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Recurrent urinary tract infection with haematuria caused by Moraxella (Branhamella) catarrhalis
Letters to the Editor
216
* Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia 'Bruno Ubertini', Via Taramelli 7, 2 7 I o o Pavia, Italy t Istituto di Anatomia Patologica Veterinaria e Patologia Aviare, Facolt~ di Medicina Veterinaria, Univers#~ di Milano, Italy Laboratorio di Batteriologia e Micologia Medica Istituto Superiore di SanitY, Roma, Italy
Massimo Fabbi* Simone Magnino* Eugenio Scanzianit Maddalena Castellani Pastoris~
References I. Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires' disease: description of an epidemic of pneumonia. N Englff Med I977; z97: II89-II97. 2. McDade JE, Shepard CC, Fraser DW, Tsai TR, Redus MA, Dowdle WR. Legionnaires' disease: isolation of a bacterium and demonstration of its role in other respiratory disease. N EnglJ Med I977; 297: II97-I2O3. 3. Glick TH, Gregg MB, Berman B, Mallison G, Rhodes WW Jr, Kassanoff I. Pontiac fever. An epidemic of unknown etiology in a health department. I. Clinical and epidemiologic aspects. Am J Epidemiol I978; IO7: I49-r6o. 4. Boldur I, Cohen A, Tamarin-Landau R, Sompolinsky D. Isolation of Legionella pneumophila from calves and the prevalence of antibodies in cattle, sheep, horses, antelopes, buffaloes and rabbits. Vet Microbiol I987; I3: 313-32o. 5. Collins M T , Cho SN, Reif J S. Prevalence of antibodies to Legionellapneumophila in animal populations. ] Clin Microbiol I982 ; 15: I30--I36. 6. Cho SN, Collins M T , Reif JS, McChesney AE. Experimental infections of horses with Legionella pneumophila. Am J Vet Res I983; 44: 662-667. 7. Winn WC, Myerowitz RL. The pathology of the Legionella pneumonias. Hum Pathol I98I ; I2 " 401--422.
R e c u r r e n t u r i n a r y tract i n f e c t i o n w i t h h a e m a t u r l a c a u s e d b y M o r a x e l l a ( B r a n h a m e l l a ) catarrhalis
Accepted for publication I8 April I993 Sir,
Moraxella (Branhamella) catarrhalis has generally been regarded as an oropharyngeal commensal. In the early I98OS, Moraxella catarrhalis began to be recognised as an increasingly important pathogen when it was cultured f r o m paranasal sinuses and middle ear infections. 1 Its association with b r o n c h o p u l m o n a r y infection in older patients with underlying p u l m o n a r y disease has been particularly well notedfl O f all lower respiratory tract infections, 3-4 % have been reported to be caused by this organism. ~ Its role in infections elsewhere is less clear. W e wish to report a case of recurrent urinary tract infection with haematuria apparently caused by Moraxella catarrhalis. An x I - y e a r - o l d Saudi boy presented with haematuria and a burning sensation on micturition to the urology clinic at our hospital. A clean-catch m i d - s t r e a m specimen of urine was sent to the microbiology laboratory where direct examination showed uncountable red blood cells, 5-IO bacteria/high power field and i o - 2 o pus cells/high power field. T h e specimen was cultured on blood agar and M a c C o n k e y agar which were incubated aerobically. Overnight incubation yielded significant growth > io 8 C F U / 1 of Moraxella catarrhalis identified by well accepted techniques. T h e
Letters to the Editor
2I 7
identification was confirmed with the rapid carbohydrate utilisation test. 4 F u r t h e r samples also yielded Moraxella catarrhalis while no other organisms were isolated. T h e organism was sensitive to ampicillin, cefuroxime, chloramphenicol, cefotaxime, ceftizoxime, tetracycline, erythromycin and co-amoxiclav. A test for beta-lactamase was negative. F u r t h e r investigations of the patient showed that the sickling test was negative and G 6 P D activity was normal. A plain X-ray of the abdomen, an intravenous urogram and an ultrasound scan did not show any gross abnormality. A complete blood examination revealed W B C 6"5 x Io9/1, RBC 5"6x Io3/1 and a haemoglobin concentration of i I'7 g/dl while a C T scan of the renal area did not indicate any abnormality. T h e B U N concentration was 3"9 mmol/1 and that of creatinine 53 #mol/1. Cultures for Mycobacterium tuberculosis were negative. D u r i n g this time, the patient was treated with co-amoxiclav. T w o further specimens of urine failed to yield any bacterial growth, pus cells or red cells. Six months later, however, the patient presented again with haematuria and dysuria. Cultures of his urine again yielded a pure growth > IOs CFU/1 of Moraxella catarrhalis. Cystoscopy was performed. A biopsy did not show any pathological changes. N o other pathogen was isolated. T h e patient was then treated with ampicillin 250 mg, 6 hourly for Io days. His urine was monitored during treatment and for 6 months afterwards. All samples proved negative and there was no further haematuria or dysuria. T w o previous reports from England and Sweden of Moraxella catarrhalis in lower urinary tract infections 5-6 concerned patients who had been on long-term antibiotic treatment which may have selected Moraxella catarrhalis. Our patient had not been treated previously with any antibiotic. T h e wider pathogenic potential of Moraxella catarrhalis is highlighted by this case.
Department of Microbiology, Department of Surgery, Qatif Central Hospital, AI Jesh, Saudi Arabia
Ali Magzoub Elbashier Hanumant Deshpande
References
I. Wald ER, Milmore GJ, Bowen A, et al. Acute maxillary sinusitis in children. N Eng J Med 1981 ; 304: 749-754. 2. Hager H, Varghese A, Alvarez S, Berk SL. Branhamella catarrhalis respiratory infections. Rev Infect Dis 1987; 9: 114o-1149. 3. Elbashier AM, Ahmad A1-Salem, All A1-Jama, et al. Bronchopulmonary infection due to Moraxella (Branhamella) catarrhalis at Qatif Central Hospital. Ann Saudi Med 1992; 12: 562-564. 4- Young H, Paterson IC, MacDonald DR. Rapid carbohydrate utilization test for the identification of Neisseria gonorrheae. Clin Microbiol 1983 ; 18: 1262-1263. 5. Ahmad F, Calder MA, Croughan MJ, Marshall TG. Urinary tract infection caused by Branhamella catarrhalis. J Infect 1985; IO: 176-177 . 6. Jacobson SH, Bjorklind A. Symptomatic bacteriuria caused by Branhamella catarrhalis. Infect 1939; IO: 192-193.
216
* Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia 'Bruno Ubertini', Via Taramelli 7, 2 7 I o o Pavia, Italy t Istituto di Anatomia Patologica Veterinaria e Patologia Aviare, Facolt~ di Medicina Veterinaria, Univers#~ di Milano, Italy Laboratorio di Batteriologia e Micologia Medica Istituto Superiore di SanitY, Roma, Italy
Massimo Fabbi* Simone Magnino* Eugenio Scanzianit Maddalena Castellani Pastoris~
References I. Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires' disease: description of an epidemic of pneumonia. N Englff Med I977; z97: II89-II97. 2. McDade JE, Shepard CC, Fraser DW, Tsai TR, Redus MA, Dowdle WR. Legionnaires' disease: isolation of a bacterium and demonstration of its role in other respiratory disease. N EnglJ Med I977; 297: II97-I2O3. 3. Glick TH, Gregg MB, Berman B, Mallison G, Rhodes WW Jr, Kassanoff I. Pontiac fever. An epidemic of unknown etiology in a health department. I. Clinical and epidemiologic aspects. Am J Epidemiol I978; IO7: I49-r6o. 4. Boldur I, Cohen A, Tamarin-Landau R, Sompolinsky D. Isolation of Legionella pneumophila from calves and the prevalence of antibodies in cattle, sheep, horses, antelopes, buffaloes and rabbits. Vet Microbiol I987; I3: 313-32o. 5. Collins M T , Cho SN, Reif J S. Prevalence of antibodies to Legionellapneumophila in animal populations. ] Clin Microbiol I982 ; 15: I30--I36. 6. Cho SN, Collins M T , Reif JS, McChesney AE. Experimental infections of horses with Legionella pneumophila. Am J Vet Res I983; 44: 662-667. 7. Winn WC, Myerowitz RL. The pathology of the Legionella pneumonias. Hum Pathol I98I ; I2 " 401--422.
R e c u r r e n t u r i n a r y tract i n f e c t i o n w i t h h a e m a t u r l a c a u s e d b y M o r a x e l l a ( B r a n h a m e l l a ) catarrhalis
Accepted for publication I8 April I993 Sir,
Moraxella (Branhamella) catarrhalis has generally been regarded as an oropharyngeal commensal. In the early I98OS, Moraxella catarrhalis began to be recognised as an increasingly important pathogen when it was cultured f r o m paranasal sinuses and middle ear infections. 1 Its association with b r o n c h o p u l m o n a r y infection in older patients with underlying p u l m o n a r y disease has been particularly well notedfl O f all lower respiratory tract infections, 3-4 % have been reported to be caused by this organism. ~ Its role in infections elsewhere is less clear. W e wish to report a case of recurrent urinary tract infection with haematuria apparently caused by Moraxella catarrhalis. An x I - y e a r - o l d Saudi boy presented with haematuria and a burning sensation on micturition to the urology clinic at our hospital. A clean-catch m i d - s t r e a m specimen of urine was sent to the microbiology laboratory where direct examination showed uncountable red blood cells, 5-IO bacteria/high power field and i o - 2 o pus cells/high power field. T h e specimen was cultured on blood agar and M a c C o n k e y agar which were incubated aerobically. Overnight incubation yielded significant growth > io 8 C F U / 1 of Moraxella catarrhalis identified by well accepted techniques. T h e
Letters to the Editor
2I 7
identification was confirmed with the rapid carbohydrate utilisation test. 4 F u r t h e r samples also yielded Moraxella catarrhalis while no other organisms were isolated. T h e organism was sensitive to ampicillin, cefuroxime, chloramphenicol, cefotaxime, ceftizoxime, tetracycline, erythromycin and co-amoxiclav. A test for beta-lactamase was negative. F u r t h e r investigations of the patient showed that the sickling test was negative and G 6 P D activity was normal. A plain X-ray of the abdomen, an intravenous urogram and an ultrasound scan did not show any gross abnormality. A complete blood examination revealed W B C 6"5 x Io9/1, RBC 5"6x Io3/1 and a haemoglobin concentration of i I'7 g/dl while a C T scan of the renal area did not indicate any abnormality. T h e B U N concentration was 3"9 mmol/1 and that of creatinine 53 #mol/1. Cultures for Mycobacterium tuberculosis were negative. D u r i n g this time, the patient was treated with co-amoxiclav. T w o further specimens of urine failed to yield any bacterial growth, pus cells or red cells. Six months later, however, the patient presented again with haematuria and dysuria. Cultures of his urine again yielded a pure growth > IOs CFU/1 of Moraxella catarrhalis. Cystoscopy was performed. A biopsy did not show any pathological changes. N o other pathogen was isolated. T h e patient was then treated with ampicillin 250 mg, 6 hourly for Io days. His urine was monitored during treatment and for 6 months afterwards. All samples proved negative and there was no further haematuria or dysuria. T w o previous reports from England and Sweden of Moraxella catarrhalis in lower urinary tract infections 5-6 concerned patients who had been on long-term antibiotic treatment which may have selected Moraxella catarrhalis. Our patient had not been treated previously with any antibiotic. T h e wider pathogenic potential of Moraxella catarrhalis is highlighted by this case.
Department of Microbiology, Department of Surgery, Qatif Central Hospital, AI Jesh, Saudi Arabia
Ali Magzoub Elbashier Hanumant Deshpande
References
I. Wald ER, Milmore GJ, Bowen A, et al. Acute maxillary sinusitis in children. N Eng J Med 1981 ; 304: 749-754. 2. Hager H, Varghese A, Alvarez S, Berk SL. Branhamella catarrhalis respiratory infections. Rev Infect Dis 1987; 9: 114o-1149. 3. Elbashier AM, Ahmad A1-Salem, All A1-Jama, et al. Bronchopulmonary infection due to Moraxella (Branhamella) catarrhalis at Qatif Central Hospital. Ann Saudi Med 1992; 12: 562-564. 4- Young H, Paterson IC, MacDonald DR. Rapid carbohydrate utilization test for the identification of Neisseria gonorrheae. Clin Microbiol 1983 ; 18: 1262-1263. 5. Ahmad F, Calder MA, Croughan MJ, Marshall TG. Urinary tract infection caused by Branhamella catarrhalis. J Infect 1985; IO: 176-177 . 6. Jacobson SH, Bjorklind A. Symptomatic bacteriuria caused by Branhamella catarrhalis. Infect 1939; IO: 192-193.