- Email: [email protected]
Helicobacter cinaedi bacteremia in an asymptomatic patient with human immunodeficiency virus infection
oin and paraphernalia. J. Infect. Dis. 129:327-329. 11. Lemer, PJ. 1990.Nocardiaspecies,p.
Heficobacter cinaedi Bacteremia in an Asymptomatic Patient with Human Immunodeficiency Virus Infection James M. Hutchinson, M.D. Joseph D,C. Yao, M.D. Deirdre L. Church, M.D. Department of Microbiology and Infectious Diseases University of Calgary; Southern Alberta Clinic Foothills Hospital; and Clinical Microbiology Laboratory Alberta Children's Hospital Calgary, Alberta, Canada
Campylobacter species are known to cause enteric disease and systemic illness with bacteremia in individuals infected with the human immunodeficiency virus (H1V) (1). Helicobacter cinaedi, formerly Campylobacter cinaedi (2), is one of the recently recognized Campylobacter-like organisms associated with symptomatic bacteremia (3,4,5), proctocolitis (6,7), and asymptomatic rectal carriage (8) in homosexual men with or without HIV infection. However, the clinical manifestations and spectrum of illness caused by this organism remain to be defined. We report a case of prolonged asymptomatic bacteremia due to H. cinaedi in a HIV-seropositive man who recently presented to our hospital. A 30-yr-old, exclusively heterosexual, HIV-seropositive man, with a past history of intravenous drug abuse, presented to the emergency department of our hospital after sustaining a stress injury to his left knee 1 d earlier. At 5 mo prior to presentation he had undergone, uneventfully, a distal femoral varus osteotomy with placement of a metal plate and screws at another hospital, for osteochondritis dissecans of the left knee joint. His CD4 cell count was 744/m 3 1 mo earlier. He was afebrile, and physical examination showed a swollen, warm, and tender knee joint, with markedly limited range of motion. There were no crepitus, erythema, or efClinical MicrobiologyNewsletter17:19,1995
1926-1932. In G.L. Mandell, R.G. Douglas, and J.E. Bennett (eds.), Principles and practice of infectious diseases,
fusion present. The peripheral blood leukocyte count (5.9 × 109/1) and erythrocyte sedimentation rate (25 mm/h) were normal. Roentgenograms of the left joint revealed fracture of the metal plate screws and nonunion of the bone from the previous osteotomy. To rule out the possibility of septic arthritis or osteomyelitis, a set of blood cultures (BACTF~ NR6A and NR7A vials; Becton Dickinson Diagnostic, Mississauga, Ontario, Canada) was obtained. The patient was a dairy farmer, with exposures to cattle and household cats, but he denied any consumption of unpasteurized dairy products or well water. There was no history of unusual dietary habits, travel within the previous 12 months, recent diarrheal illness, or known homosexual exposure. The patient underwent surgical removal of the fractured plate and screws 10 d later, with placement of compression screws and autologous bone grafting. There were no purulent joint fluid, necrotic bone, or cartilage seen. No tissue or fluid from the left knee joint was sent for culture. Perioperative cefazolin was administered for 48 h, and oral cephalexin therapy (250 mg qid) was prescribed for 7 d for postoperative prophylaxis. After 5 d of incubation, the aerobic BACTEC NR6A blood culture vial showed a delta increase of 22 in the growth index. A Gram-stained smear from the vial was negative, but an acridine orange-stained smear revealed numerous "gull wing"-like organisms, suggestive of Campylobacter sp. After subculture onto Columbia base agar (Unipath Ltd., Basingstoke, Hampshire, U.K.) with 5% sheep blood, incubated at 37°C under microaerophilic condition (BBL GasPak; Becton Dickinson, Cockeysville, MD, USA), good growth of the organism was observed after 3 d of incubation. Acridine orange-stained smears and subsequent subcultures from the anaerobic BACTEC NR7A vial were negative. The organism did not grow aerobically at 37°C or under microaerophilic conditions at 42°C. It was positive for catalase and oxidase re-© 1995 ElsevierScienceInc.
3rd ed. Churchill Livingstone,New York.
actions, and it reduced nitrate but did not hydrolyze hippurate. A zone of growth inhibition was evident around the nalidixic acid disk but not the cephalothin disk. These characteristics were consistent with the identification of Helicobacter cinaedi, which was subsequently confirmed by the reference laboratory at the Laboratory Centre for Disease Control in Ottawa, Canada. The patient was evaluated at our institution 11 d postoperatively (21 d from initial presentation). He had completed the oral cephalexin therapy 4 d previously and remained afebrile with satisfactory healing of the left knee surgical wound. His peripheral blood leukocyte count was 5.1 × 109/1. At this visit, two sets of blood cultures were obtained at 30 min apart. After 4 d of incubation, the aerobic BACTEC NR6A vials from both sets of blood cultures showed little change in the growth (delta) values, and Gram-stained smears from the vials were negative. Acridine orange-stained smears again revealed numerous "gull wing"dike organisms, which were subsequently identified as H. cinaedi. Follow-up evaluation 21 d postoperatively (31 d after initial presentation) showed the patient to be well and entirely asymptomatic, with continued improvement of his left knee wound. The peripheral leukocyte count was 7.8 x 109/I, while three daily stool cultures for enteric pathogens and a blood culture were obtained. Oral antibiotic therapy with trimethoprim-sulfamethoxazole (160/800 mg twice daily) was instituted for 4 wk. On day 5 of incubation, the aerobic BACTEC NR6A blood culture vial showed no change in the growth (delta) value and negative Gram-stained smears. However, Campylobacter-like organisms were again present in the acridine orange-stained smears. Repeated attempts at subcuituring the blood culture vial onto Columbia base agar with 5% sheep blood and campylobacter agar (Unipath Ltd., Basingstoke, Hampshire, U.K.) under microaerophilic condition were unsuccessful. The patient remained well and as0196~399/95/$0.00 + f~9.50
159
ymptomatic 3 mo postoperatively, with complete healing of his left knee surgical wound. A blood' culture obtained then was negative. Discussion
Our patient was unique in several clinical and bacteriologic aspects. First, despite the lack of symptoms and signs of systemic infection, be had bacteremia due to H. cinaedi, persistent for up to 4 wk. The persistent bacteremia during postoperative cephalexin prophylaxis is Consistent with the observation of in vitro resistance to cephalothin. Second, although the knee joint was a highly suspected site of infection, the surgical wound had healed within 4 wk, which is the usual postoperative course of recovery as expected for this type of surgical procedure. However, poss~le H. cinaedi infection of the knee joint could not be ruled out with certainty, since there were no specimens from the knee joint submitted for cultures. Previous reports have documented the occurrence of septic arthritis associated with H. cinaedi bacteremia, with or without enteric illnesses, in children and women (9). The origin of H. cinaedi in our patient remained a pu7~le, given the absence of enteric illness and negative stool cultures. He had no unusual dietary habits or homosexual activity. Contact with household cats is a possible mode of organism acquisition in our patient (10). This case also emphasizes the usefulness of acridine orange stain for detect-
Editors Mary Jane Ferraro Paul A. Granato Josephine A. Morello R.J. Zabransky @ 1995 Elsevier Science Inc. ISSN0196-4399 CMNEEJI7(20)153-160, 1995 Elsevier
ing organisms in BACTEC blood culture vials with positive growth (delta) values but negative Gram-stained smears. Campylobacter-Fdce organisms were initially isolated from our patient's blood culture because of the routine procedure of performing acridine orange stain on blood culture smears during such instances. Standard or "blind" subcultures in aerobic and anaerobic conditions may not have yielded these organisms. In addition, a cost-effective procedure commonly practiced in many diagnostic laboratories is to incubate routine blood cultures for 5 d, which may not be sufficient to detect these fastidious organisms with the semi-automated BACTEC 660 blood culture system, such as the one used in our laboratory. Our case report extends the clinical spectrum of H. cinaedi infections to include asymptomatic bacteremia in an HIV-infected, though not overtly immunocompromised individual. References 1. Sorvillo, F.J., L.E. Lieb, and S.H. Waterman. 1991. Incidence of campylobacteriosis among patients with AIDS in Los Angeles County. J. Acquir. Immune Defic. Syndr. 7:598-602. 2. Vandamme, P., et al. 1991. Revision of Campylobacter, Helicobacterand Wolinella taxonomy:emendationof generic descriptionsand proposal of Arcobacter gen. nov. InL J. Syst. Bacteriol. 41:88-103.
4.
5.
6.
7.
8.
9.
10.
3. Cimolai, J., et al. 1987. "Campylobac-
ter cinaedi'" bacteremia: case report and laboratory findings. J. Clin. Microbiol. 25:942-942. Ng, VJ., et al. 1987. Successive bacteremias with "Campylobacter cinaedi" and "Campylobacterfennelliae" in a bisexual male. J. Clin. Microbiol. 25:2008--2009. Simor, A.E., and LL. Brunton. 1992. Bacteremia due to Helicobacter cinaedi in two patients with human immunodeficiency virus infection. Can. J. Infect. Dis. 3:139-141. Quinn, T.C., et al. 1984. Infections with Campylobacterjejuni and Campylobacter-Ske organisms in homosexual men. Ar~ Intern. Med. 101:187-192. Totten, P.A., et al. 1985. Campylobacter cinaedi (sp. nov.) and Campylobacterfenneliae (sp. nov.): two new Campyiobacter species associated with enteric disease in homosexual men. J. Infect. Dis. 151:131-139. Feunell, C.L., et al. 1984. Characterization of Campylobacter-like organisms isolated from homosexual men. J. Infect. Dis. 149:58-66. Vandamme, P., et al. 1990. Identification of Campylobacter cinaedi isolated from blood and feces of children and adult females. J. Clin. Microbiol. 28:1016-1020. Goldstein, E.J.C. 1991. Household pets and human infections, p. 117-130. In A.N. Weinberg and D.J. Weber (eds.), Infectious Disease Clinics of North America, W.B. Saunders Co., Philadelphia.
General Information Subscription information can be fmmd inside the front cover. This newsletter has been registered with the Copyright Clearance Center, Inc. Consent is given for copying articles for personal or internal use, or for the personal or internal use of specific clients. This consent is given on the condition that the copier pay through the Center the per-copy fee stated in the code on the first tinge for copying beyond that penniued by the US Copyright Law. If no code appears on an article, the author has not given broad consent to copy and permission to copy must be obtained directly from the author. Tiff s consent does not extend to other kinds of copying, such as for general distribution, resale, advertising and promotional purposes, orfor creating new collective works. Address orders, changes of address, and claims for missing issues to Journal Fulfillment Department, Elsevier Science Inc., 655 Avenue of the Americas, New York, NY I0010. Claims for missing issues can be honored only up to three months for domestic addresses and six months for foreign addresses. Duplicate copies will not be sent to replace ones undelivered due to failure to notify Elsevier of change of address. Postmaster: Send address changes to Clinical Microbiology Newsletter, Elsevier Science Inc., 655 Avenue of the Americas, New York, NY I0010.
IIIIllllill[IglilllllllllllHIi 0196-43W(I~I015) 17:20; I-W 160
0196-4399/95/$0.00 + 09.50
Editorials and letters printed in this newsletter are published for the interest of the readers and do not necessarily reflect the opinions of the editors.
Clinical Microbiology Newsletter is abstracted in Tropical Diseases Bulletin, Abstracts on Hygiene and Communicable Diseases and Current AIDS Literature.
© 1995 Elsevier Science Inc.
Clinical Microbiology Newsletter 17:19,1995
Heficobacter cinaedi Bacteremia in an Asymptomatic Patient with Human Immunodeficiency Virus Infection James M. Hutchinson, M.D. Joseph D,C. Yao, M.D. Deirdre L. Church, M.D. Department of Microbiology and Infectious Diseases University of Calgary; Southern Alberta Clinic Foothills Hospital; and Clinical Microbiology Laboratory Alberta Children's Hospital Calgary, Alberta, Canada
Campylobacter species are known to cause enteric disease and systemic illness with bacteremia in individuals infected with the human immunodeficiency virus (H1V) (1). Helicobacter cinaedi, formerly Campylobacter cinaedi (2), is one of the recently recognized Campylobacter-like organisms associated with symptomatic bacteremia (3,4,5), proctocolitis (6,7), and asymptomatic rectal carriage (8) in homosexual men with or without HIV infection. However, the clinical manifestations and spectrum of illness caused by this organism remain to be defined. We report a case of prolonged asymptomatic bacteremia due to H. cinaedi in a HIV-seropositive man who recently presented to our hospital. A 30-yr-old, exclusively heterosexual, HIV-seropositive man, with a past history of intravenous drug abuse, presented to the emergency department of our hospital after sustaining a stress injury to his left knee 1 d earlier. At 5 mo prior to presentation he had undergone, uneventfully, a distal femoral varus osteotomy with placement of a metal plate and screws at another hospital, for osteochondritis dissecans of the left knee joint. His CD4 cell count was 744/m 3 1 mo earlier. He was afebrile, and physical examination showed a swollen, warm, and tender knee joint, with markedly limited range of motion. There were no crepitus, erythema, or efClinical MicrobiologyNewsletter17:19,1995
1926-1932. In G.L. Mandell, R.G. Douglas, and J.E. Bennett (eds.), Principles and practice of infectious diseases,
fusion present. The peripheral blood leukocyte count (5.9 × 109/1) and erythrocyte sedimentation rate (25 mm/h) were normal. Roentgenograms of the left joint revealed fracture of the metal plate screws and nonunion of the bone from the previous osteotomy. To rule out the possibility of septic arthritis or osteomyelitis, a set of blood cultures (BACTF~ NR6A and NR7A vials; Becton Dickinson Diagnostic, Mississauga, Ontario, Canada) was obtained. The patient was a dairy farmer, with exposures to cattle and household cats, but he denied any consumption of unpasteurized dairy products or well water. There was no history of unusual dietary habits, travel within the previous 12 months, recent diarrheal illness, or known homosexual exposure. The patient underwent surgical removal of the fractured plate and screws 10 d later, with placement of compression screws and autologous bone grafting. There were no purulent joint fluid, necrotic bone, or cartilage seen. No tissue or fluid from the left knee joint was sent for culture. Perioperative cefazolin was administered for 48 h, and oral cephalexin therapy (250 mg qid) was prescribed for 7 d for postoperative prophylaxis. After 5 d of incubation, the aerobic BACTEC NR6A blood culture vial showed a delta increase of 22 in the growth index. A Gram-stained smear from the vial was negative, but an acridine orange-stained smear revealed numerous "gull wing"-like organisms, suggestive of Campylobacter sp. After subculture onto Columbia base agar (Unipath Ltd., Basingstoke, Hampshire, U.K.) with 5% sheep blood, incubated at 37°C under microaerophilic condition (BBL GasPak; Becton Dickinson, Cockeysville, MD, USA), good growth of the organism was observed after 3 d of incubation. Acridine orange-stained smears and subsequent subcultures from the anaerobic BACTEC NR7A vial were negative. The organism did not grow aerobically at 37°C or under microaerophilic conditions at 42°C. It was positive for catalase and oxidase re-© 1995 ElsevierScienceInc.
3rd ed. Churchill Livingstone,New York.
actions, and it reduced nitrate but did not hydrolyze hippurate. A zone of growth inhibition was evident around the nalidixic acid disk but not the cephalothin disk. These characteristics were consistent with the identification of Helicobacter cinaedi, which was subsequently confirmed by the reference laboratory at the Laboratory Centre for Disease Control in Ottawa, Canada. The patient was evaluated at our institution 11 d postoperatively (21 d from initial presentation). He had completed the oral cephalexin therapy 4 d previously and remained afebrile with satisfactory healing of the left knee surgical wound. His peripheral blood leukocyte count was 5.1 × 109/1. At this visit, two sets of blood cultures were obtained at 30 min apart. After 4 d of incubation, the aerobic BACTEC NR6A vials from both sets of blood cultures showed little change in the growth (delta) values, and Gram-stained smears from the vials were negative. Acridine orange-stained smears again revealed numerous "gull wing"dike organisms, which were subsequently identified as H. cinaedi. Follow-up evaluation 21 d postoperatively (31 d after initial presentation) showed the patient to be well and entirely asymptomatic, with continued improvement of his left knee wound. The peripheral leukocyte count was 7.8 x 109/I, while three daily stool cultures for enteric pathogens and a blood culture were obtained. Oral antibiotic therapy with trimethoprim-sulfamethoxazole (160/800 mg twice daily) was instituted for 4 wk. On day 5 of incubation, the aerobic BACTEC NR6A blood culture vial showed no change in the growth (delta) value and negative Gram-stained smears. However, Campylobacter-like organisms were again present in the acridine orange-stained smears. Repeated attempts at subcuituring the blood culture vial onto Columbia base agar with 5% sheep blood and campylobacter agar (Unipath Ltd., Basingstoke, Hampshire, U.K.) under microaerophilic condition were unsuccessful. The patient remained well and as0196~399/95/$0.00 + f~9.50
159
ymptomatic 3 mo postoperatively, with complete healing of his left knee surgical wound. A blood' culture obtained then was negative. Discussion
Our patient was unique in several clinical and bacteriologic aspects. First, despite the lack of symptoms and signs of systemic infection, be had bacteremia due to H. cinaedi, persistent for up to 4 wk. The persistent bacteremia during postoperative cephalexin prophylaxis is Consistent with the observation of in vitro resistance to cephalothin. Second, although the knee joint was a highly suspected site of infection, the surgical wound had healed within 4 wk, which is the usual postoperative course of recovery as expected for this type of surgical procedure. However, poss~le H. cinaedi infection of the knee joint could not be ruled out with certainty, since there were no specimens from the knee joint submitted for cultures. Previous reports have documented the occurrence of septic arthritis associated with H. cinaedi bacteremia, with or without enteric illnesses, in children and women (9). The origin of H. cinaedi in our patient remained a pu7~le, given the absence of enteric illness and negative stool cultures. He had no unusual dietary habits or homosexual activity. Contact with household cats is a possible mode of organism acquisition in our patient (10). This case also emphasizes the usefulness of acridine orange stain for detect-
Editors Mary Jane Ferraro Paul A. Granato Josephine A. Morello R.J. Zabransky @ 1995 Elsevier Science Inc. ISSN0196-4399 CMNEEJI7(20)153-160, 1995 Elsevier
ing organisms in BACTEC blood culture vials with positive growth (delta) values but negative Gram-stained smears. Campylobacter-Fdce organisms were initially isolated from our patient's blood culture because of the routine procedure of performing acridine orange stain on blood culture smears during such instances. Standard or "blind" subcultures in aerobic and anaerobic conditions may not have yielded these organisms. In addition, a cost-effective procedure commonly practiced in many diagnostic laboratories is to incubate routine blood cultures for 5 d, which may not be sufficient to detect these fastidious organisms with the semi-automated BACTEC 660 blood culture system, such as the one used in our laboratory. Our case report extends the clinical spectrum of H. cinaedi infections to include asymptomatic bacteremia in an HIV-infected, though not overtly immunocompromised individual. References 1. Sorvillo, F.J., L.E. Lieb, and S.H. Waterman. 1991. Incidence of campylobacteriosis among patients with AIDS in Los Angeles County. J. Acquir. Immune Defic. Syndr. 7:598-602. 2. Vandamme, P., et al. 1991. Revision of Campylobacter, Helicobacterand Wolinella taxonomy:emendationof generic descriptionsand proposal of Arcobacter gen. nov. InL J. Syst. Bacteriol. 41:88-103.
4.
5.
6.
7.
8.
9.
10.
3. Cimolai, J., et al. 1987. "Campylobac-
ter cinaedi'" bacteremia: case report and laboratory findings. J. Clin. Microbiol. 25:942-942. Ng, VJ., et al. 1987. Successive bacteremias with "Campylobacter cinaedi" and "Campylobacterfennelliae" in a bisexual male. J. Clin. Microbiol. 25:2008--2009. Simor, A.E., and LL. Brunton. 1992. Bacteremia due to Helicobacter cinaedi in two patients with human immunodeficiency virus infection. Can. J. Infect. Dis. 3:139-141. Quinn, T.C., et al. 1984. Infections with Campylobacterjejuni and Campylobacter-Ske organisms in homosexual men. Ar~ Intern. Med. 101:187-192. Totten, P.A., et al. 1985. Campylobacter cinaedi (sp. nov.) and Campylobacterfenneliae (sp. nov.): two new Campyiobacter species associated with enteric disease in homosexual men. J. Infect. Dis. 151:131-139. Feunell, C.L., et al. 1984. Characterization of Campylobacter-like organisms isolated from homosexual men. J. Infect. Dis. 149:58-66. Vandamme, P., et al. 1990. Identification of Campylobacter cinaedi isolated from blood and feces of children and adult females. J. Clin. Microbiol. 28:1016-1020. Goldstein, E.J.C. 1991. Household pets and human infections, p. 117-130. In A.N. Weinberg and D.J. Weber (eds.), Infectious Disease Clinics of North America, W.B. Saunders Co., Philadelphia.
General Information Subscription information can be fmmd inside the front cover. This newsletter has been registered with the Copyright Clearance Center, Inc. Consent is given for copying articles for personal or internal use, or for the personal or internal use of specific clients. This consent is given on the condition that the copier pay through the Center the per-copy fee stated in the code on the first tinge for copying beyond that penniued by the US Copyright Law. If no code appears on an article, the author has not given broad consent to copy and permission to copy must be obtained directly from the author. Tiff s consent does not extend to other kinds of copying, such as for general distribution, resale, advertising and promotional purposes, orfor creating new collective works. Address orders, changes of address, and claims for missing issues to Journal Fulfillment Department, Elsevier Science Inc., 655 Avenue of the Americas, New York, NY I0010. Claims for missing issues can be honored only up to three months for domestic addresses and six months for foreign addresses. Duplicate copies will not be sent to replace ones undelivered due to failure to notify Elsevier of change of address. Postmaster: Send address changes to Clinical Microbiology Newsletter, Elsevier Science Inc., 655 Avenue of the Americas, New York, NY I0010.
IIIIllllill[IglilllllllllllHIi 0196-43W(I~I015) 17:20; I-W 160
0196-4399/95/$0.00 + 09.50
Editorials and letters printed in this newsletter are published for the interest of the readers and do not necessarily reflect the opinions of the editors.
Clinical Microbiology Newsletter is abstracted in Tropical Diseases Bulletin, Abstracts on Hygiene and Communicable Diseases and Current AIDS Literature.
© 1995 Elsevier Science Inc.
Clinical Microbiology Newsletter 17:19,1995