Leslie-Ann Lasko

Considering hidradenitis suppurativa as a bacterial biofilm disease

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the skin that results in a relapsing course of painful draining sinuses and abscesses. The disease manifests largely in the apocrine gland-bearing regions of the body (axillary, inguinal and anogenital areas) and is usually treated by antibiotics and/or surgery. The exact pathogenesis of HS is still in dispute, but likely multifactorial; in some instances, a genetic component has been demonstrated. While much attention has been given to the cellular and molecular biology of the host tissues affected by HS, rather less has been given to the bacteria involved (most commonly Staphylococci or Streptococci). We note that the characteristics of HS comport exactly with the features of bacterial biofilm-based infections, and examined a case where HS of the buttocks had progressed to an advanced stage. Physical examination of the sinus tracks at surgery revealed a mucinous accumulation consistent with biofilm formation. Confocal microscopic examination using Live/Dead staining revealed clusters of bacteria attached to the sinus luminal surfaces. The paradigmatic clinical features of HS, coupled with the adherent bacterial communities we observe here, suggest that HS should be considered in the expanding spectrum of bacterial biofilm-based disorders.

Direct Demonstration of Viable Staphylococcus aureus Biofilms in an Infected Total Joint Arthroplasty

Infection following total joint arthroplasty is difficult to diagnose and treat; a nascent body of evidence from studies of prosthetic joint infections suggests that biofilm bacteria are the underlying cause. We describe the case of a patient who had chronic recurring symptoms of infection that persisted for years following total elbow arthroplasty despite numerous medical and surgical interventions. Confocal microscopy performed on fluid, tissue, and cement at the final surgical revision demonstrated viable bacteria in biofilm aggregates. Reverse transcriptase-polymerase chain reaction analysis confirmed the presence of metabolically active Staphylococcus aureus. These observations comprise compelling evidence that viable biofilm bacteria play an important role in refractory infection following joint arthroplasty.Chronic infection following joint replacement is increasingly thought to result from the presence of bacterial biofilm communities attached to the implant. Biofilm bacteria are vastly more resistant to conventional antibiotic therapy than are their single planktonic counterparts (unattached solitary bacteria living freely) and are typically difficult to culture by conventional microbiological methods. The biofilm paradigm can explain contradictory signs and symptoms that suggest infection but are often associated with negative cultures. Moreover, biofilm infections are difficult to detect by simple Gram stain and culture techniques but can persist as a nidus of infection from which recurrent acute exacerbations may arise through episodic planktonic “showering”.

Direct demonstration of bacterial biofilms on prosthetic mesh after ventral herniorrhaphy.

BACKGROUND Prosthetic mesh is employed routinely in the treatment of ventral and parastomal hernias, but its use can lead to major complications, including infection, extrusion, and fistula. Bacterial biofilms have been posited to play a role in mesh-related infection, but although bacteria have been noted to form biofilms on mesh surfaces in vitro, they have never been visualized directly in biofilms on mesh recovered from patients experiencing infectious complications. METHODS Five patients who developed complications after ventral hernia repair with prosthetic mesh were operated on again. Explanted mesh was examined for biofilm with confocal laser scanning microscopy (CLSM) and fluorescence in situ hybridization (FISH). In two cases, a novel molecular assay (the Ibis T5000) was used to characterize the biofilm-forming bacteria. RESULTS The CLSM examination demonstrated adherent biofilms on mesh surfaces in all five patients. Biofilms also were noted on investing fibrous tissue. The FISH study was able to discriminate between bacterial species in polymicrobial biofilms. In two patients the Ibis T5000 detected more species of constituent biofilm bacteria than did standard culture. Removal of the mesh and reconstruction with autologous tissues or biologic materials resolved the presenting complaints in all cases. CONCLUSION Bacterial biofilms should be considered an important contributor to the pathology and complications associated with prosthetic mesh implanted in the abdominal wall. If biofilms are present, complete removal of the mesh and repair of the resulting defect without alloplastic materials is an effective intervention.

Bacterial biofilm on monofilament suture and porcine xenograft after inguinal herniorrhaphy.

Bacterial biofilms have been implicated in multiple clinical scenarios involving infection of implanted foreign bodies, but have been little studied after hernia repair. We now report a case of revision inguinal herniorrhaphy complicated by chronic pain at the operated site without any external indication of infection. Computed tomographic imaging revealed a contrast-enhancing process in the left groin. Subsequent surgical exploration found an inflammatory focus centered on implanted porcine xenograft material and nonabsorbable monofilament sutures placed at the previous surgery. Confocal microscopic examination of these materials with Live/Dead staining demonstrated abundant viable bacteria in biofilm configuration. The removal of these materials and direct closure of the recurrent hernia defect eliminated the infection and resolved the patients complaints. These results demonstrate that implanted monofilament suture and xenograft material can provide the substratum for a chronic biofilm infection.

Hidradenitis suppurativa: a disease of apocrine gland physiology.

H idradenitis suppurativa is a disease affecting the apocrine sweat glands that often results in chronically draining sinus tracks and wounds. Over time, the affected areas become scarred and can be afflicted by contracture or tissue immobility. Physician assistants should possess the knowledge required to diagnose this condition, to initiate conservative medical treatments, and to judge when such management has reached its limitations and a surgical referral is necessary.

Secondary Surgery for Cicatricial Complications of Facial Injury

PURPOSE To investigate the nature of surgical revision procedures necessitated by cicatricial complications of facial injury. PATIENTS AND METHODS All patients who had facial trauma in a period of approximately 5 years managed by a single surgeon were reviewed. Of these, 36 were found to have undergone secondary revision procedures arising specifically from scar-related complications. RESULTS The average age of patients undergoing revision surgery was 34 years; 27 of the 36 patients (75%) were men, and 9 of the 36 (25%) required multiple revision surgical visits. The most common cause of injury was motor vehicle collision; the interval between the initial trauma and the first revision surgery was most commonly 6 to 12 months. Scar-related complications were categorized on the face by anatomic subsite; they occurred most frequently on the forehead/cheeks/chin area, with the eyes/periorbital area the second most frequent location. One hundred twelve discrete surgical procedures (as per current procedural terminology) were performed on these 36 patients to address the cicatricial sequelae of their initial injuries. CONCLUSIONS Facial trauma can frequently entail secondary morbidity in the form of facial scar deposition, which itself can necessitate surgical repair. This represents a substantial but as yet underappreciated health care burden attendant to maxillofacial injury.

PSEUDOGOUT OF THE TEMPOROMANDIBULAR JOINT: IMMEDIATE RECONSTRUCTION WITH TOTAL JOINT ARTHROPLASTY

Pseudogout of the temporomandibular joint (TMJ) is a rare disorder with <40 reported cases in the English‐language literature. It is usually treated with surgical resection and condylectomy alone.

Direct Demonstration of Viable : A Case Report staphylococcus aureus : A Case Report Biofilms in an Infected Total Joint Arthroplasty: A Case Report

Infection following total joint arthroplasty is difficult to diagnose and treat; a nascent body of evidence from studies of prosthetic joint infections suggests that biofilm bacteria are the underlying cause. We describe the case of a patient who had chronic recurring symptoms of infection that persisted for years following total elbow arthroplasty despite numerous medical and surgical interventions. Confocal microscopy performed on fluid, tissue, and cement at the final surgical revision demonstrated viable bacteria in biofilm aggregates. Reverse transcriptase-polymerase chain reaction analysis confirmed the presence of metabolically active Staphylococcus aureus. These observations comprise compelling evidence that viable biofilm bacteria play an important role in refractory infection following joint arthroplasty.Chronic infection following joint replacement is increasingly thought to result from the presence of bacterial biofilm communities attached to the implant. Biofilm bacteria are vastly more resistant to conventional antibiotic therapy than are their single planktonic counterparts (unattached solitary bacteria living freely) and are typically difficult to culture by conventional microbiological methods. The biofilm paradigm can explain contradictory signs and symptoms that suggest infection but are often associated with negative cultures. Moreover, biofilm infections are difficult to detect by simple Gram stain and culture techniques but can persist as a nidus of infection from which recurrent acute exacerbations may arise through episodic planktonic “showering”.