Letters to the Editor
IOI
endocarditis affecting the tricuspid has not been recorded earlier but a case of bacteraemia without infective endocarditis has been described. 2 Conventional therapy with penicillin and an aminoglycoside was not successful in our patient but high doses of ciprofloxacin resulted in resolution of the infection. Gynaecomastia has been described as a complication of ciprofloxacin therapy (data on record Bayer, U . K . ) but is rare.
Department of Medical Microbiology, Southmead Hospital, Westbury-on- Trym, Bristol BSzo 5NB, U.K.
A. P. MacGowan D. S. Reeves
Department of Infectious Diseases, Han Green Hospital, Pill, Bristol BS2o oHW, U.K.
C. Wright S. C. Glover
References I. Harris RC. Erysipelothrix rhusopathiae. In Dalton HP, Nottebart HC, Eds. Interpretive medical microbiology. London: Churchill Livingstone, 1986: 58-63. 2. Townsend RH, Jephcott AE, Yekta MH. Erysipelothrix septicaemia without endocarditis. Br Med J 1973 ; I : 464-465.
Epstein-Barr virus encephalitis Accepted for publication I3 June 199o Sir, We were interested to read the case report by Bhatti et al., 1 because we have recently seen a patient in w h o m the diagnosis of encephalitis caused by E p s t e i n - B a r r virus (EBV) was not entertained initially and only made serologically. An I8-year-old m a n was admitted with a 4 days' history of headache and photophobia following a glandular fever-like illness 2 weeks previously. His condition rapidly deteriorated and he developed status epilepticus during which he was ventilated and then admitted to the Intensive Care Unit. A lumbar puncture was acellular with no growth on culture. A C T scan was normal but the E E G was suggestive of encephalitis. A full blood count showed a 4o % lymphocytosis, and activated lymphocytes were seen. T h e r e was also a mild thrombocytopaenia. T h e patient was started on intravenous acyclovir and benzyl penicillin. A sample of blood taken I I days after admission was found to be positive for EBV viral capsid antigen (VCA) I g M by immunofluorescence. A blood sample was also taken on the day of admission, and this was tested as a pair with a sample taken 3 weeks later for respiratory and neurological virus screen. T h e only significant finding was a rising titre to EBV V C A I g M (40-320) and EBV V C A I g G (160-256o). Coxsackie B I g M E L I S A and viral cultures on throat swabs and stool were also negative. An acute C S F specimen was available but no I g M antibody to viral capsid antigen was detectable. In the absence of any other positive findings a diagnosis of EBV encephalitis was made. Although we were unable to detect EBV VCA I g M in the C S F , this could be a false-negative finding, as the specimen was taken early in the illness. Convalescent C S F specimens were not available to test. We would concur with Bhatti et al., 1 that encephalitis due to E p s t e i n - B a r r virus is infrequently reported. T h i s m a y be due to a low index of suspicion amongst clinicians.
Letters to the Editor
Io2
EBV should be considered as a possibility in any patient presenting with a clinical diagnosis of encephalitis, especially is aged between I5 and 25 years. Although our patient was given acyclovir, the dose (Io m g / k g body wt) was too low to achieve effective therapeutic concentrations against EBV in vitro. In our opinion the dose of acyclovir (700 m g 8-hourly) used by Bhatti et al., 1 would also have been inadequate. In view of this it is difficult to assess the role of acyclovir in m a n a g e m e n t of EBV encephalitis; however, we would agree that treatment with acyclovir should be initiated on clinical suspicion of viral encephalitis. (We thank Dr C. Hardisty for permission to report on his patient and Mr A. Siddons for performing serological tests.)
Public Heath Laboratory, Northern General Hospital, Herries Road, Sheffield, Yorkshire $5 7A U
D. Sanyal* G. Kudesia
Department of General Medicine, Northern General Hospital, Herries Road, Sheffield, U.K.
M. Young
* Address correspondence to: D. Sanyal, P.H.L.S., Northern General Hospital, Sheffield $5 7AU, U.K.
Reference
r. Bhatti N, Larson E, Hickey M , Seal D. Encephalitis due to Epstein-Barr virus. J Infect I99o; 2o : 69-72.
Kingella kingae
d a c t y l i t i s in a n i n f a n t
Accepted for publication 3 July I99o Sir,
Kingella kingae, formerly known as Moraxella kingae, is a Gram-negative coccobacillary, fermentative rod, that has been chiefly associated with bone and joint infections and endocarditis. 1 Dactylitis due to this organism has seldom been reportedfl We describe an infant with bacteraemia and dactylitis due to K. kingae. A previously healthy 6-month-old male infant was admitted through the Accident and E m e r g e n c y D e p a r t m e n t with 2 days' history of a swollen, erythematous but nontender right little finger. T h e m o t h e r could recall no recent febrile illness or trauma. Examination of the hand confirmed the presence of a swollen erythematous finger, the swelling being m o s t obvious in the proximal half of the digit. It was not tender or hot, and there was a full range of m o v e m e n t in all joints of the hand. F u r t h e r physical findings were unremarkable. L a b o r a t o r y data indicated a peripheral W B C of I6 x ~o 9 with 57 % neutrophils and 43 % lymphocytes. T h e E S R was 32 m m / h . Radiographs of the affected finger and the right hand were normal but the bones were not scanned. Blood cultures yielded G r a m - n e g a t i v e coccobacilli, identified as K. kingae (confirmed by the Central Public Health Laboratory, Colindale, London), sensitive to penicillin, ampicillin, cephradine and gentamicin by disc diffusion susceptibility tests. T h e infant was treated with a combination of Iv ampicillin and IV flucloxacillin (I25 mg of each, given four times a day). On receiving the susceptibility and identification
IOI
endocarditis affecting the tricuspid has not been recorded earlier but a case of bacteraemia without infective endocarditis has been described. 2 Conventional therapy with penicillin and an aminoglycoside was not successful in our patient but high doses of ciprofloxacin resulted in resolution of the infection. Gynaecomastia has been described as a complication of ciprofloxacin therapy (data on record Bayer, U . K . ) but is rare.
Department of Medical Microbiology, Southmead Hospital, Westbury-on- Trym, Bristol BSzo 5NB, U.K.
A. P. MacGowan D. S. Reeves
Department of Infectious Diseases, Han Green Hospital, Pill, Bristol BS2o oHW, U.K.
C. Wright S. C. Glover
References I. Harris RC. Erysipelothrix rhusopathiae. In Dalton HP, Nottebart HC, Eds. Interpretive medical microbiology. London: Churchill Livingstone, 1986: 58-63. 2. Townsend RH, Jephcott AE, Yekta MH. Erysipelothrix septicaemia without endocarditis. Br Med J 1973 ; I : 464-465.
Epstein-Barr virus encephalitis Accepted for publication I3 June 199o Sir, We were interested to read the case report by Bhatti et al., 1 because we have recently seen a patient in w h o m the diagnosis of encephalitis caused by E p s t e i n - B a r r virus (EBV) was not entertained initially and only made serologically. An I8-year-old m a n was admitted with a 4 days' history of headache and photophobia following a glandular fever-like illness 2 weeks previously. His condition rapidly deteriorated and he developed status epilepticus during which he was ventilated and then admitted to the Intensive Care Unit. A lumbar puncture was acellular with no growth on culture. A C T scan was normal but the E E G was suggestive of encephalitis. A full blood count showed a 4o % lymphocytosis, and activated lymphocytes were seen. T h e r e was also a mild thrombocytopaenia. T h e patient was started on intravenous acyclovir and benzyl penicillin. A sample of blood taken I I days after admission was found to be positive for EBV viral capsid antigen (VCA) I g M by immunofluorescence. A blood sample was also taken on the day of admission, and this was tested as a pair with a sample taken 3 weeks later for respiratory and neurological virus screen. T h e only significant finding was a rising titre to EBV V C A I g M (40-320) and EBV V C A I g G (160-256o). Coxsackie B I g M E L I S A and viral cultures on throat swabs and stool were also negative. An acute C S F specimen was available but no I g M antibody to viral capsid antigen was detectable. In the absence of any other positive findings a diagnosis of EBV encephalitis was made. Although we were unable to detect EBV VCA I g M in the C S F , this could be a false-negative finding, as the specimen was taken early in the illness. Convalescent C S F specimens were not available to test. We would concur with Bhatti et al., 1 that encephalitis due to E p s t e i n - B a r r virus is infrequently reported. T h i s m a y be due to a low index of suspicion amongst clinicians.
Letters to the Editor
Io2
EBV should be considered as a possibility in any patient presenting with a clinical diagnosis of encephalitis, especially is aged between I5 and 25 years. Although our patient was given acyclovir, the dose (Io m g / k g body wt) was too low to achieve effective therapeutic concentrations against EBV in vitro. In our opinion the dose of acyclovir (700 m g 8-hourly) used by Bhatti et al., 1 would also have been inadequate. In view of this it is difficult to assess the role of acyclovir in m a n a g e m e n t of EBV encephalitis; however, we would agree that treatment with acyclovir should be initiated on clinical suspicion of viral encephalitis. (We thank Dr C. Hardisty for permission to report on his patient and Mr A. Siddons for performing serological tests.)
Public Heath Laboratory, Northern General Hospital, Herries Road, Sheffield, Yorkshire $5 7A U
D. Sanyal* G. Kudesia
Department of General Medicine, Northern General Hospital, Herries Road, Sheffield, U.K.
M. Young
* Address correspondence to: D. Sanyal, P.H.L.S., Northern General Hospital, Sheffield $5 7AU, U.K.
Reference
r. Bhatti N, Larson E, Hickey M , Seal D. Encephalitis due to Epstein-Barr virus. J Infect I99o; 2o : 69-72.
Kingella kingae
d a c t y l i t i s in a n i n f a n t
Accepted for publication 3 July I99o Sir,
Kingella kingae, formerly known as Moraxella kingae, is a Gram-negative coccobacillary, fermentative rod, that has been chiefly associated with bone and joint infections and endocarditis. 1 Dactylitis due to this organism has seldom been reportedfl We describe an infant with bacteraemia and dactylitis due to K. kingae. A previously healthy 6-month-old male infant was admitted through the Accident and E m e r g e n c y D e p a r t m e n t with 2 days' history of a swollen, erythematous but nontender right little finger. T h e m o t h e r could recall no recent febrile illness or trauma. Examination of the hand confirmed the presence of a swollen erythematous finger, the swelling being m o s t obvious in the proximal half of the digit. It was not tender or hot, and there was a full range of m o v e m e n t in all joints of the hand. F u r t h e r physical findings were unremarkable. L a b o r a t o r y data indicated a peripheral W B C of I6 x ~o 9 with 57 % neutrophils and 43 % lymphocytes. T h e E S R was 32 m m / h . Radiographs of the affected finger and the right hand were normal but the bones were not scanned. Blood cultures yielded G r a m - n e g a t i v e coccobacilli, identified as K. kingae (confirmed by the Central Public Health Laboratory, Colindale, London), sensitive to penicillin, ampicillin, cephradine and gentamicin by disc diffusion susceptibility tests. T h e infant was treated with a combination of Iv ampicillin and IV flucloxacillin (I25 mg of each, given four times a day). On receiving the susceptibility and identification
