3o6
Letters to the Editor C i p r o f l o x a c i n t r e a t m e n t o f Haemophilus b r a i n abscess
paraphrophilus
Acceptedfor publication 24 November 199o Sir, Current antibiotic therapy for brain abscess entails 4-6 weeks parenteral therapy necessitating prolonged hospitalisation. In this report the use of oral ciprofloxacin following early hospital discharge is described. A 43-year-old man presented with sudden onset of n u m b n e s s and weakness in the left arm, headache and a grand mal seizure. H e had a history of Eisenmenger's syndrome secondary to a congenital ventricular septal defect. T w o weeks before presentation a dental extraction had been performed with oral penicillin prophylaxis. On examination there were no neurological abnormalities apart from post-ictal confusion. T h e r e was clubbing of the fingers and toes but no other stigmata of bacterial endocarditis. A systolic ejection m u r m u r was audible at the apex and left sternal edge with a loud pulmonary second sound. T h e r e were no other abnormalities noted on examination. A C T scan of the head showed a 2"5 cm x 2 cm contrast enhancing lesion with surrounding oedema in the right parieto-occipital region. An echocardiograph showed normal left ventricular function, moderately severe right ventricular h y p e r t r o p h y and dilatation, and a m e m b r a n o u s ventricular septal defect with right-to-left flow and severe pulmonary hypertension. Six sets of blood cultures taken during the next z4 h showed no growth. A right craniotomy was performed and a parieto-occipital abscess was excised. G r a m - s t a i n showed numerous granulocytes and G r a m - n e g a t i v e coccobacilli. Post-operatively he was c o m m e n c e d on intravenous ceftriaxone ~ g daily and metronidazole 50o m g 8 hourly. Culture yielded a pure growth of Haemophilus paraphrophilus. Ceftriaxone was continued and metronidazole withdrawn. T h e patient recovered p r o m p t l y from surgery and was discharged at the end of the ISt post-operative week to continue daily ceftriaxone infusions on an outpatient basis for a further week. A repeat C T scan showed a persisting contrast enhancing lesion. H e was then treated with oral ciprofioxacin 750 m g twice daily for 4 weeks although the dose had to be reduced to 500 m g twice daily because of mild gastro-intestinal symptoms. H e was able to return to light duties at work by the 4th post-operative week, with return to full time duties 8 weeks after the operation. A C T scan p e r f o r m e d at 6 weeks showed complete resolution of the abscess. Haemophilus paraphrophilus is part of the normal oropharyngeal f o r a but may infrequently cause invasive soft-tissue infections, endocarditis, septic arthritis, osteomyelitis and C N S infections including brain abscesses. T h e use of ciprofloxacin was considered in this case in view of the alternative of prolonged parenteral therapy in hospital. Data on the potential role of quinolones in C N S infection include reports on satisfactory C S F levels with pefloxacin in meningitis 1 and satisfactory concentrations of pefloxacin obtained in brain tissue 2 sampled at the time of resection of a brain tumour. Previous clinical experience includes the successful treatment of pseudomonas meningitis with both oral and intravenous ciprofloxacin. 3'~ T r e a t m e n t of this patient with oral ciprofloxacin, preceded by a 2 week course of IV ceftriaxone, markedly reduced the period of hospitalisation, assuring major cost reductions and allowing an early return to work. T h e outcome illustrates that
Letters to the Editor
307
quinolones may be used successfully in selected cases of brain abscess if the aetiological organism is susceptible.
Department of Infectious Diseases, Prince Henry Hospital, Sydney, Australia
K. Visvanathan P. D. Jones*
* Address correspondence to: Dr P. D. Jones, Department of Infectious Diseases, Prince Henry Hospital, Little Bay, N S W 2o36, Australia.
References I. Wolff M, Regnier B, Daldoss C, Nkam M, Vachon F. Penetration of pefloxacin into cerebrospinal fluid of patients with meningitis. Antimicrob Agents Chemother I984; 26: 289--29I. 2. Korinek AM, Guggiari M, Montay G, Grob R, Rivierez M, Viars P. Penetration of pefloxacin into human brain tissue (extended abstract). Rev Infect Dis 1988; IO (Suppl I): S257. 3-Isaacs D, Slack MPE, Wilkinson AR, Westwood AW. Successful treatment of pseudomonas ventriculitis with ciprofloxacin. J Antimicrob Chemother 1986; I7: 535-538. 4. Millar MR, Bransby-Zachary MA, Tompkins DS, Hawkey PM, Gibson RM. Ciprofloxacin for Pseudomonas aeruginosa meningitis (Letter). Lancet I986; i: 1325.
R a p i d d e v e l o p m e n t o f shock f o l l o w i n g cat scratch i n j u r y in a p r e v i o u s l y fit m i d d l e aged w o m a n
Accepted for publication 29 November I99O Sir, D o g and cat bites, and scratches, are a recognised cause of h u m a n infection with Pasteurella multocida 1 which is a c o m m o n inhabitant of the u p p e r respiratory tract of dogs and cats. T h e organism is a small, G r a m - n e g a t i v e facultatively anaerobic, nonmotile, oxidase-positive rod, which fails to grow on M c C o n k e y media and exhibits the classical ' s a f e t y - p i n ' bipolar staining seen in other Pasteurella species. Focal soft tissue and chronic respiratory infections and bacteraemia are manifestations of infection with P. multocida. Bacteraemia is not c o m m o n s and is usually associated with underlying i m m u n e deficiency which m a y be subtle, e.g. advanced age. Deaths have occurred. 3 A 62-year-old w o m a n presented to the Accident and Emergency (A & E) D e p a r t m e n t at 07.3 ° hours with two deep, penetrating claw injuries over her shin which had been inflicted by a feral cat she was in the habit of feeding. T h e injuries had occurred at approximately 13.oo hours on the previous day. T h e wound had bled profusely and was self treated with a topical antiseptic and sticking plaster. She attended the A & E D e p a r t m e n t the next morning because the w o u n d was painful and slightly swollen. On examination she had a t e m p e r a t u r e of 38"6 °C and BP I20/80. T h e w o u n d on her shin was red and indurated with a little sero-sanguinous discharge. Systems review did not reveal any abnormalities. She was on no medication and had previously been well. H e r white blood cell count on admission was 12"5 × IO9/1. While in the A & E D e p a r t m e n t she became shocked with a blood pressure of
Letters to the Editor C i p r o f l o x a c i n t r e a t m e n t o f Haemophilus b r a i n abscess
paraphrophilus
Acceptedfor publication 24 November 199o Sir, Current antibiotic therapy for brain abscess entails 4-6 weeks parenteral therapy necessitating prolonged hospitalisation. In this report the use of oral ciprofloxacin following early hospital discharge is described. A 43-year-old man presented with sudden onset of n u m b n e s s and weakness in the left arm, headache and a grand mal seizure. H e had a history of Eisenmenger's syndrome secondary to a congenital ventricular septal defect. T w o weeks before presentation a dental extraction had been performed with oral penicillin prophylaxis. On examination there were no neurological abnormalities apart from post-ictal confusion. T h e r e was clubbing of the fingers and toes but no other stigmata of bacterial endocarditis. A systolic ejection m u r m u r was audible at the apex and left sternal edge with a loud pulmonary second sound. T h e r e were no other abnormalities noted on examination. A C T scan of the head showed a 2"5 cm x 2 cm contrast enhancing lesion with surrounding oedema in the right parieto-occipital region. An echocardiograph showed normal left ventricular function, moderately severe right ventricular h y p e r t r o p h y and dilatation, and a m e m b r a n o u s ventricular septal defect with right-to-left flow and severe pulmonary hypertension. Six sets of blood cultures taken during the next z4 h showed no growth. A right craniotomy was performed and a parieto-occipital abscess was excised. G r a m - s t a i n showed numerous granulocytes and G r a m - n e g a t i v e coccobacilli. Post-operatively he was c o m m e n c e d on intravenous ceftriaxone ~ g daily and metronidazole 50o m g 8 hourly. Culture yielded a pure growth of Haemophilus paraphrophilus. Ceftriaxone was continued and metronidazole withdrawn. T h e patient recovered p r o m p t l y from surgery and was discharged at the end of the ISt post-operative week to continue daily ceftriaxone infusions on an outpatient basis for a further week. A repeat C T scan showed a persisting contrast enhancing lesion. H e was then treated with oral ciprofioxacin 750 m g twice daily for 4 weeks although the dose had to be reduced to 500 m g twice daily because of mild gastro-intestinal symptoms. H e was able to return to light duties at work by the 4th post-operative week, with return to full time duties 8 weeks after the operation. A C T scan p e r f o r m e d at 6 weeks showed complete resolution of the abscess. Haemophilus paraphrophilus is part of the normal oropharyngeal f o r a but may infrequently cause invasive soft-tissue infections, endocarditis, septic arthritis, osteomyelitis and C N S infections including brain abscesses. T h e use of ciprofloxacin was considered in this case in view of the alternative of prolonged parenteral therapy in hospital. Data on the potential role of quinolones in C N S infection include reports on satisfactory C S F levels with pefloxacin in meningitis 1 and satisfactory concentrations of pefloxacin obtained in brain tissue 2 sampled at the time of resection of a brain tumour. Previous clinical experience includes the successful treatment of pseudomonas meningitis with both oral and intravenous ciprofloxacin. 3'~ T r e a t m e n t of this patient with oral ciprofloxacin, preceded by a 2 week course of IV ceftriaxone, markedly reduced the period of hospitalisation, assuring major cost reductions and allowing an early return to work. T h e outcome illustrates that
Letters to the Editor
307
quinolones may be used successfully in selected cases of brain abscess if the aetiological organism is susceptible.
Department of Infectious Diseases, Prince Henry Hospital, Sydney, Australia
K. Visvanathan P. D. Jones*
* Address correspondence to: Dr P. D. Jones, Department of Infectious Diseases, Prince Henry Hospital, Little Bay, N S W 2o36, Australia.
References I. Wolff M, Regnier B, Daldoss C, Nkam M, Vachon F. Penetration of pefloxacin into cerebrospinal fluid of patients with meningitis. Antimicrob Agents Chemother I984; 26: 289--29I. 2. Korinek AM, Guggiari M, Montay G, Grob R, Rivierez M, Viars P. Penetration of pefloxacin into human brain tissue (extended abstract). Rev Infect Dis 1988; IO (Suppl I): S257. 3-Isaacs D, Slack MPE, Wilkinson AR, Westwood AW. Successful treatment of pseudomonas ventriculitis with ciprofloxacin. J Antimicrob Chemother 1986; I7: 535-538. 4. Millar MR, Bransby-Zachary MA, Tompkins DS, Hawkey PM, Gibson RM. Ciprofloxacin for Pseudomonas aeruginosa meningitis (Letter). Lancet I986; i: 1325.
R a p i d d e v e l o p m e n t o f shock f o l l o w i n g cat scratch i n j u r y in a p r e v i o u s l y fit m i d d l e aged w o m a n
Accepted for publication 29 November I99O Sir, D o g and cat bites, and scratches, are a recognised cause of h u m a n infection with Pasteurella multocida 1 which is a c o m m o n inhabitant of the u p p e r respiratory tract of dogs and cats. T h e organism is a small, G r a m - n e g a t i v e facultatively anaerobic, nonmotile, oxidase-positive rod, which fails to grow on M c C o n k e y media and exhibits the classical ' s a f e t y - p i n ' bipolar staining seen in other Pasteurella species. Focal soft tissue and chronic respiratory infections and bacteraemia are manifestations of infection with P. multocida. Bacteraemia is not c o m m o n s and is usually associated with underlying i m m u n e deficiency which m a y be subtle, e.g. advanced age. Deaths have occurred. 3 A 62-year-old w o m a n presented to the Accident and Emergency (A & E) D e p a r t m e n t at 07.3 ° hours with two deep, penetrating claw injuries over her shin which had been inflicted by a feral cat she was in the habit of feeding. T h e injuries had occurred at approximately 13.oo hours on the previous day. T h e wound had bled profusely and was self treated with a topical antiseptic and sticking plaster. She attended the A & E D e p a r t m e n t the next morning because the w o u n d was painful and slightly swollen. On examination she had a t e m p e r a t u r e of 38"6 °C and BP I20/80. T h e w o u n d on her shin was red and indurated with a little sero-sanguinous discharge. Systems review did not reveal any abnormalities. She was on no medication and had previously been well. H e r white blood cell count on admission was 12"5 × IO9/1. While in the A & E D e p a r t m e n t she became shocked with a blood pressure of
