- Email: [email protected]
Rhabdomyolysis in acute Q fever
770
Clinical M i c r o b i o l o g y a nd Infection, Volume 5 N u m b e r 12, D e c e m b e r 1999
fiequent contact with livestock. On admission, temperature was 38.8"C and blood pressure 130180 mmHg. Physical examination was unremarkable. White blood Nu0 E. I. Messen'', Elisabeth C. M . van Pampusz cell count was 1O.7X1O9/L (76% neutrophils, 19% and Jan A. Jambs' band forms, 1% lymphocytes, and 4% monocytes), Departments of 'Medical Microbiology hemoglobin level was 15 g/dL. and platelet count was and *Hematology, 133X 109/L.Laboratory tests revealed serum creatinine University Hospital Maastricht, 3.4 rng/dL, urea 193 mg/dL, creatine base 21835 PO Box 5800, 6202 AZ Maastricht, U/L (MB fraction 120U/L), lactate dehydmgenase The Netherlands 679 U/L, aspartate aminotransferase 436 U/L, alanjne *Tel: +31 43 3876643 Fax: +31 43 3876644 aminotransferase 165U/L, and a n o d bilirubin value, Antinuclear antibodies, rheumatoid fiaor, and References antineutrophil cytoplasmic antibodies were negative. 1. Aronson MD, Bor DH. Blood cultures. AM Intern Med 1987; Chest radiographs and thoracic and abdominal com106: 246-53. 2. Ryan MR, Murray PR. Historical evolution of automated blood puted tomography were normal. Cultures ofblood and culture systems. Clin Mimbiol N e d e t t 1993; 1 5 105-8. urine were sterile. Antibodies against C. bumetii were 3. W b t e i n W. Current blood culture methods and systems: not determined during the hospitalization period. clinical concepts, technology, and interpretation of mule. Clin Therapy with doxacillin and cipmfloxacin was empiInfect Dis 1996; 23: 40-6. rically started and was followed by a clear improvement 4. Ziegler R, Johnsher I, Marms P, Lcnhardt D,Just H-M. Controlled clinical laboratory comparison of two supplemented in the patient's condition. He was discharged after 11 aerobic and anaerobic media used in automated blood culture days of treatment. One month later, the patient was systems M detect bloodstream infections. J Clin Microbioll998; asymptomatic and the abnormal laboratory tests had 3 6 65761. became normal. Serologic tests for Leptospira, Bnuella, 5. JorgcascnJH, Mirrct S,McDonald LC, et 11. Controlled clinical syphilis and Borrelia burgdofm' were negative. The titer laboratory comparison of BACTEC plus aerobic/& medium with Bact/Alert aerobic F A N medium €or detection of of IgG antibodies to phase I1 antigen of C. burnetii bacteremia and f..9Mli..J Clin Microbioll997; 35: 53-8. determined by the indirect immunofluorescence test McRsen NEL, Jacobs JA. Blood volume in BACTEC plus/F (bioMerieux, Marcy l'Etoile, France) was 1/2048, and culture bodes sampled using the direct-draw technique. Clin IgM antibodies were positive. Four months after the Microbiol Infect 1998 4 471-2. onset of symptoms the titer of antibodies had fallen to Alfa M, Sanche S, Roman S, Fiola Y, Lenton P, Harding G. Continuousquality improvements for introductionof automated 1/256. blood cultun instrument. J Clin Microbiol 1995; 33: 1185-91. Although, unfortunately, seroconversion could not Martinez RM,Martinez R, P d Y,C w s J, Llosa J. A l m a g ~ ~ be confirmed in this patient because of the lack of an M. An in&quent cause of false-positive blood cultures. Clin earlier serum sample, the positivity of Igh4 and the very Microbiol Newslett 1993; 15: 7-8. high titer of IgG antibodies 45 days &er the onset of symptoms strongly suggest acute Q fever. In addition, the decrease in the titer of antibodies observed several Rhnbdonryolysis in acute Q fever months later suggests that the first determination corresponded to the peak titer of antibodies. Our Clin Minobiof Infect 1999; 5: 770-771 patient presented with transient acute r e d fiilure due to rhabdomyolysis, like one of the seven cases preAcute Q fever is a non-specific febrile illness caused by Cwciella burnetii. The most common clinical previously reported [4]. Myoglobinuric renal failure, sentations of acute C. burnetii infection are atypical which complicates up to 30% of cases of rhabdopneumonia and hepatitis [l]. Other complications of myolysis, is the result of the toxic effects of myoglobin acute Q fever include hemolytic anemia, myocarditis, on tubule epithelial cells [9]. However, pathogenetic pericarditis, pancreatitis, thyroiditis, mesenteric pannimechanisms of rhabdomyolysis in acute Q fwer are culitis, mediastinal lymphadenopathy, orchitis, erythema unclear. Nevertheless, some authors have suggested that nodosum and optic neuritis [2]. However, rhabdorhabdomyolysis in these patients might be a consemyolysis is an apparently uncommon complication of quence of release of an endotoxin or exotoxin [3]. C. burnetii infection, and this association has rarely been It is interesting that all patients reported with reported [MI. Here we report another case of severe muscle injury associated with acute Q fever, like our rhabdomyolysis secondary to acute Q fever. patient, were h m Spain, considenng that there is no A 75-year-old man was admitted to our hospital evidence that the Spanish strains of C.bumetii have a because of a 24-36 h history of fmer, chills, malaise, particular muscular tropism. However, the manifetamyalgias and severe muscular weakness. He had had tions of t h i s infection may H e r fi-om country to
when interpreting positive signals generated by automated blood-culture systems.
Correspondence
77 1
country [l]. Alternatively, this apparent concentration of cases in Spain might be due to a high index of suspicion for the infection and its associated complications in a country that has a very high prevalence of C. burnetii infection [10-13]. We suggest that subclinical rhabdomyolysis may be more common than suspected in t h i s infection, and that determination of muscular enzymes should be routinely performed in patients with acute Q fever. In addition, we believe that the possibility of C . burnetii infection should be considered in the differential diagnosis of the febrile patient who presents with rhabdomyolysis, regardless of the presence or not of pulmonary infiltrates. Fernando D i a z and Julio Collazos Service of Internal Medicine, Hospital de Galdakao, 48960 Vizcaya, Spain *Fax: +34 4 456 6268
References 1. Marrie TJ. Coxiella bumetii' (Q fmr). In Mandell GL, Bennett JE, D o h R,eds. Principles and practice of infectious diseases, 4th edn. New Yolk Churchill Livingstone, 1995: 1727-35. 2. Raoult D, Marrie T. Q fever. Clin Infect Dis 1995;20 489-96. 3. Carnscosa M, Pascull F, Borobio MV, Gonzalez 2,Napal J. Rhabdomyolpis associated with acute Q fever. Clin Infect Dis 1997;25: 1243-4. 4. Gag0 E, SaavedraJ, G6mez E, Solano A, Martinez A, AlvarezJ. Fiebre Q, rabdomiolisis y hcaso renal agudo. Nefrologia 1989; 9 437-40. L, Maldonado R, Alonso C, Bello J, Armario 5. Albeao Na.'F Rabdomiohsisy fiebre Q. Enferrn Infecc Microbiol Clin 1996; 1 4 129-30. 6. Upez Lancis A, Velilla Marc0J, Garcia-Ann& A, Udes Moreno ,'F Omeiiaca Teres M. Rabdomiolisisy fiebre Q. An Med Intern (Madrid) 1991;8: 314-15. 7. de la Prieta Upez R,Montejo Baranda M, Barreiro Garcia G, Aguirre Errasti C. Miositis y rabdomiolisis por fiebre Q. Enferm Infecc Microbiol Clin 1989;7: 452. 8. Marti J, Martinez Gil A, Ant6n E, Garcia C. Miositis necrotizantepor Coxiella bumetii. Enferm Infecc Microbiol Clin 1990; 8: 467-8. 9. Brady HR, Brenner BM. Acute renal failure. In Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's principles of internal medicine, 14th edn. New York McGraw-Hill, 1998: 1504-13. 10. S h z Estrada J, Rodriguez BarbosaJI, Gutierrez Maain CB, et al. Seroepidemiologicalsurvey of Q farer in Lcon province, Spain. Eur J Epidemiol 1996; 12 245-50. 11. Ruiz Belt& R, Herrero Herrero JI. Martin Shchez AM, Mafin GonzilezJA. Prevalence of antibodies to Rickettsia conon'i, Caxiella burnetii and Rickettsia typhi in Salamanca province (Spain). Serosurvey in the human population. Eur J Epidemiol 1990; 6 293-9. 12. SanzoJM, Gar& Calabuig MA, Audicana A, Dehesa V Q fever: prevalence of antibodies to Coxiella bumetii in the Basque country. Int J Epidemiol 1993;2 2 1183-8.
13. Cour Boveda MI, Gonzilez Sinde MC, G o d e z Cuadrado S, Palau Beato ML, G o d e z G6mez C, Ferro Dalda A. Coxieila burnetii: estudio seml6gico en distintas poblaciones. An Med Intern (Madrid) 1990; 7: 513-16.
Quality control limits for antimicrobial susceptibility tests of cefpirome
Clin Microbiol Infect 1999; 5: 771-773
Cefpirome is a broad-spectrum cephalosporin [I ,2] that has been available for use in many countries for the past decade. The National Committee for Clinical Laboratory Standards (NCCLS) selects interpretive criteria and quality control guidelines for susceptibility tests of antimicrobial agents that are marketed in the USA. Because US regulatory agencies have not yet considered cefpirome for sale in the USA, the NCCLS has not been asked to include cefpirome in its tables. In November 1997, we performed a 10-laboratory collaborative study to define quality control limits for disk &sion and broth microdilution tests performed according to the current NCCLS methods. These studies include tests of Streptococcus pneumoniae ATCC 49619, Haernophilus infuenzae ATCC 49247, Escherickia cofiATCC 25922, Pseudomoms aetuginosa ATCC 27853, Staphylococcus aureus ATCC 25923 and Stapkylococcus aureus ATCC 29213. The result of this exercise is briefly described here for those who may want to test cefpirome by NCCLS methods. Commercially prepared 30-pg cefpirome disks (BDMS lot 707629 and Oxoid lot 46141) were evaluated in parallel. There were no differences in zone diameters produced by the two lots of disks, so the data were combined for analysis. Six different lots of Mueller-Hinton agar h m four different manufacturers were included in the study design. The agar was prepared as Haemophilus Test Medium (HTM) [3] when testing H. inauenzae, and 5% defibrinated sheep blood was added to the Mueller-Hinton agars when testing Streptococcus pneumoniae. For broth microdilution tests, cefpirome was serially diluted in each of five lots of cation-adjusted Mueller-Hinton broth f?om three different manufacturers. The broth media were prepared as HTM [4] for testing the H. injuenzae strain or supplemented with 2-3% lysed horse blood for testing the pneumococcus. Cefotaxime was the control antibiotic: for any day that a cefotaxime result was outside of established limits,a l l cefpirome MIC or zone size data for that day were excluded h m the analysis, even though the excluded data were well within the proposed limits for cefpirome.
Clinical M i c r o b i o l o g y a nd Infection, Volume 5 N u m b e r 12, D e c e m b e r 1999
fiequent contact with livestock. On admission, temperature was 38.8"C and blood pressure 130180 mmHg. Physical examination was unremarkable. White blood Nu0 E. I. Messen'', Elisabeth C. M . van Pampusz cell count was 1O.7X1O9/L (76% neutrophils, 19% and Jan A. Jambs' band forms, 1% lymphocytes, and 4% monocytes), Departments of 'Medical Microbiology hemoglobin level was 15 g/dL. and platelet count was and *Hematology, 133X 109/L.Laboratory tests revealed serum creatinine University Hospital Maastricht, 3.4 rng/dL, urea 193 mg/dL, creatine base 21835 PO Box 5800, 6202 AZ Maastricht, U/L (MB fraction 120U/L), lactate dehydmgenase The Netherlands 679 U/L, aspartate aminotransferase 436 U/L, alanjne *Tel: +31 43 3876643 Fax: +31 43 3876644 aminotransferase 165U/L, and a n o d bilirubin value, Antinuclear antibodies, rheumatoid fiaor, and References antineutrophil cytoplasmic antibodies were negative. 1. Aronson MD, Bor DH. Blood cultures. AM Intern Med 1987; Chest radiographs and thoracic and abdominal com106: 246-53. 2. Ryan MR, Murray PR. Historical evolution of automated blood puted tomography were normal. Cultures ofblood and culture systems. Clin Mimbiol N e d e t t 1993; 1 5 105-8. urine were sterile. Antibodies against C. bumetii were 3. W b t e i n W. Current blood culture methods and systems: not determined during the hospitalization period. clinical concepts, technology, and interpretation of mule. Clin Therapy with doxacillin and cipmfloxacin was empiInfect Dis 1996; 23: 40-6. rically started and was followed by a clear improvement 4. Ziegler R, Johnsher I, Marms P, Lcnhardt D,Just H-M. Controlled clinical laboratory comparison of two supplemented in the patient's condition. He was discharged after 11 aerobic and anaerobic media used in automated blood culture days of treatment. One month later, the patient was systems M detect bloodstream infections. J Clin Microbioll998; asymptomatic and the abnormal laboratory tests had 3 6 65761. became normal. Serologic tests for Leptospira, Bnuella, 5. JorgcascnJH, Mirrct S,McDonald LC, et 11. Controlled clinical syphilis and Borrelia burgdofm' were negative. The titer laboratory comparison of BACTEC plus aerobic/& medium with Bact/Alert aerobic F A N medium €or detection of of IgG antibodies to phase I1 antigen of C. burnetii bacteremia and f..9Mli..J Clin Microbioll997; 35: 53-8. determined by the indirect immunofluorescence test McRsen NEL, Jacobs JA. Blood volume in BACTEC plus/F (bioMerieux, Marcy l'Etoile, France) was 1/2048, and culture bodes sampled using the direct-draw technique. Clin IgM antibodies were positive. Four months after the Microbiol Infect 1998 4 471-2. onset of symptoms the titer of antibodies had fallen to Alfa M, Sanche S, Roman S, Fiola Y, Lenton P, Harding G. Continuousquality improvements for introductionof automated 1/256. blood cultun instrument. J Clin Microbiol 1995; 33: 1185-91. Although, unfortunately, seroconversion could not Martinez RM,Martinez R, P d Y,C w s J, Llosa J. A l m a g ~ ~ be confirmed in this patient because of the lack of an M. An in&quent cause of false-positive blood cultures. Clin earlier serum sample, the positivity of Igh4 and the very Microbiol Newslett 1993; 15: 7-8. high titer of IgG antibodies 45 days &er the onset of symptoms strongly suggest acute Q fever. In addition, the decrease in the titer of antibodies observed several Rhnbdonryolysis in acute Q fever months later suggests that the first determination corresponded to the peak titer of antibodies. Our Clin Minobiof Infect 1999; 5: 770-771 patient presented with transient acute r e d fiilure due to rhabdomyolysis, like one of the seven cases preAcute Q fever is a non-specific febrile illness caused by Cwciella burnetii. The most common clinical previously reported [4]. Myoglobinuric renal failure, sentations of acute C. burnetii infection are atypical which complicates up to 30% of cases of rhabdopneumonia and hepatitis [l]. Other complications of myolysis, is the result of the toxic effects of myoglobin acute Q fever include hemolytic anemia, myocarditis, on tubule epithelial cells [9]. However, pathogenetic pericarditis, pancreatitis, thyroiditis, mesenteric pannimechanisms of rhabdomyolysis in acute Q fwer are culitis, mediastinal lymphadenopathy, orchitis, erythema unclear. Nevertheless, some authors have suggested that nodosum and optic neuritis [2]. However, rhabdorhabdomyolysis in these patients might be a consemyolysis is an apparently uncommon complication of quence of release of an endotoxin or exotoxin [3]. C. burnetii infection, and this association has rarely been It is interesting that all patients reported with reported [MI. Here we report another case of severe muscle injury associated with acute Q fever, like our rhabdomyolysis secondary to acute Q fever. patient, were h m Spain, considenng that there is no A 75-year-old man was admitted to our hospital evidence that the Spanish strains of C.bumetii have a because of a 24-36 h history of fmer, chills, malaise, particular muscular tropism. However, the manifetamyalgias and severe muscular weakness. He had had tions of t h i s infection may H e r fi-om country to
when interpreting positive signals generated by automated blood-culture systems.
Correspondence
77 1
country [l]. Alternatively, this apparent concentration of cases in Spain might be due to a high index of suspicion for the infection and its associated complications in a country that has a very high prevalence of C. burnetii infection [10-13]. We suggest that subclinical rhabdomyolysis may be more common than suspected in t h i s infection, and that determination of muscular enzymes should be routinely performed in patients with acute Q fever. In addition, we believe that the possibility of C . burnetii infection should be considered in the differential diagnosis of the febrile patient who presents with rhabdomyolysis, regardless of the presence or not of pulmonary infiltrates. Fernando D i a z and Julio Collazos Service of Internal Medicine, Hospital de Galdakao, 48960 Vizcaya, Spain *Fax: +34 4 456 6268
References 1. Marrie TJ. Coxiella bumetii' (Q fmr). In Mandell GL, Bennett JE, D o h R,eds. Principles and practice of infectious diseases, 4th edn. New Yolk Churchill Livingstone, 1995: 1727-35. 2. Raoult D, Marrie T. Q fever. Clin Infect Dis 1995;20 489-96. 3. Carnscosa M, Pascull F, Borobio MV, Gonzalez 2,Napal J. Rhabdomyolpis associated with acute Q fever. Clin Infect Dis 1997;25: 1243-4. 4. Gag0 E, SaavedraJ, G6mez E, Solano A, Martinez A, AlvarezJ. Fiebre Q, rabdomiolisis y hcaso renal agudo. Nefrologia 1989; 9 437-40. L, Maldonado R, Alonso C, Bello J, Armario 5. Albeao Na.'F Rabdomiohsisy fiebre Q. Enferrn Infecc Microbiol Clin 1996; 1 4 129-30. 6. Upez Lancis A, Velilla Marc0J, Garcia-Ann& A, Udes Moreno ,'F Omeiiaca Teres M. Rabdomiolisisy fiebre Q. An Med Intern (Madrid) 1991;8: 314-15. 7. de la Prieta Upez R,Montejo Baranda M, Barreiro Garcia G, Aguirre Errasti C. Miositis y rabdomiolisis por fiebre Q. Enferm Infecc Microbiol Clin 1989;7: 452. 8. Marti J, Martinez Gil A, Ant6n E, Garcia C. Miositis necrotizantepor Coxiella bumetii. Enferm Infecc Microbiol Clin 1990; 8: 467-8. 9. Brady HR, Brenner BM. Acute renal failure. In Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's principles of internal medicine, 14th edn. New York McGraw-Hill, 1998: 1504-13. 10. S h z Estrada J, Rodriguez BarbosaJI, Gutierrez Maain CB, et al. Seroepidemiologicalsurvey of Q farer in Lcon province, Spain. Eur J Epidemiol 1996; 12 245-50. 11. Ruiz Belt& R, Herrero Herrero JI. Martin Shchez AM, Mafin GonzilezJA. Prevalence of antibodies to Rickettsia conon'i, Caxiella burnetii and Rickettsia typhi in Salamanca province (Spain). Serosurvey in the human population. Eur J Epidemiol 1990; 6 293-9. 12. SanzoJM, Gar& Calabuig MA, Audicana A, Dehesa V Q fever: prevalence of antibodies to Coxiella bumetii in the Basque country. Int J Epidemiol 1993;2 2 1183-8.
13. Cour Boveda MI, Gonzilez Sinde MC, G o d e z Cuadrado S, Palau Beato ML, G o d e z G6mez C, Ferro Dalda A. Coxieila burnetii: estudio seml6gico en distintas poblaciones. An Med Intern (Madrid) 1990; 7: 513-16.
Quality control limits for antimicrobial susceptibility tests of cefpirome
Clin Microbiol Infect 1999; 5: 771-773
Cefpirome is a broad-spectrum cephalosporin [I ,2] that has been available for use in many countries for the past decade. The National Committee for Clinical Laboratory Standards (NCCLS) selects interpretive criteria and quality control guidelines for susceptibility tests of antimicrobial agents that are marketed in the USA. Because US regulatory agencies have not yet considered cefpirome for sale in the USA, the NCCLS has not been asked to include cefpirome in its tables. In November 1997, we performed a 10-laboratory collaborative study to define quality control limits for disk &sion and broth microdilution tests performed according to the current NCCLS methods. These studies include tests of Streptococcus pneumoniae ATCC 49619, Haernophilus infuenzae ATCC 49247, Escherickia cofiATCC 25922, Pseudomoms aetuginosa ATCC 27853, Staphylococcus aureus ATCC 25923 and Stapkylococcus aureus ATCC 29213. The result of this exercise is briefly described here for those who may want to test cefpirome by NCCLS methods. Commercially prepared 30-pg cefpirome disks (BDMS lot 707629 and Oxoid lot 46141) were evaluated in parallel. There were no differences in zone diameters produced by the two lots of disks, so the data were combined for analysis. Six different lots of Mueller-Hinton agar h m four different manufacturers were included in the study design. The agar was prepared as Haemophilus Test Medium (HTM) [3] when testing H. inauenzae, and 5% defibrinated sheep blood was added to the Mueller-Hinton agars when testing Streptococcus pneumoniae. For broth microdilution tests, cefpirome was serially diluted in each of five lots of cation-adjusted Mueller-Hinton broth f?om three different manufacturers. The broth media were prepared as HTM [4] for testing the H. injuenzae strain or supplemented with 2-3% lysed horse blood for testing the pneumococcus. Cefotaxime was the control antibiotic: for any day that a cefotaxime result was outside of established limits,a l l cefpirome MIC or zone size data for that day were excluded h m the analysis, even though the excluded data were well within the proposed limits for cefpirome.