- Email: [email protected]
Sternoclavicular arthritis in Haverhill fever
several "other" sections such as genetics and microbiology/serology. . Significant capital has been dedicated to improving the flow of information. Specifically, ordering/resulting terminals are being added throughout the hospital with the goal of one at each patient bed as well as in the doctors offices, nursing stations, pharmacy, dietary, housekeeping, materials management, etc. Hand-held devices similar to Ap-
ple Newtons are being tested for physicians to access information. 9. Capital spending to improve turnaround time and throughput in the automated section has been projected for at least 5 yr. So, what about TQM and CQI? Do we dump it? Not necessarily. TQM and CQI or some other incremental methods should be used to fme tune the reengineered institution. Quality will always be important. It is just that TQM/CQI are too slow, too methodical, and too conservative.
Radical changes are upon us and radical solutions are needed.
References 1. JCAHO. 1993. Improving organizational performance. In 1995 Comprehensive Accreditation Manual for Hospitals. Joint Commission on Accreditation of Healthcare Organizations, pg. 219-221. 2. Bergman, R. 1994. Reengineering health care. Hosp Health Net 68:2836. 3. Castaneda-Mendez, K. 1994. Re-engineering: Is it right for you. Adv Admin Lab 3:16--22.
ii |
Case Reports
Sternoclavicular Arthritis in Haverhill Fever J.M. Saavedra Martin D.M. Aguayo Canela E. Pujol de la Llave D. Vega Alemfm J. Galvez Acebal L. Pascual Barrios Departments of Microbiology and Internal
Medicine General Hospital "Juan Ramtn Jimdnez" Huelva, Spain Streptobacillus moniliformis is a gram-negative bacillus and a member of the commensal flora of the pharynx of various rodents. It is responsible for two illnesses: rat-bite fever and Haverhill fever (erythema arthriticum epidemicum) (1-3), the latter not requiring a previous rat-bite or any other injury caused by an animal; the transmission is usually due to the ingestion of contaminated food or water. This is the reason why it has always been reported as an epidemic outbreak (4,5). Even though it has been welldocumented for a long time, there are few cases reported, perhaps because of the difficulty in isolating of the organism in the clinical laboratory and the benign (usually self-limited) course of the disease. Although arthritis related to S. moniliformis infection is quite frequent, there are few reports on organism isolaClinical Microbiology Newsletter 17:17,1995
tion from joint fluid. We report a case of Haverhill fever with prominent articular symptoms and the isolation of S. moniliformis from blood and joint fluid.
Case Report A 79-yr-old female from the urban area of Huelva (Spain) was admitted to the General Hospital in the summer of 1992. A week before her admission, she had suffered from abdominal pain, nausea, vomiting, and fever, followed, 2 d later, by a rash that included the extremities but disappeared 2 d later. Simultaneously, she had pain and tenderness in her knees, left shoulder, wrists, and right stemoclavicular joint. The woman did not report any bites or scratches from rodents or other animals. On admission her fever and ill-looking appearance remained; there was no evidence of skin lesions, adenopathies, neck stiffness, heart murmur, or hepatosplenomegaly. Laboratory data included hemoglobin: 10.1 g/l, WBC: 13.7 x 10/1 with 74% polymorphonuclear leukocytes, and a high ESR. Transaminases, lactic dehydrogenase, and alkaline phosphatase were normal. Urinalysis revealed 4 to 5 leukocytes per high-power-field. Three blood cultures and a urine culture were done on admission before beginning treatment with ciprofloxacin (200 mg i.v. every 12 h). Chest radiography and abdominal ultra© 1995 Elsevier Science Inc.
sonography were normal. There were no echocardiographic images of endocarditis. Two days after beginning treatment, the patient felt better; the fever had resolved but the Dints remained tender. The blood cultures became positive for pleomorphic gram-negative bacilli after 72 h incubation (Figure 1). The Gram stain strongly suggested Streptobacillus moniliformis. We obtained other blood cultures as well as an arthrocentesis on the right sternoclavicular joint. Although these blood cultures were negative, S. moniliformis was isolated from the joint fluid. The therapy was changed to penicillin G procaine 600,000 UI i.m. every 12 h for 4 d and then penicillin V 500 mg every 6 h for 10 d. The arthritis disappeared and 3 wk later, no symptoms remained and all laboratory data obtained as an outpatient was normal. Microbiology blood was cultured in BACTEC PLUS (Becton Dickinson Diagnostic Instrument Systems) culture vials in aerobic and anaerobic conditions. Blood cultures done on admission became positive after 72 h incubation at 35°C. No organisms were observed in the Gram stain and blind subcultures were done. After 48 h incubation at 35°C, round colonies were observed on the blood plates incubated in a carbon dioxide atmosphere and under anaero0196-4399/95/$0.00 + 09.50
133
bic conditions. A Gram stain of the colony revealed pleomorphic, filamentous, gram-negative bacilli with characteristic swellings of S. moniliformis. Biochemical tests were performed on this organism (the biochemical tests for identification of S. moniliformis requires serum supplementation). The catalase and oxidase reactions were negative. The organism failed to grow on MacConkey's agar and chocolate agar. Urease, indole, and gelatinase were not produced. Nitrate and phenylalanine tests were negative. In cystine trypticase agar, the organism produced acid from glucose, maltose, and galactose but not from salicin, lactose, arabinose, sucrose, xylose, trehalose, raff'mose, inositol, inulin, mannitol, or sorbitol. Moreover, H2S was produced weakly in the triple sugar iron agar (TSI) (6,7). The organism was susceptible to penicillin, cefuroxime, cefotaxime, imipenem, vancomycin, tetracycline, gentamicin, erythromycin, and ciprofloxacin by disk diffusion using Mueller-Hinton agar enriched with 5% horse blood using now-standardized interpretations (7). The joint fluid was inoculated onto blood agar, chocolate agar, MacConkey's agar, and into thioglycolate broth, all incubated at 35°C in an atmosphere supplemented with CO2. After 48 h incubation, growth was observed on the blood plate. The colonies were round, shiny, and of a fatty consistency. In the thioglycolate broth, characteristic growth in "puff balls" was observed. The Gram stain appearance, the colony morphology, biochemical identification, and reaction to antibiotics as described above were consistent with S. moniliformis.
Discussion Infection by S. moniliformis can sometimes happen without rat bite, in epidemic outbreaks (Haverhill fever), by ingestion of contaminated food or water (8). In the case reported, the absence of any injury and the importance of digestive symptoms at the onset of disease led us to consider this mode of transmission as the most likely. This is the first ease reported in our country (Spain) without rat bite (9). 134
0196-4399/95/$0.00 + 09.50
Figure 1. Gram stain of isolate of Streptobacillus moniliformis ( x 103).
The differential diagnosis of polyarticular arthritis with fever should include S. moniliformis among infectious agents, although this is very rare (10,11). The rash (described in 75% of the cases) can also be found in secondary syphilis, gonococcemia, infections by virus or rickettsias, systemic lupus erythematosus, and drug reactions. The history of rat bite suggests the etiologic diagnosis of S. moniliformis, but the absence of this fact can lead to delay or even failure in diagnosis (12). The patient lived in an urban area and she did not report any contact with animals. Bacteriologic cultures are of great importance because the Gram stain appearance strongly suggests the causal agent. The isolation of the organism is difficult, especially in blood cultures, because the vials holding the blood usually contain SPS to which the organism is susceptible. Despite reports of the failure to grow S. moniliformis from original blood broths that contained concentration of SPS as low as 0.0125% (6), we used BACTEC PLUS blood culture vials with a concentration of SPS 0.05%, resulting in the growth of the organism. Because blood can neutralize the toxicity of SPS toward organisms sensitive to SPS, the presence of maximum blood volumes (8-10 ml) can help to optimize recovery of these organisms. © 1995ElsevierScienceInc.
The arthritis of Haverhill fever is usually asymmetric, migratory, with polyarticular involvement, and a tendency to relapse. Joints frequently affected are knees, ankles, elbows, and shoulders (5). This pattern has suggested that an immunological mechanism could be involved in the pathogenesis of the polyarthritis (13). Nevertheless, this case is not a reactive arthritis because of the isolation of the organism from joint fluid. The difficulty of growing S. moniliformis in culture is probably the reason for the reported non-isolation of this organism. Endocarditis should be ruled out as a possible complication when S. moniliformis is isolated from a patient (14). In the case reported, endocarditis was discounted because there was no heart marmur, the echocardiogram was normal, and the outcome was not complicated. The sternoclavicular joint was the most affected in this case. This has been reported in two previous reports (14), although in both cases there were rat-bite antecedents and endocarditis, but not isolation of S. moniliformis from the joint fluid. In our opinion, S. moniliformis has to be considered as a possible agent of septic arthritis in patients with rash and fever even without evidence of rat bite.
Refere~es 1. gagosa, M. 1985. Streptobacillua ClinicalMicrobiologyNewsletter17:17.1995
moniliformis and Spirilum minus, p. 4(X)-4IM. In E.H. Lennette et al. (eds.), Manual of clinical microbiology, 4th ed. American Society for Microbiology, Washington, DC. 2. Pitt, P. 1991. Gadnereila, Streptobacillus, Spirillum and Calymmatobacterium, p. 583-587. In A. Balows et al. (eds.), Manual of clinical microbiology, 5th ed. American Society for Microbiology, Washington, DC. 3. Washburn, R.G. 1990. Streptobacillus moniliformis (rat bite fever), p. 17621764. In G.L. Mandell, R.G. Douglas, J.E. Bennet (eds.), Principles and practice of infectious diseases, 3th ed. Churchill Livingstone, Inc., New York. 4. Place, E.H., and L.E. Sutton. 1934. Erytherna arthriticum epidemicum (Haverhill Fever). Arch. Intern. Med. 54:659-684.
5.
Salmonella typhi
no medication. In June 1993, he noticed a burgeoning mass in the thoracic area for which he did not seek medical attention until January 1994. A hone scan (technetium 99m and gallium-67) performed at admission showed an enhanced capsulation around the left third costo-sternal joint, and a CT scan demonstrated a 6-cm left-sided mass along the sternum with hone destruction. The patient was in good health otherwise, not complaining of any bouts of fever or chills, had no episodes of diarrhea, and his weight was stable. A bone neoplasia was suspected, and the patient was therefore scheduled for exploratory surgery. The macroscopic surgical findings consisted of a hard, fibrotic shell containing a purulent fluid, which was sent for culture. Apart from a simple open biopsy, no other surgical procedure was performed. The pathology report described a fibrotic tissue with numerous foci of chronic inflammation, but no evidence of neoplasia. The direct Gram stain demonstrated numerous white blood cells; however, no microorganisms were seen. After a 24-h incubation, the culture showed a pure growth of a gram-negative bacteria. The organism was oxidase negative, lactose negative on MacConkey, and H2S productive, and was identified by VITEK-GNI and API-20E (Biomtrieux Vitek, Inc., Hazelwood, MO) as S. ty-
Osteomyelitis in an Immunocompetent Patient K. Weiss, M.D., F.R.C.P. (C) M. Laverdi~re, M.D., F.R.C.P.(C)
Department of Microbiology and Infectious Diseases Maisonneuve-Rosemont Hospital University of Montreal Montreal, Canada Salmonella typhi infections are very common worldwide (1,2) and are known to be more common and serious in patients with sickle cell anemia (3) or with HIV infections (4). Osteomyelitis due to Salmonella species in general are usually acute infections located in the long bones' diaphysis (5). We describe in this report a very atypical case of a lingering sternal osteomyelitis due to S. typhi mimicking a mediastinal tumor.
Case R e p o r t A 76-yr-old Haitian man presented to the emergency room of our hospital in January 1994 complaining of a dull thoracic pain and a growing mass in the thoracic area. From November 1992 to July 1993, the patient returned to Haiti, where he lived in a rural area with poor sanitary conditions. He remembered having had a febrile episode in March 1993 that lasted a few days, but he took
McEvoy, M.B., N.D. Noah, and R. Pilsworth. 1987. Outbreak of fever caused by Streptobacillus moniliformis. Lancet 2:1361-1363. 6. Lambe, D.W. Jr, et al. 1973. Streptobacillus moniliformis isolated from a case of Haverhill fever: biochemical characterization and inhibitory effect of sodium polyanethol suffonate. Am. J. Clin. Pathol. 60:854--860. 7.
Edwards, R., and R.G. Finch. 1986. Characterization and antibiotic susceptibilities of Streptobacillus moniliformis. J. Med. Microbiol. 21:39-42. 8. Shanson, D.C., et al. 1983. Streptobacillus moniliformis isolated from blood in four cases of Haverhill Fever. Lancet 2:92-94. 9. Anglada, A., et al. 1990. Artritis pot"
Streptobacillus moniliformi~, tm cast de fiebre por mordedura de rata. Medicina
Clinica (Barcelona) 94:535--537. 10. Goldenber8, D.L. 1989. Bacterial arthritis, p. 1567-1585. In W.N. Kelley et al. (eds.), Textbook of rheumatology, 3rd ed. W.B. Saunders, Philadelphia. 11. Mandel, D.R. 1985. Streptobacillary fever: an unusual cause of infectious arthritis. Cleve. Clin. Q. 52:203-205. 12. Fordham, J.N., et al. 1992. Rat bite fever without the bite. Ann Rheum. Dis. 51:411-412. 13. Holroyd, K.J, A.P. Reiner, and J.D. Dick. 1988. Streptobacillus moniliformis polyarthritis mimicking rheumatoid arthritis: an urban case of rat-bite fever. Am. J. Med. 85:711-714. 14. Rupp, M.E. 1992. Streptobacillusmoniliformis endocarditis: case report and review. Clin. Infect. Dis. 14:769-772.
phi. A slide agglutination using anti-salmonella serum (Difco Laboratories, Detroit, MI) was positive for group D. Susceptibility testing done by an agar dilution technique showed the isolate to be susceptible to ampicillin, ciprofloxacin, piperacillin, ceftriaxone, and ceftazidime. Furthermore, because of the unusual nature of the case, the strain was sent to the Quebec provincial laboratory for confLrmation. Cultures for mycobacteria and fungi were negative. Other laboratory investigation, except for an elevated alkaline phosphatase, were normal (CBC, liver function tests, urine analysis); the sedimentation rate was slightly elevated at 16 (normal range for men: 1-10) and HIV serology was negative. Hemoglobin electrophoresis was not done; however, there was no history of sickle cell disease, and erythrocyte mean corpuscular volume was normal. No enteric pathogens were found in tow stool cultures taken 24 h apart. The patient was treated with ciprofloxacin orally for a 6-wk period (750 mg p.o. BID). He tolerated the medication with no major side effects, and was followed at the outpatient clinic regularly. A control hone scan done in June 1994 showed a marked improvement compared with the previous exam. Physical examination was completely normal at a follow-up visit 2 mo
iii
Clinical l~crob iology Newsletter 17:17,1995
@ 1995 Elsevier Science Inc.
0196-4399/95/$0.00 ÷ 09.50
135
ple Newtons are being tested for physicians to access information. 9. Capital spending to improve turnaround time and throughput in the automated section has been projected for at least 5 yr. So, what about TQM and CQI? Do we dump it? Not necessarily. TQM and CQI or some other incremental methods should be used to fme tune the reengineered institution. Quality will always be important. It is just that TQM/CQI are too slow, too methodical, and too conservative.
Radical changes are upon us and radical solutions are needed.
References 1. JCAHO. 1993. Improving organizational performance. In 1995 Comprehensive Accreditation Manual for Hospitals. Joint Commission on Accreditation of Healthcare Organizations, pg. 219-221. 2. Bergman, R. 1994. Reengineering health care. Hosp Health Net 68:2836. 3. Castaneda-Mendez, K. 1994. Re-engineering: Is it right for you. Adv Admin Lab 3:16--22.
ii |
Case Reports
Sternoclavicular Arthritis in Haverhill Fever J.M. Saavedra Martin D.M. Aguayo Canela E. Pujol de la Llave D. Vega Alemfm J. Galvez Acebal L. Pascual Barrios Departments of Microbiology and Internal
Medicine General Hospital "Juan Ramtn Jimdnez" Huelva, Spain Streptobacillus moniliformis is a gram-negative bacillus and a member of the commensal flora of the pharynx of various rodents. It is responsible for two illnesses: rat-bite fever and Haverhill fever (erythema arthriticum epidemicum) (1-3), the latter not requiring a previous rat-bite or any other injury caused by an animal; the transmission is usually due to the ingestion of contaminated food or water. This is the reason why it has always been reported as an epidemic outbreak (4,5). Even though it has been welldocumented for a long time, there are few cases reported, perhaps because of the difficulty in isolating of the organism in the clinical laboratory and the benign (usually self-limited) course of the disease. Although arthritis related to S. moniliformis infection is quite frequent, there are few reports on organism isolaClinical Microbiology Newsletter 17:17,1995
tion from joint fluid. We report a case of Haverhill fever with prominent articular symptoms and the isolation of S. moniliformis from blood and joint fluid.
Case Report A 79-yr-old female from the urban area of Huelva (Spain) was admitted to the General Hospital in the summer of 1992. A week before her admission, she had suffered from abdominal pain, nausea, vomiting, and fever, followed, 2 d later, by a rash that included the extremities but disappeared 2 d later. Simultaneously, she had pain and tenderness in her knees, left shoulder, wrists, and right stemoclavicular joint. The woman did not report any bites or scratches from rodents or other animals. On admission her fever and ill-looking appearance remained; there was no evidence of skin lesions, adenopathies, neck stiffness, heart murmur, or hepatosplenomegaly. Laboratory data included hemoglobin: 10.1 g/l, WBC: 13.7 x 10/1 with 74% polymorphonuclear leukocytes, and a high ESR. Transaminases, lactic dehydrogenase, and alkaline phosphatase were normal. Urinalysis revealed 4 to 5 leukocytes per high-power-field. Three blood cultures and a urine culture were done on admission before beginning treatment with ciprofloxacin (200 mg i.v. every 12 h). Chest radiography and abdominal ultra© 1995 Elsevier Science Inc.
sonography were normal. There were no echocardiographic images of endocarditis. Two days after beginning treatment, the patient felt better; the fever had resolved but the Dints remained tender. The blood cultures became positive for pleomorphic gram-negative bacilli after 72 h incubation (Figure 1). The Gram stain strongly suggested Streptobacillus moniliformis. We obtained other blood cultures as well as an arthrocentesis on the right sternoclavicular joint. Although these blood cultures were negative, S. moniliformis was isolated from the joint fluid. The therapy was changed to penicillin G procaine 600,000 UI i.m. every 12 h for 4 d and then penicillin V 500 mg every 6 h for 10 d. The arthritis disappeared and 3 wk later, no symptoms remained and all laboratory data obtained as an outpatient was normal. Microbiology blood was cultured in BACTEC PLUS (Becton Dickinson Diagnostic Instrument Systems) culture vials in aerobic and anaerobic conditions. Blood cultures done on admission became positive after 72 h incubation at 35°C. No organisms were observed in the Gram stain and blind subcultures were done. After 48 h incubation at 35°C, round colonies were observed on the blood plates incubated in a carbon dioxide atmosphere and under anaero0196-4399/95/$0.00 + 09.50
133
bic conditions. A Gram stain of the colony revealed pleomorphic, filamentous, gram-negative bacilli with characteristic swellings of S. moniliformis. Biochemical tests were performed on this organism (the biochemical tests for identification of S. moniliformis requires serum supplementation). The catalase and oxidase reactions were negative. The organism failed to grow on MacConkey's agar and chocolate agar. Urease, indole, and gelatinase were not produced. Nitrate and phenylalanine tests were negative. In cystine trypticase agar, the organism produced acid from glucose, maltose, and galactose but not from salicin, lactose, arabinose, sucrose, xylose, trehalose, raff'mose, inositol, inulin, mannitol, or sorbitol. Moreover, H2S was produced weakly in the triple sugar iron agar (TSI) (6,7). The organism was susceptible to penicillin, cefuroxime, cefotaxime, imipenem, vancomycin, tetracycline, gentamicin, erythromycin, and ciprofloxacin by disk diffusion using Mueller-Hinton agar enriched with 5% horse blood using now-standardized interpretations (7). The joint fluid was inoculated onto blood agar, chocolate agar, MacConkey's agar, and into thioglycolate broth, all incubated at 35°C in an atmosphere supplemented with CO2. After 48 h incubation, growth was observed on the blood plate. The colonies were round, shiny, and of a fatty consistency. In the thioglycolate broth, characteristic growth in "puff balls" was observed. The Gram stain appearance, the colony morphology, biochemical identification, and reaction to antibiotics as described above were consistent with S. moniliformis.
Discussion Infection by S. moniliformis can sometimes happen without rat bite, in epidemic outbreaks (Haverhill fever), by ingestion of contaminated food or water (8). In the case reported, the absence of any injury and the importance of digestive symptoms at the onset of disease led us to consider this mode of transmission as the most likely. This is the first ease reported in our country (Spain) without rat bite (9). 134
0196-4399/95/$0.00 + 09.50
Figure 1. Gram stain of isolate of Streptobacillus moniliformis ( x 103).
The differential diagnosis of polyarticular arthritis with fever should include S. moniliformis among infectious agents, although this is very rare (10,11). The rash (described in 75% of the cases) can also be found in secondary syphilis, gonococcemia, infections by virus or rickettsias, systemic lupus erythematosus, and drug reactions. The history of rat bite suggests the etiologic diagnosis of S. moniliformis, but the absence of this fact can lead to delay or even failure in diagnosis (12). The patient lived in an urban area and she did not report any contact with animals. Bacteriologic cultures are of great importance because the Gram stain appearance strongly suggests the causal agent. The isolation of the organism is difficult, especially in blood cultures, because the vials holding the blood usually contain SPS to which the organism is susceptible. Despite reports of the failure to grow S. moniliformis from original blood broths that contained concentration of SPS as low as 0.0125% (6), we used BACTEC PLUS blood culture vials with a concentration of SPS 0.05%, resulting in the growth of the organism. Because blood can neutralize the toxicity of SPS toward organisms sensitive to SPS, the presence of maximum blood volumes (8-10 ml) can help to optimize recovery of these organisms. © 1995ElsevierScienceInc.
The arthritis of Haverhill fever is usually asymmetric, migratory, with polyarticular involvement, and a tendency to relapse. Joints frequently affected are knees, ankles, elbows, and shoulders (5). This pattern has suggested that an immunological mechanism could be involved in the pathogenesis of the polyarthritis (13). Nevertheless, this case is not a reactive arthritis because of the isolation of the organism from joint fluid. The difficulty of growing S. moniliformis in culture is probably the reason for the reported non-isolation of this organism. Endocarditis should be ruled out as a possible complication when S. moniliformis is isolated from a patient (14). In the case reported, endocarditis was discounted because there was no heart marmur, the echocardiogram was normal, and the outcome was not complicated. The sternoclavicular joint was the most affected in this case. This has been reported in two previous reports (14), although in both cases there were rat-bite antecedents and endocarditis, but not isolation of S. moniliformis from the joint fluid. In our opinion, S. moniliformis has to be considered as a possible agent of septic arthritis in patients with rash and fever even without evidence of rat bite.
Refere~es 1. gagosa, M. 1985. Streptobacillua ClinicalMicrobiologyNewsletter17:17.1995
moniliformis and Spirilum minus, p. 4(X)-4IM. In E.H. Lennette et al. (eds.), Manual of clinical microbiology, 4th ed. American Society for Microbiology, Washington, DC. 2. Pitt, P. 1991. Gadnereila, Streptobacillus, Spirillum and Calymmatobacterium, p. 583-587. In A. Balows et al. (eds.), Manual of clinical microbiology, 5th ed. American Society for Microbiology, Washington, DC. 3. Washburn, R.G. 1990. Streptobacillus moniliformis (rat bite fever), p. 17621764. In G.L. Mandell, R.G. Douglas, J.E. Bennet (eds.), Principles and practice of infectious diseases, 3th ed. Churchill Livingstone, Inc., New York. 4. Place, E.H., and L.E. Sutton. 1934. Erytherna arthriticum epidemicum (Haverhill Fever). Arch. Intern. Med. 54:659-684.
5.
Salmonella typhi
no medication. In June 1993, he noticed a burgeoning mass in the thoracic area for which he did not seek medical attention until January 1994. A hone scan (technetium 99m and gallium-67) performed at admission showed an enhanced capsulation around the left third costo-sternal joint, and a CT scan demonstrated a 6-cm left-sided mass along the sternum with hone destruction. The patient was in good health otherwise, not complaining of any bouts of fever or chills, had no episodes of diarrhea, and his weight was stable. A bone neoplasia was suspected, and the patient was therefore scheduled for exploratory surgery. The macroscopic surgical findings consisted of a hard, fibrotic shell containing a purulent fluid, which was sent for culture. Apart from a simple open biopsy, no other surgical procedure was performed. The pathology report described a fibrotic tissue with numerous foci of chronic inflammation, but no evidence of neoplasia. The direct Gram stain demonstrated numerous white blood cells; however, no microorganisms were seen. After a 24-h incubation, the culture showed a pure growth of a gram-negative bacteria. The organism was oxidase negative, lactose negative on MacConkey, and H2S productive, and was identified by VITEK-GNI and API-20E (Biomtrieux Vitek, Inc., Hazelwood, MO) as S. ty-
Osteomyelitis in an Immunocompetent Patient K. Weiss, M.D., F.R.C.P. (C) M. Laverdi~re, M.D., F.R.C.P.(C)
Department of Microbiology and Infectious Diseases Maisonneuve-Rosemont Hospital University of Montreal Montreal, Canada Salmonella typhi infections are very common worldwide (1,2) and are known to be more common and serious in patients with sickle cell anemia (3) or with HIV infections (4). Osteomyelitis due to Salmonella species in general are usually acute infections located in the long bones' diaphysis (5). We describe in this report a very atypical case of a lingering sternal osteomyelitis due to S. typhi mimicking a mediastinal tumor.
Case R e p o r t A 76-yr-old Haitian man presented to the emergency room of our hospital in January 1994 complaining of a dull thoracic pain and a growing mass in the thoracic area. From November 1992 to July 1993, the patient returned to Haiti, where he lived in a rural area with poor sanitary conditions. He remembered having had a febrile episode in March 1993 that lasted a few days, but he took
McEvoy, M.B., N.D. Noah, and R. Pilsworth. 1987. Outbreak of fever caused by Streptobacillus moniliformis. Lancet 2:1361-1363. 6. Lambe, D.W. Jr, et al. 1973. Streptobacillus moniliformis isolated from a case of Haverhill fever: biochemical characterization and inhibitory effect of sodium polyanethol suffonate. Am. J. Clin. Pathol. 60:854--860. 7.
Edwards, R., and R.G. Finch. 1986. Characterization and antibiotic susceptibilities of Streptobacillus moniliformis. J. Med. Microbiol. 21:39-42. 8. Shanson, D.C., et al. 1983. Streptobacillus moniliformis isolated from blood in four cases of Haverhill Fever. Lancet 2:92-94. 9. Anglada, A., et al. 1990. Artritis pot"
Streptobacillus moniliformi~, tm cast de fiebre por mordedura de rata. Medicina
Clinica (Barcelona) 94:535--537. 10. Goldenber8, D.L. 1989. Bacterial arthritis, p. 1567-1585. In W.N. Kelley et al. (eds.), Textbook of rheumatology, 3rd ed. W.B. Saunders, Philadelphia. 11. Mandel, D.R. 1985. Streptobacillary fever: an unusual cause of infectious arthritis. Cleve. Clin. Q. 52:203-205. 12. Fordham, J.N., et al. 1992. Rat bite fever without the bite. Ann Rheum. Dis. 51:411-412. 13. Holroyd, K.J, A.P. Reiner, and J.D. Dick. 1988. Streptobacillus moniliformis polyarthritis mimicking rheumatoid arthritis: an urban case of rat-bite fever. Am. J. Med. 85:711-714. 14. Rupp, M.E. 1992. Streptobacillusmoniliformis endocarditis: case report and review. Clin. Infect. Dis. 14:769-772.
phi. A slide agglutination using anti-salmonella serum (Difco Laboratories, Detroit, MI) was positive for group D. Susceptibility testing done by an agar dilution technique showed the isolate to be susceptible to ampicillin, ciprofloxacin, piperacillin, ceftriaxone, and ceftazidime. Furthermore, because of the unusual nature of the case, the strain was sent to the Quebec provincial laboratory for confLrmation. Cultures for mycobacteria and fungi were negative. Other laboratory investigation, except for an elevated alkaline phosphatase, were normal (CBC, liver function tests, urine analysis); the sedimentation rate was slightly elevated at 16 (normal range for men: 1-10) and HIV serology was negative. Hemoglobin electrophoresis was not done; however, there was no history of sickle cell disease, and erythrocyte mean corpuscular volume was normal. No enteric pathogens were found in tow stool cultures taken 24 h apart. The patient was treated with ciprofloxacin orally for a 6-wk period (750 mg p.o. BID). He tolerated the medication with no major side effects, and was followed at the outpatient clinic regularly. A control hone scan done in June 1994 showed a marked improvement compared with the previous exam. Physical examination was completely normal at a follow-up visit 2 mo
iii
Clinical l~crob iology Newsletter 17:17,1995
@ 1995 Elsevier Science Inc.
0196-4399/95/$0.00 ÷ 09.50
135