or stroke. By performing the reactive serum rapid plasma reagent test and cerebrospinal fluid analysis, as well as the brain MRI results, we made the diagnosis as Lissauer form of GPI. The patient was started on intravenous penicillin for a total of 14 days. After that, the patient appeared with marked clinical improvement. Cognitive ability was better than before. Conclusions: GPI typically has a progressive course and normally presents 10 to 30 years after the initial infection. The manifestations of this patient and his suspicious history of Transient Ischemic Attacks (TIA) may mislead to the diagnosis of Todd's paresis or stroke. The prevalence of syphilis is rising again in recent years. To date, there is no gold standard for the diagnosis of neurosyphilis. Early diagnosis is of great importance as effective penicillin therapy is available.

Clostridium septicum myonecrosis in a pediatric patient with a self-reported penicillin allergy

Infections with Clostridium septicum are especially rare in pediatric patients. C. septicum is the most common cause of spontaneous myonecrosis and is usually associated with comorbid malignancy. Treatment of choice for cases of C. septicum myonecrosis is prompt and thorough surgical debridement and antimicrobial therapy with high dose penicillin. The experience and management of C. septicum infections in patients who are unable to take penicillin are not well described, and the optimal duration of therapy is largely unknown. We describe a case of spontaneous myonecrosis in a 14-year-old receiving cytotoxic chemotherapy for Burkitt’s lymphoma who had an anecdotal history of a penicillin allergy. Her infection was initially treated with ceftazidime and metronidazole in concert with debridement but was ultimately cured with 3 weeks of intravenous penicillin therapy following a graded penicillin challenge in hospital. We observed a delayed inflammatory tissue response to a C. septicum skin, soft tissue infection that temporally corresponded to neutrophil reconstitution in our patient with severe neutropenia. Our experience demonstrates that C. septicum myonecrosis can present indolently and progress rapidly and highlights the need for clinical vigilance and repeat “second-look” surgeries. Our case also emphasizes the importance of de-labelling penicillin allergies.

Oronasal syphilis: a forgotten disease?

<p class="abstract">Syphilis is a multistage disease that is usually transmitted through sexual contact or mother-infant transmission route. The incidence of oronasal syphilis has significantly decreased with the advent of penicillin therapy. However, it continues to exist, even though almost forgotten by the clinician. In this paper, we report one such case of a rare presentation of tertiary oronasal syphilis. A high index of suspicion is required to avoid missing the diagnosis of this masquerader.</p>

Professor George Archibald Grant Mitchell (1906–1993): his work with penicillin during World War II

George Archibald Grant Mitchell, OBE, TD, MB, ChB, ChM, MSc, DSc, FRCS (1906–1993) was a professor of anatomy at the University of Manchester from 1946 to 1973. He is mainly remembered for his research in neuroanatomy, especially of the autonomic nervous system. He studied medicine at the Aberdeen University, and after qualifying in 1929 he held posts in surgery and anatomy and worked as a surgeon in the Highlands. In 1939, he joined the Royal Army Medical Corps. He was based in Egypt and the Middle East, where he carried out trials of sulphonamides and penicillin on wounded soldiers; in 1943, he returned to England as Adviser in Penicillin Therapy for 21 Army Group, preparing for the invasion of Europe.

Predictors of serological cure after penicillin therapy in HIV-negative patients with early syphilis in Shenzhen, China

Background Syphilis is a common infectious disease worldwide. Serological monitoring is important for syphilis management. We currently know little about the characteristics of this seronegative response. The aim of this study was to explore the factors associated with serological cure after treatment of early syphilis. Methods A retrospective cohort study was conducted and the data of patients with early syphilis in a clinic in Shenzhen from 2011 to 2019 were retrieved. Univariable and multiple Cox proportional hazard regression models were utilized to identify factors associated with a serological cure state among syphilis patients with early syphilis two years after treatment. Results A total of 346 (85.9%) syphilis patients achieved serological cure. The multivariate analysis results revealed that having a baseline TRUST titer >1:8 was associated with an increased probability of serological cure, compared with having a baseline TRUST titer ≤1:8 (HR = 1.43, 95% CI = 1.10–1.85, P<0.01); primary syphilis was positively associated with serological cure, compared with participants with latent early syphilis (HR = 1.72, 95% CI = 1.27–2.33, P<0.001). Conclusions Two years after treatment, a higher percentage of early syphilis patients achieved serological cure. The study indicated that the syphilis stage and baseline serum titer were crucial factors associated with serological cure.

Cerebrospinal Fluid Cytokines in Patients with Neurosyphilis: The Significance of Interleukin-10 for the Disease

The aim of this study was to examine the cerebrospinal fluid (CSF) concentrations of proinflammatory and anti-inflammatory cytokines in neurosyphilis (NS), analyze the differences between asymptomatic NS (ANS) and symptomatic NS (SNS), and explore the diagnostic value of these cytokines. We enrolled 45 patients with a diagnosis of NS, including 18 patients with ANS and 27 patients with SNS, whose cerebrospinal fluid (CSF) samples were collected before penicillin therapy. Twelve patients with syphilis but non-NS (NNS) were also included. We measured the CSF levels of interleukin- (IL-) 1β, IL-4, IL-6, IL-10, IL-17A, IL-21, and tumor necrosis factor- (TNF-) α; the CSF levels of the microglial activation marker soluble triggering receptor expressed on myeloid cells 2 (sTREM2); and the CSF levels of the neuronal injury marker neurofilament light proteins (NFL) using the human cytokine multiplex assay or ELISA. Of the measured cytokines in the CSF, only IL-10 levels were significantly increased in NS patients compared to NNS patients (p<0.001). In a subgroup analysis, the CSF levels of IL-10 were significantly elevated in SNS patients compared to ANS and NNS patients (p=0.024 and p<0.001, respectively). The CSF IL-10 levels had a significant correlation with the markers of microglial activation and neuronal injury, and they also correlated with CSF rapid plasma reagin (RPR) titer, CSF white blood cell (WBC) count, and CSF protein concentration. The areas under the ROC curve (AUC) of CSF IL-10 in the diagnosis of NS and ANS were 0.920 and 0.891, respectively. The corresponding sensitivities/specificities were 86.7%/91.7% and 83.3%/91.7%, respectively. Therefore, the excessive production of IL-10 might facilitate bacterial persistent infection, play an important role in the pathogenesis of NS, and associate with the progression of the disease. CSF IL-10 concentration had a useful value in the diagnosis of NS, especially in ANS.

Nasopharyngeal Isolates from a Cohort of Medical Students with or without Pharyngitis

Objectives: Few studies have investigated pharyngeal colonisation in the United Arab Emirates (UAE). This study aims to identify the pharyngeal organisms present in a cohort of medical students with and without symptomatic pharyngitis. Methods: This study was conducted between September 2016 and June 2018 at the College of Medicine and Health Sciences, UAE University, Al-Ain. Nasopharyngeal swabs were collected from preclinical and clinical medical students attending the college during the study period. The specimens were tested for 16 viral and nine bacterial pathogens using a real-time polymerase chain reaction assay. Results: A total of 352 nasopharyngeal swabs were collected from 287 students; of these, 22 (7.7%) had pharyngitis symptoms. Overall, the most common isolates were human rhinovirus, Streptococcus pneumoniae and Haemophilus influenzae, with no significant differences in terms of gender, year of study or stage of study. The prevalence of S. pyogenes in asymptomatic and symptomatic students was 1.1% and 0%, respectively. A Centor score of ≥2 was not associated with S. pyogenes-positive samples. Six pathogens were isolated from symptomatic students including H. influenzae. Fusobacterium necrophorum was not detected in any of the samples. Conclusion: The diagnosis and management of pharyngitis should be tailored to common pathogens in the region. This study found that S. pyogenes and F. necrophorum were not detected among students with symptoms of pharyngitis; moreover, Centor scores of ≥2 were not associated with the presence of S. pyogenes. This cut-off score therefore should not be employed as an empirical measure to initiate penicillin therapy in this population.Keywords: Pharyngitis; Pharynx; Asymptomatic Infections; Carrier State; Fusobacterium necrophorum; Streptococcus pyogenes; Penicillins; United Arab Emirates.

“Holes” in the Jaw—A Report of Two Cases of Periapical Actinomycosis

Periapical actinomycosis is a relatively rare form of cervicofacial actinomycosis, which typically involves the periapical region with subsequent potential spread to the jaw bones. We hereby present two cases of periapical actinomycosis. Both patients presented with jaw pain and “holes” in their gum and lacked the characteristic clinical features commonly seen in cervicofacial actinomycosis such as jaw mass, draining ulcers, sinuses and fistulae. The first patient was an immunocompetent host with chronic stable medical conditions but with a rather bad dentition requiring multiple recent teeth extractions. The second patient was edentulous, had refractory multiple myeloma, was on low-dose chronic steroids and pomalidomide therapy and therefore relatively immunocompromised. Both cases of actinomycosis were diagnosed by jaw bone histopathology, which showed characteristic sulfur granules and embedded Actinomyces-like organisms. The two patients had excellent clinical response to six months of penicillin therapy without any need for surgical intervention. The cases remind clinicians of including actinomycosis in the differential diagnosis of periapical lesions and illustrates the possibility of achieving cure with non-surgical treatment.