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Pseudomeningitis due to Neisseria lactamica
Jurado RL, Farley MM, Pereira E, et al.: Increased risk of meningitis and bacteriemia due to Listeria monocytogenes in patients with human immunodeficiency virus infection. Clin Infect Dis 1993;17:224--227.
Mascola L, Lieb L, Chiu J, et al.: Listeriosis: an uncommon opportunistic infection in patients with acquired immunodeficiency syndrome. Am J Meal 1988;84:162-164. Schuchat A, Deaver KA, Wenger JD, et al.: Role of foods in sporadic listeriosis. 1.
Case-control study of dietary risk factors. JAMA 1992;267:2041-2045. WHO-EC Collaborating Centre on AIDS. AIDS surveillance in Europe. Quarterly Report no. 37, 1993.
Pseudomeningitis due to Neisseria lactamica Evelyn Jacobsen Inge Gurevich Burke A. Cunha Infection Control Section Infectious Disease Division Winthrop-University Hospital, NY and School of Medicine State University of New York Stony Brook, NY
Pseudomeningitis may be defined as the demonstration of organisms on Gram stain/culture of cerebrospinal fluid (CSF) in patients with central nervous system abnormalities requiring lumbar puncture, which are not clinically significant neuropathogens. Pseudomeningitis has been infrequently reported in the literature since 1973. Gram-negative bacilli that are able to contaminate antiseptic solutions used for the patients' skin preparation, or laboratory pipette bulbs, specimen slides/tubes or transport media, can be reported to the clinician as isolates from the spinal fluid and result in inappropriate antimicrobial therapy for nonexisting meningitis, e.g., pseudomeningitis. The clue to the recognition of pseudomeningitis is the demonstration of unusual organisms in the CSF not usually associated with meningitis. The diagnosis of pseudomeningitis is particularly difficult when the bacterial isolate reported resembles common bacterial neuropathogens, i.e., Gram-negative diplococci, which are usually Neisseria species and can be presumed to be Neisseria meningitis. We report the hrst known case of pseudomeningitis due to Neisseria lactamica. The patient was a 68-year-old male who emigrated to the U.S. from India 5 months prior to admission. He had a his-
Antimicmbics and Infectious Diseases Newsletter 13(9) 1994
tory of hypertension and suprapubic cystostomy tube insertion for chronic ureteral stricture. He was brought to our 600-bed tertiary care facility after a family member noted changes in his mental status. On physical examination the patient was mentally confused, with episodes of aphasia. There was stiffness of the right upper and lower extremities, but his neck was supple. Lumbar puncture
T h e diagnosis of pseudomeningitis is particularly difficult when a CSF isolate, such as Neisseria lactamica, resembles a common CSF pathogen,
N. meningitis.
was performed because of the mental confusion. CSF revealed a white blood cell count of 58 cells/mm3 (polymotphonuclear leukocytes 98, lymphocytes 1, monocytes 1), glucose of 57 mg/dl, total protein of 31 mg/dl, and a lactic acid of 3.3 mEq/l. The CSF Gram stain was positive for Gram-negative diplococci. Empiric penicillin G, 3.5 mu (IVPB) q4h was started. A working diagnosis of meningococcal meningitis
© 1994 Elsevier Science Inc.
was made and he was placed on respiratory isolation based on the results of the lumbar puncture Gram stain. Infection control asked all departments to determine which of their staff members may have come in close contact with the patient, to determine the need for potential chemoprophylaxis. Sixty-eight people from 12 departments requested prophylaxis, and 63 of these employees were prophylaxed with rifampin or ciprofloxacin. The next day, the Gram-negative diplococci were identified as N. lactamica. N. lactamica is an oropharyngeal commensal, and it was not clear how it gained access to the patient's cerebrospinal fluid as an extraneous contaminant. Antibiotic therapy was discontinued when the microbiology laboratory reported the species as a nonmeningococcal Neisseria. The patient did well and made a slow recovery from what was later determined to be a CVA. Many patients such as this are unnecessarily treated, and the exposed health care workers receive unnecessary prophylaxis. Clinicians should be alert to the possibility of pseudomeningitis when a CSF isolate is an unusual pathogen in the setting of possible meningitis.
Bibliography Cunha BA: Pseudomeningifis---another nosoeomial headache. Ilffect Control Hosp Epidemiol 1988;9:391-393. Cunha BA, Klein NC: Pseudoinfections. Infect Dis Clin Practice (accepted for publication), 1995. Leuau LA, Benjamin Mr, et al.: Bacillus species psuedomeningitis. Infect Control Hosp Epidemiol 1988; 9:394-397.
1069-417XD4/$0.00 + 07.OO
67
Mascola L, Lieb L, Chiu J, et al.: Listeriosis: an uncommon opportunistic infection in patients with acquired immunodeficiency syndrome. Am J Meal 1988;84:162-164. Schuchat A, Deaver KA, Wenger JD, et al.: Role of foods in sporadic listeriosis. 1.
Case-control study of dietary risk factors. JAMA 1992;267:2041-2045. WHO-EC Collaborating Centre on AIDS. AIDS surveillance in Europe. Quarterly Report no. 37, 1993.
Pseudomeningitis due to Neisseria lactamica Evelyn Jacobsen Inge Gurevich Burke A. Cunha Infection Control Section Infectious Disease Division Winthrop-University Hospital, NY and School of Medicine State University of New York Stony Brook, NY
Pseudomeningitis may be defined as the demonstration of organisms on Gram stain/culture of cerebrospinal fluid (CSF) in patients with central nervous system abnormalities requiring lumbar puncture, which are not clinically significant neuropathogens. Pseudomeningitis has been infrequently reported in the literature since 1973. Gram-negative bacilli that are able to contaminate antiseptic solutions used for the patients' skin preparation, or laboratory pipette bulbs, specimen slides/tubes or transport media, can be reported to the clinician as isolates from the spinal fluid and result in inappropriate antimicrobial therapy for nonexisting meningitis, e.g., pseudomeningitis. The clue to the recognition of pseudomeningitis is the demonstration of unusual organisms in the CSF not usually associated with meningitis. The diagnosis of pseudomeningitis is particularly difficult when the bacterial isolate reported resembles common bacterial neuropathogens, i.e., Gram-negative diplococci, which are usually Neisseria species and can be presumed to be Neisseria meningitis. We report the hrst known case of pseudomeningitis due to Neisseria lactamica. The patient was a 68-year-old male who emigrated to the U.S. from India 5 months prior to admission. He had a his-
Antimicmbics and Infectious Diseases Newsletter 13(9) 1994
tory of hypertension and suprapubic cystostomy tube insertion for chronic ureteral stricture. He was brought to our 600-bed tertiary care facility after a family member noted changes in his mental status. On physical examination the patient was mentally confused, with episodes of aphasia. There was stiffness of the right upper and lower extremities, but his neck was supple. Lumbar puncture
T h e diagnosis of pseudomeningitis is particularly difficult when a CSF isolate, such as Neisseria lactamica, resembles a common CSF pathogen,
N. meningitis.
was performed because of the mental confusion. CSF revealed a white blood cell count of 58 cells/mm3 (polymotphonuclear leukocytes 98, lymphocytes 1, monocytes 1), glucose of 57 mg/dl, total protein of 31 mg/dl, and a lactic acid of 3.3 mEq/l. The CSF Gram stain was positive for Gram-negative diplococci. Empiric penicillin G, 3.5 mu (IVPB) q4h was started. A working diagnosis of meningococcal meningitis
© 1994 Elsevier Science Inc.
was made and he was placed on respiratory isolation based on the results of the lumbar puncture Gram stain. Infection control asked all departments to determine which of their staff members may have come in close contact with the patient, to determine the need for potential chemoprophylaxis. Sixty-eight people from 12 departments requested prophylaxis, and 63 of these employees were prophylaxed with rifampin or ciprofloxacin. The next day, the Gram-negative diplococci were identified as N. lactamica. N. lactamica is an oropharyngeal commensal, and it was not clear how it gained access to the patient's cerebrospinal fluid as an extraneous contaminant. Antibiotic therapy was discontinued when the microbiology laboratory reported the species as a nonmeningococcal Neisseria. The patient did well and made a slow recovery from what was later determined to be a CVA. Many patients such as this are unnecessarily treated, and the exposed health care workers receive unnecessary prophylaxis. Clinicians should be alert to the possibility of pseudomeningitis when a CSF isolate is an unusual pathogen in the setting of possible meningitis.
Bibliography Cunha BA: Pseudomeningifis---another nosoeomial headache. Ilffect Control Hosp Epidemiol 1988;9:391-393. Cunha BA, Klein NC: Pseudoinfections. Infect Dis Clin Practice (accepted for publication), 1995. Leuau LA, Benjamin Mr, et al.: Bacillus species psuedomeningitis. Infect Control Hosp Epidemiol 1988; 9:394-397.
1069-417XD4/$0.00 + 07.OO
67