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Infections caused by Gemella morbillorum
Infections caused
by Gemella morbillorum
SiR-Human infections caused by Gemella morbillorum are unusual. von Essen and colleagues (July 17, p 177) report a case of arthritis due to this microorganism. Omran and Wood1 described another case of endovascular infection and septic arthritis and reviewed six infections caused by G morbillorum. The microorganism seems to be rarely associated with infections other than infective endocarditis and bacteraemia. We report another, ultimately fatal, infection due to G morbillorum. A previously healthy 15-year-old boy was admitted to our hospital with a one-week history of increasing pain above and behind his left eye, severe headache, and malaise. One day before admission he developed fever (39-4°C) and became confused. A few hours later he was unconscious and was admitted. He was comatose (Glasgow coma scale score 3), with a temperature of 36-6°C. There was no nucheal rigidity and there were no signs of cutaneous petechiae. He had bilateral dilated pupils, fixed to light. A corneal reflex could not be provoked, and he had a tetraparesis with areflexia. His leucocyte count was 13-8 x 109/L. Chest radiography revealed an infiltrate in the right upper lobe. Cranial computed tomography showed sinusitis maxillaris and frontalis and diffuse cerebral oedema, with almost no ventricular spaces left and signs of herniation. Because of increased intracranial presure lumbar puncture was not done. Blood, urine, and sputum cultures were taken. Intravenous antimicrobial therapy with acyclovir (500 mg every 8 h) and benzylpenicillin (2 x 106 units every 4 h) were started on suspicion of a meningoencephalitis. An electrocephalogram showed no electrical activity. The patient died a few hours after admission. Aerobic and anaerobic blood cultures taken antemortem grew gram-positive bacteria after 24 h which were identified as G morbillorum. Neuropathological examination showed a diffuse, subacute, necrotising, purulent leptomeningitis and diffuse developing meningoencephalitis. There was cerebral oedema with signs of increased intracranial pressure and herniation. Postmortem specimens of cerebrospinal fluid (CSF) grew G morbillorum
susceptible to penicillin. The isolation of G morbillorum from blood, CSF, and cerebral pus, indicates that this organism was the main pathogen in this infection. This previously healthy patient presented with symptons of sinusitis several days before the acute onset of meningitis. It is well known that meningitis, subdural empyema, and intracerebral and epidural abscesses are rare intracranial complications of sinusitis with a high mortality rate.2 We could find only one other report of G morbillorum meningitis.3 As far as we are aware, ours is the first reported lethal case of infection due to this organism. Despite its rarity, our case suggests that the pathogenecity of G morbillorum should not be underestimated. SB
Debast, R Koot, J F G M Meis
Departments of Medical Microbiology and Pathology, University Hospital Nijmegen, PO Box 9101, 6500 HB Nijmegen, Netherlands 1
2
3
Omran Y, Wood CA. Endovascular infection and septic arthritis caused by Gemella morbillorum. Diagn Microbiol Infect Dis 1993; 16: 131-34. Maniglia AJ, Goodwin WJ, Arnold JE, Ganz E. Intracranial abscesses secondary to nasal, sinus, and orbital infections in adults and children. Arch Otolyarngol Head Neck Surg 1989; 115: 1424-29. Garavelli PL. Meningitis from Streptococcus morbillorum. Minerva Med 1990; 81: 69.
SIR-von Essen and colleagues report an infection in a elbow joint caused by G morbillorum. Though unusual there have been previous published case-reports of six endovascular infections and one of meningitis caused by
prosthetic
560
G morbillorum plus an additional case of septic arthritis.1 The septic arthritis developed in the wrist of a patient who also had an endovascular infection and it resolved during medical therapy for that other infection. In his report of 391 extrarespiratory isolates of viridans streptococci, Gallis also included two bone and joint isolates, the clinical significance of which was uncertain.2 Elting et aP have reported that 6 of 46 isolates causing streptococcal shock syndrome in cancer patients were identified as G morbillorum. G morbillorum and the only other member of the genus, G haemolysans, appear to cause a spectrum of infection similar to that seen with viridans streptococci. Endocarditis and bacteraemia predominate. Although most isolates are highly susceptible to penicillin, relative resistanceand tolerance44 have been demonstrated and some strains have been shown to be nutritionally variant.5 Most gemella isolates tested have shown synergy between penicillin or vancomycin and aminoglycosides.4 Until more is known about the response to treatment, the intensity and duration of therapy for serious infection caused by Gemella spp should follow guidelines similar to those established for viridans streptococcal endocarditis and should be directed by the degree of susceptibility to
penicillin.6 Craig A Wood Division of Infectious Diseases, Hahnemann Pennsylvania 19102, USA
1
2
3
4 5
6
University, Philadelphia,
Omran O, Wood CA. Endovascular infection and septic arthritis caused by Gemella morbillorum. Diagn Microbiol Infect Dis 1993; 16: 131-34. Gallis HA. Viridans and &bgr;-hemolytic (non-group A, B, and D) streptococci. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases. New York: Churchill Livingston, 1990: 1563-72. Elting ES, Bodey GP, Keefe BH. Septicemia and shock syndrome due to viridans streptococci: a case control study of predisposing risk factors. Clin Infect Dis 14: 1201-07. Maxwell S. Endocarditis due to Streptococcus morbillorum. J Infect
1989; 18: 67-72. Coto H, Berk SL. Endocarditis caused by Streptococcus morbillorum. Am J Med Sci 1984; 287: 54-58. Bisno AL, Dismukes WE, Durack DT, et al. Antimicrobial treatment of infective endocarditis due to viridans streptococci, enterococci, and staphylococci. JAMA 1989; 261: 1471-77.
primary dengue 2 epidemic with spontaneous haemorrhagic manifestations
A
SIR-In
March-September, 1992, Townsville (population 100 000) in North Queensland, Australia, experienced an
epidemic of dengue fever caused by the serotype 2 virus. 616 patients had symptoms severe enough to seek medical attention. The most recent previous dengue epidemic, affecting the cities of Townsville and Cairns and the community on Thursday Island in the Torres Strait, had been of serotype 1 in 1981.1 A small outbreak occurred in 1990-91 and mainly affected Cairns and Thursday Island. The epidemic was first detected in early March and peaked in mid-May. All reported cases were serologically positive (395) or had symptoms and signs consistent with dengue fever, lived in the same household, or were closely associated with a serologically confirmed case, and had similar dates of onset (221). Fever, retro-orbital pain, headache, myalgia, and rash were common, and the overall frequency of spontaneous minor haemorrhagic manifestations, such as gingival bleeding, epistaxis, haematuria, or menorrhagia, was 21 % (table). No patient required admission. Cuba had an epidemic of dengue 1 in 1977, followed by a dengue 2 epidemic in 1981 with over 300 000 cases and 116 000
by Gemella morbillorum
SiR-Human infections caused by Gemella morbillorum are unusual. von Essen and colleagues (July 17, p 177) report a case of arthritis due to this microorganism. Omran and Wood1 described another case of endovascular infection and septic arthritis and reviewed six infections caused by G morbillorum. The microorganism seems to be rarely associated with infections other than infective endocarditis and bacteraemia. We report another, ultimately fatal, infection due to G morbillorum. A previously healthy 15-year-old boy was admitted to our hospital with a one-week history of increasing pain above and behind his left eye, severe headache, and malaise. One day before admission he developed fever (39-4°C) and became confused. A few hours later he was unconscious and was admitted. He was comatose (Glasgow coma scale score 3), with a temperature of 36-6°C. There was no nucheal rigidity and there were no signs of cutaneous petechiae. He had bilateral dilated pupils, fixed to light. A corneal reflex could not be provoked, and he had a tetraparesis with areflexia. His leucocyte count was 13-8 x 109/L. Chest radiography revealed an infiltrate in the right upper lobe. Cranial computed tomography showed sinusitis maxillaris and frontalis and diffuse cerebral oedema, with almost no ventricular spaces left and signs of herniation. Because of increased intracranial presure lumbar puncture was not done. Blood, urine, and sputum cultures were taken. Intravenous antimicrobial therapy with acyclovir (500 mg every 8 h) and benzylpenicillin (2 x 106 units every 4 h) were started on suspicion of a meningoencephalitis. An electrocephalogram showed no electrical activity. The patient died a few hours after admission. Aerobic and anaerobic blood cultures taken antemortem grew gram-positive bacteria after 24 h which were identified as G morbillorum. Neuropathological examination showed a diffuse, subacute, necrotising, purulent leptomeningitis and diffuse developing meningoencephalitis. There was cerebral oedema with signs of increased intracranial pressure and herniation. Postmortem specimens of cerebrospinal fluid (CSF) grew G morbillorum
susceptible to penicillin. The isolation of G morbillorum from blood, CSF, and cerebral pus, indicates that this organism was the main pathogen in this infection. This previously healthy patient presented with symptons of sinusitis several days before the acute onset of meningitis. It is well known that meningitis, subdural empyema, and intracerebral and epidural abscesses are rare intracranial complications of sinusitis with a high mortality rate.2 We could find only one other report of G morbillorum meningitis.3 As far as we are aware, ours is the first reported lethal case of infection due to this organism. Despite its rarity, our case suggests that the pathogenecity of G morbillorum should not be underestimated. SB
Debast, R Koot, J F G M Meis
Departments of Medical Microbiology and Pathology, University Hospital Nijmegen, PO Box 9101, 6500 HB Nijmegen, Netherlands 1
2
3
Omran Y, Wood CA. Endovascular infection and septic arthritis caused by Gemella morbillorum. Diagn Microbiol Infect Dis 1993; 16: 131-34. Maniglia AJ, Goodwin WJ, Arnold JE, Ganz E. Intracranial abscesses secondary to nasal, sinus, and orbital infections in adults and children. Arch Otolyarngol Head Neck Surg 1989; 115: 1424-29. Garavelli PL. Meningitis from Streptococcus morbillorum. Minerva Med 1990; 81: 69.
SIR-von Essen and colleagues report an infection in a elbow joint caused by G morbillorum. Though unusual there have been previous published case-reports of six endovascular infections and one of meningitis caused by
prosthetic
560
G morbillorum plus an additional case of septic arthritis.1 The septic arthritis developed in the wrist of a patient who also had an endovascular infection and it resolved during medical therapy for that other infection. In his report of 391 extrarespiratory isolates of viridans streptococci, Gallis also included two bone and joint isolates, the clinical significance of which was uncertain.2 Elting et aP have reported that 6 of 46 isolates causing streptococcal shock syndrome in cancer patients were identified as G morbillorum. G morbillorum and the only other member of the genus, G haemolysans, appear to cause a spectrum of infection similar to that seen with viridans streptococci. Endocarditis and bacteraemia predominate. Although most isolates are highly susceptible to penicillin, relative resistanceand tolerance44 have been demonstrated and some strains have been shown to be nutritionally variant.5 Most gemella isolates tested have shown synergy between penicillin or vancomycin and aminoglycosides.4 Until more is known about the response to treatment, the intensity and duration of therapy for serious infection caused by Gemella spp should follow guidelines similar to those established for viridans streptococcal endocarditis and should be directed by the degree of susceptibility to
penicillin.6 Craig A Wood Division of Infectious Diseases, Hahnemann Pennsylvania 19102, USA
1
2
3
4 5
6
University, Philadelphia,
Omran O, Wood CA. Endovascular infection and septic arthritis caused by Gemella morbillorum. Diagn Microbiol Infect Dis 1993; 16: 131-34. Gallis HA. Viridans and &bgr;-hemolytic (non-group A, B, and D) streptococci. In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases. New York: Churchill Livingston, 1990: 1563-72. Elting ES, Bodey GP, Keefe BH. Septicemia and shock syndrome due to viridans streptococci: a case control study of predisposing risk factors. Clin Infect Dis 14: 1201-07. Maxwell S. Endocarditis due to Streptococcus morbillorum. J Infect
1989; 18: 67-72. Coto H, Berk SL. Endocarditis caused by Streptococcus morbillorum. Am J Med Sci 1984; 287: 54-58. Bisno AL, Dismukes WE, Durack DT, et al. Antimicrobial treatment of infective endocarditis due to viridans streptococci, enterococci, and staphylococci. JAMA 1989; 261: 1471-77.
primary dengue 2 epidemic with spontaneous haemorrhagic manifestations
A
SIR-In
March-September, 1992, Townsville (population 100 000) in North Queensland, Australia, experienced an
epidemic of dengue fever caused by the serotype 2 virus. 616 patients had symptoms severe enough to seek medical attention. The most recent previous dengue epidemic, affecting the cities of Townsville and Cairns and the community on Thursday Island in the Torres Strait, had been of serotype 1 in 1981.1 A small outbreak occurred in 1990-91 and mainly affected Cairns and Thursday Island. The epidemic was first detected in early March and peaked in mid-May. All reported cases were serologically positive (395) or had symptoms and signs consistent with dengue fever, lived in the same household, or were closely associated with a serologically confirmed case, and had similar dates of onset (221). Fever, retro-orbital pain, headache, myalgia, and rash were common, and the overall frequency of spontaneous minor haemorrhagic manifestations, such as gingival bleeding, epistaxis, haematuria, or menorrhagia, was 21 % (table). No patient required admission. Cuba had an epidemic of dengue 1 in 1977, followed by a dengue 2 epidemic in 1981 with over 300 000 cases and 116 000