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Ralstonia pickettii involved in spinal osteitis in an immunocompetent adult
352
Letters to the Editor
Ralstonia pickettii Involved in Spinal Osteitis in an Immunocompetent Adult Sir,
Ralstonia pickettii is a non-fermenting, Gram-negative rod that is found in water and soil and on plants, fruits and vegetables. 1 Bacteraemia and pyuria due to this rarely pathogenic organism have been infrequently reported, and then associated with foreign material or contamination of material supposed to be sterile. 2 In 1992 the organism was transferred from the genus Pseudomonas RNA homology group II to the genus Burkholderia. 3 Recently, it was transferred to the new genus Ralstonia. 4 We describe a case of a thoracic vertebral osteitis in an immunocompetent patient, in which R. pickettii was involved. A 40-year-old, previously fit immnnocompetent female was hospitalized for investigation of a suspected vertebral tumour. Eight months previously, back pains had begun after ordinary physical exercise and became more intense with time. Clinical examination revealed circumscribed tenderness over the middle and lower end of the thoracic spine. Isotope bone scanning showed multiple hot spots in T7, Tg, T12, L2 and L3 vertebrae and the sternal end of the right first and second rib. Thoracic spine X-ray showed destruction in the body of T7 and T9 vertebrae. Magnetic resonance imaging (MRI) showed osteitislfl;e changes in T7 and T9 vertebral bodies, combined with surrounding minor soft tissue swelling but no involvement of the intervertebral discs. Laboratory examination revealed a leucocyte count of 11.2 x 109/1 (normal 4 . 0 - 1 1 . 0 x 109/1) with normal differential count. C-reactive protein and alkaline phosphatase were within the normal range, anti-streptolysin O and anti-streptococcal deoxyribonuclease B reactions were normal and rheumatoid factor was negative. Bone m a r r o w cytology was normal. A primary turnout was excluded. An open biopsy of the seventh vertebral body was taken and showed mild osteitis. Ralstonia pickettii was isolated from intraoperative bone material. In the agar disc diffusion test performed on MuellerHinton agar, the organism was susceptible to ampicillin, mezlocillin, piperacillin, cefoxitin, cefotaxime, tetracycline, trimethoprim-sulfamethoxazole, and ciprofloxacin. Staphylococcus epidermidis was also isolated but only from a swab taken intraoperatively. In addition, Propionibacterium acnes was isolated from intraoperatively obtained bone material. Therapy consisted of a 12-week course of orally administered ciprofloxacin (500 mg twice daily). In addition, the patient was immobilized for 12 weeks followed by a Boston-overlappedbrace for 6 months to reduce pain. After 12 weeks of therapy, leucocytes normalized to 6.7 x 109/I and the patient became free of pain. An MRI scan performed 6 months postoperatively showed significant reduction in the signs of osteititis. Previously, a single case of vertebral osteitis and discitis due to R. piekettii in a 71-year-old black male with chronic renal failure, diabetes mellitus, hypertension, and cirrhosis with ascites, who underwent chronic hemodialysis, has been described. 2 The authors suggested that the patient might have been infected by the haemodialysis machines and catheters, or during a preceding hospitalization w h e n the patient received corticosteroids, had an iv catheter, and a cardiac catheterization was performed. In contrast to that case, the patient described here had no underlying disease and had not received any immunosuppressive therapy.
In this case, besides R. pickettii, S. epidermidis and P, aches were isolated from intraoperative material. Unlike R, pickettii, S, epidermidis and R acnes are part of the physiological resident flora of the skin and usually represent perioperative contamination. However, involvement of these bacteria in this case of osteitis cannot be completely excluded. The clinical and radiological appearance of this vertebral osteitis showed differences to a c o m m o n spondylitis because of the lack of involvement of the intervertebral discs. In addition, radiology revealed other foci at several vertebrae and ribs which suggested a haematogenous infection. The similarity to the previously described case of osteomyelitis is striking. This case demonstrates that R. pickettii may rarely be involved in serious infections in immunocompetent patients. H.-A. Eisner I, G. P. D a h m e n a, R. Laufs 1, D. Mack 1
1Institute of Medical Microbiology and Immunology, Martinistrafle 52, D-20246 Hamburg, 2Orthopaedic University-Hospital, Martinistrafle 52, D-20246 Hamburg, Germany
References 1 Gilligan PH. Pseudomonas and Burkholderia. In: Murray PR, Baron El, Pfaller MA, Tenover FC, Yolken RH, eds. Manual of Clinical Microbiology. Washington, DE: American Society for Microbiology, 1995: 509-519. 2 Wertheim WA, Markovitz DM. Osteomyelitis and intervertebral discitis caused by Pseudomonas pJckettiL J Clin Microbiol 1992; 30: 2506-2508. 3 Yabuuchi E, Kosako Y, Oyaizu H et al. Proposal of Burkholderia gen. nov. and transfer of seven species of the genus Pseudomonas homology group II to the new genus, with the type species Burkholderia cepacia (Palleroni and Holmes 1981) comb. nov. Miclvbiol hnmunol 1992; 36: 1251-1275. 4 Yaabuchi E, Kosako Y, Yano I, Hotta H, Nishiuchi Y. Transfer of two Burkholderia and an Alcaligenes species to Ralstonia gen nov.: proposal of Ralstonia pickettii (Ralston, Palleroni and Doudoroff 1973) comb. nov., Ralstonia solanacearum (Smith 1896) comb. nov. and Ralstonia eutropha (Davis 1969) comb. nov. Microbiol Immunol 1995; 39: 897-904.
Accepted for publication 7 August 1997
Rifabutin Appears to be a Promising Agent for Combination Treatment of AIDS-related Toxoplasma Encephalitis Sir, Toxoplasma encephalitis is an important parasitic disease in AIDS patients. 1 Standard therapy consists of pyrimethamine in combination with sulfadiazine or clindamycin, but these regimens fail in a certain proportion of cases and are associated with a high frequency of adverse events, 2 Although there is little clinical experience so far with alternative treatment regimens using drugs such as atovaquone or a combination of pyrimethamine plus azithromycin, efficacy and tolerance seem to be limited. 3-5 Therefore, there is still a need for novel alternative regimens. We report a patient who has been treated successfully with a combination of pyrimethamine plus rifabutin.
Letters to the Editor
Ralstonia pickettii Involved in Spinal Osteitis in an Immunocompetent Adult Sir,
Ralstonia pickettii is a non-fermenting, Gram-negative rod that is found in water and soil and on plants, fruits and vegetables. 1 Bacteraemia and pyuria due to this rarely pathogenic organism have been infrequently reported, and then associated with foreign material or contamination of material supposed to be sterile. 2 In 1992 the organism was transferred from the genus Pseudomonas RNA homology group II to the genus Burkholderia. 3 Recently, it was transferred to the new genus Ralstonia. 4 We describe a case of a thoracic vertebral osteitis in an immunocompetent patient, in which R. pickettii was involved. A 40-year-old, previously fit immnnocompetent female was hospitalized for investigation of a suspected vertebral tumour. Eight months previously, back pains had begun after ordinary physical exercise and became more intense with time. Clinical examination revealed circumscribed tenderness over the middle and lower end of the thoracic spine. Isotope bone scanning showed multiple hot spots in T7, Tg, T12, L2 and L3 vertebrae and the sternal end of the right first and second rib. Thoracic spine X-ray showed destruction in the body of T7 and T9 vertebrae. Magnetic resonance imaging (MRI) showed osteitislfl;e changes in T7 and T9 vertebral bodies, combined with surrounding minor soft tissue swelling but no involvement of the intervertebral discs. Laboratory examination revealed a leucocyte count of 11.2 x 109/1 (normal 4 . 0 - 1 1 . 0 x 109/1) with normal differential count. C-reactive protein and alkaline phosphatase were within the normal range, anti-streptolysin O and anti-streptococcal deoxyribonuclease B reactions were normal and rheumatoid factor was negative. Bone m a r r o w cytology was normal. A primary turnout was excluded. An open biopsy of the seventh vertebral body was taken and showed mild osteitis. Ralstonia pickettii was isolated from intraoperative bone material. In the agar disc diffusion test performed on MuellerHinton agar, the organism was susceptible to ampicillin, mezlocillin, piperacillin, cefoxitin, cefotaxime, tetracycline, trimethoprim-sulfamethoxazole, and ciprofloxacin. Staphylococcus epidermidis was also isolated but only from a swab taken intraoperatively. In addition, Propionibacterium acnes was isolated from intraoperatively obtained bone material. Therapy consisted of a 12-week course of orally administered ciprofloxacin (500 mg twice daily). In addition, the patient was immobilized for 12 weeks followed by a Boston-overlappedbrace for 6 months to reduce pain. After 12 weeks of therapy, leucocytes normalized to 6.7 x 109/I and the patient became free of pain. An MRI scan performed 6 months postoperatively showed significant reduction in the signs of osteititis. Previously, a single case of vertebral osteitis and discitis due to R. piekettii in a 71-year-old black male with chronic renal failure, diabetes mellitus, hypertension, and cirrhosis with ascites, who underwent chronic hemodialysis, has been described. 2 The authors suggested that the patient might have been infected by the haemodialysis machines and catheters, or during a preceding hospitalization w h e n the patient received corticosteroids, had an iv catheter, and a cardiac catheterization was performed. In contrast to that case, the patient described here had no underlying disease and had not received any immunosuppressive therapy.
In this case, besides R. pickettii, S. epidermidis and P, aches were isolated from intraoperative material. Unlike R, pickettii, S, epidermidis and R acnes are part of the physiological resident flora of the skin and usually represent perioperative contamination. However, involvement of these bacteria in this case of osteitis cannot be completely excluded. The clinical and radiological appearance of this vertebral osteitis showed differences to a c o m m o n spondylitis because of the lack of involvement of the intervertebral discs. In addition, radiology revealed other foci at several vertebrae and ribs which suggested a haematogenous infection. The similarity to the previously described case of osteomyelitis is striking. This case demonstrates that R. pickettii may rarely be involved in serious infections in immunocompetent patients. H.-A. Eisner I, G. P. D a h m e n a, R. Laufs 1, D. Mack 1
1Institute of Medical Microbiology and Immunology, Martinistrafle 52, D-20246 Hamburg, 2Orthopaedic University-Hospital, Martinistrafle 52, D-20246 Hamburg, Germany
References 1 Gilligan PH. Pseudomonas and Burkholderia. In: Murray PR, Baron El, Pfaller MA, Tenover FC, Yolken RH, eds. Manual of Clinical Microbiology. Washington, DE: American Society for Microbiology, 1995: 509-519. 2 Wertheim WA, Markovitz DM. Osteomyelitis and intervertebral discitis caused by Pseudomonas pJckettiL J Clin Microbiol 1992; 30: 2506-2508. 3 Yabuuchi E, Kosako Y, Oyaizu H et al. Proposal of Burkholderia gen. nov. and transfer of seven species of the genus Pseudomonas homology group II to the new genus, with the type species Burkholderia cepacia (Palleroni and Holmes 1981) comb. nov. Miclvbiol hnmunol 1992; 36: 1251-1275. 4 Yaabuchi E, Kosako Y, Yano I, Hotta H, Nishiuchi Y. Transfer of two Burkholderia and an Alcaligenes species to Ralstonia gen nov.: proposal of Ralstonia pickettii (Ralston, Palleroni and Doudoroff 1973) comb. nov., Ralstonia solanacearum (Smith 1896) comb. nov. and Ralstonia eutropha (Davis 1969) comb. nov. Microbiol Immunol 1995; 39: 897-904.
Accepted for publication 7 August 1997
Rifabutin Appears to be a Promising Agent for Combination Treatment of AIDS-related Toxoplasma Encephalitis Sir, Toxoplasma encephalitis is an important parasitic disease in AIDS patients. 1 Standard therapy consists of pyrimethamine in combination with sulfadiazine or clindamycin, but these regimens fail in a certain proportion of cases and are associated with a high frequency of adverse events, 2 Although there is little clinical experience so far with alternative treatment regimens using drugs such as atovaquone or a combination of pyrimethamine plus azithromycin, efficacy and tolerance seem to be limited. 3-5 Therefore, there is still a need for novel alternative regimens. We report a patient who has been treated successfully with a combination of pyrimethamine plus rifabutin.