Actinomycosis from a toothpick injury

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Table. Data on five patients with Haemophilus influenzae type B cellulitis Cellulitis aspirate

Age (too)

Sex

Location

Gram stain

Culture

Blood culture

CSF culture

4 9 11 14 18

F M M M M

Ankle Finger Knee Thigh Knee

ND GNCB GNCB GNCB Negative

Negative* H. influenzae 11. influenzae 1t. influenzae Negative

H. influenzae H. influenzae 1t. influenzae Negative H. influenzae

H. influenzae ND ND H. influenzae ND

ND = Not done; GNCB = gram-negativecoccobacillus. *Culture obtained 24 hours after starting treatment with ampicillin.

aspirate cultures or both done. All patients with H. influenzae cellulitis had involvement of the extremities and were less than 19 months of age (Table). No evidence of joint involvement was present in any of the subjects. DISCUSSION The suspected diagnosis of H. influenzae type b cellulitis is usually based on the typically described violaceous coloration of the affected area, found in approximately 45% of the cases, and by the localization of the lesions over the face or periorbital area, reported in approximately two-thirds of the patients. 2 The final diagnosis, sometimes unsuspected, is most frequently made from the results of blood cultures, which are positive in approximately 80% of the cases? Recently Goetz and TafarP reported the value of needle aspiration of the cellulitis as a means of increasing the n u m b e r of patients in whom a definitive etiologic diagnosis can be made; two of their three patients had positive cultures from aspirate material. Our experience is similar. It is noteworthy that one of our patients had a positive

aspirate culture in the presence of a negative blood culture, emphasizing the importance of obtaining samples from both sites. Furthermore, as seen in our small series, it becomes particularly important to obtain a Gram stain of the aspirate. A preliminary diagnosis can often be made and appropriate antibiotic treatment initiated without delay. The predominance of males in our series is of interest. A recent review of H. influenzae type b cellulitis failed to disclose a sex predilection. ~ REFERENCES 1. Rapkin RH, and Bautista G: Hemophilus influenzae cellulitis, Am J Dis Child 124:540, 1972. 2. Bada H, and Wright SP: Hemophilus influenzae cellulitis, Clin Pediatr 13:658, 1974. 3. Goetz JP, and Tafari N: Needle aspiration in Hemophilus influenzae type b cellulitis, Pediatrics 54:504, 1974. 4. Granoff DM, and Narkervis GA: Cellulitis due to Hemophilus influenzae type b, Am J Dis Child 130:1211, 1976. 5. Landwirth J: Bilateral cellulitis of cheeks in an infant due to Hemophilus influenzae, Clin Pediatr 16:182, 1977.

A ctinomycosisfrom a toothpick injury Dianne Murphy, M.D.,* James McEIhinney, M.D., and James Todd, M.D., Denver, Colo.

THE FOLLOWING CASE of actinomycosis of the knee associated with a penetrating toothpick injury is presented because of the unusual location and origin of the infection. From The Department of Pediatrics, University of Colorado Medical Center and The Children's Hospital of Denver. *Reprint address: Pediatric Infectious Disease, Universityof Colorado Medical Center, 4200 East Ninth Ave./C227, Denver, CO 80262. 0022-3476/79/600925 +03500.30/0 9 1979 The C. V. Mosby Co.

CASE REPORT This 4-year-old white boy was in good health when, in November, 1977, he slipped on a rug and a toothpick penetrated his left knee through his pant leg. The toothpick was easily removed with no immediate bleeding or swelling, and was believed by the mother to be intact. The child was taken to his physician the next day because of minor pain and tenderness of the left knee, and received a ten-day course of penicillin given orally, with no further complaints concerning his knee. On January 28, 1978, he developed swelling, pain, and erythema of his left knee. He limped for 24 hours prior to admission.

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Brief cfinicat and laboratory observations

There was no history of recent significant trauma. The child was seen at another hospital, where an aspirate of the joint was performed. Gram stain revealed gram-positive organisms with a morphology consistent with actinomycetes, and the child was referred for admission. On admission, he was a well-appearing child with a temperature of 37 ~ C, an abnormal gait, and a swollen, erythematous, warm left knee. There was tenderness along the lateral distal femur and medial aspect of the joint, with minimal effusion. The child was treated with oxacillin and ampicillin, 200 mg/kg/day and 150 mg/kg/day intravenously, divided every four hours, respectively. The following day he had a temperature of38 ~C, and the knee had become more swollen, with extending erythema. Radiographs revealed only soft tissue swelling, and laboratory evaluation, including peripheral white blood cell count, differential and sedimentation rate, was unremarkable. The bone scan was consistent with cellulitis rather than osteomyelitis. Samples of fluid were aspirated from the area of maximal involvement of the distal lateral femur from beneath the periosteum, and from the medullary canal of the femur. On day five the thiogtycolate culture from the first hospital was reported as growing A ctinomyces israetii, Fusobacterium nucleaturn, diphtheroids, and Staphylococcus epidermidis. A "teasing" of a granule in the inoculum area on the original anaerobe plate was recultured, and reconfirmed by the anaerobe lab as Actinomvces israelii. The oxacillin was discontinued and the patient was maintained on ampicillin therapy intravenously. By the seventh day of hospitalization the culture obtained from the bone aspiration was positive for Actinomvces israelii. The patient was afebrile, with no residual pain or erythema of the knee, after 13 days of intravenous antibiotic therapy, and treatment was therefore switched to amoxicillin, to be given orally for two months. The child was discharged and seen frequently as an outpatient. The three-week posthospital course was marked by a progressive increase in pain and swelling of the left knee. The child was readmitted March 1, 1978, with a fever of38 ~ C, a large node in the left groin, and warmth and swelling of the left knee. There were no bone changes on radiographic examination, and laboratory evaluation, including peripheral white blood cell count and sedimentation rate, was essentially unremarkable. An incision over the fluctuant area revealed a thick, orange peel-type pseudocapsule overlying the quadriceps mechanism. On gross examination, granules were noted in the exudate, though no sulfur granules or organisms were seen on microscopic examination. There was no evidence of joint involvement but there was early formation of a sinus tract. Cultures yielded only aerobic catalase-positive diphtheroids, which grew within 48 hours, and Fusobacterium nucleatum. The child completed a seven-day course of penicillin, 100,000 units/kg/day divided every four hours, intravenously and was discharged on potassium phenoxymethyl penicillin, 100 mg/ kg/day divided every four hours, and probenecid for two months. He has had no recurrences of pain, swelling, or limitation o f motion.

The Journal of Pediatrics June 1979 DISCUSSION O f the genus Actinomyces, the species israefii is most often associated with disease. Actinomyces israelii can be a normal inhabitant o f the mouth, 1 2 along with organisms such as Fusobacterium nucleatum and diphtheroids. Mixed infection is very c o m m o n in actinomycosis.: .... Holms 5 was convinced that the disease itself was a multiple infection, some of the clinical variations being secondary to other organisms; most reports mention the frequency of involvement o f other organisms? . . . . Trauma also seems to be frequently involved, though the form of trauma most frequendy cited is usually to the oral cavity, with subsequent craniofacial i n v o l v e m e n t ? " The knee is not c o m m o n l y affected, and Brown 4 states that actinomycosis is least likely to occur in the extremities, and that bone involvement is unusual. One must assume that the toothpick involved in this case had been "used." The long asymptomatic interval, the recurrence, and the difficulty o f resolution are all c o m m o n to actinomycosis. 7 The l a c k of sinus formation early in the disease is c o m m o n and should not delay diagnosis) The inability to grow the organism is mentioned in many reviews; in this case the organism, though isolated in thioglycolate on one smear, was not found again and was recovered for identification from teasing part of a "sulfur granule" noted on the inoculum of the anaerobic plate which did not grow. Because of their pleomorphism the actinomyces may be difficult to identify; George 8 has noted that "unless branching filaments are observed some labs report these as 'diphtheroids.'" The problem o f isolation of the organism is paralleled by its propensity for recurrence. Though almost all actinomyces are sensitive to penicillin? it is difficult to eradicate them completely. It has been postulated that the chronicity is secondary to the fibrotic nature and avascularity of the healing process? Harveys in reference to thoracic disease, suggested large parenteral doses of penicillin before the operative procedure followed by oral doses of potassium phenoxymethyl penicillin of five million units per day for 12 to 18 months "to minimize the relapses which are frequent with short periods of therapy," Peabody and Seabury "~ emphasized the need for surgical debridement. Whether our patient's recurrence could have been prevented by earlier debridement, or by using penicillin during the first admission, is unknown. Lerner TM found the m i n i m u m inhibitory concentration of ampicillin for actinomyces well within the therapeutic range, and this drug should have been adequate for therapy. Rare though actinomycosis may be, it would be worth

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Brief clinical and laboratory observations

remembering in a child who has trauma associated with oral flora. If the diagnosis is confirmed, one should not be content with early clinical resolution but be committed to long-term therapy and, possibly, surgical debridement. REFERENCES 1. Waksman SA: The actinomycetes, Baltimore, 1962 and 1967, The Williams & Wilkins Company. 2. Sykes G, and Skinner FA, editors: Actinomycetales: Characteristics and practical importance. Society for Applied Bacteriology, Symposium Series No. 2, New York, 1973, Academic Press, Inc. 3. Weese WC: A study of 57 cases of actinomycosis over a 36-year period, Arch Intern Med 135:1562, 1975. 4. Brown JR: Human actinomycosis: A study of 181 subjects, Hum Pathol 4:320, 1973.

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5. Holms P: Studies on the etiology of human actinomycosis. I. The "other microbes" of actinomycosis and their importance, Acta Pathol Microbial Scand 27:736, 1950. 6. Eastridge CE: Actinomycosis: A 24-year experience, South Med J 65"839, 1972. 7. Harvey JC: Actinomycosis--its recognition and treatment, Ann Intern Med 46:868, 1957. 8. George GW: A new pathogenic anaerobic actinomycosis species, J Infect Dis 115:88, 1965. 9. Peabody JW, and Seabury JH: Actinomycosis and nocardiosis: A review of basic differences in therapy, Am J Med 28:99, 1960. 10. Lerner P: Susceptibility of pathogenic actinomycetes to antimicrobial compounds, Antimicrob Agents Chemother 5:302, 1974.

Goat milk acidosis Harold L. Harrison, M.D., Michael A. Linshaw, M.D.,* Joyce Sierk Bergen, M.D., and Terry McGeeney, M.D., Kansas City, Kan.

RECENTLY, we evaluated an infant who was receiving undiluted, raw goat milk; he grew poorly and developed severe metabolic acidosis. The infant gained weight and maintained normal serum chemistry values when receiving a standard commercial infant formula, but promptly lost weight and developed acidosis when undiluted goat milk was reintroduced. It would appear that goat milk is an inappropriate food for infants during the first weeks of life. CASE REPORT This term male infant (birth weight 3,603 gm) was the product of a normal pregnancy and delivery. He was fed commercial formula (Enfamil, Mead Johnson Laboratories) during the first two weeks of life. However, the parents thought the infant's bowel movements were "firm" and began to feed him undiluted, unpasteurized goat milk, because they felt it would "soften his stools and make him less likely to develop colic." The baby took 28 ounces of goat milk and 8 ounces of water daily eagerly for the next week and experienced no diarrhea or vomiting. During this week the infant's daily protein, potassium, and chloride intake were considerable (10 gm/kg, 6 to 10 mEq/kg, and 9.4 to 14 From the Department of Pediatrics, Section of Pediatric Nephrology, University of Kansas Medical Center. *Reprint address: Department of Pediatrics, University of Kansas Medical Center, 39th Street at Rainbow Blvd, Kansas City, KS 66103.

0022-3476/79/600927 + 03500.30/0 9 1979 The C. V. Mosby Co.

mEq/kg, respectively). Daily fluid intake was 310 ml/kg and sodium intake was 3.4 mEq/kg. Two siblings, ages 3 and 4 years, were also drinking goat milk and had no complaint. The infant presented at 3 weeks of age with tachypnea and growth failure, a weight of 3,526 gm, length 51 cm, head circumference 36 cm, heart rate 160 to 170/minute, respiratory rate 70 to 80/minute, and blood pressure 88/60 mm Hg. There was no evidence of dehydration and, except for mild nasal flaring, the remainder of the examination was normal. Admission laboratory values included hemoglobin 16.8 gm/dl, hematocrit 49.5%, WBC count 18,000 with a normal differential, reticulocyte count 0.9%, platelets 628,000. Serum electrolyte values in mEq/1 were sodium 131, chloride 116, potassium 6.1, and bicarbonate 4. Serum pH was 7.14, and Pco2 12 mm Hg. Additional laboratory data in mg/dl were BUN 30, creatinine 0.4, calcium 10.6, phosphorus 8.1, glucose 87, and uric acid 2.9. Urinalysis revealed no blood, protein, or glucose, occasional granular casts, and a specific gravity of 1.010. Urine pH was 5.0, and amino acid screen was negative. Results of a chest roentgenogram and CSF were within normal limits. A presumptive diagnosis of sepsis was made and, after obtaining appropriate cultures, the infant was treated intravenously with antibiotics (ampicillin, 200 mg/kg/24 hours; gentamicin 7.5 mg/kg/24 hours). Hydration was maintained with 5% dextrose in water plus sodium bicarbonate sufficient to partially correct the acidosis, and oral feedings (Enfamil) were started shortly thereafter. By 36 hours, serum chemistry values were normal and the infant's weight had increased 123 gm. Cultures showed no growth after 72 hours, and the antibiotics were discontinued. Over the next eight days, the infant received Enfamil (20 calories/ounce)