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Tularemia: A present day problem
vitro susceptibility of thirty strains of Haemophilus ducreyi to several antibiotics including six cephalosporins. J. Antimicrob. Chemother. 11:271-280. 27. Clarridge, J. E., et al. 1989. The routine isolation and recognition of Haemophilus ducreyi. Progr. Abstr. 29th Intersci. Conf. Antimicrob. Agents Chemother. no. 1055. 28. Clarridge, J. E. 1989. The growth of Haemophilus ducreyi on similar media from different manufacturers and various media from the same source. Diagnosis of sexually transmitted diseases. Texas Department of Health Bureau of Laboratories. Section IX. 29. Shawar, R., J. Sepulveda, and J. E. Clarridge. 1990. Use of the RapiD-
ANA system and sodium polyanetholesulfonate disk susceptibility testing in identifying Haemophilus ducreyi. J. Clin. Microbiol. 28:108-111. 30. Kilian, M. 1985. Haemophilus, p. 387-393. In E. H. Lennette et al. (ed.), Manual of clinical microbiology, 4th ed. American Society for Microbiology, Washington, D.C. 31. Kilian M. and E. L. Biberstein. 1984. Genus II. Haemophilus, p. 558-569. In N. R. Kreig and J. G. Holt. Bergey's manual of systematic bacteriology, vol. 1. Williams and Wilkins Co., Baltimore. 32. Parson, L. M., et al. 1990. Construction of DNA probes for the identification of Haemophilus ducreyi, p.
69-94. Gene probes for bacteria. Academic Press, New York. 33. Bodhidatta, L., et al. 1988. Evaluation of 500-mg and 1,000-mg doses of ciprofloxacin for the treatment of chancroid. Antimicrob. Agents Chemother. 32:723-725. 34. Nobre, G. N. 1982. Identification of Haemophilus ducreyi in the clinical laboratory. J. Med. Microbiol. 15:343-245. 35. Weaver, R. E., et al. 1982. Revised tables from "The identification of unusual pathogenic gram-negative bacteria (Elizabeth O. King)." Division of Bacterial Diseases, Center for Infectious Diseases, Centers for Disease Control, Altanta, Georgia.
The purpose of this report is to describe how this organism was recovered from the blood of a patient with fever of unknown origin using the Isolator microbial detection system (E. I. DuPont de Nemours, Wilmington, Del.). An initial diagnosis of tularemia had not been considered in this patient and was made by subsequent recovery of the organism from culture. A four-fold rise in the patient's antibody titers further confirmed the diagnosis.
showed a total white blood cell count of 15 x 106/p,l with 80% segmented neutrophils, 9% band forms, 5% lymphocytes, 5% monocytes, and 1% basophils. The hemoglobin was 13.1 gm/dl, hematocrit, 38.2%, urinalysis and Gram stain of urine were negative, and routine chemistry tests were normal. Blood cultures were drawn and cefoxitin was started. The patient was thought to have diverticulitis with abscess formation. However, an extensive evaluation of her abdomen revealed only three adenomatous polyps and an abdominal aortic aneurysm. The patient remained febrile and on the fourth hospital day, her chest X ray showed a left lower lobe infiltrate. CT scan of her chest also showed bilateral pleural effusions and infiltrates, but followup bronchoscopy was negative. Cefoxitin was discontinued and erythromycin therapy begun. An echocardiogram that was obtained to exclude bacterial endocarditis was normal except for moderate mitral valve regurgitation. The patient continued to receive an extensive evaluation for fever of unknown origin which included a bone marrow biopsy, MRI of the head, and a complete serologic evaluation for rickettsial, mycoplasmal, and viral infection. The bone marrow biopsy revealed small areas of necrosis which, in retrospect, contained minute gram-negative bacteria (Fig. 1). A tiny, gram-
Case Reports Tularemia: A Present Day Problem Denise Rule, B.A., M(ASCP) Laboratory Associate Robin Miller-Catchpole, M.D. Associate Director, Microbiology Harold G. Wedell, M.D.
Department of Medicine Eileen L. Randall, Ph.D. Director, Microbiology Evanston Hospital Evanston, IL 60201 Francisella tularensis is a fastidious, small, gram-negative coccobacillus. It was first described in 1911 by McCoy who wrote about a plaguelike disease of rodents occurring in Tulare County, California (1). McCoy and Chapin discovered the causative organism of the disease and named it Bacterium tularense. In 1925, Francis wrote extensively about the history of tularemia in humans, elaborating on the epidemiology, pathology, and laboratory diagnosis of the disease (2). Previously, the disease had been given many different names depending on the conditions encountered by various workers; for example, plaguelike disease of rodents, deerfly fever, Bacillus tularensis infections of the eye, rabbit fever, and glandular type of tick fever. Francis named the disease tularemia. In 1959, he was awarded the Nobel Prize for his work and was honored by having the name of the bacterium changed to Francisella tularensis.
Clinical Microbiology Newsletter 12:18,1990
Case History A 75-year-old white female presented to Glenbrook emergency room with a two-day history of fever and right lower quadrant abdominal pain. She denied any nausea, vomiting, diarrhea, or dysuria. She had a past history of hypertension and an appendectomy. At the time of admission she was receiving propranolol hydrochloride and lovastatin. On physical examination, the patient was a well-developed female in no apparent distress. Her vital signs were: blood pressure, 110/60; pulse rate, 108; respiratory rate, 24; and temperature, 103.5°F. Pertinent physical findings included no rash or skin ulceration, no adenopathy, clear lungs, decreased bowel sounds, no abdominal distension and no masses. She had mild discomfort on palpation of the right lower quadrant. Admission laboratory results included a complete blood count that
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was negative by darkfield examination and the organism was biochemically inert on conventional media. The Gram stain appearance of the organism, an extremely tiny gram-negative coccobacillus, was striking. When the organism was suspected to be F. tularensis, it was referred to the Illinois Department of Public Health where it was identified with specific antisera.
Epidemiology
Figure 1. Brown and Hopps tissue Gram stain ( × 1,000). Gramnegative bacillus (arrowhead) in area of necrobiosis, bone marrow biopsy consistent with Francisella tularensis.
negative coccobacillus that was later identified as F. tularensis, was isolated from two separate blood cultures. In the meantime, the patient was placed on rifampin rather than erythromycin because of deteriorating hearing. After the positive blood cultures were reported, therapy was changed to tetracycline. The patient was afebrile after being given erythromycin and she continued to improve. She was discharged on the 18th hospital day on a 10 day course of tetracycline, 5 mg q.i.d. At the time of discharge, she was afebrile with no lower abdominal pain or lung infiltrates. Acute and convalescent sera revealed titers of 320 and 5,120, respectively, to F. tularensis.
Laboratory Diagnosis Routine bacterial blood cultures drawn on days 3 and 4 of illness were inoculated into BACTEC NR6A and 7A bottles (Becton Dickinson Diagnostic Instrument Systems, Towson, Md.). The anaerobic bottles were incubated for 7 d, read on the BACTEC NR660 instrument daily for 5 d and again on day 7. The aerobic bottles were incubated and read daily for 5 d. All culture readings remained negative. Terminal subcultures were not performed because the growth indices did not reach threshold levels nor was the laboratory aware of the patient's clinical condition. In reviewing the literature, we found only a few docu-
142
0196-4399/90/$0.00 + 02.20
mented cases in which F. tularensis was recovered from blood in routine clinical situations (3). In nearly all cases, the radiometric BACTEC 460 instrument was used. In checking with the manufacturer, we found no differences in the media that might exclude or enhance the isolation of F. tularensis using the nonradiometric NR660 instrument. In addition to routine bacterial blood cultures, fungal blood cultures were simultaneously drawn on days 3 and 4 of illness using the DuPont Isolator system. F. tularensis requires cystine for growth. Part of our fungal blood culture workup includes inoculating blood that has been drawn in the Isolator tube onto a chocolate agar plate (REMEL, Lenexa, Kans.) that contains cystine. We recovered F. tularensis from the Isolator-inoculated chocolate agar plate after incubation in 5% CO 2 at 37 ° for 5 d. The classic method for isolating intracellular organisms such as Brucella and Francisella spp. has been to inoculate blood into the biphasic Castafieda bottle. In this system, white blood cells disintegrate on the agar portion of the media, thus releasing the organisms. In the Isolator system, where saponin is used as a lysing agent, the organisms are readily freed from the cells and may then grow. In addition to chocolate agar, the organism grew on buffered charcoal yeast extract agar (CYE, REMEL). Motility
© 1990 Elsevier Science Publishing Co., Inc.
In retrospect, this woman had typhoidal tularemia. How she acquired the disease is unknown. Six days before onset of symptoms, she visited relatives in St. Louis and Kansas City, Missouri, areas endemic for F. tularensis. The farm where she stayed had a wooded area with deer and a cat that hunted rabbits. She did not drink well water and had no known tick bites. On the same trip she spent several days in Evansville, Indiana. Tularemia is primarily a disease of animals but can be transmitted to humans in several ways. Ticks and deerflies serve as insect vectors with rabbits and rodents acting as animal reservoirs. Humans can acquire the organism by direct contact, by ingestion, or by insect vectors. In the past, a higher incidence of disease usually occurred in winter months and was associated with rabbit hunting. Recently, however, a greater proportion of cases are reported during the summer, suggesting that vector-borne tularemia is becoming more prevalent. All ages and races are susceptible although the highest rates are found among adults, with men accounting for 65 to 75% of tick-borne and rabbit-associated cases (4). Tularemia occurs throughout the United States with the highest incidence reported in Arkansas and Missouri (5). Two biochemical types of F. tularensis have been identified: F. tularensis biovar tularensis, type A is found in North America only and is the predominant biovar in the United States. It is usually associated with ticks and rabbits and is highly virulent for humans. F. tularensis biovar palaertica, type B is found throughout the northern hemisphere, is less virulent, usually tick- or mosquito-borne, and
Clinical Microbiology Newsletter 12:18,1990
may be associated with contaminated water. Clinical The route of exposure may determine which clinical syndrome will develop. Typically, the patient presents with fever, chills, headache, and lymphadenopathy; often there is respiratory involvement. Ulceroglandular tularemia is the most common form of the disease, accounting for 70 to 88% of cases (6). In this syndrome, an ulcerated lesion of the skin is seen in addition to the above symptoms, identifying a specific entry site of the organism. Oculoglandular and oropharyngeal tularemia are less commonly seen and are usually associated with localized infections of the eye and oropharynx, respectively. Systemic symptoms, however, may occur with these syndromes. Glandular and typhoidal tularemia are associated with abrupt onset, the absence of a skin lesion, and may or may not be accompanied by pneumonia. The typhoidal type is a systemic infection and has the highest mortality rate. Usually, a lifelong, cell-mediated immunity follows active infection (4).
Treatment Streptomycin remains the drug of choice and is highly effective. Tetracycline or chloramphenicol may be given, but relapse is more common following administration of these agents.
Comment Historically, F. tularensis has been considered a serious risk for laboratory
Unusual Morphalogic Forms of Cryptococcus neoformans from a Patient with Retroperitoneal Cryptococcoma Soo-Hoo Tuck Soon, Ph.D. Department of Medical Microbiology Faculty of Medicine University of Malaya 59100 Kuala Lumpur, Malaysia
Clinical Microbiology Newsletter 12:18,1990
personnel. Human skin has a high cystine content and Francis proposed that this was a factor contributing to the belief that Francisella organisms penetrate intact skin (2). Most likely, the organism enters through small breaks or cuts which increases the potential hazard of working with the organism. The fastidiousness of the bacterium and the high risk of laboratory infection are the reasons why serologic tests generally have been relied upon as the method of diagnosis. In the case of tularemia, however, IgM antibodies do not appear earlier than IgG antibodies (7). It may, therefore, be well into the second week of illness before an antibody titer can be detected using available methods. Notifying the microbiology laboratory when tularemia is suspected could increase tremendously the chances of recovering the organism, if present. Handling the organism in microbiological safety hoods, wearing gloves, and taking care not to produce aerosols decrease the risk of acquiring the infection by laboratory personnel.
culture, for patients with fever of unknown origin, we recommend that in addition to routine blood cultures, blood and possibly bone marrow specimens be collected in Isolator tubes for culture. In endemic areas, it is prudent to handle all specimens from suspected cases with appropriate biosafety precautions. During the 1980s, approximately 245 cases of tularemia per year have been reported in the United States (5). Perhaps by using alternative culture methods, a greater number of cases will be detected than in the past.
We recovered F. tularensis from a blood specimen that had been cultured for fungi using the Isolator system. The organism was not detected by the BACTEC NR 660 instrument in corresponding BACTEC blood culture bottles. Tularemia had not been considered as a possible diagnosis in this patient. Because of the potential seriousness of the disease and how easily the organism may be missed in routine
References 1. McCoy, G. 1911. A plague-like disease of rodents. Publ. Health Bull. 43:5371. 2. Francis, E. 1925. Tularemia. J. Am. Med. Assoc. 84:1243-1250. 3. Provenza, J. M., S. A. Klotz, and R. L. Penn. 1986. Isolation of Francisella tularensis from blood. J. Clin. Microbiol. 24:453-455. 4. Boyce, J. M. 1979. Francisella tularensis (Tularemia), p. 1784-1788. In G. L. Mandell, R. G. Douglas, Jr., and J. E. Bennett (ed.), Principles and practice of infectious diseases. Wiley, New York. 5. Centers for Disease Control. 1987. Summary of notifiable diseases. United States. Morbid. Mortal. Weekly Rep. 36:46. 6. Finley, C. R., B. W. Hamilton, and T. R. Hamilton. 1986. Tularemia, a review. Missouri Med. 83:741-743. 7. Tarnik, Arne. 1989. Nature of protective immunity to Francisella tularensis. Rev. Infect. Dis. 1:440-447.
A 21-yr-old male was admitted to the University Hospital complaining of fever and lumbar backache 5 d prior to admission. Until two yr previously, the patient had raised pigeons and budgerigars. On physical examination, he was generally well and afebrile, but a firm, irregular mass measuring 5 x 5 cm was found in the left upper quadrant of his abdomen. The mass was immobile, nonfluctuant, and nontender. A provisional clinical diagnosis of retroperitoneal lymphoma was made. Com-
puterized tomography (CT) showed a large, cystic, retroperitoneal mass extending from the level of T - 1 2 to S - 2 . At laparotomy, a large, partially cystic mass, as shown by the CT scan, was noted. Gram-stained smears of tumor tissue showed large cells measuring 50 to 100 p,m. The cells resembled the sporangia of Rhinosporidium seeberi (Fig. 1); however, the culture of tumor tissue grew Cryptococcus neoformans. In clinical material C. neoformans
Summary
© 1990 Elsevier Science Publishing Co., Inc.
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143
ANA system and sodium polyanetholesulfonate disk susceptibility testing in identifying Haemophilus ducreyi. J. Clin. Microbiol. 28:108-111. 30. Kilian, M. 1985. Haemophilus, p. 387-393. In E. H. Lennette et al. (ed.), Manual of clinical microbiology, 4th ed. American Society for Microbiology, Washington, D.C. 31. Kilian M. and E. L. Biberstein. 1984. Genus II. Haemophilus, p. 558-569. In N. R. Kreig and J. G. Holt. Bergey's manual of systematic bacteriology, vol. 1. Williams and Wilkins Co., Baltimore. 32. Parson, L. M., et al. 1990. Construction of DNA probes for the identification of Haemophilus ducreyi, p.
69-94. Gene probes for bacteria. Academic Press, New York. 33. Bodhidatta, L., et al. 1988. Evaluation of 500-mg and 1,000-mg doses of ciprofloxacin for the treatment of chancroid. Antimicrob. Agents Chemother. 32:723-725. 34. Nobre, G. N. 1982. Identification of Haemophilus ducreyi in the clinical laboratory. J. Med. Microbiol. 15:343-245. 35. Weaver, R. E., et al. 1982. Revised tables from "The identification of unusual pathogenic gram-negative bacteria (Elizabeth O. King)." Division of Bacterial Diseases, Center for Infectious Diseases, Centers for Disease Control, Altanta, Georgia.
The purpose of this report is to describe how this organism was recovered from the blood of a patient with fever of unknown origin using the Isolator microbial detection system (E. I. DuPont de Nemours, Wilmington, Del.). An initial diagnosis of tularemia had not been considered in this patient and was made by subsequent recovery of the organism from culture. A four-fold rise in the patient's antibody titers further confirmed the diagnosis.
showed a total white blood cell count of 15 x 106/p,l with 80% segmented neutrophils, 9% band forms, 5% lymphocytes, 5% monocytes, and 1% basophils. The hemoglobin was 13.1 gm/dl, hematocrit, 38.2%, urinalysis and Gram stain of urine were negative, and routine chemistry tests were normal. Blood cultures were drawn and cefoxitin was started. The patient was thought to have diverticulitis with abscess formation. However, an extensive evaluation of her abdomen revealed only three adenomatous polyps and an abdominal aortic aneurysm. The patient remained febrile and on the fourth hospital day, her chest X ray showed a left lower lobe infiltrate. CT scan of her chest also showed bilateral pleural effusions and infiltrates, but followup bronchoscopy was negative. Cefoxitin was discontinued and erythromycin therapy begun. An echocardiogram that was obtained to exclude bacterial endocarditis was normal except for moderate mitral valve regurgitation. The patient continued to receive an extensive evaluation for fever of unknown origin which included a bone marrow biopsy, MRI of the head, and a complete serologic evaluation for rickettsial, mycoplasmal, and viral infection. The bone marrow biopsy revealed small areas of necrosis which, in retrospect, contained minute gram-negative bacteria (Fig. 1). A tiny, gram-
Case Reports Tularemia: A Present Day Problem Denise Rule, B.A., M(ASCP) Laboratory Associate Robin Miller-Catchpole, M.D. Associate Director, Microbiology Harold G. Wedell, M.D.
Department of Medicine Eileen L. Randall, Ph.D. Director, Microbiology Evanston Hospital Evanston, IL 60201 Francisella tularensis is a fastidious, small, gram-negative coccobacillus. It was first described in 1911 by McCoy who wrote about a plaguelike disease of rodents occurring in Tulare County, California (1). McCoy and Chapin discovered the causative organism of the disease and named it Bacterium tularense. In 1925, Francis wrote extensively about the history of tularemia in humans, elaborating on the epidemiology, pathology, and laboratory diagnosis of the disease (2). Previously, the disease had been given many different names depending on the conditions encountered by various workers; for example, plaguelike disease of rodents, deerfly fever, Bacillus tularensis infections of the eye, rabbit fever, and glandular type of tick fever. Francis named the disease tularemia. In 1959, he was awarded the Nobel Prize for his work and was honored by having the name of the bacterium changed to Francisella tularensis.
Clinical Microbiology Newsletter 12:18,1990
Case History A 75-year-old white female presented to Glenbrook emergency room with a two-day history of fever and right lower quadrant abdominal pain. She denied any nausea, vomiting, diarrhea, or dysuria. She had a past history of hypertension and an appendectomy. At the time of admission she was receiving propranolol hydrochloride and lovastatin. On physical examination, the patient was a well-developed female in no apparent distress. Her vital signs were: blood pressure, 110/60; pulse rate, 108; respiratory rate, 24; and temperature, 103.5°F. Pertinent physical findings included no rash or skin ulceration, no adenopathy, clear lungs, decreased bowel sounds, no abdominal distension and no masses. She had mild discomfort on palpation of the right lower quadrant. Admission laboratory results included a complete blood count that
© 1990 Elsevier Science Publishing Co., Inc.
0196-4399/90/0.00 + 02.20
141
was negative by darkfield examination and the organism was biochemically inert on conventional media. The Gram stain appearance of the organism, an extremely tiny gram-negative coccobacillus, was striking. When the organism was suspected to be F. tularensis, it was referred to the Illinois Department of Public Health where it was identified with specific antisera.
Epidemiology
Figure 1. Brown and Hopps tissue Gram stain ( × 1,000). Gramnegative bacillus (arrowhead) in area of necrobiosis, bone marrow biopsy consistent with Francisella tularensis.
negative coccobacillus that was later identified as F. tularensis, was isolated from two separate blood cultures. In the meantime, the patient was placed on rifampin rather than erythromycin because of deteriorating hearing. After the positive blood cultures were reported, therapy was changed to tetracycline. The patient was afebrile after being given erythromycin and she continued to improve. She was discharged on the 18th hospital day on a 10 day course of tetracycline, 5 mg q.i.d. At the time of discharge, she was afebrile with no lower abdominal pain or lung infiltrates. Acute and convalescent sera revealed titers of 320 and 5,120, respectively, to F. tularensis.
Laboratory Diagnosis Routine bacterial blood cultures drawn on days 3 and 4 of illness were inoculated into BACTEC NR6A and 7A bottles (Becton Dickinson Diagnostic Instrument Systems, Towson, Md.). The anaerobic bottles were incubated for 7 d, read on the BACTEC NR660 instrument daily for 5 d and again on day 7. The aerobic bottles were incubated and read daily for 5 d. All culture readings remained negative. Terminal subcultures were not performed because the growth indices did not reach threshold levels nor was the laboratory aware of the patient's clinical condition. In reviewing the literature, we found only a few docu-
142
0196-4399/90/$0.00 + 02.20
mented cases in which F. tularensis was recovered from blood in routine clinical situations (3). In nearly all cases, the radiometric BACTEC 460 instrument was used. In checking with the manufacturer, we found no differences in the media that might exclude or enhance the isolation of F. tularensis using the nonradiometric NR660 instrument. In addition to routine bacterial blood cultures, fungal blood cultures were simultaneously drawn on days 3 and 4 of illness using the DuPont Isolator system. F. tularensis requires cystine for growth. Part of our fungal blood culture workup includes inoculating blood that has been drawn in the Isolator tube onto a chocolate agar plate (REMEL, Lenexa, Kans.) that contains cystine. We recovered F. tularensis from the Isolator-inoculated chocolate agar plate after incubation in 5% CO 2 at 37 ° for 5 d. The classic method for isolating intracellular organisms such as Brucella and Francisella spp. has been to inoculate blood into the biphasic Castafieda bottle. In this system, white blood cells disintegrate on the agar portion of the media, thus releasing the organisms. In the Isolator system, where saponin is used as a lysing agent, the organisms are readily freed from the cells and may then grow. In addition to chocolate agar, the organism grew on buffered charcoal yeast extract agar (CYE, REMEL). Motility
© 1990 Elsevier Science Publishing Co., Inc.
In retrospect, this woman had typhoidal tularemia. How she acquired the disease is unknown. Six days before onset of symptoms, she visited relatives in St. Louis and Kansas City, Missouri, areas endemic for F. tularensis. The farm where she stayed had a wooded area with deer and a cat that hunted rabbits. She did not drink well water and had no known tick bites. On the same trip she spent several days in Evansville, Indiana. Tularemia is primarily a disease of animals but can be transmitted to humans in several ways. Ticks and deerflies serve as insect vectors with rabbits and rodents acting as animal reservoirs. Humans can acquire the organism by direct contact, by ingestion, or by insect vectors. In the past, a higher incidence of disease usually occurred in winter months and was associated with rabbit hunting. Recently, however, a greater proportion of cases are reported during the summer, suggesting that vector-borne tularemia is becoming more prevalent. All ages and races are susceptible although the highest rates are found among adults, with men accounting for 65 to 75% of tick-borne and rabbit-associated cases (4). Tularemia occurs throughout the United States with the highest incidence reported in Arkansas and Missouri (5). Two biochemical types of F. tularensis have been identified: F. tularensis biovar tularensis, type A is found in North America only and is the predominant biovar in the United States. It is usually associated with ticks and rabbits and is highly virulent for humans. F. tularensis biovar palaertica, type B is found throughout the northern hemisphere, is less virulent, usually tick- or mosquito-borne, and
Clinical Microbiology Newsletter 12:18,1990
may be associated with contaminated water. Clinical The route of exposure may determine which clinical syndrome will develop. Typically, the patient presents with fever, chills, headache, and lymphadenopathy; often there is respiratory involvement. Ulceroglandular tularemia is the most common form of the disease, accounting for 70 to 88% of cases (6). In this syndrome, an ulcerated lesion of the skin is seen in addition to the above symptoms, identifying a specific entry site of the organism. Oculoglandular and oropharyngeal tularemia are less commonly seen and are usually associated with localized infections of the eye and oropharynx, respectively. Systemic symptoms, however, may occur with these syndromes. Glandular and typhoidal tularemia are associated with abrupt onset, the absence of a skin lesion, and may or may not be accompanied by pneumonia. The typhoidal type is a systemic infection and has the highest mortality rate. Usually, a lifelong, cell-mediated immunity follows active infection (4).
Treatment Streptomycin remains the drug of choice and is highly effective. Tetracycline or chloramphenicol may be given, but relapse is more common following administration of these agents.
Comment Historically, F. tularensis has been considered a serious risk for laboratory
Unusual Morphalogic Forms of Cryptococcus neoformans from a Patient with Retroperitoneal Cryptococcoma Soo-Hoo Tuck Soon, Ph.D. Department of Medical Microbiology Faculty of Medicine University of Malaya 59100 Kuala Lumpur, Malaysia
Clinical Microbiology Newsletter 12:18,1990
personnel. Human skin has a high cystine content and Francis proposed that this was a factor contributing to the belief that Francisella organisms penetrate intact skin (2). Most likely, the organism enters through small breaks or cuts which increases the potential hazard of working with the organism. The fastidiousness of the bacterium and the high risk of laboratory infection are the reasons why serologic tests generally have been relied upon as the method of diagnosis. In the case of tularemia, however, IgM antibodies do not appear earlier than IgG antibodies (7). It may, therefore, be well into the second week of illness before an antibody titer can be detected using available methods. Notifying the microbiology laboratory when tularemia is suspected could increase tremendously the chances of recovering the organism, if present. Handling the organism in microbiological safety hoods, wearing gloves, and taking care not to produce aerosols decrease the risk of acquiring the infection by laboratory personnel.
culture, for patients with fever of unknown origin, we recommend that in addition to routine blood cultures, blood and possibly bone marrow specimens be collected in Isolator tubes for culture. In endemic areas, it is prudent to handle all specimens from suspected cases with appropriate biosafety precautions. During the 1980s, approximately 245 cases of tularemia per year have been reported in the United States (5). Perhaps by using alternative culture methods, a greater number of cases will be detected than in the past.
We recovered F. tularensis from a blood specimen that had been cultured for fungi using the Isolator system. The organism was not detected by the BACTEC NR 660 instrument in corresponding BACTEC blood culture bottles. Tularemia had not been considered as a possible diagnosis in this patient. Because of the potential seriousness of the disease and how easily the organism may be missed in routine
References 1. McCoy, G. 1911. A plague-like disease of rodents. Publ. Health Bull. 43:5371. 2. Francis, E. 1925. Tularemia. J. Am. Med. Assoc. 84:1243-1250. 3. Provenza, J. M., S. A. Klotz, and R. L. Penn. 1986. Isolation of Francisella tularensis from blood. J. Clin. Microbiol. 24:453-455. 4. Boyce, J. M. 1979. Francisella tularensis (Tularemia), p. 1784-1788. In G. L. Mandell, R. G. Douglas, Jr., and J. E. Bennett (ed.), Principles and practice of infectious diseases. Wiley, New York. 5. Centers for Disease Control. 1987. Summary of notifiable diseases. United States. Morbid. Mortal. Weekly Rep. 36:46. 6. Finley, C. R., B. W. Hamilton, and T. R. Hamilton. 1986. Tularemia, a review. Missouri Med. 83:741-743. 7. Tarnik, Arne. 1989. Nature of protective immunity to Francisella tularensis. Rev. Infect. Dis. 1:440-447.
A 21-yr-old male was admitted to the University Hospital complaining of fever and lumbar backache 5 d prior to admission. Until two yr previously, the patient had raised pigeons and budgerigars. On physical examination, he was generally well and afebrile, but a firm, irregular mass measuring 5 x 5 cm was found in the left upper quadrant of his abdomen. The mass was immobile, nonfluctuant, and nontender. A provisional clinical diagnosis of retroperitoneal lymphoma was made. Com-
puterized tomography (CT) showed a large, cystic, retroperitoneal mass extending from the level of T - 1 2 to S - 2 . At laparotomy, a large, partially cystic mass, as shown by the CT scan, was noted. Gram-stained smears of tumor tissue showed large cells measuring 50 to 100 p,m. The cells resembled the sporangia of Rhinosporidium seeberi (Fig. 1); however, the culture of tumor tissue grew Cryptococcus neoformans. In clinical material C. neoformans
Summary
© 1990 Elsevier Science Publishing Co., Inc.
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143