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Concurrent meningococcal meningitis and Salmonella bacteremia
C O N C U R R E N T M E N I N G O C O C C A L M E N I N G I T I S AND SALMONELLA BACTEREMIA ERWlN R. NETER, M.D. BUFFALO, N . Y .
R I N G recent years our knowledge D Uman has increased considerably. It
of Salmonella infections in is obvious that an adequate understanding of the clinical and epidemiologic features of Salmonella infections can be attained only if the type of microorganism involved is determined. The genus Salmonella is comprised of more than t h i r t y antigenically different types, a fact which renders the bacteriologic diagnosis of these infections more difficult. Of the members belonging to group C, Salmonella cholerae suis, sometimes referred to as Salmonella suip,estifer, is particularly important. I t is worthy of note that infections with this organism may accompany or follow o t h e r diseases such as pneumonia, streptococcal pharyngitis, scarlet fever, rheumatic heart disease, epidemic meningitis , gonorrhea, or surgical procedures (Harvey1). I t seems likely that the simultaneous presence of the two diseases is not merely a coincidence. Concurrent infections raise additional diagnostic and therapeutic problems. Recently at this hospital a case of meningoeoccal meningitis and S. cholerue suis bacteremia was observed and studied from the clinical, bacteriologic, and immunologic point of view. The pertinent data is herewith presented : ;M;. A. G., a white female 7 years of age, was admitted to the Children's Hospital on April 16, 19r According to the past history, she had had measles and chicken pox. Yor approximately four weeks prior to admission she was suffering f r o m a cough. On the day preceding admission she complained of headache, dizziness, vomiting, and stiffness of the neck. She was a poorly nourished child. The import a n t findings were opisthotonos, marked rigidity of the neck, positive X e r n i g ' s sign, and petechiac on abdomen and elbows. Her temperature on admission was 100 ~ F. A spinal t a p was performed, and cloudy spinal fluid was obtained. The spinal fluid contained, approximately 5,000 leucocytes, polymorphonuclear cells predominating. T h e glucose content of the spinal fluid was reduced, and globulin was present. The microscopic examination revealed the presence of gram-negative diplocoeci. On culture, a pure growth of meningocoecus was obtained. A routine blood culture was taken April 17, 1943. A pure growth of a motile, g r a m - n e g a t i v e bacillus was obtMned. This organism grew well in infusion broth a n d on Endo agar, produced acid and gas from glucose, failed to f o r m acid from lactose and sucrose, and did no~ cause indele formation. Dr. E. Sellgmann kindly studied this strain arLd identified it as S. chalcrae stds. Blood cultures were a g a i n taken April 22 and 23. The former revealed five colonies of S. e~holerae suis per 1 ml. of blood, while the latter remained sterile. Several a t t e m p t s were made to determine whether or not the paratyphoid bacillus was present in the feces. Three stool cultures failed to reveal this organism. From the Children's Hospital and from the Department of Bacteriology and Immunology, University of t~uffalo School of 1Yledicine. P a r t of an investigation on Salmonella infections supported by the Statler Trust. 562
NETER:
MENINGOCOCCAL MENINGITIS AND SA[,MONELI, A BACTEREMIA
5{J3
The antibody response of the patient was ilivestigated. On April 23, 1943~ the patient ~s serum agglutinated S. cholevae suis in dilutions up to 1:1~600. The agglutinin titer ok April 29, had ~]eereased to 1:200. The patient was given 2 Gin. of sulfathiazole by mouth shortly a~ter admission and then 0.5 Gin. every four hours for seven days: On the fourth day after admission the temperature returned to normal and remained so until May 7, at which time the patient was discharged, cured of meningoeoecal meningitis and Salmonella bacteremia. DISCUSSION
The above-reported case represents an instance of the simultaneous occurrence of two different bacteriologically proved infections; namely, Salmonella bacteremia and meningococcal meningitis. It resembles the case reported b y Ravitch and Washington. 2 Their patient was admitted with meningoeoccal meningitis. The initial blood culture revealed a pure growth of meningococei. Subsecluent blood cultures, however, yielded S. su@estifer. It is interesting to note that, possibly dependent on gross contamination of the cerebrospinal fluid with blood in the course of lumbar punctures, suipestifer meningitis developed. I n our patient this complication did not occur. Furthermore, in the abovereported case the initial blood culture revealed S. cholerae suis. Of course, it is impossible to state whether or not meningococci were present in the blood at that time and escaped detection because of the presence of the profusely growing gram-negative bacillus. I t is noteworthy that there were no symptoms of, or signs pointing to, a complicating Salmonella bacteremia. The blood stream infection with S. chole,rae suis lasted for six days. It cannot be stated whether or not chemotherapy contributed to t h e disappearance of the p a r a t y p h o i d bacillus. It has been shown by several investigators in the past and confirmed by Ravitch a n d Washington t h a t suipestifer infections commonly are accompanied by mild granulocytopenia. Once localization of the infection occurs, leucocytosis usually develops. In the case reported above the leucocyte count on admission was 31,000; and rose to 55,000 on the following day. Subsequently, it decreased to 7,800 on April 21, to 3,700 on April 22, and to 2,300 on April 23. L a t e r the leucocyte count returned to normal and amounted t o 8,300 on April 29. The presence of specific agglutinins in the blood of the patient is additional proof of the pathogenic significance of this organism. As in the case of Raviteh and Washington, the antibody titer was rather h i g h . In the latter case the titer of agglutinins on the twenty-first day was 1:80, and it reached 1:2560 on the forty-second day. In the above reported case, on the other hand, the agglutinin titer reached 1:1600 on April 23, six days after the first positive blood culture was taken. Whether this represents the seventh day of the illness or whether the Salmonella infection was present during the preceding' period cannot be ascertained, although this seems to be quite unlikely. There can be little doubt that Salmonella infections occur more frequently than is generally realized. It is evident that the diagnosis of
564
THE JOURNAL OF PEDIATRICS
Salmonella bacteremia in the above-reported case was made only on the basis of a routine blood culture. It appears possible that the meningococcal infection contributed to the development of the Salmonella bacteremia, although it must be admitted that this is only a conjecture. Then it must be assumed that the patient was a carrier of the paratyphoid bacillus. As usual, examination of the feces failed to reveal the presence of this organism. The problem of Salmonella carriers deserves further attention. SUMMARY
A case of meningococcal meningitis and S, cholerae suis bacteremia is presented. Specific agglutinins in high titer against the paratyphoid bacillus developed in the course of the illness. Complete recovery followed the use of sulfathiazole. The relationship between the two infections is discussed. I wish to express my sincere appreeiatio~ for the identification of the culture to Dr. Erich Seligma~n~ Beth Israel tIospital, l~ew York, 1~. Y. REFERENCES
1. Harvey, A. M,: Arch. Int. Med. 59: 118, 1937. 2. ]~avitch, M. M., and Washington, 5. A. : J. A. M. A. 109: 1122, 1937.
R I N G recent years our knowledge D Uman has increased considerably. It
of Salmonella infections in is obvious that an adequate understanding of the clinical and epidemiologic features of Salmonella infections can be attained only if the type of microorganism involved is determined. The genus Salmonella is comprised of more than t h i r t y antigenically different types, a fact which renders the bacteriologic diagnosis of these infections more difficult. Of the members belonging to group C, Salmonella cholerae suis, sometimes referred to as Salmonella suip,estifer, is particularly important. I t is worthy of note that infections with this organism may accompany or follow o t h e r diseases such as pneumonia, streptococcal pharyngitis, scarlet fever, rheumatic heart disease, epidemic meningitis , gonorrhea, or surgical procedures (Harvey1). I t seems likely that the simultaneous presence of the two diseases is not merely a coincidence. Concurrent infections raise additional diagnostic and therapeutic problems. Recently at this hospital a case of meningoeoccal meningitis and S. cholerue suis bacteremia was observed and studied from the clinical, bacteriologic, and immunologic point of view. The pertinent data is herewith presented : ;M;. A. G., a white female 7 years of age, was admitted to the Children's Hospital on April 16, 19r According to the past history, she had had measles and chicken pox. Yor approximately four weeks prior to admission she was suffering f r o m a cough. On the day preceding admission she complained of headache, dizziness, vomiting, and stiffness of the neck. She was a poorly nourished child. The import a n t findings were opisthotonos, marked rigidity of the neck, positive X e r n i g ' s sign, and petechiac on abdomen and elbows. Her temperature on admission was 100 ~ F. A spinal t a p was performed, and cloudy spinal fluid was obtained. The spinal fluid contained, approximately 5,000 leucocytes, polymorphonuclear cells predominating. T h e glucose content of the spinal fluid was reduced, and globulin was present. The microscopic examination revealed the presence of gram-negative diplocoeci. On culture, a pure growth of meningocoecus was obtained. A routine blood culture was taken April 17, 1943. A pure growth of a motile, g r a m - n e g a t i v e bacillus was obtMned. This organism grew well in infusion broth a n d on Endo agar, produced acid and gas from glucose, failed to f o r m acid from lactose and sucrose, and did no~ cause indele formation. Dr. E. Sellgmann kindly studied this strain arLd identified it as S. chalcrae stds. Blood cultures were a g a i n taken April 22 and 23. The former revealed five colonies of S. e~holerae suis per 1 ml. of blood, while the latter remained sterile. Several a t t e m p t s were made to determine whether or not the paratyphoid bacillus was present in the feces. Three stool cultures failed to reveal this organism. From the Children's Hospital and from the Department of Bacteriology and Immunology, University of t~uffalo School of 1Yledicine. P a r t of an investigation on Salmonella infections supported by the Statler Trust. 562
NETER:
MENINGOCOCCAL MENINGITIS AND SA[,MONELI, A BACTEREMIA
5{J3
The antibody response of the patient was ilivestigated. On April 23, 1943~ the patient ~s serum agglutinated S. cholevae suis in dilutions up to 1:1~600. The agglutinin titer ok April 29, had ~]eereased to 1:200. The patient was given 2 Gin. of sulfathiazole by mouth shortly a~ter admission and then 0.5 Gin. every four hours for seven days: On the fourth day after admission the temperature returned to normal and remained so until May 7, at which time the patient was discharged, cured of meningoeoecal meningitis and Salmonella bacteremia. DISCUSSION
The above-reported case represents an instance of the simultaneous occurrence of two different bacteriologically proved infections; namely, Salmonella bacteremia and meningococcal meningitis. It resembles the case reported b y Ravitch and Washington. 2 Their patient was admitted with meningoeoccal meningitis. The initial blood culture revealed a pure growth of meningococei. Subsecluent blood cultures, however, yielded S. su@estifer. It is interesting to note that, possibly dependent on gross contamination of the cerebrospinal fluid with blood in the course of lumbar punctures, suipestifer meningitis developed. I n our patient this complication did not occur. Furthermore, in the abovereported case the initial blood culture revealed S. cholerae suis. Of course, it is impossible to state whether or not meningococci were present in the blood at that time and escaped detection because of the presence of the profusely growing gram-negative bacillus. I t is noteworthy that there were no symptoms of, or signs pointing to, a complicating Salmonella bacteremia. The blood stream infection with S. chole,rae suis lasted for six days. It cannot be stated whether or not chemotherapy contributed to t h e disappearance of the p a r a t y p h o i d bacillus. It has been shown by several investigators in the past and confirmed by Ravitch a n d Washington t h a t suipestifer infections commonly are accompanied by mild granulocytopenia. Once localization of the infection occurs, leucocytosis usually develops. In the case reported above the leucocyte count on admission was 31,000; and rose to 55,000 on the following day. Subsequently, it decreased to 7,800 on April 21, to 3,700 on April 22, and to 2,300 on April 23. L a t e r the leucocyte count returned to normal and amounted t o 8,300 on April 29. The presence of specific agglutinins in the blood of the patient is additional proof of the pathogenic significance of this organism. As in the case of Raviteh and Washington, the antibody titer was rather h i g h . In the latter case the titer of agglutinins on the twenty-first day was 1:80, and it reached 1:2560 on the forty-second day. In the above reported case, on the other hand, the agglutinin titer reached 1:1600 on April 23, six days after the first positive blood culture was taken. Whether this represents the seventh day of the illness or whether the Salmonella infection was present during the preceding' period cannot be ascertained, although this seems to be quite unlikely. There can be little doubt that Salmonella infections occur more frequently than is generally realized. It is evident that the diagnosis of
564
THE JOURNAL OF PEDIATRICS
Salmonella bacteremia in the above-reported case was made only on the basis of a routine blood culture. It appears possible that the meningococcal infection contributed to the development of the Salmonella bacteremia, although it must be admitted that this is only a conjecture. Then it must be assumed that the patient was a carrier of the paratyphoid bacillus. As usual, examination of the feces failed to reveal the presence of this organism. The problem of Salmonella carriers deserves further attention. SUMMARY
A case of meningococcal meningitis and S, cholerae suis bacteremia is presented. Specific agglutinins in high titer against the paratyphoid bacillus developed in the course of the illness. Complete recovery followed the use of sulfathiazole. The relationship between the two infections is discussed. I wish to express my sincere appreeiatio~ for the identification of the culture to Dr. Erich Seligma~n~ Beth Israel tIospital, l~ew York, 1~. Y. REFERENCES
1. Harvey, A. M,: Arch. Int. Med. 59: 118, 1937. 2. ]~avitch, M. M., and Washington, 5. A. : J. A. M. A. 109: 1122, 1937.