- Email: [email protected]
Family infection with methicillin-resistant Staphylococcus aureus
The onset of most forms of epilepsy is age-determined (see the classification system proposed by the International League Against Epilepsy) and the age of onset has a close bearing on the outcome.3 In addition, the duration of the disease (onset to outcome) is related to the severity of seizures.4 None of these reports consider the influence of the age of onset on prognosis, and we must await future findings. Although Cockerell et al find that seizure classification has little overall effect on remission rates, their classification scheme-simple comparisons between generalised and partial onset-is too imprecise for it to be of much use in clinical practice, since outcomes vary according to the particular form of epilepsy. We admire the efforts that have been made, but feel that further methodological revision would make the results of such analyses much more useful. *Kazumasa Sudo, Kunio Tashiro Department of Neurology, Hokkaido University School of Medicine, Hokkaido 060, Japan
outbreak. Community-acquired infectious endocarditis due to MRSA has been described in the USA, particularly among intravenous drugs users,but is rare in the UK. The original source of this MRSA is unclear. Either the mother or son may have acquired the organism in hospital, but dissemination within families is thought to be a rare event.’ We do not know the extent of MRSA colonisation in the community, although current UK guidelines for control of MRSA in hospitals suggest there is minimum risk to healthy contacts of MRSA carriers outside hospital.’ We suggest that serious MRSA infection may occur outside hospitals following acquisition in the community, and that patients using injectable drugs for recreational purposes may be at increased risk. We thank the PHLS Staphylococcus Reference Unit, Colindale, London, for phage-typing these isolates. We also thank Dr M Krishnamurthy, Dr P Kumar and Dr L Abrams for permission to report details of their patients, and Dr D S Tunstall-Pedoe and Dr L Neville for their advice.
*A J H
Simpson,
J R Anderson, G A Farfan
*Departments of Medical Microbiology and Gastroenterology, St Bartholomew’s Hospital Medical College, London EC1A 7BE, UK 1
2
3
4
Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet 1990; 336: 1267-71. Hart YM, Sander JW, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: recurrence after a first seizure. Lancet 1990; 336: 1271-74. Commission on Classification and Terminology of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989; 30: 389-99. Lammers MW, Wijsman DJ, Hekster YA, et al. Epilepsy treatment in the Netherlands: comparison of matched groups of two medical centres. Acta Neurol Scand 1994; 89: 415-20.
1 2
1990; 161: 894-902. 3
SiR—We report an outbreak within a family of serious infection with methicillin-resistant Staphylococcus aureus (MRSA), including two cases of endocarditis related to
injectable drugs use. Case I-An 8-year-old boy presented to his general practitioner seven months after a left grommet insertion. An swab grew group A p-haemolytic streptococcus and MRSA. The MRSA was also resistant to erythromycin. Phage typing showed this to resemble the epidemic MRSA (EMRSA) strain 15.’ Symptoms resolved after a course of ear
erythromycin. Case 2-8 months later, the 33-year-old mother of case 1 presented with pain in her right thigh. She had a history of injectable drug use, and had been treated with ampicillin and flucloxacillin for cellulitis during hospital admission 2 years previously. Blood cultures grew MRSA, which appeared indistinguishable from her son’s isolate. She was treated with vancomycin with oral fusidic acid for 6 weeks. An echocardiogram showed vegetations on the aortic and mitral valves. Her subsequent progress was complicated by septic arthritis of her hip and navicular osteomyelitis due to
MRSA, and later
a
central-line-associated Proteus mirabilis
septicaemia. Case 3-4 months later, the 36-year-old husband of case presented with rigors. He was injecting drugs intramuscularly. Blood cultures grew MRSA, with the same antibiogram and phage-typing pattern as the isolates from his wife and son. He was treated with vancomycin and oral fusidic acid because of clinical suspicion of endocarditis, and a repeat echocardiogram at 4 weeks showed a vegetation on the mitral valve. He received 6 weeks’ therapy in total. He remains well 6 months later. To our knowledge this is the first description of a family 2
914
Frenay HM, Vandenbroucke-Grauls CM, Molkenboer MJ, Verhoef J. Long-term carriage, and transmission of methicillin-resistant Staphylococcus aureus after discharge from hospital. J Hosp Infect 1992; 22: 207-15.
4 5
Family infection with methicillin-resistant Staphylococcus aureus
Anon. Methicillin-resistant Staphylococcus aureus (MRSA). Commun Dis Rep 1992; 2: 33. Haverkos HW, Lange WR. Serious infections other than human immunodeficiency virus among intravenous drug abusers. J Infect Dis
Rosenberg J. Methicillin-resistant Staphylococcus aureus (MRSA) in the community: who’s watching? Lancet 1995; 346: 132-33. Combined Working Party of the Hospital Infection Society and British Society for Antimicrobial Chemotherapy. Revised guidelines for the control of epidemic methicillin-resistant Staphylococcus aureus. J Hosp Infect 1990; 16: 351-77.
Are varicella zoster and herpes simplex sentinel lesions for cytomegalovirus in renal
transplant recipients? SiR-Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in transplant recipients and usually occurs 4-12 weeks after transplantation. CMV retinitis occurs later and may lead to blindness. Unfortunately, loss of vision is one of the first manifestations of CMV retinitis. If a sentinel lesion could be identified, CMV retinitis and blindness could be prevented. We observed varicella zoster virus (VZV) infections in two renal transplant recipients at 2 and 30 months after transplantation, respectively, which responded poorly to oral acyclovir. CMV retinitis was noted at 4 and 6 months, respectively, after the onset of VZV. Serology was positive for CMV despite the absence of other signs or symptoms of CMV. Both patients were treated with intravenous ganciclovir with prompt resolution of their VZV lesions and more gradual resolution of CMV retinitis. We retrospectively reviewed our renal-transplant database for documented VZV or herpes simplex virus (HSV) infection and associated CMV between January 1986 and June 1993. 36 patients had 39 episodes of VZV or HSV. 41% (16/39) were associated with contemporaneous CMV infection. We then prospectively monitored for CMV infection in all patients with VZV or HSV after transplantation. 22 patients had 30 episodes of VZV or HSV. 59% (13/22) had VZV and 77% (17/22) had HSV. CMV was documented in 87% (26/30) of the episodes. One patient, whose CMV serology at the time of transplantation was donor negative and
recipient negative,
never
developed
CMV. CMV culture
or
outbreak. Community-acquired infectious endocarditis due to MRSA has been described in the USA, particularly among intravenous drugs users,but is rare in the UK. The original source of this MRSA is unclear. Either the mother or son may have acquired the organism in hospital, but dissemination within families is thought to be a rare event.’ We do not know the extent of MRSA colonisation in the community, although current UK guidelines for control of MRSA in hospitals suggest there is minimum risk to healthy contacts of MRSA carriers outside hospital.’ We suggest that serious MRSA infection may occur outside hospitals following acquisition in the community, and that patients using injectable drugs for recreational purposes may be at increased risk. We thank the PHLS Staphylococcus Reference Unit, Colindale, London, for phage-typing these isolates. We also thank Dr M Krishnamurthy, Dr P Kumar and Dr L Abrams for permission to report details of their patients, and Dr D S Tunstall-Pedoe and Dr L Neville for their advice.
*A J H
Simpson,
J R Anderson, G A Farfan
*Departments of Medical Microbiology and Gastroenterology, St Bartholomew’s Hospital Medical College, London EC1A 7BE, UK 1
2
3
4
Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet 1990; 336: 1267-71. Hart YM, Sander JW, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: recurrence after a first seizure. Lancet 1990; 336: 1271-74. Commission on Classification and Terminology of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia 1989; 30: 389-99. Lammers MW, Wijsman DJ, Hekster YA, et al. Epilepsy treatment in the Netherlands: comparison of matched groups of two medical centres. Acta Neurol Scand 1994; 89: 415-20.
1 2
1990; 161: 894-902. 3
SiR—We report an outbreak within a family of serious infection with methicillin-resistant Staphylococcus aureus (MRSA), including two cases of endocarditis related to
injectable drugs use. Case I-An 8-year-old boy presented to his general practitioner seven months after a left grommet insertion. An swab grew group A p-haemolytic streptococcus and MRSA. The MRSA was also resistant to erythromycin. Phage typing showed this to resemble the epidemic MRSA (EMRSA) strain 15.’ Symptoms resolved after a course of ear
erythromycin. Case 2-8 months later, the 33-year-old mother of case 1 presented with pain in her right thigh. She had a history of injectable drug use, and had been treated with ampicillin and flucloxacillin for cellulitis during hospital admission 2 years previously. Blood cultures grew MRSA, which appeared indistinguishable from her son’s isolate. She was treated with vancomycin with oral fusidic acid for 6 weeks. An echocardiogram showed vegetations on the aortic and mitral valves. Her subsequent progress was complicated by septic arthritis of her hip and navicular osteomyelitis due to
MRSA, and later
a
central-line-associated Proteus mirabilis
septicaemia. Case 3-4 months later, the 36-year-old husband of case presented with rigors. He was injecting drugs intramuscularly. Blood cultures grew MRSA, with the same antibiogram and phage-typing pattern as the isolates from his wife and son. He was treated with vancomycin and oral fusidic acid because of clinical suspicion of endocarditis, and a repeat echocardiogram at 4 weeks showed a vegetation on the mitral valve. He received 6 weeks’ therapy in total. He remains well 6 months later. To our knowledge this is the first description of a family 2
914
Frenay HM, Vandenbroucke-Grauls CM, Molkenboer MJ, Verhoef J. Long-term carriage, and transmission of methicillin-resistant Staphylococcus aureus after discharge from hospital. J Hosp Infect 1992; 22: 207-15.
4 5
Family infection with methicillin-resistant Staphylococcus aureus
Anon. Methicillin-resistant Staphylococcus aureus (MRSA). Commun Dis Rep 1992; 2: 33. Haverkos HW, Lange WR. Serious infections other than human immunodeficiency virus among intravenous drug abusers. J Infect Dis
Rosenberg J. Methicillin-resistant Staphylococcus aureus (MRSA) in the community: who’s watching? Lancet 1995; 346: 132-33. Combined Working Party of the Hospital Infection Society and British Society for Antimicrobial Chemotherapy. Revised guidelines for the control of epidemic methicillin-resistant Staphylococcus aureus. J Hosp Infect 1990; 16: 351-77.
Are varicella zoster and herpes simplex sentinel lesions for cytomegalovirus in renal
transplant recipients? SiR-Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in transplant recipients and usually occurs 4-12 weeks after transplantation. CMV retinitis occurs later and may lead to blindness. Unfortunately, loss of vision is one of the first manifestations of CMV retinitis. If a sentinel lesion could be identified, CMV retinitis and blindness could be prevented. We observed varicella zoster virus (VZV) infections in two renal transplant recipients at 2 and 30 months after transplantation, respectively, which responded poorly to oral acyclovir. CMV retinitis was noted at 4 and 6 months, respectively, after the onset of VZV. Serology was positive for CMV despite the absence of other signs or symptoms of CMV. Both patients were treated with intravenous ganciclovir with prompt resolution of their VZV lesions and more gradual resolution of CMV retinitis. We retrospectively reviewed our renal-transplant database for documented VZV or herpes simplex virus (HSV) infection and associated CMV between January 1986 and June 1993. 36 patients had 39 episodes of VZV or HSV. 41% (16/39) were associated with contemporaneous CMV infection. We then prospectively monitored for CMV infection in all patients with VZV or HSV after transplantation. 22 patients had 30 episodes of VZV or HSV. 59% (13/22) had VZV and 77% (17/22) had HSV. CMV was documented in 87% (26/30) of the episodes. One patient, whose CMV serology at the time of transplantation was donor negative and
recipient negative,
never
developed
CMV. CMV culture
or