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Listeria and Mycobacteria Meningitis following Haemophilus influenzae pneumonia
Table 1 Symptoms of 15 adult patients with shigellosis* Symptom
# Patients
%
Diarrhea Abdominal pain Vomiting Fever Nausea Bloody diarrhea Tenesmus
14 11 9 8 7 7 2
93.3 73.3 60.0 53.3 46.7 46.7 13.3
* University of Illinois/Chicago Hospital
ease Control, 1,079 of which were reported from Illinois (8). Of these reported cases, 8,962 (51.3%) were in persons under 20 years of age. The highest single age incidence has been reported to be in 2-year-old children (6). Our 5-year survey in the two study laboratories reveals a cumulative percentage of 67% in the group over age 20, which is significantly higher than the proportion reported nationally (P < 0.001). This experience emphasizes that shigellosis cannot be considered solely a pediatric problem. Several reasons may account for these local trends. Shigellosis is known to be a serious problem in adult custodial institutions (9), in crowded low-socioeconomic populations (10), and in homosexual males (4). The UIC is in an urban, low-socioeconomic area of the city; Northwestern Memorial Hospital is one of the regional centers
for AIDS patients. We likely experienced some bias due to underreporting of pediatric cases, particularly in the period from 1982 to 1985. As shown in Figure 1, few cases of Shigella infections were reported in the <9-yearold-age group during this period. However, if only the results from 1986 and 1987 are considered, the incidence of shigellosis in patients under 9 years of age more closely resembles that reported nationally (40% for 1986 and 52% for 1987). In 1982 the percentage of Shigella isolates in the age group 30 to 39 was 60%; however, by 1986 the incidence dropped to 25% and to 12% in 1987. The percentage of isolates in the 20- to 29-year-old age group was more consistent from year to year, with a peak incidence in 1985. S. sonnei was our most common isolate, consistent with the nationwide experience (1, 6). The diversity of species in the 20- to 39-year-old groups likely is related to changing modes of acquiring the infection in the older age groups i.e., increased travel to endemic areas, homosexual activity, and exposure to ill children. Clinical microbiologists and infectious-disease clinicians should be aware of the changing epidemiology of shigellosis and the increased risk of infection in older age groups so that diagnoses are not missed.
References 1. Rosenberg, M. L. et al. 1976. Shigellosis in the United States: ten year re-
2.
3.
4.
5.
6.
7.
8.
9.
10.
view of nationwide surveillance, 1964-1973. Am. J. Epidemiol. 104:543-551. Dupont, H. L. 1985. Shigella species (bacillary dysentery), In G. Mandell, R. G. Douglas, Jr., and J. E. Bennett (ed.), Principles and practices of infectious diseases, 2nd ed. p. 1269-1274. John Wiley & Sons. New York. Weissman J. B., E. J. Gangarosa, and A. Schmerier. 1975. Shigellosis in day-care centers. Lancet i:88:90. Quinn, T. C. et al. 1983. The polymicrobial origin of intestinal infections in homosexual men. New Engl. J. Med. 309:576- 582. Black, R. E., F. C. Gunther, and P. A. Blake. 1978. Epidemiology of common-source outbreaks of shigellosis in the United States, 1961-t975. Am. J. Epidemiol. 108:45-47. Centers for Disease Control. 1985. Shigellosis-- United States 1984. Morbid. Mortal. Weekly Rep. 34:600601. Keusch, G. T. 1984. Enteric bacterial pathogens: Shigella, Campylobacter, Salmonella. In K. K. Holmes et al. (ed.), Sexually transmitted diseases, p. 429. McGraw-Hill, New York. Centers for Disease Control. 1987. Summary of notifiable diseases United States 1986. Morbid. Mortal. Weekly Rep. 35:3,8,10,36. Levine, M. M. et al. 1974. Shigellosis in custodial institutions. J. Pediatr. 84:803-806. Mosley, W. H., B. Adams, and E. D. Lyman. 1962. Epidemiologic and sociologic features of a large urban outbreak of shigellosis. J. Am. Med. Assoc. 182:1307-1311.
Case Report
Listeria and Mycobacteria Meningitis Following
Haemophilus influenzae Pneumonia Rita Koshinski, B.S. John Hasyn, M.S., S.M.(AAM) Departments of Laboratory Medicine and Pathology
Nick Burdash, Ph.D. Department of Microbiology and Immunology Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania 19131
174
0196-4399/88/$0.00 + 02.20
A 79-year-old male was admitted to the emergency room in acute respiratory distress. The patient had had several previous admissions, all of which were attributed to chronic obstructive pulmonary disease (COPD), pulmonary infections secondary to alcohol abuse, and poor nutrition. The patient was hypoxic and hypercapneic, therefore he was intubated and transferred to the intensive care unit, where aggressive intravenous bronchodilator and steroid therapies were initiated. Chest radiographs revealed right hilar pneumonia. Sputum Gram stains revealed numerous polymorphonuclear neutrophils (PMN)
© 1988 Elsevier Science PublishingCo., Inc.
and a moderate amount of gram-negative bacilli, which were later identified as Haemophilus influenzae. The organism was beta-lactamase negative, and appropriate antibiotic therapy including ampicillin was initiated. Treatment, in conjunction with continued respiratory therapy, resulted in progressive improvement. On day 9 the patient became febrile and disoriented with labored breathing, tachycardia, and elevated blood pressure. His condition deteriorated, and he had seizure-like episodes increasing in both intensity and frequency. His white blood cell count was 19,500/mm s, with
Clinical Microbiology Newsletter 10:22,1988
96% segmented PMNs. Cerebrospinal fluid (CSF) cell count showed 407 white blood cells (WBC)/mm 3, with 67% PMNs. CSF protein was 750 mg/dL, and glucose was 27 mg/dL. No organisms were detected by microscopy, but CSF and blood cultures grew small gram-positive diphtheroidike, beta-hemolytic coccobacilli. The organisms were identified as Listeria monocytogenes because they were motile, catalase-positive, and did not produce urease or reduce nitrates. Sputum and urine cultures were negative. Despite appropriate supportive and antimicrobial therapy, including both ampicillin and gentamicin, the patient's condition continued to worsen, and a second lumbar puncture was performed. CSF protein was 903 mg/dL, glucose was 37 mg/dL, and there were 4 WBCs/mm 3, with no organism seen by Gram or acid-fast stain. CSF cultures for bacteria, mycobacteria, and fungi were negative after 7 days. The patient died 2 weeks later. Permission for autopsy was refused. On the day the patient expired, growth was detected in the Bactec 12B vial (Johnston Laboratories, Inc., Towson, Md.), and the organism was identified as a member of the Mycobacterium avium complex (MAC).
Discussion Alcoholism increases the risk of H. influenzae pneumonia in adults (7), and L. monocytogenes and MAC are traditional agents of disease in immunosuppressed patients (2, 4, 5). Listeria and Mycobacterium are facultative intracellular parasites. With these organisms, the cell-mediated immune response plays the primary role in controlling disease, while humoral immunity is of lesser importance.
Septic Arthritis Caused by Mycobacterium f ortuitum George E. Buck, Ph.D. Phyllis Risch, M.T. (ASCP) Clinical Laboratory, NKC Hospitals, Inc. Louisville, Kentucky 40232 Gerard P. Rabalais, M.D. Department of Pediatrics University of Louisville School of Medicine Louisville, Kentucky 40202
Clinical Microbiology Newsletter 10:22,1988
was evident, HIV antibody testing was not performed, and no assessment of immune function was made. Whatever the reason for immunosuppression, especially in elderly patients with an already waning immune system, organisms that historically are opportunists in this situation should be considered. Multiple infections in these patients constitute a distinct possibility.
L. monocytogenes is ubiquitous in nature and can be cultured from soil, water, vegetation, and animals but remains an uncommon human pathogen. However, after Streptococcus pneumoniae, the organism is the most common cause of bacterial meningitis in persons over 60, and meningitis is the most commonly recognized form of listeriosis in this age group. Although meningitis does occur in persons without known predisposing factors, patients generally have some form of underlying disorder, such as diabetes, malignancy, alcoholism, or are undergoing some form of immunosuppressive therapy (2). Mortality rates range from 30 to 50% (8). There are no distinguishing clinical features of listerial meningitis, and definitive diagnosis depends upon laboratory detection and identification of the organism. MAC is also worldwide in distribution and is found in water, soil, and animals. The organism appears to be a fairly common agent of inapparent infections, as judged from skin test surveys. Other than Mycobacterium tuberculosis, MAC is the most frequently isolated mycobacterium in the United States (3, 9). It is responsible for increasing numbers of human disease in the U.S., and chronic pulmonary disease caused by this agent is found to be highest in elderly white males (6). Today MAC commonly causes disseminated infections in patients with AIDS and has been shown to infect up to 50% of these patients (1). In this case the geriatric patient was a likely candidate for all three infectious agents, having COPD, a history of alcohol abuse and poor nutrition, and an indirect history of immunosuppression based on intermittent steroid therapy. Since no indication of AIDS
References 1. Armstrong, D. J. et al. 1985. Treatment of infections in patients with the acquired immuno-deficiency syndrome. Ann. Intern. Med. 103:738-743. 2. Chemik, N. L., D. Armstrong, and G. Posner. 1973. Central nervous system infections in patients with cancer. Medicine 52:563-581. 3. Good, R. C. and D. E. Snider. Isolation of nontuberculous mycobacteria in the United States, 1980. J. Infect. Dis. 146:829-833. 4. Hawkins, C. C. et al. 1986. Mycobacterium avium complex infections in patients with the acquired immunodeficiency syndrome. Ann. Intern. Med. 105:184-188. 5. Horsburgh, C. R., Jr., et al. 1986. Mycobacterium avium-M, intracellulare isolates from patients with or without acquired immunodeficiency syndrome. Antimicrob. Agents Chemother. 30:955-957. 6. Iseman, M. D. et al. 1986. Mycobacterium avium complex (MAC) and human disease. Am. Rev. Resp. Dis. 134:821-822. 7. Levin, D. C. et al. 1977. Bacteremic Haemophilus influenzae pneumonia in adults. Am. J. Med. 62:219-224. 8. Nieman, R. E. and B. Lorber. 1980. Listeriosis in adults: a changing pattern. Report of eight cases and review of the literature, 1968-1978. Rev. Infect. Dis. 2:207-213. 9. Wolinsky, E. 1979. Nontuberculous mycobacteria and associated diseases. Am. Rev. Respir. Dis. 119:107-159.
A five-year-old male sustained a puncture wound with a stick on the medial aspect of his right knee. Two to three days later, the knee began to swell, and the patient was seen by his family physician, who removed a splinter from the puncture site and initiated therapy with cephalexin. Swelling continued, and the patient was referred to an orthopedic surgeon, who
noted a temperature of 38.6°C and aspirated 15 mL of turbid, yellow fluid. A Gram-stained smear of this fluid showed many polymorphonuclear leukocytes but no microorganisms. An acid-fast stain was also negative. The fluid was cultured for aerobes, anaerobes, and mycobacteria, and these cultures were all subsequently negative. The patient was admitted to the
© 1988 Elsevier Science Publishing Co., Inc.
0196-4399/88/$0.00 + 02.20
175
# Patients
%
Diarrhea Abdominal pain Vomiting Fever Nausea Bloody diarrhea Tenesmus
14 11 9 8 7 7 2
93.3 73.3 60.0 53.3 46.7 46.7 13.3
* University of Illinois/Chicago Hospital
ease Control, 1,079 of which were reported from Illinois (8). Of these reported cases, 8,962 (51.3%) were in persons under 20 years of age. The highest single age incidence has been reported to be in 2-year-old children (6). Our 5-year survey in the two study laboratories reveals a cumulative percentage of 67% in the group over age 20, which is significantly higher than the proportion reported nationally (P < 0.001). This experience emphasizes that shigellosis cannot be considered solely a pediatric problem. Several reasons may account for these local trends. Shigellosis is known to be a serious problem in adult custodial institutions (9), in crowded low-socioeconomic populations (10), and in homosexual males (4). The UIC is in an urban, low-socioeconomic area of the city; Northwestern Memorial Hospital is one of the regional centers
for AIDS patients. We likely experienced some bias due to underreporting of pediatric cases, particularly in the period from 1982 to 1985. As shown in Figure 1, few cases of Shigella infections were reported in the <9-yearold-age group during this period. However, if only the results from 1986 and 1987 are considered, the incidence of shigellosis in patients under 9 years of age more closely resembles that reported nationally (40% for 1986 and 52% for 1987). In 1982 the percentage of Shigella isolates in the age group 30 to 39 was 60%; however, by 1986 the incidence dropped to 25% and to 12% in 1987. The percentage of isolates in the 20- to 29-year-old age group was more consistent from year to year, with a peak incidence in 1985. S. sonnei was our most common isolate, consistent with the nationwide experience (1, 6). The diversity of species in the 20- to 39-year-old groups likely is related to changing modes of acquiring the infection in the older age groups i.e., increased travel to endemic areas, homosexual activity, and exposure to ill children. Clinical microbiologists and infectious-disease clinicians should be aware of the changing epidemiology of shigellosis and the increased risk of infection in older age groups so that diagnoses are not missed.
References 1. Rosenberg, M. L. et al. 1976. Shigellosis in the United States: ten year re-
2.
3.
4.
5.
6.
7.
8.
9.
10.
view of nationwide surveillance, 1964-1973. Am. J. Epidemiol. 104:543-551. Dupont, H. L. 1985. Shigella species (bacillary dysentery), In G. Mandell, R. G. Douglas, Jr., and J. E. Bennett (ed.), Principles and practices of infectious diseases, 2nd ed. p. 1269-1274. John Wiley & Sons. New York. Weissman J. B., E. J. Gangarosa, and A. Schmerier. 1975. Shigellosis in day-care centers. Lancet i:88:90. Quinn, T. C. et al. 1983. The polymicrobial origin of intestinal infections in homosexual men. New Engl. J. Med. 309:576- 582. Black, R. E., F. C. Gunther, and P. A. Blake. 1978. Epidemiology of common-source outbreaks of shigellosis in the United States, 1961-t975. Am. J. Epidemiol. 108:45-47. Centers for Disease Control. 1985. Shigellosis-- United States 1984. Morbid. Mortal. Weekly Rep. 34:600601. Keusch, G. T. 1984. Enteric bacterial pathogens: Shigella, Campylobacter, Salmonella. In K. K. Holmes et al. (ed.), Sexually transmitted diseases, p. 429. McGraw-Hill, New York. Centers for Disease Control. 1987. Summary of notifiable diseases United States 1986. Morbid. Mortal. Weekly Rep. 35:3,8,10,36. Levine, M. M. et al. 1974. Shigellosis in custodial institutions. J. Pediatr. 84:803-806. Mosley, W. H., B. Adams, and E. D. Lyman. 1962. Epidemiologic and sociologic features of a large urban outbreak of shigellosis. J. Am. Med. Assoc. 182:1307-1311.
Case Report
Listeria and Mycobacteria Meningitis Following
Haemophilus influenzae Pneumonia Rita Koshinski, B.S. John Hasyn, M.S., S.M.(AAM) Departments of Laboratory Medicine and Pathology
Nick Burdash, Ph.D. Department of Microbiology and Immunology Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania 19131
174
0196-4399/88/$0.00 + 02.20
A 79-year-old male was admitted to the emergency room in acute respiratory distress. The patient had had several previous admissions, all of which were attributed to chronic obstructive pulmonary disease (COPD), pulmonary infections secondary to alcohol abuse, and poor nutrition. The patient was hypoxic and hypercapneic, therefore he was intubated and transferred to the intensive care unit, where aggressive intravenous bronchodilator and steroid therapies were initiated. Chest radiographs revealed right hilar pneumonia. Sputum Gram stains revealed numerous polymorphonuclear neutrophils (PMN)
© 1988 Elsevier Science PublishingCo., Inc.
and a moderate amount of gram-negative bacilli, which were later identified as Haemophilus influenzae. The organism was beta-lactamase negative, and appropriate antibiotic therapy including ampicillin was initiated. Treatment, in conjunction with continued respiratory therapy, resulted in progressive improvement. On day 9 the patient became febrile and disoriented with labored breathing, tachycardia, and elevated blood pressure. His condition deteriorated, and he had seizure-like episodes increasing in both intensity and frequency. His white blood cell count was 19,500/mm s, with
Clinical Microbiology Newsletter 10:22,1988
96% segmented PMNs. Cerebrospinal fluid (CSF) cell count showed 407 white blood cells (WBC)/mm 3, with 67% PMNs. CSF protein was 750 mg/dL, and glucose was 27 mg/dL. No organisms were detected by microscopy, but CSF and blood cultures grew small gram-positive diphtheroidike, beta-hemolytic coccobacilli. The organisms were identified as Listeria monocytogenes because they were motile, catalase-positive, and did not produce urease or reduce nitrates. Sputum and urine cultures were negative. Despite appropriate supportive and antimicrobial therapy, including both ampicillin and gentamicin, the patient's condition continued to worsen, and a second lumbar puncture was performed. CSF protein was 903 mg/dL, glucose was 37 mg/dL, and there were 4 WBCs/mm 3, with no organism seen by Gram or acid-fast stain. CSF cultures for bacteria, mycobacteria, and fungi were negative after 7 days. The patient died 2 weeks later. Permission for autopsy was refused. On the day the patient expired, growth was detected in the Bactec 12B vial (Johnston Laboratories, Inc., Towson, Md.), and the organism was identified as a member of the Mycobacterium avium complex (MAC).
Discussion Alcoholism increases the risk of H. influenzae pneumonia in adults (7), and L. monocytogenes and MAC are traditional agents of disease in immunosuppressed patients (2, 4, 5). Listeria and Mycobacterium are facultative intracellular parasites. With these organisms, the cell-mediated immune response plays the primary role in controlling disease, while humoral immunity is of lesser importance.
Septic Arthritis Caused by Mycobacterium f ortuitum George E. Buck, Ph.D. Phyllis Risch, M.T. (ASCP) Clinical Laboratory, NKC Hospitals, Inc. Louisville, Kentucky 40232 Gerard P. Rabalais, M.D. Department of Pediatrics University of Louisville School of Medicine Louisville, Kentucky 40202
Clinical Microbiology Newsletter 10:22,1988
was evident, HIV antibody testing was not performed, and no assessment of immune function was made. Whatever the reason for immunosuppression, especially in elderly patients with an already waning immune system, organisms that historically are opportunists in this situation should be considered. Multiple infections in these patients constitute a distinct possibility.
L. monocytogenes is ubiquitous in nature and can be cultured from soil, water, vegetation, and animals but remains an uncommon human pathogen. However, after Streptococcus pneumoniae, the organism is the most common cause of bacterial meningitis in persons over 60, and meningitis is the most commonly recognized form of listeriosis in this age group. Although meningitis does occur in persons without known predisposing factors, patients generally have some form of underlying disorder, such as diabetes, malignancy, alcoholism, or are undergoing some form of immunosuppressive therapy (2). Mortality rates range from 30 to 50% (8). There are no distinguishing clinical features of listerial meningitis, and definitive diagnosis depends upon laboratory detection and identification of the organism. MAC is also worldwide in distribution and is found in water, soil, and animals. The organism appears to be a fairly common agent of inapparent infections, as judged from skin test surveys. Other than Mycobacterium tuberculosis, MAC is the most frequently isolated mycobacterium in the United States (3, 9). It is responsible for increasing numbers of human disease in the U.S., and chronic pulmonary disease caused by this agent is found to be highest in elderly white males (6). Today MAC commonly causes disseminated infections in patients with AIDS and has been shown to infect up to 50% of these patients (1). In this case the geriatric patient was a likely candidate for all three infectious agents, having COPD, a history of alcohol abuse and poor nutrition, and an indirect history of immunosuppression based on intermittent steroid therapy. Since no indication of AIDS
References 1. Armstrong, D. J. et al. 1985. Treatment of infections in patients with the acquired immuno-deficiency syndrome. Ann. Intern. Med. 103:738-743. 2. Chemik, N. L., D. Armstrong, and G. Posner. 1973. Central nervous system infections in patients with cancer. Medicine 52:563-581. 3. Good, R. C. and D. E. Snider. Isolation of nontuberculous mycobacteria in the United States, 1980. J. Infect. Dis. 146:829-833. 4. Hawkins, C. C. et al. 1986. Mycobacterium avium complex infections in patients with the acquired immunodeficiency syndrome. Ann. Intern. Med. 105:184-188. 5. Horsburgh, C. R., Jr., et al. 1986. Mycobacterium avium-M, intracellulare isolates from patients with or without acquired immunodeficiency syndrome. Antimicrob. Agents Chemother. 30:955-957. 6. Iseman, M. D. et al. 1986. Mycobacterium avium complex (MAC) and human disease. Am. Rev. Resp. Dis. 134:821-822. 7. Levin, D. C. et al. 1977. Bacteremic Haemophilus influenzae pneumonia in adults. Am. J. Med. 62:219-224. 8. Nieman, R. E. and B. Lorber. 1980. Listeriosis in adults: a changing pattern. Report of eight cases and review of the literature, 1968-1978. Rev. Infect. Dis. 2:207-213. 9. Wolinsky, E. 1979. Nontuberculous mycobacteria and associated diseases. Am. Rev. Respir. Dis. 119:107-159.
A five-year-old male sustained a puncture wound with a stick on the medial aspect of his right knee. Two to three days later, the knee began to swell, and the patient was seen by his family physician, who removed a splinter from the puncture site and initiated therapy with cephalexin. Swelling continued, and the patient was referred to an orthopedic surgeon, who
noted a temperature of 38.6°C and aspirated 15 mL of turbid, yellow fluid. A Gram-stained smear of this fluid showed many polymorphonuclear leukocytes but no microorganisms. An acid-fast stain was also negative. The fluid was cultured for aerobes, anaerobes, and mycobacteria, and these cultures were all subsequently negative. The patient was admitted to the
© 1988 Elsevier Science Publishing Co., Inc.
0196-4399/88/$0.00 + 02.20
175