Salmonella infantis Osteomyelitis in Sickle Cell Disease

Letters to the Editor associated with prosthetic joints2 as well as prosthetic valve endocarditis.3 While P. multocida is known to rarely colonize the human upper respiratory tract, it is not known to exist as part of the skin flora. The isolation of this organism in a pure culture of the drainage from this patient’s wound is unlikely to represent contamination. Although most P. multocida infections are related to animal bites or scratches, a smaller proportion are associated with atraumatic animal exposures.4 We suspect that P. multocida was introduced into the wound because of this patient’s close contact with multiple cats while post-operative drains were in place. Subsequently she developed implant infection that improved while on intravenous antibiotics and relapsed during oral therapy. This case illustrates that close contact with cats during the post-operative period might be a risk factor for infection with P. multocida. L. B. Johnson, M. J. Busuito and R. Khatib Division of Infectious Diseases, Department of Internal Medicine, St. John Medical Center, Detroit, Michigan, U.S.A.

References

111

examination there was swelling, local rise of temperature and tenderness in the left iliac region, left shoulder and in the right temporal and left parietal regions of the scalp. Haematological investigations showed haemoglobin 4.1 g/dl, WBC count 21 700 mm3, with 55% neutrophils, 43% lymphocytes and platelet count was 38 000/mm3. The peripheral blood picture showed moderate anisopoikilocytosis with a few elongated cells and nucleated red cells. Subsequently, sickling was confirmed with sodium metabisulphite test. Haemoglobin electrophoresis revealed the presence of 78% haemoglobin S. The serum bilirubin was 2.5 mg/dl. Aspiration from the left iliac crest and the scalp swellings yielded frank pus. A whole body bone scan using Tc-99m showed bilaterally increased uptake in hip joint regions and many other sites (Fig. 1). The blood, pus as well as stool culture showed the growth of Salmonella species which was subsequently identified by biotyping and serotyping as S. infantis (6.7, 14 : r : 1, 5) as confirmed by National Salmonella and Escherichia Centre, Central Research Institute, Kasauli (HP). The antibiogram of S. infantis showed sensitivity to amoxycillin, amikacin, ciprofloxacin, chloramphenicol and gentamicin. The child was managed by giving antipyretics, analgesics and intravenous ciprofloxacin along with fluids for rehydration. Blood culture and pus culture sent subsequently were reported to be sterile. She was discharged after 1 month of hospitalization, afebrile and

1 Weber DJ, Wolfson JS, Swartz MN, Hooper DC. Pasteurella multocida infections: report of 34 cases and review of the literature. Medicine 1984; 63: 133–154. 2 Arvan GD, Goldberg V. A case report of total knee arthroplasty infected by Pasteurella multocida. Clin Orthop 1978; 132: 167–169. 3 Nettles RE, Sexton DJ. Pasteurella multocida prosthetic valve endocarditis: case report and review. Clin Infect Dis 1997; 25: 920–921. 4 Hubbert WT, Rosen MN. Pasteurella multocida infection in man unrelated to human bite. Am J Public Health 1970; 60: 1109–1117. Accepted for publication 24 February 2000

doi:10.1053/jinf.2000.0674, available online at http://www.idealibrary.com on

Salmonella infantis Osteomyelitis in Sickle Cell Disease Sir, Salmonella enterica subsp. enterica serovar infantis (Salmonella infantis: 6, 7, 14 : r : 1, 5) was first identified by Blackburn in 1967 from soya feed meal.1 The primary reservoir of S. infantis is poultry but it has spilled over to cattle in some countries.2 Salmonella infantis is one of the prevalent serotypes isolated from humans in many developed countries.3 The association of S. infantis with sickle cell disease has been reported earlier from stool samples of two patients suffering from gastroenteritis.4 We report a case of S. infantis as a cause of multifocal osteomyelitis and septicaemia in a patient with sickle cell disease. A 10-year-old girl presented with high-grade fever associated with acute pain and swelling in both the gluteal regions, left shoulder and in the scalp of 3 days’ duration. She had a history suggestive of recurrent febrile episodes with painful swellings of the hands and feet from the age of 4 months. On general physical examination the child was found to be toxic, febrile, anaemic and mildly icteric, but haemodynamically stable. On local

Figure 1. Whole body bone scan, showing increased uptake in both the hip joint regions and inhomogenity of radiotracer concentration throughout the skeleton. © 2000 The British Infection Society

Letters to the Editor

112

otherwise well, with an advice to continue antibiotics for 2 weeks more, after which on active follow-up she was found to be clinically well and symptom-free. Salmonellosis is a serious infection in sickle cell disease. Bone and/or joint infections are usually found in cases with Salmonella septicaemia.5 Salmonella invasion is due to capillary occlusion secondary to intravascular sickling which devitalizes and causes infarction of the gut. Reduced function of the liver and spleen, along with that of the reticulo-endothelial system due to erythrophagocytosis, further suppresses clearing of organisms from the blood stream. Defective opsonization may also play a role.6 The association of Salmonella osteomyelitis with sickle cell disease is well established since the first report in 1951.7 To our knowledge, osteomyelitis caused by Salmonella infantis in patients with sickle cell disease has not been reported earlier. This is thought to be due to preceding episodes of avascular necrosis of the bones resulting from sickling crisis and dead bone acting as the nidus for the organisms. The bones most commonly affected in sickle cell disease are the long bones;6 involvement of skull bones to our knowledge, as in this case, has not been reported earlier. Salmonellosis is usually a zoonotic disease; human infections are mostly acquired from contaminated food. Source of infection can only be traced by efficient typing methods. There is some evidence that S. infantis has an increased propensity to cause invasive disease but incidentally this serotype is usually sensitive to routine antibiotics and carries only a few plasmids.2 The present strain was also found to be sensitive to the routinely used antibiotics, including ciprofloxacin, to which the patient responded satisfactorily. As salmonella infections are a cause of concern in sickle cell disease patients, awareness and appropriate treatment can help in preventing complications of salmonellosis. V. Gupta*1, B. Poddar2, R. Kumar Gupta3, M. Issaivanan2, Sabita Basu4, Aparna Yadav1, and R. M. Joshi1 1 Department of Microbiology, 2 Department of Paediatrics, 3 Department of Orthopaedics, 4 Department of Haematology & Transfusion Medicine, Government Medical College Hospital, Sector 32, Chandigarh, India

Acknowledgement The authors are grateful to the Director, Central Research Institute, Kasauli (HP) India for confirming the species identification.

References 1 Kelterborn E. Catalogue of Salmonella first isolation 1965–1984. VEB Gustav Fischer, Verlag Jena, 1987. 2 Old DC, Threlfall EJ. Salmonella. In: Collier L, Balows A, Sussman M (eds). Microbiology and Microbial Infections, 9th ed. Madison Avenue, New York: Oxford University Press, 1998: 988. 3 Pelkonen S, Romppanen E, Siitonen A, Pelkonen J. Differentiation of Salmonella serovar infantis isolates from human and animal sources by finger printing IS 200 and 16S rrn loci. J Clin Microbiol 1994; 32: 2128–2133. © 2000 The British Infection Society

4 Wright J, Thomas P, Serjeant GR. Septicaemia caused by Salmonella infection: an overlooked complication of sickle cell disease. J Paediatr 1997; 130: 394–399. 5 Ware RE. Salmonella infection in sickle cell disease: a clear and present danger. J Paediatr 1997; 130: 350–351. 6 Anand AJ, Glatt AE. Salmonella osteomyelitis and arthritis in sickle cell disease. Semin Arthritis Rheum 1994; 24: 211–221. 7 Hodges FJ, Holt JF. Editorial comment. In: Hodges FJ et al (eds) 1951 Year Book of Radiology. Chicago: Year Book, 1951: 89. Accepted for publication 22 March 2000

doi:10.1053/jinf.2000.0675, available online at http://www.idealibrary.com on

Does Helicobacter pylori Colonize the Vagina of Pregnant Women? Sir, The prevention of prematurity is a major obstetric challenge today. Although 85% of infants with a birth weight of less than 1500 g survive, approximately 10% of survivors later exhibit cerebral palsy, and 25%–50% also exhibit abnormalities of cognition and behaviour.1 Evidence suggests a link between subclinical infection and pre-term birth: a significant association between pre-term labour and histological findings of chorioamnionitis, presumably due to ascending infection, is seen.2 Bacterial vaginosis is associated with pre-term delivery independently of other recognized risk factors,3 and treatment with antibiotics reduces the rate of premature delivery in women with bacterial vaginosis and an increased risk for pre-term delivery.4 To date, Gardnerella vaginalis, Mycoplasma hominis, and anaerobic bacteria are known to constitute the pathological core of bacterial vaginosis.5 More than 300 strains of micro-organisms have been reported to colonize the vagina of healthy, non-pregnant women.6 Helicobacter pylori is often isolated from gastric biopsy specimens,7 and thus, presumably, tolerates an acid environment, although there is a pH gradient from acid (pH around 1.0)8 in the gastric lumen to near neutral in the mucosal vessels. The lower genital tract of female organs also has a pH gradient from acid (pH of around 4.2) in the vagina9 to near neutral in the uterine endocervical canal. Helicobacter pylori has been isolated from saliva,10 dental plaque,11 faeces,12 and fingernails.13 The oral cavity is suggested to be a reservoir for H. pylori, and the hands are suggested to play a key role in transmission of H. pylori infection.13 It is, therefore, possible that H. pylori colonizes the vagina. However, it is not known whether this organism colonizes the vagina of healthy pregnant women. Whether this organism may be associated with pre-term births is also not known. We therefore cultured vaginal specimens from 286 consecutive pregnant Japanese women (aged 30.7<4.5 years, 15–20 weeks’ gestation) for H. pylori during the 6-month period between May and October 1998. Each individual provided informed oral consent for the examination. A non-lubricated speculum was passed prior to sampling the endocervical mucosa and the fluid from the posterior vaginal fornix with cottontipped swabs. Each swab was placed in a transport medium (Seedswab, Eiken Kagaku, Tokyo). Specimens were cultured for H. pylori under microaerophilic conditions within 2 h of sampling (AnaeroPack Campylo, Mitsubishi Gas Chemical, Tokyo) at