Vol. 11, 1992
Appendicitis due to Both Streptococcus pneumoniae and Haemophilus influenzae Acute appendicitis has been associated with common intestinal tract pathogens, such as Bacteroides species, anaerobic gram-positive bacteria, Enterobacteriaceae and Yersinia species. Streptococcus pneumoniae has been considered an infectious agent in acute appendicitis and secondary peritonitis in children (1, 2). Haemophilus species have been isolated from the appendix in 7,8 % of cases, 77 % of the isolates being Haemophilus influenzae (3). This organism was isolated in association with the common intestinal tract pathogens (3). However, the presence of only Streptococcus pneumoniae and Haemophilus influenzae without other microorganisms in an appendix specimen and the involvement of these organisms in the development of acute appendicitis have not been reported previously. On 28 March 1991 a 4-year-old boy presented with pain in the right lower quadrant of the abdomen. No vomiting, diarrhea or fever were associated with the pain. On pre-operative examination there were signs of appendicitis, such as tenderness in the right iliac fossa and an elevated leukocyte count of 11,0001~1. There were no clinical signs of peritonitis. The body temperature was 37.5 °C. Other parameters and the chest radiograph were normal. The boy had a history of intermittent abdominal pain for one year. No episodes of upper or lower respiratory tract infection had been experienced. However, at the beginning of March 1991, pharyngeal adenoid vegetations were removed because of nocturnal snore and josamycin was given subsequently for seven days. On 29 March 1991 appendicectomy was performed. On perioperative macroscopic examination the appendix was found to be swollen and associated with satellite mesenterial lymphadenitis. Pathologic examination showed an acute nonsuppurative endo-appendicitis with major lymphoid hyperplasia and rare granulocyte infiltrates within the mucosa. Microscopic examination with Gram stain revealed gram-positive diploid cocci in the appendix specimen. Both Streptococcus pneumoniae and Haemophilus influenzae (biotype 5) were isolated from the appendix.using blood agar and chocolate Isovitalex agar respectively. Streptococci, Escherichia coli, anaerobes and other common microorganisms of the intestinal tract were not isolated on the usual media. Streptococcus pneumoniae (capsulated, serotype 8) was also present in the patient's pharynx,
559
whereas Haemophilus influenzae was not. A filtration technique with a millipore filter (pore size 45 lam) was used in an effort to selectively isolate Haemophilus species from the common flora in the stools, as described for isolation of Campylobacter species (4), however neither Streptococcus pneumoniae nor Haemophilus species were isolated from the faeces. In the post-operative period no antibiotic agents were given and the abdominal pain soon disappeared. Asymptomatic nasopharyngeal carriage of Streptococcuspneumoniae and uncapsulated or encapsulated strains of Haemophilus species is common in young children, and repeated bacterial colonization of the lymphoid organs could be related to acquisition of the immune status in childhood (5). Both Streptococcus pneurnoniae and Haemophilus influenzae could be causative agents of appendicitis in young children, which emphasizes the need to use appropriate media to isolate these two organisms from the appendix. Although mesenterial adenolymphitis, hypertrophied adenoid vegetations and oropharyngeal asymptomatic carriage were observed concomitantly in our patient, the pathway of the appendix colonization remains unclear. Further investigations are necessary to determine optimal therapy regimens and the indications for antibiotic therapy after appendicectomy.
P. A s t a g n e a u 1 EW. Goldstein 1. S. F r a n c o u a l 1 E. Baviera 2 M. Barthalon 3 J.E A c a r 1 1 Laboratoire de Microbiologie M6dieale, 2Service Anatomo-Pathologie, and 3Service de Chirurgie Orthop6dique, Hfpital Saint-Joseph, 7 rue Pierre Larousse, 75674 Paris C6dex 14, France.
References 1, Children with appendicitis. British Medical Journal
1976, ii: 440 441. 2. Heltberg O, Komer B, Sehouenborg P: Six cases of acute appendicitis with secondary peritonitis caused by Streptococcus pneumoniae. European Journal of Clinical Microbiology 1984, 3: 141-143.
560
Eur. J. Clin. Microbiol. Infect. Dis.
3. M6graud IF, B6b6ar C, Dabernat H, Deimas C: Haemophilus species in the human gastrointestinal tract. European Journal of Clinical Microbiology and Infectious Diseases 1988, 7: 437-438. 4. M6graud F, Elharrif Z: Isolation of Campylobacter species by filtration. European Journal of Clinical Microbiology 1985, 4: 437-438. 5. Moxon ER: The carrier state: Haemophilusinfluenzae. Journal of Antimicrobial Chemotherapy 1989, 18, Supplement A: 17-24.
Non-Tropical Pyomyositis Caused by Salmonella enterica enterica in an
Immunocompetent Patient Pyomyositis is a bacterial infection of skeletal muscle. It is an endemic infection in the tropical regions but very rare in temperate climates, although in recent years it has been reported with increasing frequency in the immunocompromised host and AIDS patients (1, 2). Staphylococcus aureus is the most frequent causative agent, followed by Streptococcus pyogenes. Only a few cases of pyomyositis caused by gramnegative bacilli have been described (3-10). We report the first case of pyomyositis caused by Salmonella enterica enterica (serogroup O:9,d). A healthy 28-year-old fireman reported for medical attention because ten days before he had noted a mass in the upper left abdomen. A few days later he developed nocturnal fever and sweating. He had no history of trauma, travel to a tropical area or gastroenteritis in recent weeks. The patient did not belong to an AIDS risk group. The findings on physical examination were unremarkable except for a hard mass in the upper portion of the left rectus abdominis muscle. The leucocyte count was 15,600 mm 3 with 72 % segmented neutrophils. Blood cultures were negative. A malignant soft tissue neoplasm was suspected and a CT scan performed (Figure 1). A mass with hypodense areas was evident in the rectus abdominis muscle. Surgical incision and drainage yielded purulent material without malignant cells. Salmonella enterica enterica serogroup O:9,d resistant to ampicillin (MIC > 16 /ag/ml) was grown on culture. An EIA to detect antibodies to HIV was negative. The patient was treated with ciprofloxacin (500 mg/12 h p.o.) with a favorable response. Various predisposing factors have been considered in the development of primary pyomyo-
Figure 1: CT scan showing a mass with hypodense areas in the rectus abdominis muscle.
sitis including prior muscular trauma, travel in the tropics, immunocompromised status and intramuscular parasites. A quarter of patients have no predisposing factor. The most relevant clinical symptoms are muscular pain and swelling. Pyomyositis is frequently misdiagnosed as muscular distension, synovitis, thrombophlebitis and soft tissue neoplasm (as in our patient). Psoas and gastrocnemius are the muscles more frequently affected. Diagnostic tests include gallium 67 scan, echography, CT scan and MRI (11, 12). Treatment consists of surgical incision, drainage and antibiotic chemotherapy. Our case is unusual in two respects. Firstly, the infection was located in the anterior abdominal wall, which is rare although it has been reported (13, 14). Secondly, the causative agent was Salmonella enterica enterica (serogroup O:9,d). To our knowledge this is the first case reported in the literature caused by this organism. Although uncommon in temperate climates, pyomyositis should be considered in the differential diagnosis of soft tissue masses. Salmonella enterica enterica can be added to the growing list of bacteria that can cause this infection.
E Tebas* E Bonilla J. Ruiz B. Di6guez E Espafia Departamcnto de Oncologfa M6dica, Ctinica Puerta de Hierro, C/San Martin de Pones 4, 28035 Madrid, Spain.
Appendicitis due to Both Streptococcus pneumoniae and Haemophilus influenzae Acute appendicitis has been associated with common intestinal tract pathogens, such as Bacteroides species, anaerobic gram-positive bacteria, Enterobacteriaceae and Yersinia species. Streptococcus pneumoniae has been considered an infectious agent in acute appendicitis and secondary peritonitis in children (1, 2). Haemophilus species have been isolated from the appendix in 7,8 % of cases, 77 % of the isolates being Haemophilus influenzae (3). This organism was isolated in association with the common intestinal tract pathogens (3). However, the presence of only Streptococcus pneumoniae and Haemophilus influenzae without other microorganisms in an appendix specimen and the involvement of these organisms in the development of acute appendicitis have not been reported previously. On 28 March 1991 a 4-year-old boy presented with pain in the right lower quadrant of the abdomen. No vomiting, diarrhea or fever were associated with the pain. On pre-operative examination there were signs of appendicitis, such as tenderness in the right iliac fossa and an elevated leukocyte count of 11,0001~1. There were no clinical signs of peritonitis. The body temperature was 37.5 °C. Other parameters and the chest radiograph were normal. The boy had a history of intermittent abdominal pain for one year. No episodes of upper or lower respiratory tract infection had been experienced. However, at the beginning of March 1991, pharyngeal adenoid vegetations were removed because of nocturnal snore and josamycin was given subsequently for seven days. On 29 March 1991 appendicectomy was performed. On perioperative macroscopic examination the appendix was found to be swollen and associated with satellite mesenterial lymphadenitis. Pathologic examination showed an acute nonsuppurative endo-appendicitis with major lymphoid hyperplasia and rare granulocyte infiltrates within the mucosa. Microscopic examination with Gram stain revealed gram-positive diploid cocci in the appendix specimen. Both Streptococcus pneumoniae and Haemophilus influenzae (biotype 5) were isolated from the appendix.using blood agar and chocolate Isovitalex agar respectively. Streptococci, Escherichia coli, anaerobes and other common microorganisms of the intestinal tract were not isolated on the usual media. Streptococcus pneumoniae (capsulated, serotype 8) was also present in the patient's pharynx,
559
whereas Haemophilus influenzae was not. A filtration technique with a millipore filter (pore size 45 lam) was used in an effort to selectively isolate Haemophilus species from the common flora in the stools, as described for isolation of Campylobacter species (4), however neither Streptococcus pneumoniae nor Haemophilus species were isolated from the faeces. In the post-operative period no antibiotic agents were given and the abdominal pain soon disappeared. Asymptomatic nasopharyngeal carriage of Streptococcuspneumoniae and uncapsulated or encapsulated strains of Haemophilus species is common in young children, and repeated bacterial colonization of the lymphoid organs could be related to acquisition of the immune status in childhood (5). Both Streptococcus pneurnoniae and Haemophilus influenzae could be causative agents of appendicitis in young children, which emphasizes the need to use appropriate media to isolate these two organisms from the appendix. Although mesenterial adenolymphitis, hypertrophied adenoid vegetations and oropharyngeal asymptomatic carriage were observed concomitantly in our patient, the pathway of the appendix colonization remains unclear. Further investigations are necessary to determine optimal therapy regimens and the indications for antibiotic therapy after appendicectomy.
P. A s t a g n e a u 1 EW. Goldstein 1. S. F r a n c o u a l 1 E. Baviera 2 M. Barthalon 3 J.E A c a r 1 1 Laboratoire de Microbiologie M6dieale, 2Service Anatomo-Pathologie, and 3Service de Chirurgie Orthop6dique, Hfpital Saint-Joseph, 7 rue Pierre Larousse, 75674 Paris C6dex 14, France.
References 1, Children with appendicitis. British Medical Journal
1976, ii: 440 441. 2. Heltberg O, Komer B, Sehouenborg P: Six cases of acute appendicitis with secondary peritonitis caused by Streptococcus pneumoniae. European Journal of Clinical Microbiology 1984, 3: 141-143.
560
Eur. J. Clin. Microbiol. Infect. Dis.
3. M6graud IF, B6b6ar C, Dabernat H, Deimas C: Haemophilus species in the human gastrointestinal tract. European Journal of Clinical Microbiology and Infectious Diseases 1988, 7: 437-438. 4. M6graud F, Elharrif Z: Isolation of Campylobacter species by filtration. European Journal of Clinical Microbiology 1985, 4: 437-438. 5. Moxon ER: The carrier state: Haemophilusinfluenzae. Journal of Antimicrobial Chemotherapy 1989, 18, Supplement A: 17-24.
Non-Tropical Pyomyositis Caused by Salmonella enterica enterica in an
Immunocompetent Patient Pyomyositis is a bacterial infection of skeletal muscle. It is an endemic infection in the tropical regions but very rare in temperate climates, although in recent years it has been reported with increasing frequency in the immunocompromised host and AIDS patients (1, 2). Staphylococcus aureus is the most frequent causative agent, followed by Streptococcus pyogenes. Only a few cases of pyomyositis caused by gramnegative bacilli have been described (3-10). We report the first case of pyomyositis caused by Salmonella enterica enterica (serogroup O:9,d). A healthy 28-year-old fireman reported for medical attention because ten days before he had noted a mass in the upper left abdomen. A few days later he developed nocturnal fever and sweating. He had no history of trauma, travel to a tropical area or gastroenteritis in recent weeks. The patient did not belong to an AIDS risk group. The findings on physical examination were unremarkable except for a hard mass in the upper portion of the left rectus abdominis muscle. The leucocyte count was 15,600 mm 3 with 72 % segmented neutrophils. Blood cultures were negative. A malignant soft tissue neoplasm was suspected and a CT scan performed (Figure 1). A mass with hypodense areas was evident in the rectus abdominis muscle. Surgical incision and drainage yielded purulent material without malignant cells. Salmonella enterica enterica serogroup O:9,d resistant to ampicillin (MIC > 16 /ag/ml) was grown on culture. An EIA to detect antibodies to HIV was negative. The patient was treated with ciprofloxacin (500 mg/12 h p.o.) with a favorable response. Various predisposing factors have been considered in the development of primary pyomyo-
Figure 1: CT scan showing a mass with hypodense areas in the rectus abdominis muscle.
sitis including prior muscular trauma, travel in the tropics, immunocompromised status and intramuscular parasites. A quarter of patients have no predisposing factor. The most relevant clinical symptoms are muscular pain and swelling. Pyomyositis is frequently misdiagnosed as muscular distension, synovitis, thrombophlebitis and soft tissue neoplasm (as in our patient). Psoas and gastrocnemius are the muscles more frequently affected. Diagnostic tests include gallium 67 scan, echography, CT scan and MRI (11, 12). Treatment consists of surgical incision, drainage and antibiotic chemotherapy. Our case is unusual in two respects. Firstly, the infection was located in the anterior abdominal wall, which is rare although it has been reported (13, 14). Secondly, the causative agent was Salmonella enterica enterica (serogroup O:9,d). To our knowledge this is the first case reported in the literature caused by this organism. Although uncommon in temperate climates, pyomyositis should be considered in the differential diagnosis of soft tissue masses. Salmonella enterica enterica can be added to the growing list of bacteria that can cause this infection.
E Tebas* E Bonilla J. Ruiz B. Di6guez E Espafia Departamcnto de Oncologfa M6dica, Ctinica Puerta de Hierro, C/San Martin de Pones 4, 28035 Madrid, Spain.
