Letters to the Editor
266
surgical site with non typhoidal salmonella following total hip replacement, though rare, has also been well documented. 3 However, our case was unusual because there was no history of any predisposing factors. Therefore the portal of entry of this microorganism, its dissemination and sequestration remain speculative though presumably the focus of infection was the gut from which there was haematogenous spread. (We thank Mrs M. White for her typing.)
Roding Hospital, Roding Lane South, Ilford, Essex IG4 5PZ, U.K.
B. Chattopadhyay J. D. Jeremiah G. Sadler
References i. Barrett-Connor E. Bacterial infection and sickle cell anaemia: analysis of 25o infections in I66 patients and a review of the literature. Medicine I971 ; 5o: 97-I I2. 2. Knowles GK, Murphy MFG. Paratyphoid A fever diagnosed from bone marrow culture after indiscriminate antibiotic treatment. BMJ I979; I" 384. 3. Samra Y, Shaked Y, Maier MK. Non typhoid salmonellosis in patients with total hip replacement: report of four cases and review of the literature. Rev Infect Dis I986; 8" 978-983.
Acute a c t i n o m y c o t i c osteomyelitis o f the skull with subdural e m p y e m a
Accepted for publication 19 December I989 Sir, We read with interest your recent editorial and correspondence on actinomycosis. 1'2 We would like to report an atypical case of actinomycotic osteomyelitis of the skull with subdural empyema. T h i s in itself is extremely rare. However, this case also demonstrates that this infection may present in an acute fashion without any apparent p r i m a r y focus. A 48-year-old coal-face worker was admitted with a 7 day history of frontal headache and malaise. On the day of admission he was noted by his work-mates to be drowsy and disorientated. H e had had middle ear disease as a child but not since. On examination he was drowsy and pyrexial (38"5 °C) with a tachycardia of i o o / m i n . H e was restless and had some neck stiffness, could obey commands but was unable to speak. T h e r e were no other focal neurological signs. His teeth were neglected but there was no evidence of cervicofacial infection. Investigation revealed a peripheral W B C of z I x IO9/1. C S F contained I35 x io ~ white cells/1 (all lymphocytes), with a glucose of 3"6 mmol/1 (blood glucose 5"7 mmol/1) and protein of o'3 g/1. Skull X - r a y d e m o n strated partial obliteration of the right frontal sinus and erosion of the skull vault in the right frontal region. A C T scan showed in addition a subdural fluid collection, most marked in the right sub-frontal region. T h e patient was taken to theatre where burr holes revealed grossly diseased bone, which was removed, and subdural pus, which was drained. Microscopy of the pus demonstrated Gram-positive branching bacilli. Actinomyces viscosus and Fusobacterium nucleatum were cultured. Antimicrobial therapy was with benzylpenicillin, chloramphenicol and metronidazole initially, followed by benzylpenicillin alone. An E N T surgeon examined the patient and explored the frontal and ethmoidal sinuses at surgery, but no focus of infection was found. T h e patient made an uneventful recovery. Actinomycotic osteomyelitis of the skull with C N S involvement is extremely rare
Letters to the Editor
267
with only two previously reported cases to our knowledge.8' 4 One of these involved the skull and epidural space in a man who had mandibular osteomyelitis 22 years p r e v i o u s l y ? Another patient had actinomycotic osteomyelitis of the skull with intracranial granuloma. 4 Smego 5 reviewed 70 cases of C N S actinomycosis but found none secondary to osteomyelitis of the skull. T h i s report leads us to make the observation that although actinomycosis usually presents as a chronic suppurative disease, it may rarely do so as a m u c h more acute illness. It also emphasises the point that a p r i m a r y focus of infection may not always be apparent in actinomycosis. Such atypical features of a case should not dissuade one f r o m including actinomycosis in the differential diagnosis of clinical infections. (We thank Mr R. D. E. Battersby for permission to report this case.)
Department of Bacteriology and Neurosurgery, Royal Hallamshire Hospital, Glossop Road, Sheffield SIO 2JF, U.K.
Linda A. Jewes R. J. C. Laing
Address correspondence to: Dr Linda Jewes, Public Health Laboratory, Northern General Hospital, Herries Road, Sheffield $5 7AU, U.K. References
I. Burden P. Actinomycosis. ff Infect 1989; x9: 95-99. 2. Birley H D L , Teare EL, Utting JA. Actinomycotic osteomyelitis of the thoracic spine in a penicillin-sensitive patient. J Infect I989; I9: 193-194. 3. Kirsch WM, Skcess JC. Actinomycotic osteomyelitis of the skull and epidural space. J Neurol 197o; 33: 347-351. 4- Khosler UK, Banerjee AK, Chopra JS. Intracranial actinomycoma with osteomyelitis simulating meningioma. J Neurosurg 1984; 6o: 204-207. 5. Smego RA. Actinomycosis of the central nervous system. Rev Infect Dis 1987; 9: 855-865.
Observations on Aeromonas species isolated from human faeces
Accepted for publication 6 January 199o Sir, Recent reports 1,2 suggest that it is rare to find multiple species or biotypes of Aeromonas in h u m a n faeces. I f true, this would contrast with the multiple biotypes and species found in environmental samples and animal faeces, s-~ Further, it has been suggested that h u m a n beings acquire enteric aeromonads from the environment. 6 We wish to report some observations we have made on the isolation of aeromonads from h u m a n faeces. D u r i n g the period N o v e m b e r 1986 to September 1988, all faecal samples submitted to this laboratory f r o m patients with diarrhoea were screened for the presence of aeromonads by direct culture on Bile Salt Irgasan Brilliant G r e e n Agar (Difco Laboratories Ltd., U.K.). Morphologically distinct non-xylose fermenting colonies were subcultured for further investigation. After adjustment for multiple submissions from some patients and the exclusion of k n o w n repeated samples, aeromonads were isolated f r o m 91 (2"4 %) of 3766 faecal specimens. O f these 91 samples, 23 (25 %) also contained a well recognised enteropathogen. (Eleven contained Campylobacter spp., nine Salmonellae, one Shigella sonnei, one Clostridium difficile and one contained b o t h Campylobacter spp. and Giardia lamblia).
266
surgical site with non typhoidal salmonella following total hip replacement, though rare, has also been well documented. 3 However, our case was unusual because there was no history of any predisposing factors. Therefore the portal of entry of this microorganism, its dissemination and sequestration remain speculative though presumably the focus of infection was the gut from which there was haematogenous spread. (We thank Mrs M. White for her typing.)
Roding Hospital, Roding Lane South, Ilford, Essex IG4 5PZ, U.K.
B. Chattopadhyay J. D. Jeremiah G. Sadler
References i. Barrett-Connor E. Bacterial infection and sickle cell anaemia: analysis of 25o infections in I66 patients and a review of the literature. Medicine I971 ; 5o: 97-I I2. 2. Knowles GK, Murphy MFG. Paratyphoid A fever diagnosed from bone marrow culture after indiscriminate antibiotic treatment. BMJ I979; I" 384. 3. Samra Y, Shaked Y, Maier MK. Non typhoid salmonellosis in patients with total hip replacement: report of four cases and review of the literature. Rev Infect Dis I986; 8" 978-983.
Acute a c t i n o m y c o t i c osteomyelitis o f the skull with subdural e m p y e m a
Accepted for publication 19 December I989 Sir, We read with interest your recent editorial and correspondence on actinomycosis. 1'2 We would like to report an atypical case of actinomycotic osteomyelitis of the skull with subdural empyema. T h i s in itself is extremely rare. However, this case also demonstrates that this infection may present in an acute fashion without any apparent p r i m a r y focus. A 48-year-old coal-face worker was admitted with a 7 day history of frontal headache and malaise. On the day of admission he was noted by his work-mates to be drowsy and disorientated. H e had had middle ear disease as a child but not since. On examination he was drowsy and pyrexial (38"5 °C) with a tachycardia of i o o / m i n . H e was restless and had some neck stiffness, could obey commands but was unable to speak. T h e r e were no other focal neurological signs. His teeth were neglected but there was no evidence of cervicofacial infection. Investigation revealed a peripheral W B C of z I x IO9/1. C S F contained I35 x io ~ white cells/1 (all lymphocytes), with a glucose of 3"6 mmol/1 (blood glucose 5"7 mmol/1) and protein of o'3 g/1. Skull X - r a y d e m o n strated partial obliteration of the right frontal sinus and erosion of the skull vault in the right frontal region. A C T scan showed in addition a subdural fluid collection, most marked in the right sub-frontal region. T h e patient was taken to theatre where burr holes revealed grossly diseased bone, which was removed, and subdural pus, which was drained. Microscopy of the pus demonstrated Gram-positive branching bacilli. Actinomyces viscosus and Fusobacterium nucleatum were cultured. Antimicrobial therapy was with benzylpenicillin, chloramphenicol and metronidazole initially, followed by benzylpenicillin alone. An E N T surgeon examined the patient and explored the frontal and ethmoidal sinuses at surgery, but no focus of infection was found. T h e patient made an uneventful recovery. Actinomycotic osteomyelitis of the skull with C N S involvement is extremely rare
Letters to the Editor
267
with only two previously reported cases to our knowledge.8' 4 One of these involved the skull and epidural space in a man who had mandibular osteomyelitis 22 years p r e v i o u s l y ? Another patient had actinomycotic osteomyelitis of the skull with intracranial granuloma. 4 Smego 5 reviewed 70 cases of C N S actinomycosis but found none secondary to osteomyelitis of the skull. T h i s report leads us to make the observation that although actinomycosis usually presents as a chronic suppurative disease, it may rarely do so as a m u c h more acute illness. It also emphasises the point that a p r i m a r y focus of infection may not always be apparent in actinomycosis. Such atypical features of a case should not dissuade one f r o m including actinomycosis in the differential diagnosis of clinical infections. (We thank Mr R. D. E. Battersby for permission to report this case.)
Department of Bacteriology and Neurosurgery, Royal Hallamshire Hospital, Glossop Road, Sheffield SIO 2JF, U.K.
Linda A. Jewes R. J. C. Laing
Address correspondence to: Dr Linda Jewes, Public Health Laboratory, Northern General Hospital, Herries Road, Sheffield $5 7AU, U.K. References
I. Burden P. Actinomycosis. ff Infect 1989; x9: 95-99. 2. Birley H D L , Teare EL, Utting JA. Actinomycotic osteomyelitis of the thoracic spine in a penicillin-sensitive patient. J Infect I989; I9: 193-194. 3. Kirsch WM, Skcess JC. Actinomycotic osteomyelitis of the skull and epidural space. J Neurol 197o; 33: 347-351. 4- Khosler UK, Banerjee AK, Chopra JS. Intracranial actinomycoma with osteomyelitis simulating meningioma. J Neurosurg 1984; 6o: 204-207. 5. Smego RA. Actinomycosis of the central nervous system. Rev Infect Dis 1987; 9: 855-865.
Observations on Aeromonas species isolated from human faeces
Accepted for publication 6 January 199o Sir, Recent reports 1,2 suggest that it is rare to find multiple species or biotypes of Aeromonas in h u m a n faeces. I f true, this would contrast with the multiple biotypes and species found in environmental samples and animal faeces, s-~ Further, it has been suggested that h u m a n beings acquire enteric aeromonads from the environment. 6 We wish to report some observations we have made on the isolation of aeromonads from h u m a n faeces. D u r i n g the period N o v e m b e r 1986 to September 1988, all faecal samples submitted to this laboratory f r o m patients with diarrhoea were screened for the presence of aeromonads by direct culture on Bile Salt Irgasan Brilliant G r e e n Agar (Difco Laboratories Ltd., U.K.). Morphologically distinct non-xylose fermenting colonies were subcultured for further investigation. After adjustment for multiple submissions from some patients and the exclusion of k n o w n repeated samples, aeromonads were isolated f r o m 91 (2"4 %) of 3766 faecal specimens. O f these 91 samples, 23 (25 %) also contained a well recognised enteropathogen. (Eleven contained Campylobacter spp., nine Salmonellae, one Shigella sonnei, one Clostridium difficile and one contained b o t h Campylobacter spp. and Giardia lamblia).
