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      Folliculitis caused by Pantoea dispersa as a souvenir from a self-discovery excursion in bat caves

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          Abstract

          Introduction Increasing globalization and access to exotic travel destinations have led to a change in the spectrum of diseases. Recent disease outbreaks, such as the COVID-19 pandemic, have shed light on animal pathogens turning into human health threats. Typical examples in dermatology include larva migrans, but relatively unknown bacterial infections are gaining ground and challenging clinicians. Compared with animal pathogens, plant pathogens are exceptionally rare pathogens encountered in clinical settings with until now unclear underlying pathogenetic mechanisms. Herein, we report the case of a generalized skin infection caused by the plant pathogen Pantoea dispersa potentially imported from a cave trip in Latin America. Case report A 33-year-old man presented to our outpatient department after returning from a trip to the Mexican jungle. He reported having spent 6 hours naked in a dark, humid cave inhabited by bats to find his inner balance. Four days after returning to society, he and his fellow meditative companions developed numerous yellow-reddish pustules, first occurring on body parts that were in contact with the soil of the cave. Under the assumption that the condition was a vasculitis, the patient was treated with systemic corticosteroids (40 mg/d for 7 days) by a local general practitioner, which unfortunately aggravated the symptoms and the skin lesions. At initial presentation, physical examination revealed erythematous, slightly pruritic papules next to disseminated pustules around inflamed hair follicles alongside small, shallow, punched-out ulcers with thick, red-brown crusts and surrounding erythema on the entire integument (Fig 1, A-C). Biopsies of the trunk and the arm were performed, showing an abscessing folliculitis and perifolliculitis (Fig 2, A and B). No organisms were present in the biopsies. Blood testing revealed a slightly increased leukocytosis. An HIV test was negative. A microbiologic culture of the pustules revealed P dispersa. We thereby diagnosed a P dispersa associated folliculitis. In accordance with the antibiogram, the patient was prescribed trimethoprim-sulfamethoxazole (960 mg twice daily) for 7 days and an antiseptic washing lotion, which led to an abatement of the skin lesions within 10 days. Fig 1 A-C. Physical examination at initial presentation revealed erythematous, slightly pruritic papules next to disseminated pustules around inflamed hair follicles alongside small, shallow, punched-out ulcers with thick, red-brown crusts and surrounding erythema on the whole integument. Fig 2 A and B. Biopsies of the trunk and the arm revealed an abscessing folliculitis and perifolliculitis. (A and B, Hematoxylin-eosin stain; original magnification: A, ×40 and B, ×100). Discussion Folliculitis affects the superficial aspect of the hair follicle and can involve the perifollicular area. 1 Folliculitis has a broad clinical presentation because of its etiology, but it mostly manifests in acute cases as 1-mm–wide pustules and papulopustules, with the possibility of developing into nonhealing ulcerations with crusts. 1 Common bacteria that cause folliculitis are Staphylococcous aureus and species of Streptococcus, Pseudomonas, and Proteus. 2 Folliculitis caused by gram-negative bacteria is rare, 2 and to our knowledge Pantoea species as a cause of folliculitis have not been described in the literature until now. Pantoea is a gram-negative, versatile member of the Enterobacteriaceae family that can be isolated from a variety of environments. 3 Macroscopically it presents as a yellow-pigmented, rod-shaped, motile bacterium. 3 The very first identified members were observed to cause wilting, soft rot, and necrosis in a variety of agriculturally relevant plants, such as beets, maize, and epiphytes. Pantoea species have since been isolated from many aquatic and terrestrial environments and described to have an association with insects and other animals. 3 Furthermore, recent research has disclosed data on the bioremediation potential of Pantoea species and on its role as a immunopotentiator in the development of supportive drugs that treat melanoma, infections, allergy, and immunosuppression. 4 These mechanisms can primarily be explained by the activation of macrophages by lipopolysaccharides derived from Pantoea species, leading to activation of the immune system and thereby antiinflammatory effects. 4 The genus Pantoea is divided into 20 different species and includes Pantoea agglomerans, P septica, P ananatis, and P dispersa. 3 P dispersa inhabits plants, soil, and humid ground. 5 Dismissed in the past as a plant pathogen that forms host associations with different plants and fungi, recent evidence suggests an additional role in human disease. 3 P agglomerans, the most common member, causes opportunistic human infections; eg, wound infections, after contact with plant material in addition to hospital-acquired infections. 4 Although in most cases of generalized folliculitis amoxicillin is used as treatment, Pantoea species are often resistant to common clinically used antibiotics, such as penicillin G, bacitracin, rifampicin, vancomycin, and fosfomycin. 6 The literature reports of only 6 cases of human infections caused by P dispersa. The clinical presentation of P dispersa infections in these cases varied from bacteremia to respiratory tract infections. Two patients were neonates, who developed early-onset sepsis. Treating the newborns with meropenem and amikacin according to an antibiogram and a resistogram improved symptoms. 7 In the first report of an adult infected with P dispersa, a 71-year-old immunocompromised woman with acute myeloid leukemia and multiple myeloma developed a respiratory tract infection that was treated successfully with test-appropriate antibiotic therapy. 8 Furthermore, the literature contains 3 reports on bloodstream infections caused by P dispersa in a 64-year-old man after implantation of a pacemaker, a 38-year-old woman with acute cholangitis, and a 23-year-old woman with lethal sepsis. 9 Although to our knowledge no cases of skin infections with P dispersa have been described, the literature reports cases of skin infections with P agglomerans. 4 These include a 58-year-old woman presenting with a wound infection after a penetrating plant injury and a patient with multiple skin eruptions presenting as small papules. 10 Overall, P dispersa infections can apparently occur in immunocompetent patients in the same manner as in immunocompromised hosts, although the literature on this is very limited. Detecting P dispersa remains challenging because of its rarity and because of difficulty in correct identification. As P dispersa belongs to the Enterobacter species, some cases may be incorrectly identified as being caused by species of Enterobacteriaceae. 9 Common diagnostic tools, such as the MALDI Biotyper often misidentify Erwiniacea as Klebsiella species. 9 A detailed anamnesis can be helpful in these vague cases. All species of Pantoea can be isolated form plant, soil, and feculent material. 3 As our patient spent hours in a humid cave inhabited by bats and other animals, the existing fecal matter and moist soil may have provided an ideal breeding ground for Pantoea. 3 It stands to reason that he contracted this rare infection during his trip to the jungle. The pathogenetic mechanisms of P dispersa remain unclear, and the current case report generates a range of questions as to what degree these plant pathogens can cause infections in humans. 9 Conflicts of interest None disclosed.

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          Most cited references10

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          Pantoea: insights into a highly versatile and diverse genus within the Enterobacteriaceae.

          The bacterial genus Pantoea comprises many versatile species that have been isolated from a multitude of environments. Pantoea was delineated as a genus approximately 25 years ago, but since then, approximately 20 species have been identified having a diversity of characteristics. Isolates from water and soil have been harnessed for industrial purposes including bioremediation, and the degradation of herbicides and other toxic products. Other isolates possess nitrogen fixation and plant growth-promoting capabilities, which are currently being explored for agricultural applications. Some isolates are antibiotic producers, and have been developed into biocontrol agents for the management of plant diseases. Pantoea is also known to form host associations with a variety of hosts, including plants, insects and humans. Although often thought of as a plant pathogen, recent evidence suggests that Pantoea is being frequently isolated from the nosocomial environment, with considerable debate as to its role in human disease. This review will explore this highly versatile group and its capabilities, its known associations, and the underlying genetic and genomic determinants that drive its diversity and adaptability.
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            Skin microflora and bacterial infections of the skin.

            The skin is a milieu for controlled bacterial growth. Skin supports the growth of commensal bacteria, which protect the host from pathogenic bacteria. Environmental and local factors, host immunity, and organism adherence and virulence are intricately related to cutaneous infection. Resident gram-positive bacteria include Staphylococcus, Micrococcus, and Corynebacterium sp. Staphylococcus aureus and Streptococcus pyogenes are notoriously pathogenic in the skin. In order for bacteria to be pathogenic, they must be able to adhere to, grow on, and invade the host. Bacteria possess numerous virulence genes that allow for growth in these privileged niches. Epidermal infections caused by S. aureus and S. pyogenes include impetigo and ecthyma. Dermal infections consist of erysipelas, cellulitis, and necrotizing fasciitis. The pilosebaceous unit is involved in folliculitis, furunculosis, and carbunculosis. Moreover, S. aureus and S. pyogenes produce toxins that may elicit a superantigen response, causing massive release of cytokines. Staphylococcal scalded skin syndrome, toxic shock syndrome, and scarlet fever are all superantigen-mediated. Gram-negative organisms such as Pseudomonas aeruginosa, Pasteurella multocida, Capnocytophaga canimorsus, Bartonella sp., Klebsiella rhinoscleromatis, and Vibrio vulnificus are not typical resident skin microflora but may cause cutaneous infection.
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              Phylogeny and identification of Pantoea species associated with plants, humans and the natural environment based on multilocus sequence analysis (MLSA).

              Species belonging to the genus of Pantoea are commonly isolated from plants, humans and the natural environment. The species of the genus are phenotypically closely related, making rapid identification of Pantoea strains to the species level difficult. Multilocus sequence analysis (MLSA) was evaluated as a means for rapid classification and identification of Pantoea strains. Four housekeeping genes, gyrB, rpoB, atpD and infB, were sequenced for strains assigned to the genus. Included in the study were (1) reference strains from the seven currently recognized species of Pantoea, (2) strains belonging to Brenner DNA groups II, IV and V, previously isolated from clinical samples and difficult to identify because of high phenotypic similarity to P. agglomerans or P. ananatis and (3) isolates from diseased Eucalyptus, maize and onion, assigned to the genus on the basis of phenotypic tests. Phylogenetic trees were constructed from the sequences of the four housekeeping genes. The "core"Pantoea species formed a cluster separate from the "Japanese" species which formed a tight cluster that included the genus Tatumella when the tree was based on concatenated sequences of the four genes. The MLSA data further suggested the existence of ten potential novel species, phylogenetically related to the currently recognized Pantoea species and the possible inclusion of Pectobacterium cypripedii in the genus Pantoea. When compared with DNA-DNA hybridization data, a good congruence was observed between both methods, with gyrB sequence data being the most consistent. In conclusion, MLSA of partial nucleotide sequences of the genes gyrB, rpoB, atpD and infB can be used for classification, identification and phylogenetic analyses of Pantoea strains.
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                Author and article information

                Contributors
                Journal
                JAAD Case Rep
                JAAD Case Rep
                JAAD Case Reports
                Elsevier
                2352-5126
                18 May 2022
                July 2022
                18 May 2022
                : 25
                : 15-17
                Affiliations
                [a ]Department of Dermatology and Allergy, School of Medicine, Technical University of Munich, Munich, Germany
                [b ]Institute for Medical Microbiology, Immunology and Hygiene, School of Medicine, Technical University of Munich, Munich, Germany
                [c ]Division of Dermatology and Venereology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
                Author notes
                []Correspondence to: Sarah Preis, MD, Department of Dermatology and Allergy, School of Medicine, Technical University of Munich, Biedersteiner Str. 29, D-80802 Munich, Germany. sarah.preis@ 123456mri.tum.de
                Article
                S2352-5126(22)00221-1
                10.1016/j.jdcr.2022.05.009
                9168063
                fda721d2-9aaf-478c-83f3-7854c51c2b6a
                © 2022 by the American Academy of Dermatology, Inc. Published by Elsevier, Inc.

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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                Case Report

                folliculitis,pantoea dispersa,skin infection,p dispersa, pantoea dispersa

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