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Chromogenic Acid-Fast Bacillus Infection of the Urinary Tract
CHROMOGENIC ACID-FAST BACILLUS INFECTION OF THE URINARY TRACT GEORGE SEWELL, M.D., JOSEPH KASPER, M.D.,
AND
NORMA BROOM
From the Urological Service and Laboratory, Herman Kiefer Hospital, Department of Health, Detroit, Michigan
In the thorough study of an infected urinary tract, cystoscopy, pyelography and the renal function tests are usually supplemented by the bacteriological examination of the urine. For the latter procedure, the specimens are obtained by catheteriz;ation of the bladder or the ureters. The catheterized specimens, upon reaching the laboratory, are centrifugalized and the sediment is examined for the presence of bacteria. A direct microscopic study is first made of the smears which are stained by the Gram method, or by the Ziehl-Neelsen method if a search is to be made for acid-fast bacilli. This preliminary study of the sediment is then followed by cultural and immunological studies for the more definite identification of the bacteria causing the infection. Until a few years ago, whenever acid-fast bacilli were observed in the direct smear of the urine sediment, or even if they were not found, inoculation of a guinea pig was considered the most reliable means by which a diagnosis of tubercle bacillus infection could be made. Now, since the perfection of artificial media by Petroff and Petragagni, animal inoculation is employed only as a confirmation procedure when unusual forms of acid-fast bacilli are encountered in the cultures. In the laboratory of the Herman Kiefer Hospital, the artificial culture media have almost entirely replaced animal inoculations for the identification of tubercle bacilli. In a parallel series of studies, Norton, Broom and Thomas have found that the culture method gave as reliable results as those obtained from animal inoculations, and in some instances positive findings were obtained earlier. Occasionally, acid-fast bacilli observed in urine specimens and other body fluids show the tinctorial characteristics of tubercle bacilli, but when the material containing them is injected into animals true tubercles do not develop. Under such conditions the animal test may be negative and the exact identification of the bacilli cannot be made. If, however, the material containing such acid-fast bacilli is planted on artificial media suitable for their cultivation, not only can the tubercle bacilli be isolated, but other acid-fast organisms will also be found to grow. In this respect 385
386
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
the culture method possesses a decided advantage over the animal inoculation method because it will serve to isolate those pseudo-tubercle bacilli which, although not capable of causing tubercles in animal tissues, are known to be responsible for the appearance of other types of lesions. Recent experiments with these bacteria would seem to indicate that their significance is becoming increasingly great. When grown on Petragagni's medium, the pseudo-tubercle bacilli produce pigmented colonies, varying from yellow to orange, making it possible to distinguish them from true tubercle bacilli whose colonies are of a characteristic buff color. This tendency to develop pigment on artificial media has prompted the adoption of the name "chromogenic acid-fast bacilli" for this group of organisms. They have been isolated from sputum, pleural fluids and from urines. The following case report presents some interesting observations which were made in the course of a study of an unusual human urinary tract infection. Case report. P. 0., a white male, aged 49 years, was admitted to the Herman Kiefer Hospital, November 17, 1933. He was transferred from another hospital with the diagnosis of "Tuberculosis of the Kidney. " The chief complaint was frequency, nocturia, incontinence at times, pain over bladder region, and loss of weight and strength. The patient had not felt well during the previous summer and noted a gradual loss of weight, amounting to 15 pounds in the past year. For two years he was troubled with nocturia. About six or eight weeks prior to admission to the hospital he was troubled with incontinence at times. There were associated sensations of burning and some pain. Frequently, the urine appeared "thick and muddy." Recently, a progressive weakness developed. The past history included only a reference to measles in childhood and a fracture of the leg at the age of ten. The patient was exposed to a brother who died of tuberculosis in 1930. He had been married 27 years, and his wife and two children were in good health. He was a mechanical engineer and had not been exposed to excessive dust. The patient was found to be well developed and fairly well nourished. He appeared tired and drowsy but was well oriented. There was no cough. The skin was pale and dry. There was no gland enlargement. Several teeth were carious. The well developed thorax showed a slight respiratory lag in the upper third on the right side. Dullness was found over the upper third of the right lung. Breath sounds in this area were harsh and the vocal fremitus increased. Fine rales were heard in the right apical and infraclavicular regions. The left lung showed no abnormality. Heart was normal. Blood pressure was 140/80. There was no evidence of peripheral vascular sclerosis. Reflexes
CHROMOGENIC ACID-FAST BACILLUS INFECTION
387
were normal. Abdomen was negative. Seminal vesicals were distended and tender. The prostate was not enlarged. Temperature was 99.2°F., pulse 76, respirations 18, red blood cells 4,610,000, hemoglobin 80 per cent, white blood cells 14,100, polymorphonuclears 67 per cent, Kahn test negative. A trace of albumin was found in the urine and numerous pus cells. At the clinical conference the case was classified minimal pulmonary tuberculosis, favorable for treatment; renal tuberculosis and tuberculous cystitis.
FIG. 1. Left kidney showing lesions in cortex and pelvis caused by "chromogenic acid-fast bacilli."
X-ray report on lungs (Dr. C. C. Birkelo): Minimal tuberculosis of productive type in infraclavicular region on the right side. Small area of rarefaction at this level. We doubt that this is an excavation. The infiltrations show very little perifocal reaction. The patient was referred to the Urological Service. Simple cystoscopy a few days later was attempted but had to be deferred on account of the extreme pam. Heliotherapy over the bladder region was then started.
388
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
December 11, 1933, cystoscopy was done under spinal anaesthesia. The bladder tolerated only SO cc. of fluid. Further distention caused bleeding. The entire bladder mucosa showed bullous · edema. Ulcerations were observed at the bladder base and were more pronounced about the left ureteral orifice which could not be readily recognized. This ureter could not be catheterized because of the free bleeding produced by the catheter manipulation. It was easy to catheterize the right ureter; which yielded clear urine. Bacteriological studies showed that chromogenic acid-fast bacilli were grown from the bladder specimen and no growth from the urine obtained from the right ureter. Indigo-carmine, intravenously, appeared at end of 9 minutes with good intensity. No dye was seen to appear in the region of the left ureter in 15 minutes. Sodium iodide injected up right ureter and pyelogram
FIG. 2. Section of cortex of left kidney showing characteristic lesion caused by infection of "chromogenic acid-fast bacilli."
made. This revealed loss of cupping of the upper minor calyx and blunting of upper major calyx. Thought to be due to beginning hydronephrosis. An intravenous pyelogram was inconclusive. Urine specimens from bladder and right ureter were cultured on Petroffs' and Petragagnis' media. Two months later intravenous pyelograms were repeated. These showed irregularities of the minor calyces on the left side and questionable changes on the right side. Cystoscopy, under spinal anesthesia, disclosed no change in the bladder condition. Indigo-carmine appeared from right ureter at end of 6 minutes but not fully intense until after 17 minutes. No dye appeared on left side in 20 minutes. Right pyelogram showed evidence of slight hydronephrosis.
CHROMOGENIC ACID-FAST BACILLUS INFECTION
389
Cultures from right kidney were reported negative, and inasmuch as the bladder symptoms were still present, removal of the left kidney was decided upon since the condition of the lung was considered satisfactory. A nephrectomy was performed March 12, 1934, using spinal anesthesia. The usual kidney incision was made on the left side. The retroperitoneal space and fatty capsule were entered. The fat was easily stripped from the kidney although some evidence of perinephritis was noted. The kidney was mobilized and vascular pedicle was separated after clamping. The ureter was stripped down as far as possible and kidney with approximately 10 cm. of the ureter was removed. The distal end of the ureter was cauterized and ligated. The wound was closed without drainage. The patient left the operating room in good condition.
FIG. 3. Ureter showrng narrowed lumen and greatly thickened wall. in the wall are monocytes.
The infiltrating cells
Following operation there was marked decrease of the pain in the bladder and of the urinary frequency. Blood nitrogen did not fall below 44 mgm. per 100 cc. The wound healed rapidly, and the convalescence was uneventful. The patient was discharged from the hospital July 18, 1934. Upon returning to his home he continued to show improvement, gaining 15 pounds in weight. He had been working for more than one year and when last seen has had no return of his former symptoms. These have disappeared entirely following the nephrectomy. Pathological report: Left kidney was normal in size but showed discrete foci, resembling tubercles, in the cortex just under the capsule. On section, the pelvis revealed roughening and some thickening of its wall. The ureter wall was thickened and quite firm. Its lumen showed definite narrowing. In one
390
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
lobule of the parenchyma the kidney revealed a pale discoloration with necrosis. This extended from the periphery of the cortex into the medulla. Microscopically, the ureter revealed an extensive, diffuse infiltration of its wall with monocytes and lymphocytes. The mucosa was destroyed and was replaced by mononuclear cells. Hyaline degeneration and edema was found in the muscle and connective tissue of the wall of the ureter. The wall of the pelvis showed diffuse mononuclear cell infiltration. Vascular and hyaline changes were similar to those found in the ureter. In the parenchyma of the kidney were patchy infiltrations of monocytes and some lymphocytes, particularly in the cortex. Several glomeruli showed advanced hyaline degeneration. About such glomeruli were groups of mononuclear cells and in one area was found a marked destruction of the convoluted
FIG. 4. Higher magnification of kidney cortex showing type of reaction. The arrow points to a monocyte containing acid-fast granules. Kinyon stain for acid-fast bacilli.
tubules as well as glomeruli. In this area could be seen several mutinucleated giant cells. No distinct tubercles could be observed in any of the areas of reaction studied. The reaction was suggestive of that caused by those acid-fast bacilli which are chromogenic and which experimentally have never been shown to cause the development of tubercles.
Stains of the surgical tissue sections have failed to reveal the presence of acid-fast bacilli, but in the kidney many scattered monocytes were found which contained acid-fast granules, apparently phagocytosed by these cells. An occasional monocyte was found to contain acid-fast particles having a slight resemblance to bacilli. However, no free acidfast or any other bacteria were found in the tissue sections.
CHROMOGENIC ACID-FAST BACILLUS INFECTION
391
In view of the bacteriological and pathological findings, the lesions observed in the kidney and the ureter are attributed to an infection of chromogenic acid-fast bacilli. Bacteriology. A clean specimen of urine was received in the laboratory November 24, 1933. The direct smear of the s~diment of this specimen was negative for acid-fast bacilli but a growth of chromogenic bacilli was observed on Petragagni's medium January 8, 1934 (after 58 days) . Cystoscopic specimens of urine from the bladder and right ureter were received December 12, 1933. The specimen from the right ureter was negative for acid-fast organisms on direct examinations, and the culture showed no growth after 90 days. The urine from the bladder was positive on direct examination. No culture was made. After the kidney was removed and the organ bisected, swabs were made of the grossly apparent lesions in the pelvis and parenchyma. These showed the presence of numerous acid-fast bacilli on direct examination of smears. After 43 days, cultures showed growth of chromogenic bacilli. Morphology: Fine, short, non-motile rods, occasionally showing granules, which cannot be distinguished from tubercle bacilli by examination of direct smears. Staining reaction: Acid-fast and Gram positive. Cultural characteristics: On the standard media for the cultivation of tubercle bacilli, such as Glycerin Agar, Lowenstein's, Petroff's and Petragagni's, the colonies are circular, moist, smooth and raised. They are non-spreading and of a deep orange color. Growth is slightly slower than that of tubercle bacilli and is best at 37°C. No growth could be obtained on plain agar or agar enriched with blood or ascitic fluid. No growth was obtained in plain broth. In glycerin broth and Souton's fluid growth was very slow and resulted in a slimy, creamy, orange sediment. Some flocculent deposits appeared along the sides of the tubes. Smears made of this sediment revealed pleomorphic, partially acid-fast rods, some of which occurred in chains. Agglutination reaction: Antiserum of a titer of 1: 1000 was obtained from rabbits injected with chromogenic acid-fast bacilli grown from the kidney of another case. The organisms isolated from the kidney of P. 0. gave a positive agglutination in a dilution of 1:400 when mixed with the rabbit serum. Normal rabbit serum gave negative results. Pat hogenicity : One cubic centimet er of a heavy saline suspension of the chromogenic acid-fast bacilli grown from t he kidney of P . 0 . was
392
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
injected inguinally into a 400 gram guinea pig. After four weeks the animal was killed and examined. The inguinal lymph nodes were found to be enlarged and soft. There was much thick, yellowish pus containing numerous acid-fast bacilli. These, when grown on Petragagni's medium were found to be of the chromogenic type. Histological studies of the lymph nodes showed that marked monocytic proliferation was taking place in the lymphoid tissue. There was also a monocytic infiltration of the adjacent tissues of the inguinal region. Several giant-cells were observed but no tubercles were seen to be developing. Bacterial stains revealed the presence of very many acidfast bacilli in the sections of the guinea pig tissues. DISCUSSION AND SUMMARY
The bacteriological and histological examinations of the kidney lesion of the case here reported indicates that chromogenic acid-fast liacilli may be pathogenic for man, and be capable of causing changes in the tissues which might be confused with those caused by the infection of tubercle bacilli. An error in diagnosis might result if such organisms are studied only by means of the direct smear, or if reliance is placed on animal inoculation for the diagnosis. Pinner (2) has demonstrated that inoculation of animals with chromogenic acid-fast bacilli will result in the development of lesions which may disappear by the end of the period usually required for the development of tubercles. Since the pathogenicity of some, at least, of the chromogenic acid-fast bacilli is established, caution should be exercised when reporting on the direct microscopic findings of cystoscopic or simple catheterized specimens of urine. Otherwise, an erroneous diagnosis of tuberculosis might be the result. The true nature of the chromogenic acid-fast bacilli has not yet been determined. Further work is now in progress to learn if they are related to tubercle bacilli. In a series of 130 sputum specimens from known tuberculous patients, out of 34 positive cultures, approximately 20 per cent were found to contain chromogenic organisms. Although the case here reported required nephrectomy for the complete relief of symptoms, it is probable that other similar cases showing less extensive involvement of the urinary tract might recover spontaneously. The animal experiments of Pinner and in our laboratory tend to support this view.
CHROMOGENIC ACID-FAST BACILLUS INFECTION
393
Future observations based upon careful bacteriological studies of the acid-fast bacilli found in urine and other body fluids may explain many of the spontaneous recoveries from supposed "tubercle bacillus" infections. REFERENCES BROOM, N. H .: Laboratory tests for tubercle bacilli by culture methods. Amer. Rev. Tuberc., 26: 378, 1932 . (2) PINNER, MAX : Atypical acid-fast microorganisms, III. Chromogenic acid-fast bacilli from human beings. Amer. Rev. Tuberc., 32: 424, 1935.
(1) NORTON,
J. F., TuoMAs, J. G. AND
AND
NORMA BROOM
From the Urological Service and Laboratory, Herman Kiefer Hospital, Department of Health, Detroit, Michigan
In the thorough study of an infected urinary tract, cystoscopy, pyelography and the renal function tests are usually supplemented by the bacteriological examination of the urine. For the latter procedure, the specimens are obtained by catheteriz;ation of the bladder or the ureters. The catheterized specimens, upon reaching the laboratory, are centrifugalized and the sediment is examined for the presence of bacteria. A direct microscopic study is first made of the smears which are stained by the Gram method, or by the Ziehl-Neelsen method if a search is to be made for acid-fast bacilli. This preliminary study of the sediment is then followed by cultural and immunological studies for the more definite identification of the bacteria causing the infection. Until a few years ago, whenever acid-fast bacilli were observed in the direct smear of the urine sediment, or even if they were not found, inoculation of a guinea pig was considered the most reliable means by which a diagnosis of tubercle bacillus infection could be made. Now, since the perfection of artificial media by Petroff and Petragagni, animal inoculation is employed only as a confirmation procedure when unusual forms of acid-fast bacilli are encountered in the cultures. In the laboratory of the Herman Kiefer Hospital, the artificial culture media have almost entirely replaced animal inoculations for the identification of tubercle bacilli. In a parallel series of studies, Norton, Broom and Thomas have found that the culture method gave as reliable results as those obtained from animal inoculations, and in some instances positive findings were obtained earlier. Occasionally, acid-fast bacilli observed in urine specimens and other body fluids show the tinctorial characteristics of tubercle bacilli, but when the material containing them is injected into animals true tubercles do not develop. Under such conditions the animal test may be negative and the exact identification of the bacilli cannot be made. If, however, the material containing such acid-fast bacilli is planted on artificial media suitable for their cultivation, not only can the tubercle bacilli be isolated, but other acid-fast organisms will also be found to grow. In this respect 385
386
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
the culture method possesses a decided advantage over the animal inoculation method because it will serve to isolate those pseudo-tubercle bacilli which, although not capable of causing tubercles in animal tissues, are known to be responsible for the appearance of other types of lesions. Recent experiments with these bacteria would seem to indicate that their significance is becoming increasingly great. When grown on Petragagni's medium, the pseudo-tubercle bacilli produce pigmented colonies, varying from yellow to orange, making it possible to distinguish them from true tubercle bacilli whose colonies are of a characteristic buff color. This tendency to develop pigment on artificial media has prompted the adoption of the name "chromogenic acid-fast bacilli" for this group of organisms. They have been isolated from sputum, pleural fluids and from urines. The following case report presents some interesting observations which were made in the course of a study of an unusual human urinary tract infection. Case report. P. 0., a white male, aged 49 years, was admitted to the Herman Kiefer Hospital, November 17, 1933. He was transferred from another hospital with the diagnosis of "Tuberculosis of the Kidney. " The chief complaint was frequency, nocturia, incontinence at times, pain over bladder region, and loss of weight and strength. The patient had not felt well during the previous summer and noted a gradual loss of weight, amounting to 15 pounds in the past year. For two years he was troubled with nocturia. About six or eight weeks prior to admission to the hospital he was troubled with incontinence at times. There were associated sensations of burning and some pain. Frequently, the urine appeared "thick and muddy." Recently, a progressive weakness developed. The past history included only a reference to measles in childhood and a fracture of the leg at the age of ten. The patient was exposed to a brother who died of tuberculosis in 1930. He had been married 27 years, and his wife and two children were in good health. He was a mechanical engineer and had not been exposed to excessive dust. The patient was found to be well developed and fairly well nourished. He appeared tired and drowsy but was well oriented. There was no cough. The skin was pale and dry. There was no gland enlargement. Several teeth were carious. The well developed thorax showed a slight respiratory lag in the upper third on the right side. Dullness was found over the upper third of the right lung. Breath sounds in this area were harsh and the vocal fremitus increased. Fine rales were heard in the right apical and infraclavicular regions. The left lung showed no abnormality. Heart was normal. Blood pressure was 140/80. There was no evidence of peripheral vascular sclerosis. Reflexes
CHROMOGENIC ACID-FAST BACILLUS INFECTION
387
were normal. Abdomen was negative. Seminal vesicals were distended and tender. The prostate was not enlarged. Temperature was 99.2°F., pulse 76, respirations 18, red blood cells 4,610,000, hemoglobin 80 per cent, white blood cells 14,100, polymorphonuclears 67 per cent, Kahn test negative. A trace of albumin was found in the urine and numerous pus cells. At the clinical conference the case was classified minimal pulmonary tuberculosis, favorable for treatment; renal tuberculosis and tuberculous cystitis.
FIG. 1. Left kidney showing lesions in cortex and pelvis caused by "chromogenic acid-fast bacilli."
X-ray report on lungs (Dr. C. C. Birkelo): Minimal tuberculosis of productive type in infraclavicular region on the right side. Small area of rarefaction at this level. We doubt that this is an excavation. The infiltrations show very little perifocal reaction. The patient was referred to the Urological Service. Simple cystoscopy a few days later was attempted but had to be deferred on account of the extreme pam. Heliotherapy over the bladder region was then started.
388
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
December 11, 1933, cystoscopy was done under spinal anaesthesia. The bladder tolerated only SO cc. of fluid. Further distention caused bleeding. The entire bladder mucosa showed bullous · edema. Ulcerations were observed at the bladder base and were more pronounced about the left ureteral orifice which could not be readily recognized. This ureter could not be catheterized because of the free bleeding produced by the catheter manipulation. It was easy to catheterize the right ureter; which yielded clear urine. Bacteriological studies showed that chromogenic acid-fast bacilli were grown from the bladder specimen and no growth from the urine obtained from the right ureter. Indigo-carmine, intravenously, appeared at end of 9 minutes with good intensity. No dye was seen to appear in the region of the left ureter in 15 minutes. Sodium iodide injected up right ureter and pyelogram
FIG. 2. Section of cortex of left kidney showing characteristic lesion caused by infection of "chromogenic acid-fast bacilli."
made. This revealed loss of cupping of the upper minor calyx and blunting of upper major calyx. Thought to be due to beginning hydronephrosis. An intravenous pyelogram was inconclusive. Urine specimens from bladder and right ureter were cultured on Petroffs' and Petragagnis' media. Two months later intravenous pyelograms were repeated. These showed irregularities of the minor calyces on the left side and questionable changes on the right side. Cystoscopy, under spinal anesthesia, disclosed no change in the bladder condition. Indigo-carmine appeared from right ureter at end of 6 minutes but not fully intense until after 17 minutes. No dye appeared on left side in 20 minutes. Right pyelogram showed evidence of slight hydronephrosis.
CHROMOGENIC ACID-FAST BACILLUS INFECTION
389
Cultures from right kidney were reported negative, and inasmuch as the bladder symptoms were still present, removal of the left kidney was decided upon since the condition of the lung was considered satisfactory. A nephrectomy was performed March 12, 1934, using spinal anesthesia. The usual kidney incision was made on the left side. The retroperitoneal space and fatty capsule were entered. The fat was easily stripped from the kidney although some evidence of perinephritis was noted. The kidney was mobilized and vascular pedicle was separated after clamping. The ureter was stripped down as far as possible and kidney with approximately 10 cm. of the ureter was removed. The distal end of the ureter was cauterized and ligated. The wound was closed without drainage. The patient left the operating room in good condition.
FIG. 3. Ureter showrng narrowed lumen and greatly thickened wall. in the wall are monocytes.
The infiltrating cells
Following operation there was marked decrease of the pain in the bladder and of the urinary frequency. Blood nitrogen did not fall below 44 mgm. per 100 cc. The wound healed rapidly, and the convalescence was uneventful. The patient was discharged from the hospital July 18, 1934. Upon returning to his home he continued to show improvement, gaining 15 pounds in weight. He had been working for more than one year and when last seen has had no return of his former symptoms. These have disappeared entirely following the nephrectomy. Pathological report: Left kidney was normal in size but showed discrete foci, resembling tubercles, in the cortex just under the capsule. On section, the pelvis revealed roughening and some thickening of its wall. The ureter wall was thickened and quite firm. Its lumen showed definite narrowing. In one
390
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
lobule of the parenchyma the kidney revealed a pale discoloration with necrosis. This extended from the periphery of the cortex into the medulla. Microscopically, the ureter revealed an extensive, diffuse infiltration of its wall with monocytes and lymphocytes. The mucosa was destroyed and was replaced by mononuclear cells. Hyaline degeneration and edema was found in the muscle and connective tissue of the wall of the ureter. The wall of the pelvis showed diffuse mononuclear cell infiltration. Vascular and hyaline changes were similar to those found in the ureter. In the parenchyma of the kidney were patchy infiltrations of monocytes and some lymphocytes, particularly in the cortex. Several glomeruli showed advanced hyaline degeneration. About such glomeruli were groups of mononuclear cells and in one area was found a marked destruction of the convoluted
FIG. 4. Higher magnification of kidney cortex showing type of reaction. The arrow points to a monocyte containing acid-fast granules. Kinyon stain for acid-fast bacilli.
tubules as well as glomeruli. In this area could be seen several mutinucleated giant cells. No distinct tubercles could be observed in any of the areas of reaction studied. The reaction was suggestive of that caused by those acid-fast bacilli which are chromogenic and which experimentally have never been shown to cause the development of tubercles.
Stains of the surgical tissue sections have failed to reveal the presence of acid-fast bacilli, but in the kidney many scattered monocytes were found which contained acid-fast granules, apparently phagocytosed by these cells. An occasional monocyte was found to contain acid-fast particles having a slight resemblance to bacilli. However, no free acidfast or any other bacteria were found in the tissue sections.
CHROMOGENIC ACID-FAST BACILLUS INFECTION
391
In view of the bacteriological and pathological findings, the lesions observed in the kidney and the ureter are attributed to an infection of chromogenic acid-fast bacilli. Bacteriology. A clean specimen of urine was received in the laboratory November 24, 1933. The direct smear of the s~diment of this specimen was negative for acid-fast bacilli but a growth of chromogenic bacilli was observed on Petragagni's medium January 8, 1934 (after 58 days) . Cystoscopic specimens of urine from the bladder and right ureter were received December 12, 1933. The specimen from the right ureter was negative for acid-fast organisms on direct examinations, and the culture showed no growth after 90 days. The urine from the bladder was positive on direct examination. No culture was made. After the kidney was removed and the organ bisected, swabs were made of the grossly apparent lesions in the pelvis and parenchyma. These showed the presence of numerous acid-fast bacilli on direct examination of smears. After 43 days, cultures showed growth of chromogenic bacilli. Morphology: Fine, short, non-motile rods, occasionally showing granules, which cannot be distinguished from tubercle bacilli by examination of direct smears. Staining reaction: Acid-fast and Gram positive. Cultural characteristics: On the standard media for the cultivation of tubercle bacilli, such as Glycerin Agar, Lowenstein's, Petroff's and Petragagni's, the colonies are circular, moist, smooth and raised. They are non-spreading and of a deep orange color. Growth is slightly slower than that of tubercle bacilli and is best at 37°C. No growth could be obtained on plain agar or agar enriched with blood or ascitic fluid. No growth was obtained in plain broth. In glycerin broth and Souton's fluid growth was very slow and resulted in a slimy, creamy, orange sediment. Some flocculent deposits appeared along the sides of the tubes. Smears made of this sediment revealed pleomorphic, partially acid-fast rods, some of which occurred in chains. Agglutination reaction: Antiserum of a titer of 1: 1000 was obtained from rabbits injected with chromogenic acid-fast bacilli grown from the kidney of another case. The organisms isolated from the kidney of P. 0. gave a positive agglutination in a dilution of 1:400 when mixed with the rabbit serum. Normal rabbit serum gave negative results. Pat hogenicity : One cubic centimet er of a heavy saline suspension of the chromogenic acid-fast bacilli grown from t he kidney of P . 0 . was
392
GEORGE SEWELL, JOSEPH KASPER AND NORMA BROOM
injected inguinally into a 400 gram guinea pig. After four weeks the animal was killed and examined. The inguinal lymph nodes were found to be enlarged and soft. There was much thick, yellowish pus containing numerous acid-fast bacilli. These, when grown on Petragagni's medium were found to be of the chromogenic type. Histological studies of the lymph nodes showed that marked monocytic proliferation was taking place in the lymphoid tissue. There was also a monocytic infiltration of the adjacent tissues of the inguinal region. Several giant-cells were observed but no tubercles were seen to be developing. Bacterial stains revealed the presence of very many acidfast bacilli in the sections of the guinea pig tissues. DISCUSSION AND SUMMARY
The bacteriological and histological examinations of the kidney lesion of the case here reported indicates that chromogenic acid-fast liacilli may be pathogenic for man, and be capable of causing changes in the tissues which might be confused with those caused by the infection of tubercle bacilli. An error in diagnosis might result if such organisms are studied only by means of the direct smear, or if reliance is placed on animal inoculation for the diagnosis. Pinner (2) has demonstrated that inoculation of animals with chromogenic acid-fast bacilli will result in the development of lesions which may disappear by the end of the period usually required for the development of tubercles. Since the pathogenicity of some, at least, of the chromogenic acid-fast bacilli is established, caution should be exercised when reporting on the direct microscopic findings of cystoscopic or simple catheterized specimens of urine. Otherwise, an erroneous diagnosis of tuberculosis might be the result. The true nature of the chromogenic acid-fast bacilli has not yet been determined. Further work is now in progress to learn if they are related to tubercle bacilli. In a series of 130 sputum specimens from known tuberculous patients, out of 34 positive cultures, approximately 20 per cent were found to contain chromogenic organisms. Although the case here reported required nephrectomy for the complete relief of symptoms, it is probable that other similar cases showing less extensive involvement of the urinary tract might recover spontaneously. The animal experiments of Pinner and in our laboratory tend to support this view.
CHROMOGENIC ACID-FAST BACILLUS INFECTION
393
Future observations based upon careful bacteriological studies of the acid-fast bacilli found in urine and other body fluids may explain many of the spontaneous recoveries from supposed "tubercle bacillus" infections. REFERENCES BROOM, N. H .: Laboratory tests for tubercle bacilli by culture methods. Amer. Rev. Tuberc., 26: 378, 1932 . (2) PINNER, MAX : Atypical acid-fast microorganisms, III. Chromogenic acid-fast bacilli from human beings. Amer. Rev. Tuberc., 32: 424, 1935.
(1) NORTON,
J. F., TuoMAs, J. G. AND