- Email: [email protected]
A rare case of oral leishmaniasis
Personal view
Education to improve antibiotic use
49 50
51
52
multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA 1999; 281: 1512–19. Perz JF, Craig AS, Coffey CS, et al. Changes in antibiotic prescribing for children after a communitywide campaign. JAMA 2002; 287: 3103–09. Seppälä H, Klaukka T, Lehtonen R, Neonen E, Huovinen P. Outpatient use of erythromycin: link to increased erythromycin resistance in Group A streptococci. Clin Infect Dis 1995; 21: 1378–85. Granizo JJ, Aguilar L, Casal J, Garcia-Rey C, Dal-Re R, Baquero F. Streptococcus pneumoniae resistance to erythromycin and penicillin in relation to macrolide and beta-lactam consumption in Spain (1979–1997). J Antimicrob Chemother 2000; 46: 767–73. Granizo JJ, Aguilar L, Casal J, Dal-Re R, Baquero F. Streptococcus pyogenes resistance to erythromycin and penicillin in relation to macrolide and beta-lactam consumption in Spain (1979–1997). J Antimicrob Chemother 2000; 46: 959–64.
53 Garcia-Rey C, Aguilar L, Baquero F, Casal J, Dal-Re R. Importance of local variations in antibiotic consumption and geographical differences of erythromycin and penicillin resistance in Streptococcus pneumoniae. J Clin Microbiol 2002; 40: 159–64. 54 Guillemot D, Henriet L, Lecoeur H, Weber P, Carbon C. Optimization of antibiotic use rapidly decreases penicillin resistant Streptococcus pneumoniae (PRSp) carriage: the AUBEPPIN Study [Abstract 1527]. In: Abstracts of the 41st Annual Interscience Conference on Antimicrobial Agents and Chemotherapy; 2001 December 16–19; Chicago, IL, USA. Washington, DC: American Society for Microbiology, 2001: 264. 55 Felmingham D, Feldman C, Hryniewicz W, et al. Surveillance of bacterial resistance in communityacquired respiratory tract infections. Clin Microbiol Infect 2002; 8 (suppl 2): 12–42. 56 Vilhelmsson SE, Tomasz A, Kristinsson KG. Molecular evolution in a multidrug-resistant lineage
57
58
59
60
of Streptococcus pneumoniae: emergence of strains belonging to the serotype 6B Icelandic clone that lost antibiotic resistance traits. J Clin Microbiol 2000; 38: 1375–81. Bronzwaer SL, Cars O, Buchholz U, et al. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis 8: 278–82. Steinke D, Davey PG. The association between antibiotic resistance and community prescribing: a critical review of bias and confounding in published studies. Clin Infect Dis 2001; 33 (suppl 3): S193–205. Harbarth S, Harris AD, Carmeli Y, Samore MH. Parallel analysis of individual and aggregated data on antibiotic exposure and resistance in gram-negative bacilli. Clin Infect Dis 2001; 33: 1462–68. Hall AJ. Ecological studies and debate on rotavirus vaccine and intussusception. Lancet 2001; 358: 1197–98.
Clinical picture A rare case of oral leishmaniasis Philip A Van Damme, Monique Keuter, Sander Van Assen, Peter C M DeWilde, and Pieter J A Beckers
A Dutch 86-year-old retired physician presented with symptoms of self-diagnosed and self-treated palatal actinomycosis. His history included a trout-fish-bone puncture 2 years earlier in the south of France (Mediterranean Pyrenees), and ever since a progressive swelling of his maxillary soft tissues. He reported episodes of evacuation of pus and so-called amorphic sulphurgranules, which were suggested—by a pathologist elsewhere—to be grains of Actinomyces species. A remaining fish-bone part was not objectified. 6 weeks of antibiotic self-treatment (amoxicillin) brought no improvement. At presentation, a reddish livid tumescent palate was seen, with fistulas, indurations, erosions, ulcerations, mucosal tags, and granulations (figure 1). Clinical head and neck investigation, occlusal/orthopantomographic radiographs, and magnetic-resonance imaging were not conclusive. He had no fever, lymphadenopathy, hepatosplenomegaly, or rash. Laboratory examination showed low CD4+ T-lymphocyte count (0·24 x 109/L) as the only abnormality, which was probably age-related. The differential diagnosis included squamous cell carcinoma, Candida albicans, Wegener’s granulomatosis, tuberculosis, and malignant lymphoma. Histopathological examination of incisional biopsies showed a diffuse subepithelial granulomatous inflammatory reaction with lymphocytes, plasma cells, scattered nests of multinucleated giant cells, and several histiocytic cells. Ring-shaped inclusions within the cytoplasm of histiocytic cells, seen in haematoxylin eosin and Grocott stainings, were suggested to be either imposing as toxoplasma, histoplasma, or leishmania. In Gram and Ziehl Neelsen stainings, no reaction was noticed. Immunohistological assessments ruled out toxoplasma and histoplasma. Notwithstanding the fact that the patient had never visited tropical areas, and in the Mediterranean zone normally only visceral localisations are reported to occur, leishmaniasis was very much suspected. Impression smears stained with Giemsa, showed the characteristic intracellular parasites—the perinuclear kinetoplasts in the ovoid amastigotes, apart from THE LANCET Infectious Diseases Vol 4 January 2004
the densely stained large nuclei—within the histiocytic cells (figure 2). Additionally, penicillin-sensitive Actinomyces viscosus was isolated. Molecular differentiation provided the final diagnosis: oral mucous membrane leishmaniasis caused by Leishmania infantum. L infantum usually causes visceral infection and, rarely, mucocutaneous infection. Mucocutaneous leishmaniasis is almost exclusively caused by the American Viannia genus Leishmania (V) braziliensis. The treatment advice in this case was: liposomal amphotericin B 5mg/kg, once, based on its effectivity against visceral L infantum infection in patients with low CD4+ T-lymphocyte count; however, the patient refused and went elsewhere. PAVD is at the Department of Oral and Craniomaxillofacial Surgery; MK and SVA are at the Departments of Internal Medicine, Infectiology, and Tropical Medicine; PCMD is at the Departments of Pathology and Oral Pathology; and PJAB is at the Departments of Medical Microbiology and Parasitology; all authors are at the University Medical Center Nijmegen, Nijmegen, Netherlands Correspondence: Dr Philip A Van Damme, Department of Oral and Cranio-Maxillofacial Surgery, UMC St Radboud Nijmegen (421), PO Box 9101, 6500 HB Nijmegen, Netherlands. Tel +31 24 3617314; fax +31 24 3541165; email [email protected]
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
53
Education to improve antibiotic use
49 50
51
52
multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA 1999; 281: 1512–19. Perz JF, Craig AS, Coffey CS, et al. Changes in antibiotic prescribing for children after a communitywide campaign. JAMA 2002; 287: 3103–09. Seppälä H, Klaukka T, Lehtonen R, Neonen E, Huovinen P. Outpatient use of erythromycin: link to increased erythromycin resistance in Group A streptococci. Clin Infect Dis 1995; 21: 1378–85. Granizo JJ, Aguilar L, Casal J, Garcia-Rey C, Dal-Re R, Baquero F. Streptococcus pneumoniae resistance to erythromycin and penicillin in relation to macrolide and beta-lactam consumption in Spain (1979–1997). J Antimicrob Chemother 2000; 46: 767–73. Granizo JJ, Aguilar L, Casal J, Dal-Re R, Baquero F. Streptococcus pyogenes resistance to erythromycin and penicillin in relation to macrolide and beta-lactam consumption in Spain (1979–1997). J Antimicrob Chemother 2000; 46: 959–64.
53 Garcia-Rey C, Aguilar L, Baquero F, Casal J, Dal-Re R. Importance of local variations in antibiotic consumption and geographical differences of erythromycin and penicillin resistance in Streptococcus pneumoniae. J Clin Microbiol 2002; 40: 159–64. 54 Guillemot D, Henriet L, Lecoeur H, Weber P, Carbon C. Optimization of antibiotic use rapidly decreases penicillin resistant Streptococcus pneumoniae (PRSp) carriage: the AUBEPPIN Study [Abstract 1527]. In: Abstracts of the 41st Annual Interscience Conference on Antimicrobial Agents and Chemotherapy; 2001 December 16–19; Chicago, IL, USA. Washington, DC: American Society for Microbiology, 2001: 264. 55 Felmingham D, Feldman C, Hryniewicz W, et al. Surveillance of bacterial resistance in communityacquired respiratory tract infections. Clin Microbiol Infect 2002; 8 (suppl 2): 12–42. 56 Vilhelmsson SE, Tomasz A, Kristinsson KG. Molecular evolution in a multidrug-resistant lineage
57
58
59
60
of Streptococcus pneumoniae: emergence of strains belonging to the serotype 6B Icelandic clone that lost antibiotic resistance traits. J Clin Microbiol 2000; 38: 1375–81. Bronzwaer SL, Cars O, Buchholz U, et al. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis 8: 278–82. Steinke D, Davey PG. The association between antibiotic resistance and community prescribing: a critical review of bias and confounding in published studies. Clin Infect Dis 2001; 33 (suppl 3): S193–205. Harbarth S, Harris AD, Carmeli Y, Samore MH. Parallel analysis of individual and aggregated data on antibiotic exposure and resistance in gram-negative bacilli. Clin Infect Dis 2001; 33: 1462–68. Hall AJ. Ecological studies and debate on rotavirus vaccine and intussusception. Lancet 2001; 358: 1197–98.
Clinical picture A rare case of oral leishmaniasis Philip A Van Damme, Monique Keuter, Sander Van Assen, Peter C M DeWilde, and Pieter J A Beckers
A Dutch 86-year-old retired physician presented with symptoms of self-diagnosed and self-treated palatal actinomycosis. His history included a trout-fish-bone puncture 2 years earlier in the south of France (Mediterranean Pyrenees), and ever since a progressive swelling of his maxillary soft tissues. He reported episodes of evacuation of pus and so-called amorphic sulphurgranules, which were suggested—by a pathologist elsewhere—to be grains of Actinomyces species. A remaining fish-bone part was not objectified. 6 weeks of antibiotic self-treatment (amoxicillin) brought no improvement. At presentation, a reddish livid tumescent palate was seen, with fistulas, indurations, erosions, ulcerations, mucosal tags, and granulations (figure 1). Clinical head and neck investigation, occlusal/orthopantomographic radiographs, and magnetic-resonance imaging were not conclusive. He had no fever, lymphadenopathy, hepatosplenomegaly, or rash. Laboratory examination showed low CD4+ T-lymphocyte count (0·24 x 109/L) as the only abnormality, which was probably age-related. The differential diagnosis included squamous cell carcinoma, Candida albicans, Wegener’s granulomatosis, tuberculosis, and malignant lymphoma. Histopathological examination of incisional biopsies showed a diffuse subepithelial granulomatous inflammatory reaction with lymphocytes, plasma cells, scattered nests of multinucleated giant cells, and several histiocytic cells. Ring-shaped inclusions within the cytoplasm of histiocytic cells, seen in haematoxylin eosin and Grocott stainings, were suggested to be either imposing as toxoplasma, histoplasma, or leishmania. In Gram and Ziehl Neelsen stainings, no reaction was noticed. Immunohistological assessments ruled out toxoplasma and histoplasma. Notwithstanding the fact that the patient had never visited tropical areas, and in the Mediterranean zone normally only visceral localisations are reported to occur, leishmaniasis was very much suspected. Impression smears stained with Giemsa, showed the characteristic intracellular parasites—the perinuclear kinetoplasts in the ovoid amastigotes, apart from THE LANCET Infectious Diseases Vol 4 January 2004
the densely stained large nuclei—within the histiocytic cells (figure 2). Additionally, penicillin-sensitive Actinomyces viscosus was isolated. Molecular differentiation provided the final diagnosis: oral mucous membrane leishmaniasis caused by Leishmania infantum. L infantum usually causes visceral infection and, rarely, mucocutaneous infection. Mucocutaneous leishmaniasis is almost exclusively caused by the American Viannia genus Leishmania (V) braziliensis. The treatment advice in this case was: liposomal amphotericin B 5mg/kg, once, based on its effectivity against visceral L infantum infection in patients with low CD4+ T-lymphocyte count; however, the patient refused and went elsewhere. PAVD is at the Department of Oral and Craniomaxillofacial Surgery; MK and SVA are at the Departments of Internal Medicine, Infectiology, and Tropical Medicine; PCMD is at the Departments of Pathology and Oral Pathology; and PJAB is at the Departments of Medical Microbiology and Parasitology; all authors are at the University Medical Center Nijmegen, Nijmegen, Netherlands Correspondence: Dr Philip A Van Damme, Department of Oral and Cranio-Maxillofacial Surgery, UMC St Radboud Nijmegen (421), PO Box 9101, 6500 HB Nijmegen, Netherlands. Tel +31 24 3617314; fax +31 24 3541165; email [email protected]
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
53