Uncommon acute bacterial pneumonias

Uncommon Acute Bacterial

Pneumonias

Yahya M. Berkmen

T

HE PNEUMONIAS discussed in this presentation are more than curiosities, and not merely of academic interest. Some of them, such as tularemia and anthrax, still make their existence felt unexpectedly in rural as well as urban areas; others are newly described (ie, legionnaires’ disease). Interestingly enough, certain bacteria originally thought to be nonpathogenic for humans are now found to cause serious and sometimes fatal disease (ie, Serratia marcescens). Although distinguishing radiographic characteristics are few, the patient’s background, clinical history, and physical findings and the radiographic changes complement each other and may suggest or lead to the diagnosis. Here, then, in alphabetic order, is a discussion of the uncommon bacterial pneumonias. ANTHRAX

Anthrax is a disease of sheep, cattle, cows, and goats. In this country, it is endemic in the states where livestock is concentrated.79 Its causative agent is Gram-positive, aerobic, spore-forming Bacillus anthracis. Human disease is acquired through the skin or the lungs after contact with wool, hides, furs, or other animal products contaminated by spores. With the possible exception of one case, finished products such as upholstered furniture, leather jackets, wool carpets, and rugs are not a source of infection.’ The disease is occasionally transported by insects from carcasses of infected animals to man.79 Human-to-human transmission through communal toilet articles or shaving brushes may occur.3’ The disease has also been diagnosed in individuals living in close proximity to a plant that processes wool and hair, without a direct contact with raw material.g Pulmonary involvement is either by inhalation or by hematogenous dissemination from a cutaneous lesion. In inhalation anthrax, spores upon entering the lung are carried by macrophages to hilar and mediastinal nodes. They germinate while being transported to or within the nodes, producing severe lymphangitis and hemorrhagic lymphadenitis with marked adenopathy. From the lymphatics, bacilli may enter the blood

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XV,

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1 (January),

1980

stream and spread hematogenously, causing meningitis, necrotic intestinal lesions, and toxemia.58.80 Inhalation anthrax carries a very high mortality. Clinically, the onset is insidious, with low grade fever, malaise, and nonproductive cough lasting several days; then suddenly high fever, acute dyspnea with cyanosis, and shock develop, leading to death usually within 24 hr.58 Enlarged mediastinal nodes may compress the trachea and cause marked stridor. The most common cause of death is toxemia. Recovery and cure is only rarely recorded in inhalation anthrax.58,80 B anthracis is very sensitive to penicillin; resistance is infrequent.” In suspected cases, high dose penicillin treatment, preferably with addition of anthrax antitoxin or antiserum, is curative if administered before the second stage. Unfortunately, anthrax antiserum is not commercially available in the United States.58 Radiographically, pulmonary anthrax presents with marked hilar and mediastinal lymphadenopathy; patchy or diffuse confluent pulmonary infiltrates; and consolidations due to hemorrhagic pneumonia, areas of edema from lymphatic blockage, and pleural effusion.80 BRUCELLOSIS

Human infection with aerobic Gram-negative organisms of the Brucella family (B abortus, B melitensis, B suis) is usually through ingestion of unpasteurized dairy products, contact with diseased cattle, swine, or wild animals such as caribou or moose, laboratory accidents, etc.24 Pulmonary involvement is rare and radiographitally may appear as single or multiple nodules, bronchopneumonia, lung abscess, pleural effusion, and empyema. Hilar adenopathy may be present and may cause atelectasis by extreme pressure on a bronchus.‘9.2R.82.83 From the Deparrment of Radiology, New York Medical College, Metropolitan Hospiial Center, New York, N. Y. Address reprint requests to Yahya Berkmen, Professor of Clinical Radiology, Department of Radiology, New York Medical College, 1901 Firs1 Ave., Metropolitan Hospital Center, New York, N.Y. 10029. o 1980 by Grune & Srrarron. Inc. 0037-I 98X/80/1501-0004 %02.00/O

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M. BERKMEN

Pathologically, nodules of Brucellosis resemble tuberculous granuloma.83 The true nature of the lesion may be established by culture. LEGIONNAIRES’

DISEASE

In July of 1976, 182 persons who attended the 58th Annual Convention of the American Legion in Philadelphia were struck by an outbreak of a mysterious disease. Common features of their illness were malaise and headache followed within 24 hr by high fever, nonproductive cough, and increasing dyspnea. The disease ended fatally in 29 patients.” Histologically, there was an extensive pneumonic consolidation with abundant polymorphonuclear neutrophils and macrophages, fibrin, some red cells, destruction of alveolar walls, hyaline membrane formation, and fibrosis.6325,37,84 The mystery disease became known as legionnaires’ disease and eventually proved to be caused by an aerobic Gram-negative bacterium, named Legionella pneumophilia.68 The organism is stained by Dieterle silver-impregnation method. Sections previously stained by hematoxylin-eosin may be decolorized and restained by this method.” Serologic tests disclosed that many similar undiagnosed outbreaks in the U.S. and different parts of Europe, the Middle East, and Australia were indeed legionnaires’ disease.49,68.74New epidemics and sporadic cases are now being reported from various parts of the world. 21.37,44,47,61 In the acutely ill patient, bacteria may be isolated from tracheal aspirate,43 pleural effusion, or the lung.68 Epidemiology of the disease is still obscure. It is presumed to be an airborne infection. Personto-person transmission has not been demonstrated,2s but has been recently suggested.68 Growth of the bacteria in cooling towers of air conditioners has been shown, and a question of a causal relationship has been raised.68 Age of the patients range between 10 mo and 84 yr. Previously healthy individuals as well as patients with underlying disease, such as alcoholism, diabetes, heart disease, malignancy, renal transplantation, and other conditions may be infected.7.2’ Radiographically, the disease usually presents

A

Fig. 1. Legionnaire disease. IA) Portable AP chest film seen after admission. The pneumonia is confined to the left lower lobe. (6) Four days later. The pneumonia has extended in the left lung and has spread to the right lung. The patient slowly recovered on erythromycin therapy. (Courtesy of Dr. B. Felson, Cincinnati)

as extensive unilateral or bilateral patchy or confluent alveolar densities with poorly outlined margins without specific distribution,” or with lobar consolidation.6’ Cavities may develop.68l84 Pleural effusion occurs in 40%50% of cases.2”68 Progression of the pneumonia after admission in the hospital should suggest the possibility of this disease (Fig. 1). Treatment is with erythromytin. LISTERIOSIS

Listeria monocytogenes is a Gram-positive, aerobic bacterium with worldwide distribution. Human infection is acquired through contact with wild or domestic animals and birds, milk and meat, or soil contaminated by these animals.8~33~57 It is being recognized with increasing frequency as a hospital and community infection acquired from asymptomatic human carriers or patients with listeriosis.8,26,77 Previously healthy individuals as well as patients with malignant tumors (especially lymphoma)

UNCOMMON

ACUTE BACTERIAL

and renal transplants may become infected. IS.16.26.46 Listeriosis in pregnant women may be either subclinical or associated with a brief and mild febrile episode. It may cause abortion or stillbirth.8 Genital listeriosis in men, presumably transmitted by sexual intercourse with an infected partner, may result in infertility, which is reversible if properly treated.**” Intrauterine fetal infection results in necrotic, granulomatous lesions of multiple organs and is called granulomatosis infantiseptica.” Clinical manifestations may be those of meningitis, encephalitis, septicemia, endocarditis, or myocardial abscess. Oculoglandular, cervicoglandular, or typhoid forms may occur. 8.10,17,32,53 Radiographic description of listeria pneumonia is rare. Homogenous infiltrates, diffuse miliary lesions, and pleural effusion have been reported.‘0.46*53 L monocytogenes usually shows resistance to one or more antibiotics. Penicillin, streptomycin, chloramphenicol, and erythromycin have been used.” NEISSERIA

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PNEUMONIAS

MENINGITIDIS

PNEUMONIA

Pneumonia due to this aerobic Gram-negative microorganism is a serious and often fatal disease. Although it is commonly cited as a complication of influenza epidemics and adenovirus infections,3~34,40.59 primary pneumonia34 or secondary infection during meningococcemia4’ are frequent. There is constant change in the predominant group of N meningitidis that causes meningococcal disease. Until 1963, Group A, and later Groups B and C were the common agents. Since 1970, Group Y, once thought to be nonpathogenic, has been found to be a major serotype. There is now evidence suggesting that even Group Y may be waning, and new groups may be expected to replace it in the future.40 The patients present clinically with cough, fever, chest pain, and dyspnea. Chest roentgenogram reveals patchy or confluent densities involving either or both lungs with occasional cavities. A small amount of pleural effusion may be present .34.40 N meningitidis is sensitive to penicillin-G.

erythromycin, chloramphenicol, and tetracycline are effective in patients allergic to penicillin.40 PASTEURELLOSIS

Several bacteria of the genus Pasteurella have recently been reclassified and separated into different genera: P pestis and P pseudotuberculosis to genus Yersinia, P tularensis to genus Francisella. P multocida is the most commonly encountered pathogen. It is a Gram-negative aerobic microorganism. It may cause localized skin infection with lymphadenitis following animal bites and scratches, or systemic infection with septicemia, pneumonia, lung abscess, and empyema.64.7’Recently, pneumonia secondary to P ureae has been reported.” P multocida is sensitive to penicillin, chloramphenicol, and cephalotin.64 PROTEUS

PNEUMONIA

Since the advent of antibiotics, the incidence of infections secondary to Bacillus proteus (aerobic and Gram-negative) has been on the rise. It occurs as a nosocomial or communityacquired infection. P mirabilis is the most common agent, although P vulgaris and P morganii are also isolated in many cases. Infection of the urinary tract, surgical wounds, decubitus ulcers, umbilical cord of newborns, meninges, middle ear, and synovial joints have been reported.‘*“~30,38~55.76.87 Only a small percentage of Gram-negative pneumonias is caused by Proteus species.78 Proteus pneumonia is most often caused by aspiration.76 Tracheostomy and thracotomy tubes may also introduce the infection.’ Patients infected by Proteus commonly have an underlying chronic disease such as diabetes, chronic lung disease, or alcoholism. Radiographically, proteus pneumonia usually presents as a segmental or lobar consolidation. Loss of volume of the involved lobe with shift of the trachea to this side is frequently seen.76,78 Cavitation and empyema are common.‘~76.7* Nosocomial infections are often resistant to antibiotics. SALMONELLOSIS

Bacteria of the genus Salmonella are aerobic and Gram-negative. Pulmonary and pleural

YAHYA

M. BERKMEN

Fig. 2. Fatal Serratia pneumonia in the postoperative period following tricuspid and mitral valve replacements. There is a small pleural effusion on the right. (Courtesy of Dr. E. Robert Heitzman. Syracuse, N.Y.)

disease occur either independently or is associated with Salmonella gastroenteritis. A number of serotypes (S cholerasuis, S typhimurium, S oranienburg, S paratyphi B, S Stanley, S suipestifer) have been isolated from lungs and empyema fluid. Radiographically, the disease presents as bronchopneumonia, lobar consolidation, abscess, miliary lesions, or pleural effusion (empyema). Pericarditis has also been reported,5,‘2,27.42 SERRATIA

MARCfSCfNS

PNEUMONIA

S marcescens is a Gram-negative, aerobic microorganism of the family of Enterobacteriaceae, which also includes Klebsiella and Enterobacter.86 Although it was thought to be nonpathogenic for humans until recently, infections due to Serratia are now being reported with ever increasing frequency. Postsurgical and other hospitalized patients are prone to develop serratia infection, which is commonly transmitted through hospital equipment used for peritoneal dialysis and hemodialysis, transfusion sets, respicatheters, etc. Hospital rators, indwelling personnel and patients with serratia infection may be the source of the disease.48350,86 Immunosuppressed and debilitated patients, heroin addicts, patients receiving broad spectrum antibiotic therapy, and those with chronically

elevated blood glucose levels due to intravenous therapy are also susceptible to serratia infections.62,86Cases of cystitis, wound infection, septicemia, meningitis, osteomyelitis, septic arthritis, endocarditis;86 and mycotic aneurysm,54 produced by S marcescens have been reported. Serratia pneumonia appears as patchy or confluent infiltrates. Cavitation is not demonstrated.‘4,5’ Cavitary lesions reported in Serratia pneumonia22,63 are probably due to other superimposed infectious agents5’ A small pleural effusion may be present (Fig. 2). The organism is commonly sensitive to gentamycin and kanamycin; for gentamycin-resistant strains, amikacin and combination of synergistic antimicrobials have been successfully used.50@ TULAREMIA

Tularemia is endemic in Europe, Asia, and North America. In the U.S., small epidemics and sporadic cases have been reported from all parts of the country, with a higher incidence in Arkansas, Louisiana, Oklahoma, and Texas.39@‘38’,85 Aerobic Gram-negative Francisella tularemia (originally classified with genus Pasteurefla) is the causative agent. Human disease is commonly contracted through injured as well as intact dermis by skinning diseased muskrats or rabbits or

UNCOMMON

ACUTE

BACTERIAL

handling their moist pelts; through tick, mosquito, biting gnat, or deerfly bites;39’85 and by contact with infected domestic animals; or by dog or cat bites or scratches.36.60In the U.S., 90% of the cases are of cutaneous (ulceroglandular) variety. 5hThe intestinal (typ hoidal) form results from ingestion of contaminated food, water, or swallowing aerosol particles3’ The pulmonary form results either from inhalation of infected particles from the carcass of a disease anima1,29,52from a laboratory accident,s6 from contaminated dust,39 or by hematogenous spread.” The incubation period of 1-14 days is foilowed by prodromal symptoms of chill, fever, malaise, cough, and tightness in the chest, which may last from IO days to 3 wk. Pneumonia may occur 7-10 days after the onset of symptoms.56 Pulmonary involvement may be unilateral or bilateral with lobar, segmental, or patchy infiltrates. Miliary pattern, cavitation, and residual cysts are less common. 4’.66Tularemic pneumonia stimulates tissue response similar to tuberculosis, so that fibrosis and calcification may occur later.52’66 Hilar lymphadenopathy is reported with an incidence of 32%64% (Fig. 3).66 Unilateral or bilateral pleural effusion is frequent; empyema may be complicated by bronchopleural fistula.52,66 Pericarditis is often associated with pleuropulmonary disease.45 Streptomycin is the drug of choice. Tetracycline and chloramphenicol are also used.29*45.52

Fig.

Tularemia

3.

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There

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developed following

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(Courtesy and

Bruce

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lymphadepatchy

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pulmonary of

Javors,

21

PNEUMONIAS

Drs.

Donald Brooklyn,

YERSINIOSIS

Yersinia enterocofitica is a Gram-negative aerobic bacterium widely distributed in nature and in animals (horses, pigs, and dogs). Its epidemiology is rather obscure. Infections due to this organism result mainly in acute gastroenteritis and enterocolitis. In children and young adults, the infection commonly involves the ileum and adjacent lymph nodes, clinically simulating appendicitis or mesenteric lymphadenitis. Other manifestations of this infection include erythema nodosum, Reiter syndrome, septicemia, myocarditis, osteomyelitis, and septic arthritis.69.73 Yersinia pneumonia may present as fluffy infiltrates, nodules, or consolidations. An abscess may form (Fig. 4). Hilar adenopathy is found with or without associated pulmonary infiltrates. A sarcoid-like form with hilar adenopathy and erythema nodosum has been described.2,67.69.73 The organism is sensitive to chloramphenicol, streptomycin, and tetracycline. OTHER BACTERIAL

PNEUMONIAS

Other unusual bacterial pneumonias include pneumonia resembling lung tumor caused by the aerobic Gram-variable Bacillus sphericus; pneumonia, miliary nodules, lung abscess, or empyema caused by anaerobic Gram-positive Bifidobacterium eriksonii (previously called Actinomyces eriksonii);75 pneumonia and em-

22

Fig. 4. enterocolitis.

YAHYA

Pulmonary (Courtesy

and chest wall abscesses of Dr. Jack G. Rabinowitz.

and osteomyelitis New York”)

pyema due to Clostridium perfringens, C sporogenes, or C. sordellii.4.23 Aerobic Gram-negative Acinobacter (formerly referred to as Herellea vaginicola and Mima polymorpha) can cause pneumonia in alcoholics, hospitalized and intu-

with

pathologic

fracture

of rib associated

M. BERKMEN

with

Yersinia

bated patients,65 and patients with chronic pulmonary disease.13 Lung abscess due to BacilIus cereus,*O abscess and empyema caused by Campylobacter fetus (previously called Vibrio fetus)‘* have also been reported.

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naire’s disease in renal transplant recipients. Lancet 1:410413, 1978 8. Bojsen-M$ller J: Human listeriosis Diagnostic, epidemiological and clinical studies. Acta Pathol Microbial Stand (B) Suppl229, 1972 9. Brachman PS, Pagan0 JS, Albrink WS: Two cases of fatal inhalation anthrax, one associated with sarcoidosis. N Engl J Med 265:203-208, 1961 IO. Buchner LH, Schneierson SS: Clinical and laboratory aspects of Listeria monocytogenes infections. Am J Med 45:904-921, 1968 Il. Burke JP, Ingall D, Klein JO, et al: Proteus mirabilis infections in a hospital nursery traced to a human carrier. N Engl J Med284:115-121,197l 12. Burney DP, Fisher RD, Schaffner W: Salmonella empyema: A review. South Med J 70:375-377, 1977 13. Buscaglia AJ: Acinobacter pneumonia. Ann Intern Med 89:lOlO. 1978 14. Carlon GC, Dickinson PCT, Goldiner PL, et al:

UNCOMMON

ACUTE BACTERIAL

Serratia marcescens pneumonia. Arch Surg 112: 1220-I 224, 1917 15. Case Records of the Massachusetts General Hospital (Case 3551974). N Engl J Med 291:516-524, 1974 16. Case Records of the Massachusetts General Hospital (Case 41-1976). N Engl J Med 295:8288834, 1976 17. Case Records of the Massachusetts General Hospital (Case40-1978). N Engl J Med 299:819-826, 1978 18. Chandler FW, Hicklin MD, Blackman JA: Demonstration of the agent of Legionnaires’ disease in tissue. N Engl J Med 297:1218-1220, 1977 19. Chavez CA, Veach GE: Localized pulmonary nodule due to Brucella suis. J Kans Med Sot 77x434-431, 1976 20. Coonrad JD, Leadley PJ, Eickhoff TC: Bacillus cereus pneumonia and bacteremia: A case report. Am Rev RespDis 103:711-714, 1971 21. Dietrich PA, Johnson RD, Fairbank JT, et al: The chest radiograph in Legionnaires’ disease. Radiology 127:577-582, 1978 22. Elston HR, Magnuson CW: Lung abscess caused by

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23. File Jr TM, Fass RJ, Perkins RL: Pneumonia and empyema caused by Clostridium sordellii. Am J Med Sci 274:211-212, 1977 24. Fox MD, Kaufmann AF: Brucellosis in the United States, 196551974. J Infect Dis 136:312-316, 1977 25. Fraser DW, Tsai TR, Orenstein W, et al: Legionnaires’ disease. Description of an epidemic of pneumonia. N Engl J Med 297:1189-l 197, 1977 26. Green HT, Macanley MB: Hospital outbreak of Lisferia monocytogenes septicemia: A problem of cross infection? Lancet 2:1039-1040, 1978 27. Greenspan RH, Feinberg SB: Salmonella bacteremia: A case with miliary lung lesions and spondylitis. Radiology 68:86&862, 1957 28. Greer AE: Pulmonary 519, 1956

brucellosis. Dis Chest 29:508-

29. Halsted CC, Kulasinghe

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PNEUMONIAS

HP: Tularemia pneumonia in urban children. Pediatrics 61:660-662, 1976 30. Hardin JG: Occult chronic septic arthritis due to Proteus mirabilis. JAMA 240:1889-1890, 1978 31. Heyworth 8, Ropp ME, Voos UG, et al: Anthrax in Gambia: An epidemiological study. Br Med J 4:79-82, 1975 32. Hoeprich PD, ChernoIT HM: Subacute bacterial endocarditis due to Listeria monocytogenes. Am J Med 19:488-494, 1955 33. Hood M: Listeriosis. Report of 10 cases. Am J Clin Path01 28: 18826, 1957 34. Irwin RS, Woelk WK, Coudon WL: Primary meningococcal pneumonia. Ann Intern Med 82:493-498, 1975 35. lsaacson P, Jacobs PH, MacKenzie AMR, et al: Pseudotumor of the lung caused by infection with Bacillus sphericus. J Clin Path01 29:806-81 1, 1976 36. Jackson RT, Lester JP: Tularemia presenting as unresponsive pneumonia: Diagnosis and therapy with gentamicin. J Tenn Med Assoc 71:189-191, 1978 37. Keys TF: A sporadic case of pneumonia due to Legionnaires’ disease. Mayo Clin Proc 52:657-660, 1977 38. Khan AJ, Ubriani RS, Ombach EB, et al: Initial

urinary tract infection caused by Proteus mirabilis in infancy and childhood. J Pediatr 93:791-793, 1978 39. Klock LE, Olsen PF, Fukushima T: Tularemia epidemic associated with the deerfly. JAMA 226:149-l 52, 1973 40. Koppes GM, Ellenbogen C, Gebhart RJ: Group Y meningococcal disease in United States Air Force recruits. Am J Med 62:661-666, 1977 41. Kozak AJ, Hall WH, Gerding DN: Cavitary pneumonia associated with tularemia. Chest 73:426-427, 1978 42. Kunjaitis J, Okutan AM: Empyema due to Salmonella typhimurium. Am Rev Resp Dis 83:741-743, 1961 43. Lattimer GL, McCrone C, Galgon J: Diagnosis of Legionnaires’ disease from transtracheal aspirate by direct fluorescent-antibody staining and isolation of the bacterium. N Engl J Med 299:1172-1173, 1978 44. Lees AW, Tyrell WF, Boyd JF: Legionnaires’ disease. Lancet 2: I 187, 1977 45. Louria DB: Bacterial pneumonia, in Baum GL (Ed): The Textbook of Pulmonary Diseases (ed 2). Boston, Little, Brown, 1974 46. Louria DB, Hensle T, Armstrong D, et al: Listeriosis complicating malignant disease-A new association. Ann Intern Med 67:261-28 1, 1967 47. MacRae AD, Lewis MJ: Legionnaires’ disease in Nottingham. Lancet 2: 122551226, 1977 48. McCormack RC, Kunin CM: Control of a single source nursery epidemic due to Serratia marcescens. Pediatrics 37:75&755, 1966 49. McDade JE, Shepard CC, Fraser DW, et al: Legionnaires’ disease: Isolation of a bacterium and demonstration of its role in other respiratory disease. N Engl J Med 297:1197-1203, 1977 50. Meers PD, Foster CS, Churcher GM: Cross-infection with Serratia marcescens. Br Med J I:2388239, 1978 51. Meltz DJ, Grieco MH: Characteristics of Serratia marcescens pneumonia. Arch Intern Med 132:359-364, 1973 52. Miller RP, Bates JH: Pleuropulmonary tularemia: A review of 29 patients. Am Rev Resp Dis 99:3 l-4 I, 1969 53. Moore PH. Brogdon BG: Granulomatosis infantiseptica. Radiology 79:4 1554 19, 1962 54. Myers BR, Shah R, Lefkowitz M: Mycotic aneurysm of the ascending aorta secondary to Serratia infection: Differentiation from prosthetic endocarditis. Chest 65:215217, 1974 55. Ostfeld E, Hare11 M, Michaeli D, et al: Acute Gramnegative bacillary otitis media. Am J Dis Child 132:721722, 1978 56. Overholt

EL, Tigertt WD: Roentgenographic manifestations of pulmonary tularemia. Radiology 74:758-765, 1960 57. Owen CR, Meis A, Jackson JW, et al: A case of primary cutaneous listeriosis. N Engl J Med 262:1026-1028, 1960 58. Plotkin SA, Brachman PS, Utell M, et al: An epidemic of inhalation anthrax, the first in the twentieth century. I: Clinical features. Am J Med 29:992-1001, 1960 59. Putsh RW, Hamilton JD, Wolinsky E: Neisseria meningitidis, a respiratory pathogen? J Infect Dis 121:4854, 1970

24 60. Quenzer RW, Mostow SR, Emerson JK: Cat-bite tularemia. JAMA 238: 1845, 1977 61. Reed JC, McLelland R, Nelson P: Legionnaires’ disease. Am J Roentgen01 13 1:892-894, 1978 62. Richards NM, Levitsky S: Outbreak of Serratia marcescens infections in a cardiothoracic surgical intensive care unit. Ann Thorac Surg 19:503-513, 1975 63. Ringrose RE, McKown B, Felton FG, et al: A hospital outbreak of Serratia marcescens associated with ultrasonic nebulizers. Ann Intern Med 69:7 199729, 1968 64. Rose HD, Mathai G: Acute Pasteurella multocida pneumonia. Br J Dis Chest 7 1:123-l 26, 1977 65. Rosenthal SL: Acinobacter; New name in the microbial game. Ann Intern Med 88:123-l 24, 1978 66. Rubin SA: Radiographic spectrum of pleuropulmonary tularemia. Am J Roentgen01 I3 1:277-28 I, 1978 67. Sairanen E: Hilar Adenopathy with yersinia infection. Ann Intern Med 80:673-674, 1974 68. Sanford JP: Legionnaries’ disease-The first thousand days. N Engl J Med 300:654-656, 1979 69. Sebes JI, Mabry Jr EH, Rabinowitz JG: Lung abscess and osteomyelitis of rib due to Yersinia enterocolitica. Chest 69546-548, 1976 70. Severn M: A fatal case of pulmonary anthrax. Br Med J 1:748, 1976 71. Starkebaum GA, Plorde JJ: Pasteurella pneumonia: Report of a case and review of the literature. J Clin Microbiol 5:332-335, 1977 72. Targan SR, Chow AW, Guze LB: Campylobacter fetus association with pulmonary abscess and empyema. Chest 71:1055108, 1977 73. Taylor BG, Zafarzai MZ, Humpreys DW, et al: Nodular pulmonary infiltrates and septic arthritis associated with Yersinia enterocolitica bacteremia. Am Rev Resp Dis 116525-529, 1977 74. Terranova W, Cohen ML, Fraser DW: 1974 outbreak

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of Legionnaires’ disease diagnosed in 1977. Clinical and epidemiological features. Lancet 2: 122-i 24, 1978 75. Thomas AV, Sodeman TH, Bentz RR: Bifidobacterium (Actinomyces) eriksonii infection. Am Rev Resp Dis llO:663-668, 1974 76. Tillotson JR, Lerner AM: Characteristics of pneumonias caused by Bacillus proteus. Ann Intern Med 68:2877 294, 1968 77. Toaff R, Krochik N, Rabinowitz M: Genital listeriosis in the male. Lancet 2:482-483, 1962 78. Unger JD, Rose HD, Unger GF: Gram-negative pneumonia. Radiology 107:283-291, 1973 79. Van Ness GB: Ecology of anthrax. Science 172: I303l307,1971 80. Vessal K, Yeganehdoust J, Dutz W, et al: Radiological changes in inhalation anthrax. A report of radiological and pathological correlation in two cases. Clin Radio] 26:471-474, 1975 8 I. Warring WB, Ruffin JS: Tick-born epidemic of tularemia. N Engl J Med 234:1377140, 1946 82. Webb WA, Thoroughman JC: Solitary pulmonary nodule due to Brurella suis. Report of a case. Dis Chest 491222-224, 1966 83. Weed LA, Sloss PT: Chronic localized pulmonary brucellosis. JAMA 161:1044-1047, 1956 84. Winn WC Jr, Glavin FL, Per] DP, et al: The pathology of Legionnaires’ disease. Fourteen fatal cases from the 1977 outbreak in Vermont. Arch Pathol Lab Med 102:344350, 1978 85. Young LS, Bicknell DS, Archer BG, et al: Tularemia epidemic: Vermont 1968. N Engl J Med 280:1253-1260, 1969 86. Yu VL: Serratia marcescens. Historial perspective and clinical review. N Engl J Med 300:887-893, 1979 87. Zoumboulakis D, Kossoglu K, Karaboula K, et al: Meningitis caused by Proteus mirabilis: Report of two cases. Clin Pediatr 13:669-67 I, 1974