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Recalcitrant acne vulgaris secondary to a dental abscess
Abstract
This case report describes a middle-aged man with acne that was recalcitrant to numerous medications, including three courses of isotretinoin. His condition cleared after an infected tooth was removed and recurred when another tooth became carious. Acne vulgaris is associated with several immunologic responses including the production of antibodies against Propionibacterium acnes, the gram-positive bacteria found in acne lesions. We believe that the presence of our patient's dental infections provoked a follicular inflammatory response resulting in his recalcitrant acne.
Dental diseases has long been proposed as a potential causative agant in certain dermatological diseases. However, literature data on this association are scarce. The aim of this retrospective study was to evaluate dental status in 92 patients with various dermatological diseaseswho were reffered to our Department for elimination of dental diseasesand to assess the relationship between dental infection and dermatological diseases. Dermatological conditions due to which patients were reffered were alopecia, urticaria, eczematoid dermatitis, psoriasis, edema, etc. Out of 92 patients, 42 patients were reffered for further dental treatment, while the remaining 50 patients had no observable dental pathology. None of the patients reported improvement following dental treatment. Based on the results of this study, we might conclude that dental infection does not play any role in the development of dermatological disease.
Objective:
Dental disease has been for a long time proposed as a potential causative agent in certain dermatological diseases. However, literature data on this association are scarce.
Method:
The aim of this retrospective study was to evaluate dental status in 92 patients with various dermatologic diseases who were referred to our Department for the elimination of dental disease and assess the correlation between dental infection and dermatological diseases.
Result:
Dermatological conditions due to which patients were referred were alopetia, urticaria, eczematoid dermatitis, psoriasis, oedema, etc. Out of 92 patients, 42 (45.7%) patients were referred for further dental treatment, while remaining 50 (54.3%) had no observable dental pathology. None of the patients reported improvement following dental treatment.
Conclusion:
Based on the results of this study, we might conclude that the dental infection does not play any role in the development of dermatologic disease.
With 4 million platelet units transfused per year in the United States and with the current estimate of bacteria contamination rate in PLT units, it would be expected that 2000 to 4000 bacterially contaminated units are transfused and associated with 333 to 1000 cases of clinical sepsis.
Apheresis platelets were sampled on Day 2 of storage (collection day=Day 0) and issue (or following outdate, Days 6-8) using a sterile connection device (SCD) to attach a sampling bag. Using aseptic technique and a laminar flow hood, bottles were inoculated and placed onto an automated liquid culture system (BacT/ALERT 3D Microbial Detection System) for 7 days.
A total of 2397 apheresis PLT units were sampled. A triple apheresis collection was reactive within 14 hours of the Day 2 sampling (aerobic bottles) and the bags were removed from inventory. Staphylococcus epidermidis was identified in all three contaminated bags. Two double-apheresis collections were found to be contaminated with Proprionibacterium sp. after 6 days of incubation but had been transfused to four patients without discernible clinical sequelae. There was one false-positive aerobic bottle and one false-positive anaerobic result due to inadvertent contamination of a bottle. Thus, the overall true-positive rate was 7 of 2397 apheresis units (0.29%) with a true-positive rate for aerobic organisms of 0.13% and an anaerobic true-positive rate of 0.17%. The false-positive rate was 2 out of 4794 samplings (0.04%) or 2 out of 9588 bottles (0.02%).
This preliminary data suggests that the use of a SCD, aseptic technique, and a laminar flow hood is associated with a low rate of contamination. In no case did an issue (or outdate) detect contamination that was not detected by the Day 2 culture. Additional surveillance is necessary before we can conclude that a Day 2 sterile culture is truly predictive of an issue (or outdate) sterile culture. Bacterial culture surveillance of PLTs would be expected to save lives and may facilitate an extension in PLT storage.
This study was aimed at comparing the cultivable microorganisms in canals with periapical radiolucencies with exposed and unexposed pulp space. Microbiological samples were taken and analyzed from 45 canals with exposed pulp space, and 43 canals with unexposed pulp space. The canal contents were analyzed by aerobic/anaerobic culture, and conventional identification techniques. There were 211 isolates of bacteria belonging to 28 genera and 55 species recovered from exposed canals. In the unexposed group, 185 isolates of bacteria were recovered, of which 54 species of 28 genera were identified. Among the four most common genera, Prevotella was significantly more common in the exposed group (51/211 in the exposed group versus 30/185 in the unexposed group) (p = 0.049), while there were no differences in prevalence of Actinomyces, Peptostreptococcus, and Campylobacter between two groups of canals. In addition, Fusobacterium nucleatum and Propionibacterium acne were significantly more common in the unexposed canals (p = 0.047 and p = 0.0051, respectively). Similarity in bacterial species in these two groups suggests that pulp space exposure may not be a significant factor in determining the type of bacteria present in infected canals.
Single and mixed infections with 11 clinical isolates of Propionibacterium acnes and three facultative bacteria (Staphylococcus aureus, Escherichia coli and Klebsiella pneumoniae) were studied in a subcutaneous abscess model in mice. Abscesses were induced by pure cultures of six of 11 strains of P. acnes and by the three facultative bacteria. The abscesses produced by each of the six "virulent" P. acnes isolates mixed with S. aureus, E. coli or K. pneumoniae were larger than those induced by the single organisms in 16 of the 18 combinations. There was a significant increase in the numbers of the six P. acnes strains in 13 of the 18 bacterial mixtures and in the numbers of the facultative bacteria in 17 of the 18 combinations. These data illustrate the potential virulence of some P. acnes strains and their synergic capacity with facultative bacteria.
The bacterial species found in pus aspirated from brain abscesses in two patients were typical of those found in dental sepsis. Subsequently apical-root abscesses were demonstrated in the upper jaws of both patients. This evidence strongly suggests that these cerebral abscesses were secondary to dental sepsis which could have spread from the teeth to the frontal lobes by several possible antaomical pathways.
The factors that initiate the inflammatory response in acne are not known. The presence of pro-inflammatory cytokines in acne comedones was therefore investigated. One hundred eight open comedones were collected from 18 untreated acne patients (10 male, 8 female). Each comedone was homogenized and centrifuged, and the supernatant was analyzed for bioactive and immunochemically detectable IL-1 alpha, IL-1 beta, and TNF alpha. Viable counts of propionibacteria, staphylococci, and Malassezia spp. were determined in the comedone pellet. Bioactive IL-1 alpha-like material was demonstrated in 76% of open comedones (range of 23-4765 pg IL-1 alpha-like bioactivity/mg of comedone material). In 58% of comedones, levels exceeded 100 pg/mg. There was no correlation between IL-1 alpha-like bioactivity and IL-1 alpha determined immunochemically. Bioactive IL-1 beta was not detected in any comedones. Twenty-four percent contained low levels of immunochemical IL-1 beta (range 12-103 pg IL-1 beta/mg comedone material). Bioactive TNF alpha was detected in three comedones with a further five comedones containing immunochemical TNF alpha (range of 61-820 pg TNF alpha/mg comedone material). The majority of open comedones (97%) contained microorganisms. There was, however, no significant correlation (Spearman's rank) between levels of any cytokine, in particular IL-1 alpha-like bioactivity, and numbers of microorganisms. Thus, bioactive IL-1 alpha-like material in the majority of open comedones may be concerned in the initiation of inflammation in acne following spongiosis or rupture of the pilosebaceous follicle wall.
Propionibacterium acnes was isolated in pure culture from brain abscesses that occurred in two patients after intracranial surgery. Although such infections are usually associated with cerebrospinal fluid shunts and other foreign bodies, these cases clearly demonstrate the pathogenicity of this anaerobic diphtheroid in the absence of such. Progression of P. acnes infection in the central nervous system can be insidious. To treat such infections adequately, therapy cannot rely upon some standard antimicrobial agents. Metronidazole, which is useful against most anaerobic organisms, is not effective against P. acnes.
We examined 69 biopsies of acne lesions known to be 6, 24 or 72 h old and found that the lymphocyte was the predominant cell at 6 and 24 h. The helper:suppressor T cell ratio in the inflammatory infiltrate was 2.8:1. Polymorphonuclear leukocytes were increasingly seen at 24 and 72 h and were associated with disruption of the duct. We hypothesize that this early lymphocytic infiltrate represents a cell mediated immune response to an antigen within the duct lumen.
In spite of considerable advances during the last years, classification and identification of Actinomycetaceae and Propionibacteriaceae still present major problems. Uncertainties about the systematic position and taxonomic status of several genera and species, the lack of reliable distinguishing characteristics or use of inadequately adapted techniques of investigation interfere with both micribiological and clinical research and also with routine work in the diagnostic laboratory. Nevertheless, besides actinomycosis, an etiologically well defined suppurative infection, several other diseases and lesions such as lacrimal canaliculitis, caries and periodontal disease, inflammation following use of intrauterine pessaries, various types of abscess, septicaemia, and acne vulgaris have been attributed to the direct or indirect pathogenic effects of fermentative actinomycetes, propionibacteria, or eubacteria. Many questions concerning their individual pathogenicity and their pathomechanisms still remain to be answered, however.
Recent findings suggest that an overly vigorous immune response to Propionibacterium acnes may be the fundamental problem in patients with inflammatory acne. These data and evidence for the antiinflammatory effects of acne medications are reviewed.
IgG subclasses specific to Staphylococcus epidermidis and Propionibacterium acnes were determined in sera from patients with mild, moderate or severe acne and from a control group. Titres specific to S. epidermidis were all within the same range and did not differ between groups. The titres of IgG subclasses to specific to P. acnes did vary between groups. IgG1 and IgG3 were significantly higher in severe acne patients compared with moderate acne patients, while IgG2 was significantly higher in moderate and severe patients compared with controls. Titres of IgG4 did not differ between groups. The pattern of titres observed suggests that, while the antibody response to S. epidermidis is relatively harmless, antibodies to P. acnes may be involved in the pathogenesis of acne vulgaris.
Administration of killed Propionibacterium acnes to experimental animals leads to the development of hypersensitivity to the lethal and cytokine-inducing effects of endotoxin. This sensitizing property of P. acnes is not always expressed by different bacterial preparations. Its expression depends very much on the conditions employed for the cultivation of this microorganism. The present study investigates which culturing conditions result in P. acnes preparations with optimal sensitizing properties. The composition of the medium, the culturing time and temperature as well as the type of cultivation (in minifermentor or stationary culture) were all varied for this purpose. The resulting bacterial preparations were killed at 65 degrees C for 1 h and tested for sensitizing activity. The results show that stationary cultures of P. acnes grown at 37 degrees C for 4 to 5 days in the appropriate medium produce biologically active preparations with satisfactory sensitizing activity.