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A case of measles encephalitis complicated by Alcaligenes faecalis septicemia
738
The Journal o[ P E D i A T R I C S
November 1960
A case of measles o,cepbalitis complicated by Alcaligenes faecalis septicemia Marjorie M. Mengedoht, M.D., ~ James K. Aton, M.D., and A b r a m Berry, M.D. CHARLESTON,
S.
C.
M E a s L E S, although seldom of serious consequence in its characteristic p a t t e r n , m a y have a variety of serious complications. 1 Secondary bacterial infections are relatively common, but no cases have been reported of Alcaligenes [aecalis septicemia as a complication. This bacterium is a normal intestinal saphrophyte, but it may invade body tissues to produce a variety of clinical patterns. It is a short, gram-negative bacillus which is weakly motile, possessing poorly developed peritrichal flagellae. First isolated by Petruschky = from stale beer, the bacterium was named for its ability to produce an alkaline reaction in certain media. It ferments none of the usual carbohydrates, does not form indol or liquefy gelatin, and is not agglutinated by polyvalent Salmonella sera. Litmus paper shows a strongly alkaline reaction, and a brown pigment is formed on potato media. Colonies resemble those of Escherichia coli, but are flatter, have a raised central portion, and a spreading undulant edgeY
CASE REPORT Five days prior to admission, a 3 ~ - y e a r old white gM with a history of recent exposure to measles had a sudden onset of fever, rhinorrhea, cough, and flushed facies. *Address, $0 Montagu 8trect, Charlcston~ S, G,
The following day an eruption appeared over the face and upper thorax, and frequent dark brown stools were noted. Three days later, the eruption was generalized, but the fever and diarrhea had subsided. On the day of admission, she ate poorly and was unusually drowsy. She was first seen in the emergency room in a generalized convulsion which subsided after intravenous administration of a barbiturate. A widespread petechial eruption was present with the heaviest distribution on the arms and abdomen. The pulse was 130 per minute, regular, and thready. The initial blood pressure was 140/110, but it soon fell to 100/60. Rectal temperature was 102.4 ~ F. The conjunctivae were injected; the pupils were small, reacting poorly to light, and corneal reflexes were intermittently absent. A spinal tap revealed a cell count of 42 mononucleated cells per cubic millimeter, a sugar level of 66 mg. per cent, and protein of 82 rag. per cent. No microorganisms were detected by Gram's stain. The tentative diagnosis was hemorrhagic measles with encephalitis. A white blood cell count and differential were reported as 19,400 cells per cubic millimeter, 62 per cent polymorphonuclear leukocytes (17 nonfilamented), 34 per cent lymphocytes, and 4 per cent monocytes. Urinalysis showed 1 plus albumin and 2 plus acetone.
Volume 57 Number 5
Two blood cultures were obtained and penicillin-sulfadiazine therapy instituted. Except for another generalized seizure the patient's condition remained unchanged through the first night. Spinal fluid findings the following day were unaltered and the white cell count of the blood was 32,150 with polymorphonuclear predominance. The hemoglobin level which was 17.5 Gm. per cent initially had fallen to 11 Gm. per cent by the fifth day. The white blood cell and differential counts became normal on the fifth day. A roentgenogram of the chest was negative as were two additional urinalyses. Bleeding and clotting times were normal and serum agglutinations for Salmonella, Brucella, and Rickettsia were negative. On the fourth day growth was noted in both blood cultures, and the microorganism was subsequently identified as Alcaligenes faecalis. It was sensitive to all antibiotics tested except penicillin and streptomycin. Agglutination of this organism was positive in a dilution of 1:320 on the eighth and fourteenth days, respectively. Agglutination studies on a random group of white patients were negative. For the first 5 days the patient was unresponsive and disoriented; she did not recognize her parents. Her temperature fell slowly and was normal on the fifth hospital day. Prior to discharge she was an alert, talkative child with no apparent neurological sequelae.
Measles and Alcaligenes septicemia
739
resulted from these infections, but RaveneP ~ reported one case with postmortem lesions similar to those of typhoid fever. Alcaligenes faecalis was found in the spleen and intestinal ulcers. Symptoms may simulate those of other diseases such as infectious hepatitis, leukemia, bacillary dysentery, and rheumatic fever. 11 Endocarditis ~2-~4 and puerperal sepsis 15 have been reported. Central nervous system involvement has been reported in 11 cases? 6-~9 Two instances of baeteremia and meningitis in the newborn were reported by Bischoff? 9 The organism may cause or be associated with localized disorders including gallstones, 2~ renal stones, 2~ cervical abscess, 22 and conjunctivitis. 2a Why this girl with measles developed septicemia from Alcaligenes [aecalis is, of course, purely speculative. Hirst 24 suggests that this saprophytic organism becomes pathogenic during intestinal disease. It is known that measles may cause a generalized lymphoid hyperplasia including swollen Peyer's patches2S; such lesions may have offered an entrance for the bacteria. SUMMARY
A case of measles encephalitis with A1caligenes faecalis septicemia is presented. A review of the literature indicates the infrequency of systemic invasion by this organism. A mode of pathogenesis has been suggested.
DISCUSSION Approximately 40 cases of systemic infection by Alcaligenes faeealis have appeared in the literature. 4-1~ The majority have had a clinical pattern similar to that of mild typhoid. ~-~~ Constitutional symptoms include slight chill, severe headache, anorexia, nausea and vomiting. Constipation or frequent yellow liquid stools may occur. Typically the temperature varies between 101 ~ and 105 ~ F. for 2 to 5 days, becomes normal, and then recurs. In one case urticaria appeared, but no other dermatological manifestations have been recorded2 Blood cultures were positive for Alcaligenes faecalis, and agglutination titers varied from 1:60 to 1:1,500. Few deaths have
REFERENCES
1. Karelitz, S.: Measles, in Brennemann's Practice of Pediatrics, Hagerstown, Md., 1959, W. F. Prior, Co., Inc., vol. 2, chap. 1I. 2. Petrusehky, J.: Bacillus faecalis alcaligenes, Zentralbl. Bakt. 19: 187, 1896. 3. Topley, W. W. C., and Wilson, G. S.: TopIcy and Wilson's Principles of Bacteriology and Immunity, revised by G. S. Wilson and A. A. Miles, ed. 3, Baltimore, 1946, Williams & Wilkins Company, vol. 1, p. 902. 4. Weinstein, L., and Wasserman, E.: Bacterium alcaligenes (Alcaligenes faecalis) Infections in Man, New England J. Med. 244: 662, 1951. 5. Wyatt, W. S.: Bacteremia Due to Bacillus fecalis alkaligenes, Am. J. M. Sc. 174: 181, 1927. 6. Girolami, M.: Sulla patogenicit~ del "Bacillus foecalis alcallgenes" nell'uomo; studio clinico e bacteriologico, Arch. per le st. reed. 64: 665, 1937.
7 40
Mengedoht, Aton, and Berry
7. Dureux, J., De Lavergne, E., and Burdin, J. O.: A propos d'un cas de septic6mie ~t faecalis alcaligenes, Rev. m6d. Nancy 78: 304, 1953. 8. Librach, I. M.: B. faecalis alcaligenes Infections, With a Report of a Case of Septicaemia, Postgrad. M. J. 30: 424, 1954. 9. Shearman, C. H., and Noorhead, T. G.: Bacillaemia Due to Infection With B. faecalis alcaligenes, Brit. M. J. 2: 893, 1916. 10. Ravenel, M. P.: Lesions of Typhoid Fever Produced by Bacillus faecalis alkaligenes, J. A. M. A. 76: 720, 1921. 11. Vickers, H. E.: The Finding of Bact. alkaligenes on Blood Culture; Its Significance in 17 Unselected Cases, Postgrad. M. J. 34: 484, 1958. 12. Cole, A. O. E., and Marshall, C.: Infective Endocarditis Due to Bact. faecalis alcaligenes, Brit. M. J. 2: 867, 1952. 13. Berengo, A., and Bussinello, E.: Su un eccezlonale case de endocarditis batterica subacuta da Bacillus faeealis alcaligenes; trattamento con associazione penicillina-sulfamidicl , Minerva reed. 44: 1322, 1953. 14. Kuley, M., and Eran, I.: Endocarditis Lenta Due to Bacillus faecalis alcaligenes, Tiirk. tip cem. mec. 21: 348, 1955. 15. De Alemaquer, M.: Sobre um caso do sepsis puerperal pot Alcaligenes faecalis, Gaz. med. port. 9: 449, 1956. 16. Gildberg, L. H.: Bacillus alcaligenes Infections, New York J. Med. 38: 122, 1938.
November 1960
17. Voorhies, N. W., and Wilen, C. J.: Alcaligenes faecalis Bacteremia, Am. J. M. Sc. 204: 719, 1942. 18. Terry, L. L., McBane, J. K., and Dean, K. F.: Bacteremia and Acute Meningitis Due to Alcaligenes faecalis, J. Lab. & Olin. Med. 32: 1262, 1947. 19. Bischoff, H. W., Recinos, A., Jr., Anderson, W.' S., and Rice, E. C.: Alkaligenes fecalis Bacteremia and Meningitis; Report of Two Cases in Newborn infants, J. PEDIAT. 32: 558, 1948. 20. Daniel, W. W., and Greene, E. H.: Recovery of Bacillus fecalis alkaligenes From Gall Stones, South. M. J. 22: 977, 1929. 21. Stuart, G., Thompson, W. E., and Krikorian, K. S.: Bacillus alkaligenes faecalis as Organic Nucleus in Renal Calculus, Brit. J. Urol. 6: 243, 1934. 22. Pohl, C., and Raymond, S. W.: Bacillus fecalis alcaligenes Abscess, J. Internat. Coll. Surgeons 4: 547, 1941. 23. Barrow, R. H. B.: Epidemic of Conjunctivitis Due to Infection With Bacillus faecalis alkaligenes, Brit. J. Ophth. 15: 319, 1931. 24. Hirst, L. F.: Observations on Pathogenicity and Septic Characters of the Bacillus faecalis alkaligenes, J. Roy. Army M. Corps 29: 476, 1917. 25. Roberts, C. B. C., and Bain, A. D.: The Pathology of Measles, J. Path. & Bact. 76: 111, 1958.
The Journal o[ P E D i A T R I C S
November 1960
A case of measles o,cepbalitis complicated by Alcaligenes faecalis septicemia Marjorie M. Mengedoht, M.D., ~ James K. Aton, M.D., and A b r a m Berry, M.D. CHARLESTON,
S.
C.
M E a s L E S, although seldom of serious consequence in its characteristic p a t t e r n , m a y have a variety of serious complications. 1 Secondary bacterial infections are relatively common, but no cases have been reported of Alcaligenes [aecalis septicemia as a complication. This bacterium is a normal intestinal saphrophyte, but it may invade body tissues to produce a variety of clinical patterns. It is a short, gram-negative bacillus which is weakly motile, possessing poorly developed peritrichal flagellae. First isolated by Petruschky = from stale beer, the bacterium was named for its ability to produce an alkaline reaction in certain media. It ferments none of the usual carbohydrates, does not form indol or liquefy gelatin, and is not agglutinated by polyvalent Salmonella sera. Litmus paper shows a strongly alkaline reaction, and a brown pigment is formed on potato media. Colonies resemble those of Escherichia coli, but are flatter, have a raised central portion, and a spreading undulant edgeY
CASE REPORT Five days prior to admission, a 3 ~ - y e a r old white gM with a history of recent exposure to measles had a sudden onset of fever, rhinorrhea, cough, and flushed facies. *Address, $0 Montagu 8trect, Charlcston~ S, G,
The following day an eruption appeared over the face and upper thorax, and frequent dark brown stools were noted. Three days later, the eruption was generalized, but the fever and diarrhea had subsided. On the day of admission, she ate poorly and was unusually drowsy. She was first seen in the emergency room in a generalized convulsion which subsided after intravenous administration of a barbiturate. A widespread petechial eruption was present with the heaviest distribution on the arms and abdomen. The pulse was 130 per minute, regular, and thready. The initial blood pressure was 140/110, but it soon fell to 100/60. Rectal temperature was 102.4 ~ F. The conjunctivae were injected; the pupils were small, reacting poorly to light, and corneal reflexes were intermittently absent. A spinal tap revealed a cell count of 42 mononucleated cells per cubic millimeter, a sugar level of 66 mg. per cent, and protein of 82 rag. per cent. No microorganisms were detected by Gram's stain. The tentative diagnosis was hemorrhagic measles with encephalitis. A white blood cell count and differential were reported as 19,400 cells per cubic millimeter, 62 per cent polymorphonuclear leukocytes (17 nonfilamented), 34 per cent lymphocytes, and 4 per cent monocytes. Urinalysis showed 1 plus albumin and 2 plus acetone.
Volume 57 Number 5
Two blood cultures were obtained and penicillin-sulfadiazine therapy instituted. Except for another generalized seizure the patient's condition remained unchanged through the first night. Spinal fluid findings the following day were unaltered and the white cell count of the blood was 32,150 with polymorphonuclear predominance. The hemoglobin level which was 17.5 Gm. per cent initially had fallen to 11 Gm. per cent by the fifth day. The white blood cell and differential counts became normal on the fifth day. A roentgenogram of the chest was negative as were two additional urinalyses. Bleeding and clotting times were normal and serum agglutinations for Salmonella, Brucella, and Rickettsia were negative. On the fourth day growth was noted in both blood cultures, and the microorganism was subsequently identified as Alcaligenes faecalis. It was sensitive to all antibiotics tested except penicillin and streptomycin. Agglutination of this organism was positive in a dilution of 1:320 on the eighth and fourteenth days, respectively. Agglutination studies on a random group of white patients were negative. For the first 5 days the patient was unresponsive and disoriented; she did not recognize her parents. Her temperature fell slowly and was normal on the fifth hospital day. Prior to discharge she was an alert, talkative child with no apparent neurological sequelae.
Measles and Alcaligenes septicemia
739
resulted from these infections, but RaveneP ~ reported one case with postmortem lesions similar to those of typhoid fever. Alcaligenes faecalis was found in the spleen and intestinal ulcers. Symptoms may simulate those of other diseases such as infectious hepatitis, leukemia, bacillary dysentery, and rheumatic fever. 11 Endocarditis ~2-~4 and puerperal sepsis 15 have been reported. Central nervous system involvement has been reported in 11 cases? 6-~9 Two instances of baeteremia and meningitis in the newborn were reported by Bischoff? 9 The organism may cause or be associated with localized disorders including gallstones, 2~ renal stones, 2~ cervical abscess, 22 and conjunctivitis. 2a Why this girl with measles developed septicemia from Alcaligenes [aecalis is, of course, purely speculative. Hirst 24 suggests that this saprophytic organism becomes pathogenic during intestinal disease. It is known that measles may cause a generalized lymphoid hyperplasia including swollen Peyer's patches2S; such lesions may have offered an entrance for the bacteria. SUMMARY
A case of measles encephalitis with A1caligenes faecalis septicemia is presented. A review of the literature indicates the infrequency of systemic invasion by this organism. A mode of pathogenesis has been suggested.
DISCUSSION Approximately 40 cases of systemic infection by Alcaligenes faeealis have appeared in the literature. 4-1~ The majority have had a clinical pattern similar to that of mild typhoid. ~-~~ Constitutional symptoms include slight chill, severe headache, anorexia, nausea and vomiting. Constipation or frequent yellow liquid stools may occur. Typically the temperature varies between 101 ~ and 105 ~ F. for 2 to 5 days, becomes normal, and then recurs. In one case urticaria appeared, but no other dermatological manifestations have been recorded2 Blood cultures were positive for Alcaligenes faecalis, and agglutination titers varied from 1:60 to 1:1,500. Few deaths have
REFERENCES
1. Karelitz, S.: Measles, in Brennemann's Practice of Pediatrics, Hagerstown, Md., 1959, W. F. Prior, Co., Inc., vol. 2, chap. 1I. 2. Petrusehky, J.: Bacillus faecalis alcaligenes, Zentralbl. Bakt. 19: 187, 1896. 3. Topley, W. W. C., and Wilson, G. S.: TopIcy and Wilson's Principles of Bacteriology and Immunity, revised by G. S. Wilson and A. A. Miles, ed. 3, Baltimore, 1946, Williams & Wilkins Company, vol. 1, p. 902. 4. Weinstein, L., and Wasserman, E.: Bacterium alcaligenes (Alcaligenes faecalis) Infections in Man, New England J. Med. 244: 662, 1951. 5. Wyatt, W. S.: Bacteremia Due to Bacillus fecalis alkaligenes, Am. J. M. Sc. 174: 181, 1927. 6. Girolami, M.: Sulla patogenicit~ del "Bacillus foecalis alcallgenes" nell'uomo; studio clinico e bacteriologico, Arch. per le st. reed. 64: 665, 1937.
7 40
Mengedoht, Aton, and Berry
7. Dureux, J., De Lavergne, E., and Burdin, J. O.: A propos d'un cas de septic6mie ~t faecalis alcaligenes, Rev. m6d. Nancy 78: 304, 1953. 8. Librach, I. M.: B. faecalis alcaligenes Infections, With a Report of a Case of Septicaemia, Postgrad. M. J. 30: 424, 1954. 9. Shearman, C. H., and Noorhead, T. G.: Bacillaemia Due to Infection With B. faecalis alcaligenes, Brit. M. J. 2: 893, 1916. 10. Ravenel, M. P.: Lesions of Typhoid Fever Produced by Bacillus faecalis alkaligenes, J. A. M. A. 76: 720, 1921. 11. Vickers, H. E.: The Finding of Bact. alkaligenes on Blood Culture; Its Significance in 17 Unselected Cases, Postgrad. M. J. 34: 484, 1958. 12. Cole, A. O. E., and Marshall, C.: Infective Endocarditis Due to Bact. faecalis alcaligenes, Brit. M. J. 2: 867, 1952. 13. Berengo, A., and Bussinello, E.: Su un eccezlonale case de endocarditis batterica subacuta da Bacillus faeealis alcaligenes; trattamento con associazione penicillina-sulfamidicl , Minerva reed. 44: 1322, 1953. 14. Kuley, M., and Eran, I.: Endocarditis Lenta Due to Bacillus faecalis alcaligenes, Tiirk. tip cem. mec. 21: 348, 1955. 15. De Alemaquer, M.: Sobre um caso do sepsis puerperal pot Alcaligenes faecalis, Gaz. med. port. 9: 449, 1956. 16. Gildberg, L. H.: Bacillus alcaligenes Infections, New York J. Med. 38: 122, 1938.
November 1960
17. Voorhies, N. W., and Wilen, C. J.: Alcaligenes faecalis Bacteremia, Am. J. M. Sc. 204: 719, 1942. 18. Terry, L. L., McBane, J. K., and Dean, K. F.: Bacteremia and Acute Meningitis Due to Alcaligenes faecalis, J. Lab. & Olin. Med. 32: 1262, 1947. 19. Bischoff, H. W., Recinos, A., Jr., Anderson, W.' S., and Rice, E. C.: Alkaligenes fecalis Bacteremia and Meningitis; Report of Two Cases in Newborn infants, J. PEDIAT. 32: 558, 1948. 20. Daniel, W. W., and Greene, E. H.: Recovery of Bacillus fecalis alkaligenes From Gall Stones, South. M. J. 22: 977, 1929. 21. Stuart, G., Thompson, W. E., and Krikorian, K. S.: Bacillus alkaligenes faecalis as Organic Nucleus in Renal Calculus, Brit. J. Urol. 6: 243, 1934. 22. Pohl, C., and Raymond, S. W.: Bacillus fecalis alcaligenes Abscess, J. Internat. Coll. Surgeons 4: 547, 1941. 23. Barrow, R. H. B.: Epidemic of Conjunctivitis Due to Infection With Bacillus faecalis alkaligenes, Brit. J. Ophth. 15: 319, 1931. 24. Hirst, L. F.: Observations on Pathogenicity and Septic Characters of the Bacillus faecalis alkaligenes, J. Roy. Army M. Corps 29: 476, 1917. 25. Roberts, C. B. C., and Bain, A. D.: The Pathology of Measles, J. Path. & Bact. 76: 111, 1958.