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Haemophilus influenzae and H. parainfluenzae as urinary pathogens
Journal of Infection (I99o) zo, I43-I45
CASE REPORTS
Haemophilus
influenzae a n d H. parainfluenzae a s u r i n a r y pathogens
M. G. M o r g a n a n d J. M. T. H a m i l t o n - M i l l e r
* Department of Medical Microbiology, The Royal Free Hospital and School of Medicine, Pond Street, London NW3 2QG Accepted for publication 6 August I989 Summary Two cases are described, one of Haemophilus influenzae urinary infection in a female with no past history of urinary tract infection (UTI) and the other of Haemophilus parainfluenzae infection in a male with a renal calculus. Haemophilus spp. are rare urinary pathogens and these cases are even more unusual because H. influenzae U T I has almost always previously been found in either children or adult males, while H. parainfluenzae U T I has only been reported once before. Introduction
Haemophilus spp. colonise the u p p e r respiratory tract whence they m a y spread to cause infections o f s u r r o u n d i n g tissues such as the lower respiratory tract, meninges, epiglottis and middle ear. O n the other h a n d infections of the urinary tract of adults by m e m b e r s o f this genus are very rare: H. influenzae has been implicated in urinary infections in males I and there is a single report of H. parainfluenzae infecting the urine of a woman. 2 W e report here two m o r e c a s e s - one due to H. influenzae (which was at first mistakenly identified as Pasteurella pneumotropica, having been processed b y the A P I system), and the other of H. parainfluenzae in a male with a renal calculus.
Case reports Case I An 89-year-old female visited her General Practitioner complaining of f r e q u e n c y and dysuria. She had a history of heart disease b u t none of previous U T I and hence she had not been investigated for urinary tract abnormality in the past. T h r e e m i d - s t r e a m specimens of urine ( M S U ) taken over the course o f 2 weeks s h o w e d no bacterial g r o w t h although there was pyuria in two of the specimens. A fourth M S U s h o w e d gross pyuria ( > 4o0 white c e l l / m m ~) and a heavy g r o w t h of bacteria on the plate used for sensitivity t e s t i n g Diagnostic Sensitivity T e s t agar ( D S T ) containing 5 % lysed and 5 % whole horse blood. T h e p r i m a r y isolation m e d i u m cystine electrolyte deficient ( C L E D ) s h o w e d only very sparse growth. T h e organism isolated was identified b y its A P I 2oE profile (IO54OO4) as 'Pasteurella spp.' and by the A P I 2 O N E system (profile 3200004) as P. pneumotropica (86 % certainty). T h e strain was oi63-4453/9o/o2oi43 +03 $02.00/0
© I99o The British Society for the Study of Infection
I44
M.G. MORGAN
AND J.M.T.
HAMILTON-MILLER
sensitive to ampicillin, Augmentin, trimethoprim, nitrofurantoin and cephalexin, but resistant to nalidixic acid. In view of the unusual nature of the infecting organism another M S U was obtained: this contained > iooo white cells/mm 3, and again there was heavy growth on D S T but little or none on C L E D . T h e API 2oE profile (oo5ooo4) was on this occasion unhelpful, but the profile from the z O N E system (72000o4) computed as P. pneumotropica with a certainty of 98"2 %. However, the Computer Reference Laboratory and the National Collection of T y p e Cultures at the Public Health Laboratory Service (PHLS) Colindale unequivocally identified the organism as Haemophilus influenzae biotype II (unencapsulated). T h e patient was treated with trimethoprim zoo mg Iz-hourly for 7 days; her symptoms and pyuria disappeared, and three subsequent M S U ' s did not yield any bacterial growth even when plated on to chocolate agar. Case z
A 69-year-old male had a large calculus in the pelvis of the right kidney. Following a ' debulking' operation the urine grew small numbers of coagulasenegative staphylococci only. Five weeks later, just before the patient was sent for lithotripsy, an M S U showed > 4oo white cells and zoo red cells/mm 3 but yielded no bacterial growth. T w o weeks after lithotripsy (which was only partly successful) the patient complained of frequency and dysuria. An M S U showed > IOOO white cells and Ioo red cells/mm 3, and lO5 H. parainfluenzae per ml were cultured. Growth on C L E D was in the form of tiny colonies that were very difficult to see, but the strain grew well on D S T with added blood. It was resistant to ampicillin and Augmentin, although it did not produce fl-lactamase and sensitive to trimethoprim, tetracycline, cefotaxime, cephalexin, nitrofurantoin and nalidixic acid. When the patient returned for follow-up 4 months later, an M S U showed ioo white cells/mm 3 but gave no growth on chocolate agar.
Discussion
T h e great majority of previous cases of adults with urinary infection due to H. influenzae has been in males with an abnormality of the urinary tract: only two of the I6 cases reported in four previous publications over the past 5o years have been in females. 1'3-5 It is a curious coincidence that the API system identified the causal organism in Case I as P. pneumotropica, as while Pasteurella spp. are very u n c o m m o n but well-documented urinary pathogens (P. multocida having been reported on nine occasions, and P. haemolytica once6), P. pneumotropica has not previously been found as a urinary pathogen. While the API system can be used for biotyping H. influenzae, 7 it is not suitable for identifying this genus, as Haemophilus is not part of the data base (personal communication). It is notable that this isolate was resistant to nalidixic acid. Haemophilus influenzae isolates from sites other than the urinary tract are not usually tested against nalidixic acid and hence the paucity of data regarding its susceptibility to this drug (Sterling Research Laboratories, personal communication).
H a e m o p h i l u s spp. as urinary pathogens
I45
N e w s o m et al., 8 h o w e v e r , t e s t e d IO strains o f H . influenzae a n d f o u n d t h e M I C 9° to b e less t h a n 0"06 m g / 1 a n d n o n e h a d an M I C o f o v e r 8 mg/1. Case 2 a p p e a r s to b e o n l y t h e s e c o n d p u b l i s h e d case o f H . parainfluenzae c a u s i n g a u r i n a r y i n f e c t i o n . 2 I t is o f i n t e r e s t t h a t t h e o r g a n i s m was isolated f o l l o w i n g t h e d i s r u p t i o n o f a renal calculus, as H . parainfluenzae is a p o w e r f u l urease producer, and the connection between urease production and infection stones is well e s t a b l i s h e d 2 F i n a l l y , it s h o u l d b e p o i n t e d o u t t h a t in n e i t h e r case was g o o d g r o w t h o b t a i n e d o n t h e p r i m a r y isolation m e d i u m ( C L E D ) , a n d t h e i n f e c t i n g o r g a n i s m s w o u l d h a v e e s c a p e d d e t e c t i o n h a d n o t the u r i n e s also b e e n p l a t e d for ' d i r e c t s e n s i t i v i t y ' t e s t i n g o n D S T c o n t a i n i n g lysed b l o o d , w h i c h is o u r p r a c t i c e for s p e c i m e n s s h o w i n g p y u r i a . Also essential was t h e alertness o f t h e l a b o r a t o r y scientist r e a d i n g t h e plates. (We are grateful to M r R. Morgan, D r L. T. N e w m a n and D r S. R. Luksenberg for permission to report on their patients, and to the Public Health Laboratories, Colindale for identifying organisms.)
References
I. Stegmayr B, Malmborg AS. Urinary tract infection caused by Haemophilus influenzae. Seand ff Urol Nephrol 1988; 22: 75-772. Blaylock BL, Baber S. Urinary tract infection caused by Haemophilus parainfluenzae. Am J Clin Path I98O; 73: 285-287. 3. Albright F, Dienes L, Sulkowitch HW. Pyelonephritis with nephrocalcinosis. J A M A 1938; 1IO: 357-36o. 4. Chen WN, Richards R, Carpenter R, Ramachander N. Haemophilus influenzae as an agent of urinary tract infection. West Indian Med J I976; 25: I58-I6I. 5. Gabre-Kidan T, Lipsky BA, Plorde JJ. Haemophilus influenzae as a cause of urinary tract infection in men. Arch Intern Med I984; 144: I623-I627. 6. Mann BA, Quenzer RW. Pasteurella multocida urinary tract infection. West J Med 1987; I47"
2OO--2OI.
7. Kilian M. Haemophilus. In: Lennette EH, Balows A, Hausler WJ, Shadomy HJ, Eds. Manual of clinical microbiology 4th ed. Washington: American Society of Microbiology, 1985 : 387-393. 8. Newsom SWB, Mathews J, Amphlett M, Warren RE. Norfloxacin and the antibacterial y pyridone fl carboxylic acids. J Antimicrob Chemother I98e; IO: 25-3o. 9. Rosenstein IJM, Hamilton-Miller JMT. Inhibitors of urease as chemotherapeutic agents. CRC Crit Revs Microbiol 1984; IX " I--I2.
CASE REPORTS
Haemophilus
influenzae a n d H. parainfluenzae a s u r i n a r y pathogens
M. G. M o r g a n a n d J. M. T. H a m i l t o n - M i l l e r
* Department of Medical Microbiology, The Royal Free Hospital and School of Medicine, Pond Street, London NW3 2QG Accepted for publication 6 August I989 Summary Two cases are described, one of Haemophilus influenzae urinary infection in a female with no past history of urinary tract infection (UTI) and the other of Haemophilus parainfluenzae infection in a male with a renal calculus. Haemophilus spp. are rare urinary pathogens and these cases are even more unusual because H. influenzae U T I has almost always previously been found in either children or adult males, while H. parainfluenzae U T I has only been reported once before. Introduction
Haemophilus spp. colonise the u p p e r respiratory tract whence they m a y spread to cause infections o f s u r r o u n d i n g tissues such as the lower respiratory tract, meninges, epiglottis and middle ear. O n the other h a n d infections of the urinary tract of adults by m e m b e r s o f this genus are very rare: H. influenzae has been implicated in urinary infections in males I and there is a single report of H. parainfluenzae infecting the urine of a woman. 2 W e report here two m o r e c a s e s - one due to H. influenzae (which was at first mistakenly identified as Pasteurella pneumotropica, having been processed b y the A P I system), and the other of H. parainfluenzae in a male with a renal calculus.
Case reports Case I An 89-year-old female visited her General Practitioner complaining of f r e q u e n c y and dysuria. She had a history of heart disease b u t none of previous U T I and hence she had not been investigated for urinary tract abnormality in the past. T h r e e m i d - s t r e a m specimens of urine ( M S U ) taken over the course o f 2 weeks s h o w e d no bacterial g r o w t h although there was pyuria in two of the specimens. A fourth M S U s h o w e d gross pyuria ( > 4o0 white c e l l / m m ~) and a heavy g r o w t h of bacteria on the plate used for sensitivity t e s t i n g Diagnostic Sensitivity T e s t agar ( D S T ) containing 5 % lysed and 5 % whole horse blood. T h e p r i m a r y isolation m e d i u m cystine electrolyte deficient ( C L E D ) s h o w e d only very sparse growth. T h e organism isolated was identified b y its A P I 2oE profile (IO54OO4) as 'Pasteurella spp.' and by the A P I 2 O N E system (profile 3200004) as P. pneumotropica (86 % certainty). T h e strain was oi63-4453/9o/o2oi43 +03 $02.00/0
© I99o The British Society for the Study of Infection
I44
M.G. MORGAN
AND J.M.T.
HAMILTON-MILLER
sensitive to ampicillin, Augmentin, trimethoprim, nitrofurantoin and cephalexin, but resistant to nalidixic acid. In view of the unusual nature of the infecting organism another M S U was obtained: this contained > iooo white cells/mm 3, and again there was heavy growth on D S T but little or none on C L E D . T h e API 2oE profile (oo5ooo4) was on this occasion unhelpful, but the profile from the z O N E system (72000o4) computed as P. pneumotropica with a certainty of 98"2 %. However, the Computer Reference Laboratory and the National Collection of T y p e Cultures at the Public Health Laboratory Service (PHLS) Colindale unequivocally identified the organism as Haemophilus influenzae biotype II (unencapsulated). T h e patient was treated with trimethoprim zoo mg Iz-hourly for 7 days; her symptoms and pyuria disappeared, and three subsequent M S U ' s did not yield any bacterial growth even when plated on to chocolate agar. Case z
A 69-year-old male had a large calculus in the pelvis of the right kidney. Following a ' debulking' operation the urine grew small numbers of coagulasenegative staphylococci only. Five weeks later, just before the patient was sent for lithotripsy, an M S U showed > 4oo white cells and zoo red cells/mm 3 but yielded no bacterial growth. T w o weeks after lithotripsy (which was only partly successful) the patient complained of frequency and dysuria. An M S U showed > IOOO white cells and Ioo red cells/mm 3, and lO5 H. parainfluenzae per ml were cultured. Growth on C L E D was in the form of tiny colonies that were very difficult to see, but the strain grew well on D S T with added blood. It was resistant to ampicillin and Augmentin, although it did not produce fl-lactamase and sensitive to trimethoprim, tetracycline, cefotaxime, cephalexin, nitrofurantoin and nalidixic acid. When the patient returned for follow-up 4 months later, an M S U showed ioo white cells/mm 3 but gave no growth on chocolate agar.
Discussion
T h e great majority of previous cases of adults with urinary infection due to H. influenzae has been in males with an abnormality of the urinary tract: only two of the I6 cases reported in four previous publications over the past 5o years have been in females. 1'3-5 It is a curious coincidence that the API system identified the causal organism in Case I as P. pneumotropica, as while Pasteurella spp. are very u n c o m m o n but well-documented urinary pathogens (P. multocida having been reported on nine occasions, and P. haemolytica once6), P. pneumotropica has not previously been found as a urinary pathogen. While the API system can be used for biotyping H. influenzae, 7 it is not suitable for identifying this genus, as Haemophilus is not part of the data base (personal communication). It is notable that this isolate was resistant to nalidixic acid. Haemophilus influenzae isolates from sites other than the urinary tract are not usually tested against nalidixic acid and hence the paucity of data regarding its susceptibility to this drug (Sterling Research Laboratories, personal communication).
H a e m o p h i l u s spp. as urinary pathogens
I45
N e w s o m et al., 8 h o w e v e r , t e s t e d IO strains o f H . influenzae a n d f o u n d t h e M I C 9° to b e less t h a n 0"06 m g / 1 a n d n o n e h a d an M I C o f o v e r 8 mg/1. Case 2 a p p e a r s to b e o n l y t h e s e c o n d p u b l i s h e d case o f H . parainfluenzae c a u s i n g a u r i n a r y i n f e c t i o n . 2 I t is o f i n t e r e s t t h a t t h e o r g a n i s m was isolated f o l l o w i n g t h e d i s r u p t i o n o f a renal calculus, as H . parainfluenzae is a p o w e r f u l urease producer, and the connection between urease production and infection stones is well e s t a b l i s h e d 2 F i n a l l y , it s h o u l d b e p o i n t e d o u t t h a t in n e i t h e r case was g o o d g r o w t h o b t a i n e d o n t h e p r i m a r y isolation m e d i u m ( C L E D ) , a n d t h e i n f e c t i n g o r g a n i s m s w o u l d h a v e e s c a p e d d e t e c t i o n h a d n o t the u r i n e s also b e e n p l a t e d for ' d i r e c t s e n s i t i v i t y ' t e s t i n g o n D S T c o n t a i n i n g lysed b l o o d , w h i c h is o u r p r a c t i c e for s p e c i m e n s s h o w i n g p y u r i a . Also essential was t h e alertness o f t h e l a b o r a t o r y scientist r e a d i n g t h e plates. (We are grateful to M r R. Morgan, D r L. T. N e w m a n and D r S. R. Luksenberg for permission to report on their patients, and to the Public Health Laboratories, Colindale for identifying organisms.)
References
I. Stegmayr B, Malmborg AS. Urinary tract infection caused by Haemophilus influenzae. Seand ff Urol Nephrol 1988; 22: 75-772. Blaylock BL, Baber S. Urinary tract infection caused by Haemophilus parainfluenzae. Am J Clin Path I98O; 73: 285-287. 3. Albright F, Dienes L, Sulkowitch HW. Pyelonephritis with nephrocalcinosis. J A M A 1938; 1IO: 357-36o. 4. Chen WN, Richards R, Carpenter R, Ramachander N. Haemophilus influenzae as an agent of urinary tract infection. West Indian Med J I976; 25: I58-I6I. 5. Gabre-Kidan T, Lipsky BA, Plorde JJ. Haemophilus influenzae as a cause of urinary tract infection in men. Arch Intern Med I984; 144: I623-I627. 6. Mann BA, Quenzer RW. Pasteurella multocida urinary tract infection. West J Med 1987; I47"
2OO--2OI.
7. Kilian M. Haemophilus. In: Lennette EH, Balows A, Hausler WJ, Shadomy HJ, Eds. Manual of clinical microbiology 4th ed. Washington: American Society of Microbiology, 1985 : 387-393. 8. Newsom SWB, Mathews J, Amphlett M, Warren RE. Norfloxacin and the antibacterial y pyridone fl carboxylic acids. J Antimicrob Chemother I98e; IO: 25-3o. 9. Rosenstein IJM, Hamilton-Miller JMT. Inhibitors of urease as chemotherapeutic agents. CRC Crit Revs Microbiol 1984; IX " I--I2.