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Herellea Vaginicola in Urinary Tract Infection: A Case Report and Review of Literature
THE .j 0 1 Rl'iAL
Vol. 110, October
~JROLOGY
© 19?;3 by 'The \Vi!haE1s
Vhlkins Co,
Frint2d in U.S.1-L
HERELLEA VAGINICOLA IN URINARY TRACT INFECTION: A CASE REPORT AND REVIEW OF LITERATURE HABIB R. KELLY, SUBBARAO V. YALLA
AND
HARRY M. BURROS
From the Department of Urology, Graduate Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Herellea vaginicola is one of the lesser known gram-negative agents causing urinary tract infection. 1 It is isolated with increased frequency in various laboratories. 2 It is a non-motile gram-negative diplococcus (or rod), which is pleomorphic and ubiquitous in habitat. It has been isolated alone or in association with other infective agents from every site of the human body in infectious persons or in healthy carriers. It can cause urethritis, which clinically may mimic gonorrhea. 1 • 3 - 5 It has been associated with cystitis, instrumentation of the urinary tract, pyelonephritis and renal abscess. 1 • 2 • 6 - 9 We report herein a case of Herellea vaginicola and a brief review of the literature.
amphenicol, kanamycin and nalidixic acid. The patient was given parenteral ampicillin. Blood and sputum cultures were repeatedly negative. Cystoscopy on day 5 of hospitalization revealed extensive infiltration of prostatic carcinoma into the vesical neck and trigone. A suprapubic cystostomy was performed under local anesthesia in order to establish adequate drainage of the thick purulent contents of the bladder. Postoperatively, the patient's condition deteriorated and he died 4 weeks after hospitalization. Autopsy revealed evidence of severe urinary tract infection, infiltrating and metastatic carcinoma of the prostate and severe bronchopneumonia with microabscesses in the lungs.
CASE REPORT
J. J., a 72-year-old black man, had metastatic adenocarcinoma of the prostate diagnosed in 1964. He had undergone bilateral orchiectomy and stilbestrol therapy and was being periodically followed in the outpatient clinic. Periodic urethral dilatation was used to improve the voiding pattern. In August 1970 dysuria, urinary incontinence, severe backache, anorexia and temperature of 102F with chills, dehydration and azotemia were noted. Catheterization because of urinary retention drained thick, purulent urine. Urine culture yielded more than 100,000 organisms per ml. of pure Herellea vaginicola, sensitive to ampicillin, chlor-
Accepted for publication April 6, 1973. 1 Daly, A. K., Postic, B. and Kass, E. H.: Infections due to organisms of the genus Herellea. B5W and B. antitratum. Arch. Intern. Med., HO: 580, 1962. 'Reynolds, R. C. and Cluff, L. E.: Infection of man with Mimeae. Ann. Intern. Med., 58: 759, 1963. 3 Marraro, R. V. and Rheins, M. S.: Identification of the Mima-Herellea group of organisms and selected members of the genus Neisseria. Appl. Microbiol., 18: 575, 1969. 'Dalton, H. P., Allison, M. J. and Escobar, M. R.: Herellea vaginicoia. Virginia Med. Monthly, 96: 412, 1969.
J. P.: Pseudogonococcal ophthalmia infection with vaginicola. Med. J. Aust., 2: 1104, 1968. s Elston, H. R. and Hoffman, K. C.: Identification and clinical significance of achromobacter (Herellea) anitratus in urinary infections. Amer. J. Med. Sci., 251: 75, 1966. 7 Caldera, L. and Bettagno, G.: Rinvenimento Di Herellea Vaginicola in Casa Di Rene Policystico. Instituti Ospitaiieri Di Verona Laboratorio Analisi E Recerche Cliniche, pp. 524-529. 'Wintrobe, M. M.: Harrison's Principles of Internal Medicine. New York: McGraw-Hill Book Co., p. 838, 1969. 9 Inclan, A. P., Massey, L. C., Crook, B. G. and Bell, J. S .: Organisms of the tribe Mimeae: incidence of isolation and clinical correlation at the City of Memphis Hospitals. Southern Med. J., 58: 1261, 1965.
REVIEW OF THE LITERATURE
Pure culture of Herellea vaginicola, as seen in our case, occurred in approximately 26 per cent of all cases. 9 In the remaining cases this organism was associated with other agents such as Klebsiella, Staphylococcus aureus, Pseudomonas, Streptococcus faecalis and Escherichia coli. In these mixed infections the degree of contribution of Herellea was difficult to assess and was considered by some investigators to be doubtful. One cause of confusion is the varying nomenclature: the terms Diplococcus mucosus, Bacterium anitratum, B5W, Achromobacter anitratus, N eisseria winogradsky, Moraxella lwoffia, Moraxella glucidolitica and Moraxella vaginalis have all been used to describe this organism.,, 2. '· •. •. to There has been general agreement in considering Herellea vaginicola a member of the genus Herellea which is a member of the tribe Mimeae. Mirna polymorpha belongs to the same tribe and clinically and pathologically mimics Herellea vaginicola and Neisseria. 11 Herellea vaginicola is a gram-negative, non-motile diplococcus. It is considered •-"~A-~A,.,-,"A,,'"'k' since it could be or coccobacillus. It is and aerobic. Herellea vaginicola ferments 10 per cent lactose and has nitrate utilization (anitratus). Its colonies are vw,--v••, mucoid and are white or pale pink in color. The luxuriant growth gene;ally obtained in routine medium should aid in differentiating Herellea vaginicola from Neisseria gonorrhoea and meningitidis. On the other hand, Herellea vaginicola cannot be differentiated from patho10 Controni, G., Ballard, S. and Griffifth, M. A.: A review of the literature on classification of the MimaMoraxella. Amer. J. Med. Techn., 30: 257, 1964. 11 DeBord, G. G.: Organisms invalidating diagnosis of gonorrhea by smear method. J. Bact., 38: 119, 1939.
457
458
KELLY, YALLA AND BURROS
genie N eisseria on Gram stains. 11 -• 3 Serological studies••-•• and immunofluorescent staining 17 are usually helpful in identifying this organism. Pathogenicity. The pleomorphism of Herellea vaginicola and its clinical ubiquity illustrate the uncertainty of its pathogenic role. 1 2 • '· 8 • 9 • 18 It has been considered a harmless commensal and has been isolated from the sputum and skin of human carriers. The association in many cases with agents such as Klebsiella, Pseudomonas and Escherichia coli casts doubt on its pathogenic role in disease. In other cases it is considered an opportunistic commensal with a definite pathogenic potential because of its frequent association alone or with other agents in severe infection and fatal sepsis in patients with lowered defense mechanisms.'· 2 • 9 • 15 Premature infants, chronically debilitated patients with diabetes, cancer, chronic renal disease, individuals with burns'" and patients on prolonged antibiotic or steroid therapy• are susceptible to this organism. It was considered the primary infecting organism in many reported cases of septicemia, pneumonia, meningitis and endocarditis. 1 • 2 • 8 • 9 , 15 , 18, 20-22
Herellea vaginicola in urological practice. In the Gangarosa, E. J. and Cary, S. G.: Validity of report of penicillin-resistant gonococci. J.A.M.A., 173:· 1808, 1960. 13 DeBord, G. G.: Species of tribes Mimeae, Neisserieae and Streptococceae which confuse diagnosis of gonorrhea by smears. J. Lab. & Clin. Med., 28: 710, 1943. 14 Nelson, J. D. and Shelton, S.: Cultural, biochemical, and immunological properties of Mirna, Herellea, and Flavobacterium species. Appl. Microbial., 13: 801, 1965. 15 Robinson, R. G., Garrison, R. G. and Brown, R. W.: Evaluation of the clinical significance of the genus Herellea. Ann. Intern. Med., 60: 19, 1964. 1 •Reinranz, J.B., Ways, B. B. and Sanford, J.P.: In vitro sensitivit_y determination of Herellea and Flavobacterium species. Antimicrob. Agents Chemother., pp. 451-456, 1964. 11 Marcus, B. B., Samuels, S. B., Pittman, B. and Cherry, W. B.: A serologic study of Herellea vaginicola and its identification by immunofluorescent staining. Amer. J. Clin. Path., 52: 309, 1969. 18 Thompson, W. R.: Vaginicola endocarditis in a heroin addict. J .A.M.A., 215: 982, 1971. 19 Graber, C. D., Rabin, E. R., Mason, A. D., Jr. and Vogel, E. H., Jr.: Increasing incidence of nosocomial Herellea vaginicola infections in burned patients. Surg., Gynec. & Obst., 114: 109, 1962. '"Townsend, F. M., Hersey, D. F. and Wilson, F. W.: Mirna polymorpha as causative agent in WaterhouseFridericksen syndrome. U. S. Armed Forces Med. J., 5: 673, 1954. 21 Gromisch, D. S., Gordon, S. G., Bedrosian, L. and Sall, T.: Simultaneous mixed bacterial meningitis in an infant caused by Diplococcus pneumoniae and Herellea vaginicola. Amer. J. Dis. Child., 119: 284, 1970. 12
Here/lea vaginicola antibiotic sensitivity Sensitive: Kanamycin Colistin Polymyxin B Less sensitive: Chloramphenicol Nitrofurantoin Sulfa Tetracycline Novobiocin Resistant: Ampicillin Cephalothin Erythromycin
urogenital tract this agent has been isolated from the urine, vagina, urethral exudate, renal abscess and infected polycystic kidneys. 7 • • Catheterization and repeated instrumentation serve as portals of entry for this organism into the urinary tract. Obstruction to the urinary tract certainly acts as a predisposing factor. The usual clinical manifestations are urethritis, cystitis, acute or chronic pyelonephritis and septicemia.•. 9 Urethritis caused by this organism is usually mistaken for gonorrhea. 11 - 13 The pleomorphic nature of this organism distinguishes it from gonococcus. Antibiotic sensitivity. Herellea vaginicola has been found to be penicillin-resistant in most of the in vitro studies (see table).'· 2 • 4 • 6 • •. 15 • 22 Neomycin has been effective on topical use. Studies by Reinranz and associates demonstrated that the antibiotic sensitivity of this organism was not predictable. 16 They advised that severe infection should be treated with usual drugs of choice such as kanamycin, colymycin and polymyxin B, while awaiting culture-sensitivity characteristics. SUMMARY
A case of urinary tract infection caused by Herellea vaginicola is presented. Metastatic carcinoma of the prostate and associated lower urinary tract obstruction probably were the predisposing factors. Pure cultures of this bacterial agent isolated on 2 successive occasions demonstrated sensitivity to ampicillin. The literature on the bacteriological characteristics, antibiotic sensitivity and pathogenicity of Herellea vaginicola was reviewed. 22 King, 0. H., Jr., Copeland, G. D. and Berton, W. M.: Cardiovascular lesions of the Mimeae organisms. Amer. J. Med., 35: 241, 1963.
Vol. 110, October
~JROLOGY
© 19?;3 by 'The \Vi!haE1s
Vhlkins Co,
Frint2d in U.S.1-L
HERELLEA VAGINICOLA IN URINARY TRACT INFECTION: A CASE REPORT AND REVIEW OF LITERATURE HABIB R. KELLY, SUBBARAO V. YALLA
AND
HARRY M. BURROS
From the Department of Urology, Graduate Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Herellea vaginicola is one of the lesser known gram-negative agents causing urinary tract infection. 1 It is isolated with increased frequency in various laboratories. 2 It is a non-motile gram-negative diplococcus (or rod), which is pleomorphic and ubiquitous in habitat. It has been isolated alone or in association with other infective agents from every site of the human body in infectious persons or in healthy carriers. It can cause urethritis, which clinically may mimic gonorrhea. 1 • 3 - 5 It has been associated with cystitis, instrumentation of the urinary tract, pyelonephritis and renal abscess. 1 • 2 • 6 - 9 We report herein a case of Herellea vaginicola and a brief review of the literature.
amphenicol, kanamycin and nalidixic acid. The patient was given parenteral ampicillin. Blood and sputum cultures were repeatedly negative. Cystoscopy on day 5 of hospitalization revealed extensive infiltration of prostatic carcinoma into the vesical neck and trigone. A suprapubic cystostomy was performed under local anesthesia in order to establish adequate drainage of the thick purulent contents of the bladder. Postoperatively, the patient's condition deteriorated and he died 4 weeks after hospitalization. Autopsy revealed evidence of severe urinary tract infection, infiltrating and metastatic carcinoma of the prostate and severe bronchopneumonia with microabscesses in the lungs.
CASE REPORT
J. J., a 72-year-old black man, had metastatic adenocarcinoma of the prostate diagnosed in 1964. He had undergone bilateral orchiectomy and stilbestrol therapy and was being periodically followed in the outpatient clinic. Periodic urethral dilatation was used to improve the voiding pattern. In August 1970 dysuria, urinary incontinence, severe backache, anorexia and temperature of 102F with chills, dehydration and azotemia were noted. Catheterization because of urinary retention drained thick, purulent urine. Urine culture yielded more than 100,000 organisms per ml. of pure Herellea vaginicola, sensitive to ampicillin, chlor-
Accepted for publication April 6, 1973. 1 Daly, A. K., Postic, B. and Kass, E. H.: Infections due to organisms of the genus Herellea. B5W and B. antitratum. Arch. Intern. Med., HO: 580, 1962. 'Reynolds, R. C. and Cluff, L. E.: Infection of man with Mimeae. Ann. Intern. Med., 58: 759, 1963. 3 Marraro, R. V. and Rheins, M. S.: Identification of the Mima-Herellea group of organisms and selected members of the genus Neisseria. Appl. Microbiol., 18: 575, 1969. 'Dalton, H. P., Allison, M. J. and Escobar, M. R.: Herellea vaginicoia. Virginia Med. Monthly, 96: 412, 1969.
J. P.: Pseudogonococcal ophthalmia infection with vaginicola. Med. J. Aust., 2: 1104, 1968. s Elston, H. R. and Hoffman, K. C.: Identification and clinical significance of achromobacter (Herellea) anitratus in urinary infections. Amer. J. Med. Sci., 251: 75, 1966. 7 Caldera, L. and Bettagno, G.: Rinvenimento Di Herellea Vaginicola in Casa Di Rene Policystico. Instituti Ospitaiieri Di Verona Laboratorio Analisi E Recerche Cliniche, pp. 524-529. 'Wintrobe, M. M.: Harrison's Principles of Internal Medicine. New York: McGraw-Hill Book Co., p. 838, 1969. 9 Inclan, A. P., Massey, L. C., Crook, B. G. and Bell, J. S .: Organisms of the tribe Mimeae: incidence of isolation and clinical correlation at the City of Memphis Hospitals. Southern Med. J., 58: 1261, 1965.
REVIEW OF THE LITERATURE
Pure culture of Herellea vaginicola, as seen in our case, occurred in approximately 26 per cent of all cases. 9 In the remaining cases this organism was associated with other agents such as Klebsiella, Staphylococcus aureus, Pseudomonas, Streptococcus faecalis and Escherichia coli. In these mixed infections the degree of contribution of Herellea was difficult to assess and was considered by some investigators to be doubtful. One cause of confusion is the varying nomenclature: the terms Diplococcus mucosus, Bacterium anitratum, B5W, Achromobacter anitratus, N eisseria winogradsky, Moraxella lwoffia, Moraxella glucidolitica and Moraxella vaginalis have all been used to describe this organism.,, 2. '· •. •. to There has been general agreement in considering Herellea vaginicola a member of the genus Herellea which is a member of the tribe Mimeae. Mirna polymorpha belongs to the same tribe and clinically and pathologically mimics Herellea vaginicola and Neisseria. 11 Herellea vaginicola is a gram-negative, non-motile diplococcus. It is considered •-"~A-~A,.,-,"A,,'"'k' since it could be or coccobacillus. It is and aerobic. Herellea vaginicola ferments 10 per cent lactose and has nitrate utilization (anitratus). Its colonies are vw,--v••, mucoid and are white or pale pink in color. The luxuriant growth gene;ally obtained in routine medium should aid in differentiating Herellea vaginicola from Neisseria gonorrhoea and meningitidis. On the other hand, Herellea vaginicola cannot be differentiated from patho10 Controni, G., Ballard, S. and Griffifth, M. A.: A review of the literature on classification of the MimaMoraxella. Amer. J. Med. Techn., 30: 257, 1964. 11 DeBord, G. G.: Organisms invalidating diagnosis of gonorrhea by smear method. J. Bact., 38: 119, 1939.
457
458
KELLY, YALLA AND BURROS
genie N eisseria on Gram stains. 11 -• 3 Serological studies••-•• and immunofluorescent staining 17 are usually helpful in identifying this organism. Pathogenicity. The pleomorphism of Herellea vaginicola and its clinical ubiquity illustrate the uncertainty of its pathogenic role. 1 2 • '· 8 • 9 • 18 It has been considered a harmless commensal and has been isolated from the sputum and skin of human carriers. The association in many cases with agents such as Klebsiella, Pseudomonas and Escherichia coli casts doubt on its pathogenic role in disease. In other cases it is considered an opportunistic commensal with a definite pathogenic potential because of its frequent association alone or with other agents in severe infection and fatal sepsis in patients with lowered defense mechanisms.'· 2 • 9 • 15 Premature infants, chronically debilitated patients with diabetes, cancer, chronic renal disease, individuals with burns'" and patients on prolonged antibiotic or steroid therapy• are susceptible to this organism. It was considered the primary infecting organism in many reported cases of septicemia, pneumonia, meningitis and endocarditis. 1 • 2 • 8 • 9 , 15 , 18, 20-22
Herellea vaginicola in urological practice. In the Gangarosa, E. J. and Cary, S. G.: Validity of report of penicillin-resistant gonococci. J.A.M.A., 173:· 1808, 1960. 13 DeBord, G. G.: Species of tribes Mimeae, Neisserieae and Streptococceae which confuse diagnosis of gonorrhea by smears. J. Lab. & Clin. Med., 28: 710, 1943. 14 Nelson, J. D. and Shelton, S.: Cultural, biochemical, and immunological properties of Mirna, Herellea, and Flavobacterium species. Appl. Microbial., 13: 801, 1965. 15 Robinson, R. G., Garrison, R. G. and Brown, R. W.: Evaluation of the clinical significance of the genus Herellea. Ann. Intern. Med., 60: 19, 1964. 1 •Reinranz, J.B., Ways, B. B. and Sanford, J.P.: In vitro sensitivit_y determination of Herellea and Flavobacterium species. Antimicrob. Agents Chemother., pp. 451-456, 1964. 11 Marcus, B. B., Samuels, S. B., Pittman, B. and Cherry, W. B.: A serologic study of Herellea vaginicola and its identification by immunofluorescent staining. Amer. J. Clin. Path., 52: 309, 1969. 18 Thompson, W. R.: Vaginicola endocarditis in a heroin addict. J .A.M.A., 215: 982, 1971. 19 Graber, C. D., Rabin, E. R., Mason, A. D., Jr. and Vogel, E. H., Jr.: Increasing incidence of nosocomial Herellea vaginicola infections in burned patients. Surg., Gynec. & Obst., 114: 109, 1962. '"Townsend, F. M., Hersey, D. F. and Wilson, F. W.: Mirna polymorpha as causative agent in WaterhouseFridericksen syndrome. U. S. Armed Forces Med. J., 5: 673, 1954. 21 Gromisch, D. S., Gordon, S. G., Bedrosian, L. and Sall, T.: Simultaneous mixed bacterial meningitis in an infant caused by Diplococcus pneumoniae and Herellea vaginicola. Amer. J. Dis. Child., 119: 284, 1970. 12
Here/lea vaginicola antibiotic sensitivity Sensitive: Kanamycin Colistin Polymyxin B Less sensitive: Chloramphenicol Nitrofurantoin Sulfa Tetracycline Novobiocin Resistant: Ampicillin Cephalothin Erythromycin
urogenital tract this agent has been isolated from the urine, vagina, urethral exudate, renal abscess and infected polycystic kidneys. 7 • • Catheterization and repeated instrumentation serve as portals of entry for this organism into the urinary tract. Obstruction to the urinary tract certainly acts as a predisposing factor. The usual clinical manifestations are urethritis, cystitis, acute or chronic pyelonephritis and septicemia.•. 9 Urethritis caused by this organism is usually mistaken for gonorrhea. 11 - 13 The pleomorphic nature of this organism distinguishes it from gonococcus. Antibiotic sensitivity. Herellea vaginicola has been found to be penicillin-resistant in most of the in vitro studies (see table).'· 2 • 4 • 6 • •. 15 • 22 Neomycin has been effective on topical use. Studies by Reinranz and associates demonstrated that the antibiotic sensitivity of this organism was not predictable. 16 They advised that severe infection should be treated with usual drugs of choice such as kanamycin, colymycin and polymyxin B, while awaiting culture-sensitivity characteristics. SUMMARY
A case of urinary tract infection caused by Herellea vaginicola is presented. Metastatic carcinoma of the prostate and associated lower urinary tract obstruction probably were the predisposing factors. Pure cultures of this bacterial agent isolated on 2 successive occasions demonstrated sensitivity to ampicillin. The literature on the bacteriological characteristics, antibiotic sensitivity and pathogenicity of Herellea vaginicola was reviewed. 22 King, 0. H., Jr., Copeland, G. D. and Berton, W. M.: Cardiovascular lesions of the Mimeae organisms. Amer. J. Med., 35: 241, 1963.