Erosive balanitis caused by Staphylococcus haemolyticus in a healthy, circumcised adult male
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Introduction. Balanitis is an inflammation of the glans penis. Balanoposthitis involves both the glans penis and prepuce and occurs only in uncircumcised males. Recurrent balanoposthitis represents a strong indication for circumcision. After Candida infections, aerobic bacteria are the second most common aetiological cause of acute infectious balanoposthitis, mainly streptococci groups B and D, and staphylococci, usually S. aureus . Their clinical manifestations are variable inflammatory changes, including diffuse erythema and oedema. Severe balanopreputial oedema with purulent exudate occurs in painful, erosive streptococcal balanoposthitis.
Coagulase-negative staphylococci (CoNS) are commensal skin bacteria, but are also recognized pathogens of the genitourinary system, mainly related to urinary tract infections. Staphylococcus haemolyticus is one of the main species of CoNS that is part of the cutaneous microflora but is also associated with nosocomial infections. In addition, S. haemolyticus also causes other infections of the male urogenital tract, such as chronic prostatitis and epididymo-orchitis, but it has not been associated with balanitis.
Case presentation. A 45-year-old man reports having suffered several episodes of balanoposthitis in the last 3 years, which were treated with topical antifungal treatments alone or associated with corticosteroids. For this reason, he underwent a postectomy by his urologist 8 months ago to avoid further recurrences.
The patient consulted for an episode of painful, erosive and exudative lesions on the glans penis and over the post-operative scars lasting 5 days. He had no urinary discomfort or inguinal lymphadenopathy. A complete blood count, biochemical analysis, C-reactive protein (CRP), prostate-specific antigen (PSA) and urinalysis were normal. Abundant growth of S. haemolyticus was obtained in the culture on tryptone soya agar with sheep blood and chocolate agar with Vitox media. The MicroScan panel CIM 37 (PM37) was used to study the antimicrobial susceptibilities of the isolated bacteria. The fungal culture on Sabouraud dextrose agar was negative. Based on the antimicrobial susceptibility study, treatment with oral ciprofloxacin and topical mupirocin was started, and the genital infection was completely cured.
Conclusion. We present a healthy, non-diabetic, circumcised male patient with severe, erosive and painful balanitis probably due to S. haemolyticus .
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The authors have taken the reviewer and editorial comments into consideration and the case report is now suitable for acceptance.
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Thank you for addressing the points raised by the reviewers. However, this report neglects to outline a major limitation of the case. The report presents evidence for S. haemolyticus as the causative agent of infection, however this evidence is not definitive. Please address this limitation, as outlined by reviewer 1, in the report.
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Comments to Author
I note responses to the majority of the questions and thank the authors for clarification of how the organism was identified and the drug sensitivities generated and more background information about the case. I still feel that the premise on which the case is built is lacking. In this case the evidence that the infection was caused by the skin commensal staphylococcus haemolyticus is only the result of one skin swab taken at one time point from a non sterile site. The treatment used was also very broad spectrum coving a variety of gram positive and gram negative bacteria. In comparison, the case of epididymo-orchitis associated with S. haemolyticus referenced in the authors conclusions was diagnosed via multiple positive blood culture results. I still believe that the case would benefit from a …
Comments to Author
I note responses to the majority of the questions and thank the authors for clarification of how the organism was identified and the drug sensitivities generated and more background information about the case. I still feel that the premise on which the case is built is lacking. In this case the evidence that the infection was caused by the skin commensal staphylococcus haemolyticus is only the result of one skin swab taken at one time point from a non sterile site. The treatment used was also very broad spectrum coving a variety of gram positive and gram negative bacteria. In comparison, the case of epididymo-orchitis associated with S. haemolyticus referenced in the authors conclusions was diagnosed via multiple positive blood culture results. I still believe that the case would benefit from a more clear explanation of the limitations of the diagnostic uncertainty in this case
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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The reviewers have highlighted major concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
[Delete this text before submitting your review. Please include comments to the author here, and include the below sections, where possible. All comments here will be posted publicly online alongside the article once the Editor has made a decision.] 1. Description of the case(s) There are several notes regarding your manuscript as follows. This paper does not fit with the journal topics. The title: I suggest you make a few changes that would be more appropriate to the study. Abstract - The abstract very short and wasn't included modern tools in this article . - There are several grammatical mistakes that should be corrected. Introduction - Need to add more details about all study subjects about the This subject Infectious balanoposthitis are the most frequent of the acute conditions; …
Comments to Author
[Delete this text before submitting your review. Please include comments to the author here, and include the below sections, where possible. All comments here will be posted publicly online alongside the article once the Editor has made a decision.] 1. Description of the case(s) There are several notes regarding your manuscript as follows. This paper does not fit with the journal topics. The title: I suggest you make a few changes that would be more appropriate to the study. Abstract - The abstract very short and wasn't included modern tools in this article . - There are several grammatical mistakes that should be corrected. Introduction - Need to add more details about all study subjects about the This subject Infectious balanoposthitis are the most frequent of the acute conditions; other noninfectious causes can be traumatic, irritative or contact. Candida infections are the most common of the infectious balanoposthitis. Bacteria are the second cause in frequency of these acute entities Methodology - Non methodology - Need to add methodology with more details 2. Presentation of results the results non clear ( non- results ) 3. How the style and organization of the paper communicates and represents key findings Research needs attention and writing with modern tools 4. Literature analysis or discussion Research needs attention and writing with modern tools 5. Any other relevant comments
Please rate the quality of the presentation and structure of the manuscript
Very poor
To what extent are the conclusions supported by the data?
Not at all
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
The work done here is well presented, however there are some comments need to be addressed before accepting for publication. The introduction needs to be rewritten to clarify the research question and research hypothesis. The author need to add in the discussion more explanation and details why although S. haemolyticus is one of the most frequent etiological agents of staphylococcal infections, they have not found its relationship with balanitis. Rewrite the conclusion to add the significant of your case
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other …
Comments to Author
The work done here is well presented, however there are some comments need to be addressed before accepting for publication. The introduction needs to be rewritten to clarify the research question and research hypothesis. The author need to add in the discussion more explanation and details why although S. haemolyticus is one of the most frequent etiological agents of staphylococcal infections, they have not found its relationship with balanitis. Rewrite the conclusion to add the significant of your case
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
-
Comments to Author
The authors present a case of erosive balanitis in which they isolate and treat a staphylococcus haemolyticus. While the case is well written and the discussion informative, unfortunately in its current state I do not recommend accepting this paper without major revision. The principal shortcoming of this case lies in the conclusion that the balanitis was caused by the S. haemolyticus. As the authors mention, coagulase negative staphylococcus are common skin commensals and are typically less virulent than the coagulase positive S. Aureus or the streptococcal species which are more commonly associated with skin and soft tissue infections. The article would benefit from more details in support of the assumption that the S. haemolyticus was indeed the causative agent of the balanitis. i.e. was S. …
Comments to Author
The authors present a case of erosive balanitis in which they isolate and treat a staphylococcus haemolyticus. While the case is well written and the discussion informative, unfortunately in its current state I do not recommend accepting this paper without major revision. The principal shortcoming of this case lies in the conclusion that the balanitis was caused by the S. haemolyticus. As the authors mention, coagulase negative staphylococcus are common skin commensals and are typically less virulent than the coagulase positive S. Aureus or the streptococcal species which are more commonly associated with skin and soft tissue infections. The article would benefit from more details in support of the assumption that the S. haemolyticus was indeed the causative agent of the balanitis. i.e. was S. haemolyticus cultured on previous occasions when the patient presented over the last 3 years? Did the patient fail any treatment that may have been target toward a sensitive staph / strep i.e flucloxacillin prior to presentation on this occasion? Is there anything else in his history that would you make you suspect that this culture result is significant i.e immunosuppressed in any other way. It is stated that 'samples' were taken, this implies multiple samples were taken from the infected area. If this is the case, how many grew the S. haemolyticus? If multiple were positive this may again be more significant. Related to the above, this case would benefit from more detail, not just in supporting the diagnosis but in better describing the patient's presentation and the microbiological work up. For example. 1. How long had the lesion had been there for? 2. It is stated that the blood tests and urinalysis were normal, it would be useful to know which pertinent tests had been requested even if just a few select but important tests. i.e. his full flood count, CRP etc. 3. Likewise what was tested in the urine? is this how we know he was not diabetic? 3. How was the S. haemolyticus identified i.e was MALDI-TOF used or were more traditional tests used? if MALDI-TOF was used what was the confidence score etc. What specific media was used to culture the bacteria and in what conditions? 4. The authors provide sensitivities in table 1, this is useful for the reader, but it would be good to include how these were arrived at, was disc diffusion testing used? and if any further susceptibility testing was done then including the MICs would add value. In conclusion while the case requires significantly more detail, and the discussion while well written and informative would be improved if more focus was placed on the difficulty of deciding when S. haemolyticus is significant from a skin swab and not just a commensal
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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