Pseudomonas stutzeri infection of the hip joint

Letters to the Editor

I83

P s e u d o m o n a s s t u t z e r i infection of the hip joint

Accepted for publication I3 August I985 Sir, Pseudomonas stutzeri has from time to time been isolated from clinical specimens but its r61e as a pathogen has not always been clear. 1-4 Recently, we recovered P. stutzeri from a destructive lesion of the hip joint of a severely debilitated diabetic man under circumstances in which no other pathogen could be implicated. T h e patient, a 37-year-old chronic alcoholic and diabetic man, presented with constant pain and limited movements in the left shoulder and left hip joints. He was apyrexial and showed no other clinical abnormality. X-ray examination disclosed translucent areas over the metaphyseal region of the left shoulder and the head and neck of the left femur. Haematological, serological and biochemical tests gave normal values apart from leucocytosis (total leucocyte count I6.6 x I09/1), an erythrocyte sedimentation rate of I6 × IO-3 m / h , and a blood glucose concentration of I3"9 mmol/1. Surgical exploration of the hip joint disclosed a large quantity of pus within the joint capsule. Bacteriological examination of this material, including microscopy and cultures for aerobic, anaerobic and acid-fast bacteria, as well as serological examinations for virus infections, all gave negative results. Following a second exploratory operation 7 weeks later, however a Gramnegative bacillus was isolated in pure culture from a sample of synovial m e m b r a n e incubated for 2 days at 37 °C on blood agar. T h e organism was catalase-positive, oxidase-positive, aerobic with atypical adherent wrinkled colonies and did not ferment lactose. Citrate, H2S and indole tests were negative. W h e n tested by the A P I 20E system it gave the pattern oooi004 and was identified as P. stutzeri T h e isolate was fully susceptible to gentamicin, amikacin, netilmicin, tobramycin, ceftazidime, latamoxef, piperacillin and ticarcillin; partially susceptible to amoxycillin and trimethoprim, but resistant to cephazolin, cefuroxime and cefoxitin. Histological examination of excised joint tissue indicated a destructive process accompanied by non-specific inflammatory changes. In addition to Septopal (gentamicin) chains placed in the hip joint cavity at the time of operation, treatment for P. stutzeri infection was instituted with intravenous ceftazidime 2 g, three times daily. Within a few days of beginning treatment, the condition of the patient improved considerably and the erythrocyte sedimentation rate fell to 5 x Io-~ m / h , over the next few weeks. After 2 weeks treatment with ceftazidime, total hip replacement was performed by insertion of a Hastings prosthesis. At this stage the joint appeared healthy without any signs of inflammation and bacteriological examination of excised tissue gave negative results. T w o weeks after insertion of the prosthesis the patient was discharged from

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Letters to the Editor

hospital with only slight residual pain and stiffness of the hip. T h e pain and stiffness o f his left shoulder also improved following therapy with ceftazidime. Hospital of S t Cross Barby Road Rugby, C V 2 2 5 P X

Irene Thangkhiew

References I. Von Graevenitz A. Pseudomonasstutzeri isolated from clinical specimens. Am J Clin Pathol 1965; 43: 357-360. 2. Lapage SP, Hill LR, Reeve JD: Pseudomonas stutzeri in pathological material. J Med Microbiol 1968; I : 195-2o2. 3, Gilardi GL. Infrequently encountered pseudomonas species causing human infections. Ann Int Med 1972; 77: 2I i-2I 5. 4. Keys, TF, Melton LJ III, Maker MD, Ilstrup DM. A suspected hospital outbreak of pseudobacteraemia due to Pseudomonas stutzeri. J. Inf Dis I983; x47: 489-493-

Infective endocarditis presenting with back pain and stroke Accepted for publication 2 September 1985 Sir, Infective endocarditis m a y have m a n y different clinical manifestations. 1-4 Recognition of these should lead to earlier diagnosis. W e wish to report on infective endocarditis, presenting with a stroke, in a y o u n g w o m a n w h o had a history of recent low back pain. T h e s e clinical features resolved with antibiotic treatment. A 35-year-old w o m a n was admitted to hospital following s u d d e n onset of aphasia and right-sided hemiplegia. F o r 5 days she had complained of low back pain. Previously she had been well and was not taking any medication. She had had no recent dental or surgical p r o c e d u r e s ; there was no history o f back injury. O n examination she was pyrexial. T h e r e was no clubbing of the fingers, splinter haemorrhages or R o t h ' s spots. A late systolic m u r m u r with a systolic click could be heard in the mitral area. H e r chest was clear. H e r spleen was not palpable. She had expressive aphasia, right-sided u p p e r m o t o r n e u r o n e facial weakness and weakness of the right arm and leg. T h e r e was no tenderness over the l u m b a r spine and a full range of spinal m o v e m e n t s was elicited. Investigations revealed haemoglobin i i . o g / d l , white blood cell count IO"5 × 109/1 and E S R lO4 m m / h . Tests for auto-antibodies were negative. T h e urine was normal. Blood cultures yielded Streptococcus sanguis from four bottles. Chest X - r a y and l u m b a r spine X-rays were normal; X-rays of the teeth revealed no evidence of periodontal disease. An echocardiogram showed mitral valve prolapse, b u t neither vegetations nor clots were seen. A computerised t o m o g r a m of the brain showed a left-sided parietal haematoma compatible with the diagnosis of a mycotic aneurysm. T h e patient was treated with intravenous benzylpenicillin and gentamicin. F o u r weeks later she had m a d e a good recovery, with normal p o w e r returning