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Pneumococcal cellulitis
Pneumococcal Cellulitis MICHEL DHAENE, MD,* JEAN-PIERRE THYS, MD,t ROBERT ASKENASI, MD,* CHARLES TOUSSAINT, MD* A 42-year-old man with pneumonia was admitted for rhabdomyolysis. Streptococcus pneumoniae was isolated from the cellulitis surrounding the muscular necrosis. Subcutaneous localisation of S. ~~eu~off~~e in the course of a septicemia has never been described, although rhabdomyolysis may be associated with bacterial infections. (AmJ Emerg Med 1986;4:225-226)
Streptococcus pneumoniae has rarely been identified as a causal microorganism of cellulitis. Only few cases have been reported, occurring chiefly in children and drug addicts. ‘Z We describe a case of pneumococcal associated
pneumonia with septicemia with rhabdomyolysis.
and
cellulitis,
CASE REPORT History A 42-year-old man, without past medical history but known to be an occasional drinker of alcoholic beverages, was admitted to the emergency department with fever and pain in right arm and leg. Eight days before admission, he developed asthenia, fever, and dry cough. According to his family, the patient remained bedridden and presented intermittent instuporation. Five days before admission, erythema and tenderness appeared on the extensor surface of right elbow and forearm, and on the lateral face of right thigh and buttock.
Physical Examination The patient was well oriented, but somewhat amnestic. He appeared pale and markedly dehydrated. Blood pressure was 100160 mm Hg, temperature 38”C, and respiratory rate 30imin. Inspiratory dry rales were heard over the lower half of the right lung. The external face of right elbow, forearm, hand, buttock, and thigh was painful and appeared swollen and purple. Muscles were very tender to palpation. A small (about 2 mm) serous bullous lesion was seen on the buttock.
From the Departments *Emergency Medicine, Belgium. Manuscript 1985.
received
of l Nephrology, Erasme Hospital,
September
tMicrobiology, and University of Brussels,
3, 1985; accepted
October
25,
Address reprint requests to Dr. Dhaene: rology, Hopital Erasme, Route de Lennik Belgium.
Department of Neph808, B-1070 Brussels,
Key Words: Cellulitis, coccus pneumoniae.
septicemia,
rhabdomyolysis,
Strepto-
Laboratory Data Erythrocyte sedimentation rate was I15 mm/hour, hematocrit was 30%, leukocyte B.C. count was 22,300/mm3 (96% neutrophils), blood urea was 32.5 mmolil (195 mg/dl), serum creatinine was 362.8 mol/l (4.1 mgidl), creatine phosphokinase (CPK) was 242 IU, glutamate-pyruvate transaminase (GPT) was 42 IU, and lactate dehydrogenase (LDH) was 370 IU. Other laboratory data included: sodium, I25 mEq/l; potassium, 4 mEq/l; chloride, 83 mEq/l; carbon dioxide, 18 mEq/l. On the second hospital day, calcium was 1.95 mEq/l (7.8 mg/dl), phosphorus was 0.84 mEq/l(2.6 mg/dl), and uric acid was 0.8 mEq/l (13.3 mg/dl). Urine was dark-colored, and urinalysis revealed few leukocytes and hyaline casts. The peroxydase reaction was positive, and myoglobinuria was measured at 1,702 mg/dl. Urinary sodium was I mEq/l. The results of an electrocardiograph (ECG) were normal, and chest x-ray film revealed inferior right lobe pneumonia. A radiograph of the right elbow disclosed only swollen soft tissues. Smear examination of a needle aspiration of the cellulitis showed Gram-positive diplococci; aerobic culture of blood and of this aspiration material yielded Streptococcus pneumoniae, and anaerobic cultures were negative.
Evolution The patient was treated with intravenous (IV) penicillin (4 x lo6 U/day) but remained subfebrile. On the sixth hospital day, a subcutaneous abscess of the right forearm was drained, and the temperature fell to normal. Culture of the pus removed was negative. Renal function rapidly returned to normal, and the physical condition of the patient improved markedly. He was discharged on the 21st hospital day, complaining of some stiffness of the right forearm.
DISCUSSION As suggested by a urinary sodium level of only 1 mEq/l, severe dehydration more than rhabdomyolysis, was probably the cause of the renal failure of this patient. Nevertheless, although moderate, rhabdomyolysis was indisputable and was attested to by the results of the physical examination and the myoglobinuria. The slightly elevated CPK levels could be explained by the delayed admission, given that serum CPK fell by 40% of the previous day’s value per subsequent day.3 Association of septicemic pneumococcal pneumonia with cellulitis and rhabdomyolysis is quite unusual. It is very likely that our patient developed a semi-comatose state, lying on his right side, with a resulting muscle damage caused by pressure-induced 225
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
n Volume
4, Number
ischemia. The injured tissues could then have been secondarily colonized by S. pneumoniae. However, although local tissue injury and edema could account for preferential metastatic foci in the case of anaerobic microorganism,4 subcutaneous seeding during pneumococcal bacteremia has not been described. Other possible mechanisms must be considered. As reported in the literature, rhabdomyolysis may be associated with non-clostridial bacteremic infections.5-‘2 Dehydration, hypoxia, acidosis, and hypophosphatemia, all features shared by our patient. are said to predispose to such complication. At present time, only one caseI of pneumococcal sepsis associated with rhabdomyolysis has been reported, but muscle biopsy had failed to demonstrate Streptocouus pnerrmoniae in that patient. In our case, the strictly unilateral distribution of lesions strongly favors tissue compression as the etiology of the muscle damage. Finally, a last sequence of events may be discussed. Cellulitis and myositis could have been the initial injury, leading subsequently to septicemia and secondary pneumonia. However, the history of our patient definitely excludes such possibility. REFERENCES 1. Lewis RJ, Richmond AS, McGrory moniae cellulitis in drug addicts.
226
JP. Diplococcus pneuJAMA 1975;232:54-55.
3 n May 1986
2. Fleisher G, Ludwig S, Lampos J. Cellulitis. Bacterial etiology, clinical features, and laboratory findings. J Pediatr 1980;97:591-593. 3. Gabow PA, Kaehny WD. Kellemer SP. The spectrum of rhabdomyolysis. Medicine 1982;61:141-151. 4. Maclennan JD. The histotoxic clostridial infections of man. Bacterial Rev 1962;26:177. 5. Kalish SB. Tallman MS, Cook FV, et al. Polymicrobial septicemia associated with rhabdomyofosis, myoglobinuria, and acute renal failure. Arch Intern Med 1982;142:133134. 6. Elnahas AM, Farrington K, Quyyums S, et al. Rhabdomyolysis and systemic infection. Br Med J 1983;286:349-350. 7. Friedman HM. Legionnaire’s disease in non-legionnaires. Ann Intern Med 1978;88:294. 8. Posner MR, Caudill MA, Brass R, et al. Legronnarre’s disease associated with rhabdomyolysis and myoglobinuria. Arch Intern Med 1980;140:848. 9. Svane S. Peracute spontaneous streptococcal Acta Chir Stand 1971;137:1553-1355.
myositis.
10. Timmis A, Nyholm E. Dawson RJ. A case of haemophilus parainfluenzae meningitis in an adult associated with acute myositis. Postgrad Med J 1980;56:117-120. 11. Heinrich WL, Prophet D, Knochel JP. Rhabdomyolysis ciated with Escherichia co/i septicemia. South 1980;73:936-937.
assoMed J
12. Adamski GB, Garin EH. Batlinger non-suppurative myositis with cemia. J Pediatr 1980;96:694-697.
WE, et al. Generalized staphylococcal septi-
13. Chun CH, Raff MJ. Rhabdomyolysis mococcal sepsis. Diagn Microbial 261.
associated with pneuInfect Dis. 1985;3:257-
Streptococcus pneumoniae has rarely been identified as a causal microorganism of cellulitis. Only few cases have been reported, occurring chiefly in children and drug addicts. ‘Z We describe a case of pneumococcal associated
pneumonia with septicemia with rhabdomyolysis.
and
cellulitis,
CASE REPORT History A 42-year-old man, without past medical history but known to be an occasional drinker of alcoholic beverages, was admitted to the emergency department with fever and pain in right arm and leg. Eight days before admission, he developed asthenia, fever, and dry cough. According to his family, the patient remained bedridden and presented intermittent instuporation. Five days before admission, erythema and tenderness appeared on the extensor surface of right elbow and forearm, and on the lateral face of right thigh and buttock.
Physical Examination The patient was well oriented, but somewhat amnestic. He appeared pale and markedly dehydrated. Blood pressure was 100160 mm Hg, temperature 38”C, and respiratory rate 30imin. Inspiratory dry rales were heard over the lower half of the right lung. The external face of right elbow, forearm, hand, buttock, and thigh was painful and appeared swollen and purple. Muscles were very tender to palpation. A small (about 2 mm) serous bullous lesion was seen on the buttock.
From the Departments *Emergency Medicine, Belgium. Manuscript 1985.
received
of l Nephrology, Erasme Hospital,
September
tMicrobiology, and University of Brussels,
3, 1985; accepted
October
25,
Address reprint requests to Dr. Dhaene: rology, Hopital Erasme, Route de Lennik Belgium.
Department of Neph808, B-1070 Brussels,
Key Words: Cellulitis, coccus pneumoniae.
septicemia,
rhabdomyolysis,
Strepto-
Laboratory Data Erythrocyte sedimentation rate was I15 mm/hour, hematocrit was 30%, leukocyte B.C. count was 22,300/mm3 (96% neutrophils), blood urea was 32.5 mmolil (195 mg/dl), serum creatinine was 362.8 mol/l (4.1 mgidl), creatine phosphokinase (CPK) was 242 IU, glutamate-pyruvate transaminase (GPT) was 42 IU, and lactate dehydrogenase (LDH) was 370 IU. Other laboratory data included: sodium, I25 mEq/l; potassium, 4 mEq/l; chloride, 83 mEq/l; carbon dioxide, 18 mEq/l. On the second hospital day, calcium was 1.95 mEq/l (7.8 mg/dl), phosphorus was 0.84 mEq/l(2.6 mg/dl), and uric acid was 0.8 mEq/l (13.3 mg/dl). Urine was dark-colored, and urinalysis revealed few leukocytes and hyaline casts. The peroxydase reaction was positive, and myoglobinuria was measured at 1,702 mg/dl. Urinary sodium was I mEq/l. The results of an electrocardiograph (ECG) were normal, and chest x-ray film revealed inferior right lobe pneumonia. A radiograph of the right elbow disclosed only swollen soft tissues. Smear examination of a needle aspiration of the cellulitis showed Gram-positive diplococci; aerobic culture of blood and of this aspiration material yielded Streptococcus pneumoniae, and anaerobic cultures were negative.
Evolution The patient was treated with intravenous (IV) penicillin (4 x lo6 U/day) but remained subfebrile. On the sixth hospital day, a subcutaneous abscess of the right forearm was drained, and the temperature fell to normal. Culture of the pus removed was negative. Renal function rapidly returned to normal, and the physical condition of the patient improved markedly. He was discharged on the 21st hospital day, complaining of some stiffness of the right forearm.
DISCUSSION As suggested by a urinary sodium level of only 1 mEq/l, severe dehydration more than rhabdomyolysis, was probably the cause of the renal failure of this patient. Nevertheless, although moderate, rhabdomyolysis was indisputable and was attested to by the results of the physical examination and the myoglobinuria. The slightly elevated CPK levels could be explained by the delayed admission, given that serum CPK fell by 40% of the previous day’s value per subsequent day.3 Association of septicemic pneumococcal pneumonia with cellulitis and rhabdomyolysis is quite unusual. It is very likely that our patient developed a semi-comatose state, lying on his right side, with a resulting muscle damage caused by pressure-induced 225
AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
n Volume
4, Number
ischemia. The injured tissues could then have been secondarily colonized by S. pneumoniae. However, although local tissue injury and edema could account for preferential metastatic foci in the case of anaerobic microorganism,4 subcutaneous seeding during pneumococcal bacteremia has not been described. Other possible mechanisms must be considered. As reported in the literature, rhabdomyolysis may be associated with non-clostridial bacteremic infections.5-‘2 Dehydration, hypoxia, acidosis, and hypophosphatemia, all features shared by our patient. are said to predispose to such complication. At present time, only one caseI of pneumococcal sepsis associated with rhabdomyolysis has been reported, but muscle biopsy had failed to demonstrate Streptocouus pnerrmoniae in that patient. In our case, the strictly unilateral distribution of lesions strongly favors tissue compression as the etiology of the muscle damage. Finally, a last sequence of events may be discussed. Cellulitis and myositis could have been the initial injury, leading subsequently to septicemia and secondary pneumonia. However, the history of our patient definitely excludes such possibility. REFERENCES 1. Lewis RJ, Richmond AS, McGrory moniae cellulitis in drug addicts.
226
JP. Diplococcus pneuJAMA 1975;232:54-55.
3 n May 1986
2. Fleisher G, Ludwig S, Lampos J. Cellulitis. Bacterial etiology, clinical features, and laboratory findings. J Pediatr 1980;97:591-593. 3. Gabow PA, Kaehny WD. Kellemer SP. The spectrum of rhabdomyolysis. Medicine 1982;61:141-151. 4. Maclennan JD. The histotoxic clostridial infections of man. Bacterial Rev 1962;26:177. 5. Kalish SB. Tallman MS, Cook FV, et al. Polymicrobial septicemia associated with rhabdomyofosis, myoglobinuria, and acute renal failure. Arch Intern Med 1982;142:133134. 6. Elnahas AM, Farrington K, Quyyums S, et al. Rhabdomyolysis and systemic infection. Br Med J 1983;286:349-350. 7. Friedman HM. Legionnaire’s disease in non-legionnaires. Ann Intern Med 1978;88:294. 8. Posner MR, Caudill MA, Brass R, et al. Legronnarre’s disease associated with rhabdomyolysis and myoglobinuria. Arch Intern Med 1980;140:848. 9. Svane S. Peracute spontaneous streptococcal Acta Chir Stand 1971;137:1553-1355.
myositis.
10. Timmis A, Nyholm E. Dawson RJ. A case of haemophilus parainfluenzae meningitis in an adult associated with acute myositis. Postgrad Med J 1980;56:117-120. 11. Heinrich WL, Prophet D, Knochel JP. Rhabdomyolysis ciated with Escherichia co/i septicemia. South 1980;73:936-937.
assoMed J
12. Adamski GB, Garin EH. Batlinger non-suppurative myositis with cemia. J Pediatr 1980;96:694-697.
WE, et al. Generalized staphylococcal septi-
13. Chun CH, Raff MJ. Rhabdomyolysis mococcal sepsis. Diagn Microbial 261.
associated with pneuInfect Dis. 1985;3:257-