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Pasteurella multocida Meningitis Following Orbital Exenteration
698
AMERICAN JOURNAL OF OPHTHALMOLOGY
References 1. Schuman, J. S., Orellana, J., Friedman, A. H., and Teich, S. A.: Acquired immunodeficiency syn drome (AIDS). Surv. Ophthalmol. 31:384, 1987. 2. Kohn, S. R.: Molluscum contagiosum in pa tients with acquired immunodeficiency syndrome. Arch. Ophthalmol. 105:458, 1987. 3. Fujikawa, L. S., Schwartz, L. K., and Rosenbaum, E. H.: Acquired immunodeficiency syndrome associated with Burkitt's lymphoma presenting with ocular findings. Ophthalmology 90(suppl.):50, 1983. 4. Jakobiec, F. A., and Font, R. L.: Orbit. In Spencer, W. H. (ed.): Ophthalmic Pathology. Phila delphia, W. B. Saunders Company, 1986, p. 2674. 5. Kennerdell, J. S., and Dresner, S. C : The non specific orbital inflammatory syndromes. Surv. Oph thalmol. 29:93, 1984.
Pasteurella multocida Meningitis Following Orbital Exenteration Peter J. D o l m a n , M . D . , Shereen Ezzat, M . D . , Jack Rootman, M . D . , and William R. B o w i e , M . D . Department of Ophthalmology (P.J.D. and J.R.), and Division of Infectious Diseases (S.E. and W.R.B.), Department of Medicine, Faculty of Medicine, Uni versity of British Columbia. Inquiries to William R. Bowie, M.D., G. F. Strong Research Laboratory, Vancouver General Hospital, Heather St., Vancouver, B.C., V5Z 1M9, Canada. Pasteurella multocida, a commensal in the upper respiratory tract of mammals and birds, is a frequent cause of infection in animals. 1 Rarely, humans are infected from animal bites or close contact with household pets. 1,2 Pasteu rella multocida meningitis has been reported after compound skull fractures, intracranial surgery, and ethmoid sinus surgery. 3 We en countered a case following orbital surgery. Without prophylactic antibiotics, a 34-yearold man underwent exenteration of his right orbit for a long-standing, progressive orbital myxoid liposarcoma. The exenteration in volved all soft tissues to the superior orbital fissure and optic canal as well as 2 cm of the lateral orbital bony margin and a portion of the anterior temporalis muscle. Upper and lower eyelid skin flaps were preserved to help line the socket. The orbital lateral rim was reconstruct ed and the orbital cavity skin grafted.
June, 1988
Thirty-six hours postoperatively, he devel oped occipital pain and numbness, low back pain, and a fever of 39.2 C. Examination dis closed marked neck stiffness with a positive Kernig's sign, but no focal neurologic signs. The surgical wound was moderately edematous and erythematous, but there was minimal wound drainage. Blood tests showed a leukocytosis. Cranial computed tomography did not show a wound, temporalis fossa, or intracranial abscess. Cerebrospinal fluid was cloudy with an opening pressure of 19.5 cm H 2 0 , protein level of 2,220 mg/1, and glucose level of 3.0 u.mol/1 (blood glucose level, 7.9 (xmol/1). It contained 2.9 x 106/1 white blood cells with 71% granulocytes, 5% lymphocytes, and 24% monocytes, but no bacteria on Gram stain. Intravenous cloxacillin (2 g every four hours) and cefotaxime (2 g every six hours) were started. Within 12 hours, the neck pain and stiffness had lessened and his temperature re turned to normal. Cerebrospinal fluid cultures grew P. multocida, sensitive to ampicillin, peni cillin, chloramphenicol, erythromycin, and cefotaxime. The wound grew only Staphylococcus epidermidis. Three blood cultures were nega tive. Treatment was thus changed to intrave nous penicillin (3 million units every four hours), but because of intolerance was later switched to intravenous and then oral chloram phenicol (500 mg every six hours) to complete 14 days of antibiotics. The patient remained well after treatment. 2733 The patient owned a cat and a dog, which he nuzzled affectionately. The night before sur gery he stayed with a friend whose dog licked his face and beard repeatedly. Oropharyngeal swabs from these pets yielded P. multocida from the cat only. Pasteurella multocida is a small, nonmotile gram-negative coccobacillus isolated from the upper respiratory tract of 50% to 70% of healthy, domestic cats. 1 Unlike enteric gramnegative bacteria, it does not grow on MacConkey's agar 2 and is inhibited by penicil lin. 1 It is resistant to erythromycin and aminoglycosides. 1 Chloramphenicol is the drug of choice in patients allergic to penicillin. There are no reports of treatment with the newer cephalosporins. In the review by Weber and associates 4 of 34 cases of P. multocida infection, 21 patients had cellulitis. Those who contracted meningitis were either young (50% less than 1 year old) or elderly (30% over 60 years old). Our case is
Vol. 105, No. 6
Letters to the Journal
699
A 34-year-old woman had a seven-year histo ry of hyperthyroidism and a five-year history of bilateral proptosis with intermittent spontane ous subluxation of both globes in front of the eyelids. The patient was able to revert the eyelids manually and so did not seek medical attention for this problem. Two years before we examined her she had References been involved in a disagreement with her hus band, who struck her about the right eye. 1. Francis, D. P., Holmes, M. A., and Brandon, Following this she noted improvement of the G.: Pasteurella multocida infections after domestic ani proptosis on that side, and no further episodes mal bites and scratches. JAMA 233:42, 1975. of subluxation of the globe. However, she con 2. Boyce, J. M.: Pasteurella species. In Mandell, G. tinued to have subluxation of the left globe, C., Douglas, R. G., and Bennett, J. E. (eds.): Princi which became increasingly frequent and more ples and Practice of Infectious Diseases, ed. 2. New difficult to reverse. The patient recognized the York, John Wiley & Sons, 1979, p. 1294. therapeutic ocular effects achieved by the blow 3. Permezel, J. M. H., Smith, C. C , Fint, E., and to her right eye, and would occasionally taunt Young, H. A.: Opportunistic Pasteurella multocida her husband to similarly "fix" her left eye. He meningitis. J. Laryngol. Otol. 98:939, 1984. 4. Weber, D. J., Wolfson, J. S., Swartz, M. N., and attempted this during another episode of do Hooper, D. C : Pasteurella multocida infections. Re mestic violence, but instead his blow resulted port of 34 cases and review of the literature. Medi in a fracture of the patient's nose. Shortly cine 63:133, 1984. thereafter, she and her husband were separat ed. The patient then sought consultation. Exophthalmometry disclosed readings of 23 mm on the right side and 28 mm on the left. Pal Traumatic Orbital Decompression pebral fissures were 12 mm on the right and 16 mm on the left (Fig. 1). Orbital computed to Robert C. Kersten, M.D., mography demonstrated a blowout fracture of and Dwight R. Kulwin, M.D. the right orbital floor with herniation of the University of Cincinnati Hospital. orbital contents into the maxillary antrum (Fig. 2). We discussed treatment options of orbital Inquiries to Robert C. Kersten, M.D., University of Cincinnati Hospital, Eden and Bethesda Avenues, Cincin decompression or lateral tarsorrhaphy for man nati, OH 45267. agement of her left eye. She elected to undergo unusual because of the patient's age and lack of skin involvement. The portal of entry was un doubtedly the exposed surgical site. Coloniza tion probably took place in the oropharynx or conjunctiva.
Fig. 1 (Kersten and Kulwin). Note the asymmetry of blow to the right orbit.
iral fissures (left), and proptosis (right) following a
AMERICAN JOURNAL OF OPHTHALMOLOGY
References 1. Schuman, J. S., Orellana, J., Friedman, A. H., and Teich, S. A.: Acquired immunodeficiency syn drome (AIDS). Surv. Ophthalmol. 31:384, 1987. 2. Kohn, S. R.: Molluscum contagiosum in pa tients with acquired immunodeficiency syndrome. Arch. Ophthalmol. 105:458, 1987. 3. Fujikawa, L. S., Schwartz, L. K., and Rosenbaum, E. H.: Acquired immunodeficiency syndrome associated with Burkitt's lymphoma presenting with ocular findings. Ophthalmology 90(suppl.):50, 1983. 4. Jakobiec, F. A., and Font, R. L.: Orbit. In Spencer, W. H. (ed.): Ophthalmic Pathology. Phila delphia, W. B. Saunders Company, 1986, p. 2674. 5. Kennerdell, J. S., and Dresner, S. C : The non specific orbital inflammatory syndromes. Surv. Oph thalmol. 29:93, 1984.
Pasteurella multocida Meningitis Following Orbital Exenteration Peter J. D o l m a n , M . D . , Shereen Ezzat, M . D . , Jack Rootman, M . D . , and William R. B o w i e , M . D . Department of Ophthalmology (P.J.D. and J.R.), and Division of Infectious Diseases (S.E. and W.R.B.), Department of Medicine, Faculty of Medicine, Uni versity of British Columbia. Inquiries to William R. Bowie, M.D., G. F. Strong Research Laboratory, Vancouver General Hospital, Heather St., Vancouver, B.C., V5Z 1M9, Canada. Pasteurella multocida, a commensal in the upper respiratory tract of mammals and birds, is a frequent cause of infection in animals. 1 Rarely, humans are infected from animal bites or close contact with household pets. 1,2 Pasteu rella multocida meningitis has been reported after compound skull fractures, intracranial surgery, and ethmoid sinus surgery. 3 We en countered a case following orbital surgery. Without prophylactic antibiotics, a 34-yearold man underwent exenteration of his right orbit for a long-standing, progressive orbital myxoid liposarcoma. The exenteration in volved all soft tissues to the superior orbital fissure and optic canal as well as 2 cm of the lateral orbital bony margin and a portion of the anterior temporalis muscle. Upper and lower eyelid skin flaps were preserved to help line the socket. The orbital lateral rim was reconstruct ed and the orbital cavity skin grafted.
June, 1988
Thirty-six hours postoperatively, he devel oped occipital pain and numbness, low back pain, and a fever of 39.2 C. Examination dis closed marked neck stiffness with a positive Kernig's sign, but no focal neurologic signs. The surgical wound was moderately edematous and erythematous, but there was minimal wound drainage. Blood tests showed a leukocytosis. Cranial computed tomography did not show a wound, temporalis fossa, or intracranial abscess. Cerebrospinal fluid was cloudy with an opening pressure of 19.5 cm H 2 0 , protein level of 2,220 mg/1, and glucose level of 3.0 u.mol/1 (blood glucose level, 7.9 (xmol/1). It contained 2.9 x 106/1 white blood cells with 71% granulocytes, 5% lymphocytes, and 24% monocytes, but no bacteria on Gram stain. Intravenous cloxacillin (2 g every four hours) and cefotaxime (2 g every six hours) were started. Within 12 hours, the neck pain and stiffness had lessened and his temperature re turned to normal. Cerebrospinal fluid cultures grew P. multocida, sensitive to ampicillin, peni cillin, chloramphenicol, erythromycin, and cefotaxime. The wound grew only Staphylococcus epidermidis. Three blood cultures were nega tive. Treatment was thus changed to intrave nous penicillin (3 million units every four hours), but because of intolerance was later switched to intravenous and then oral chloram phenicol (500 mg every six hours) to complete 14 days of antibiotics. The patient remained well after treatment. 2733 The patient owned a cat and a dog, which he nuzzled affectionately. The night before sur gery he stayed with a friend whose dog licked his face and beard repeatedly. Oropharyngeal swabs from these pets yielded P. multocida from the cat only. Pasteurella multocida is a small, nonmotile gram-negative coccobacillus isolated from the upper respiratory tract of 50% to 70% of healthy, domestic cats. 1 Unlike enteric gramnegative bacteria, it does not grow on MacConkey's agar 2 and is inhibited by penicil lin. 1 It is resistant to erythromycin and aminoglycosides. 1 Chloramphenicol is the drug of choice in patients allergic to penicillin. There are no reports of treatment with the newer cephalosporins. In the review by Weber and associates 4 of 34 cases of P. multocida infection, 21 patients had cellulitis. Those who contracted meningitis were either young (50% less than 1 year old) or elderly (30% over 60 years old). Our case is
Vol. 105, No. 6
Letters to the Journal
699
A 34-year-old woman had a seven-year histo ry of hyperthyroidism and a five-year history of bilateral proptosis with intermittent spontane ous subluxation of both globes in front of the eyelids. The patient was able to revert the eyelids manually and so did not seek medical attention for this problem. Two years before we examined her she had References been involved in a disagreement with her hus band, who struck her about the right eye. 1. Francis, D. P., Holmes, M. A., and Brandon, Following this she noted improvement of the G.: Pasteurella multocida infections after domestic ani proptosis on that side, and no further episodes mal bites and scratches. JAMA 233:42, 1975. of subluxation of the globe. However, she con 2. Boyce, J. M.: Pasteurella species. In Mandell, G. tinued to have subluxation of the left globe, C., Douglas, R. G., and Bennett, J. E. (eds.): Princi which became increasingly frequent and more ples and Practice of Infectious Diseases, ed. 2. New difficult to reverse. The patient recognized the York, John Wiley & Sons, 1979, p. 1294. therapeutic ocular effects achieved by the blow 3. Permezel, J. M. H., Smith, C. C , Fint, E., and to her right eye, and would occasionally taunt Young, H. A.: Opportunistic Pasteurella multocida her husband to similarly "fix" her left eye. He meningitis. J. Laryngol. Otol. 98:939, 1984. 4. Weber, D. J., Wolfson, J. S., Swartz, M. N., and attempted this during another episode of do Hooper, D. C : Pasteurella multocida infections. Re mestic violence, but instead his blow resulted port of 34 cases and review of the literature. Medi in a fracture of the patient's nose. Shortly cine 63:133, 1984. thereafter, she and her husband were separat ed. The patient then sought consultation. Exophthalmometry disclosed readings of 23 mm on the right side and 28 mm on the left. Pal Traumatic Orbital Decompression pebral fissures were 12 mm on the right and 16 mm on the left (Fig. 1). Orbital computed to Robert C. Kersten, M.D., mography demonstrated a blowout fracture of and Dwight R. Kulwin, M.D. the right orbital floor with herniation of the University of Cincinnati Hospital. orbital contents into the maxillary antrum (Fig. 2). We discussed treatment options of orbital Inquiries to Robert C. Kersten, M.D., University of Cincinnati Hospital, Eden and Bethesda Avenues, Cincin decompression or lateral tarsorrhaphy for man nati, OH 45267. agement of her left eye. She elected to undergo unusual because of the patient's age and lack of skin involvement. The portal of entry was un doubtedly the exposed surgical site. Coloniza tion probably took place in the oropharynx or conjunctiva.
Fig. 1 (Kersten and Kulwin). Note the asymmetry of blow to the right orbit.
iral fissures (left), and proptosis (right) following a