322
Letters to the Editor
f r o m the pharynx. T r a n s i e n t E. coli bacteraemia m a y occur in healthy people during menstruation, after intra-oral manipulation or after tonsillectomy, but urinary tract or gastro-intestinal infections are the m o r e usual source. 3 T h e oropharynx harbours E. coli in 2 % of the normal population but does not provide a suitable environment for growth of the organisms. Chronically or severely ill patients however have increased colonization with G r a m - n e g a t i v e bacilli in the oropharynx and therefore are at greater risk of p u l m o n a r y infection by aspiration. 1 I n one published series of aerobic G r a m negative pneumonias one or m o r e serious chronic disease was present in every case. ~ T h e s e included chronic renal disease, diabetes mellitus, alcoholism, heart disease, lung disease, cancer, blood dyscrasia and immunosuppression, whilst other published series fail to clarify whether cases of p r i m a r y E. coli pneumonia were free of serious associated disease. 2' 5 T h e normal M C V and transient abnormality of liver function in our patient do not suggest chronic alcohol abuse. Escherichia coli lobar p n e u m o n i a occurring in a previously well patient is exceedingly rare and this case m a y be unique.
* Infectious Diseases Unit, t Bacteriology Laboratory, City Hospital, Greenbank Drive, Edinburgh, EHIo 5SB, Scotland, U.K.
J. Bligh* F . X . S . Emmanuel% M. E. Jones*:~
Address correspondence to: Dr M. E. Jones.
I. 2. 345.
References Pierce AK, Sanford JP. Aerobic Gram-negative bacillary pneumonias. Am Rev Respir Dis 1974; n o : 647-658. Dorff GJ, Rytel MW, Farmer SG, Scanlon G. Etiologies and characteristic features of pneumonias in a municipal hospital. Am J Med Sci 1973 ; 266: 349-358. Salomon PF, Tamlyn T T , Grieco MH. Escherichia coli pneumonia--case report. Am Rev Respir Dis 197o; I02: 248--257. Tillotson JR, Lerner AM. Characteristics of pneumonias caused by Escherichia coli. N Engl J Med 1967; 277: 115-122. Sullivan RJ, Dowdle WR, Marine WM, Hierholzer JC. Adult pneumonia in a general hospital. Arch Intern Med 1972; 129: 935-942.
Lactobacillus jensenii prosthetic valve endocarditis Accepted for publication IO May 199o Sir, M e m b e r s of the genus Lactobacillus are c o m m o n l y present in the gastro-intestinal and genito-urinary tracts and in the mouth, 1 yet serious disease attributable to these organisms is raref1-9 W e describe the first recorded case of prosthetic valve endocarditis due to Lactobacillus jensenii. A 6 I - y e a r - o l d male engineer presented in M a r c h 1989 with a 3 weeks' history of malaise, night sweats, intermittent fever and progressive dyspnoea. H e had suffered previous episodes of infective endocarditis in 1983 (with a Streptococcus sp., necessitating aortic valve replacement) ; in 1986 (no causative organism was identified); and in 1988 (due to Streptococcus faecalis serotype 9/19). Following the third episode of infection, all his teeth were extracted because of severe periodontal disease. Clinical examination revealed a low-grade fever, signs of mixed aortic valve disease and moderate enlargement of the liver and spleen. T h e haemoglobin concentration was 7 g / d l and the E S R was 40 m m in the first hour. F o u r sets of blood cultures (eight
Letters to the Editor
323
bottles) grew a presumptive Streptococcus sp. A diagnosis of infective endocarditis was made. T h e M I C and M B C of ampicillin in respect of the organism were o'25 rag/1 and 8 mg/1 respectively, both reducing to 0.007 mg/1 on the addition of 5 rag/1 netilmicin to each tube of the tests. T h e patient responded well to a 6 weeks' course of these two antibiotics. In view of the repeated episodes of endocarditis, the patient was investigated for possible sources of bacteraemia. Tests for faecal occutt blood were positive on several occasions. Colonoscopic examination, under additional vancomycin cover, revealed multiple polyps containing areas of carcinoma in situ. Cardiac catheterisation had previously demonstrated an aneurysm at the root of the aorta. T h e patient is now awaiting aortic root replacement and a hemicolectomy. T h e presumptive Streptococcus sp. could not be identified by standard methods and was referred to the Streptococcus Reference Unit, Central Public Health Laboratory ( C P H L ) , Colindale, L o n d o n . Similar difficulties were encountered at the Reference U n i t ; the organism was finally identified as L. jensenii by the Miscellaneous Identification Unit, C P H L . Infective endocarditis due to other species of lactobacilli has been r e p o r t e d ? -~ T h o s e patients at greatest risk typically have pre-existing valvular disease, recent dental manipulation or infection, or are intravenous drug abusers. ~ T h e use of an aminoglycoside in addition to a fl-lactam antibiotic in serious infections with these organisms is recommended by some authors since this combination is often synergistic in vitro. 7-11 Our experience tends to support this approach. Vancomycin is a useful alternative agent in treating Gram-positive infections. Even so, resistance to vancomycin among lactobacilli has been reported, and sensitivity to this agent cannot be assumed, r' 11.1~ (We thank Dr M. R. Stephens for permission to report this case and Dr G. Colman for his assistance.)
* Department of Medical Microbiology, ~.Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff CF4 4 X W , Wales
M . C . Atkins* L. Nicolsont G. A. J. Harrison* A. Paull*
:~National Collection of Type Cultures, Division of Hospital Infection, Central Public Health Laboratory, Colindale, London N W 9 5EQ, U.K.
H. Malnick:~ D. Morrison~
References i. Parker MT. Streptococcus and Lactobacillus. In: Wilson G, Miles A, Parker MT, Eds. Topley and Wilson's Principles of Bacteriology, Virology and Immunity, z, Systematic Bacteriology. 7th ed. London: Edward Arnold; i983: I74-zi7. 2. Sussman JI, Baron EJ, Goldberg SM, Kaplan MH, Pizzario RA. Clinical manifestations and therapy of Lactobacillus endocarditis : report of a case and review of the literature. Rev Infect Dis I986; 8 (5): 771-776. 3. Thangkhiew I, Gunstone RF. Association of Lactobacillus plantarum with endocarditis. J Infect I988; I6:304-305. 4. Tenenbaum MJ, Warner JF. Lactobacillus casei endocarditis. Ann Intern Med I974; 8z: 539. 5. Naude WD, Swanepoel A, Bohmer RH, Bolding E. Endocarditis caused by Lactobacillus casei s rhamnosus. A case report. S Afr MedJ I988; 73 (Io): 6Iz-614.
324
Letters to the Editor
6. Golledge C. Vancomycin resistant lactobacilli, ff Hosp Infect 1988; I I : 292-295. 7. Bayer AS, Chow AW, Betts SD, Guze LB. Lactobacillaemia--report of nine cases. Am J Med 1978; 64: 8o8-813. 8. Rahman M. Chest infestion caused by Lactobacillus casei ss rhamnosus. Br Medff 1982 ; 284 : 471-472. 9. Allison D, Galloway A. Empyema of the gallbladder due to Lactobacillus casei, ff Infect 1988; 17: 191. IO. Bayer AS, Chow AW, Morrison JO, Guze LB. Bactericidal synergy between pencillin or ampicillin and aminoglycosides against antibiotic tolerant lactobacilli. Antimicrob Agents Chemother 198o; I7: 359-363. I I. Holliman RE, Bone GP. Vancomycin resistance of clinical isolates of lactobacilli. J Infect I988; I6: 279-283. 12. Colman G, Efstratiou A. Vancomycin resistant leuconostocs, lactobacilli and now pediococci, ff Hosp Infect 1987; IO: 1-3.
S e p t i c arthritis due to L i s t e r i a m o n o c y t o g e n e s Accepted for publication 23 M a y 199o Sir, T h e r e have been only a few reported cases of septic arthritis caused by Listeria monocytogenes 1-4 and in these the patients were i m m u n o - c o m p r o m i s e d or had an underlying disease. We had recently a case of septic arthritis due to L. monocytogenes in a patient who had undergone revision of the right hip 2 years before but who had no apparent immunological abnormality. T h e patient was a 73-year-old m a n admitted to the hospital in S e p t e m b e r I989 with a painful right hip and thigh. T h e pain was sudden in onset 24 h before admission and he was unable to walk or m o v e his right leg. His past history was not significant except that in August I986 he had revision of the right hip replacement. In January 1988 he developed a left hemiparesis following a cerebro-vascular accident. At that time he fell and then noticed discomfort in the right leg. T h e pain was sometimes severe but of short duration. H e was examined in July 1988 when some restriction of m o v e m e n t was found but there was no discomfort on axial pressure. X - r a y showed satisfactory position of the prosthesis apart from the trochanteric osteotomy which had not united. On examination following admission in S e p t e m b e r I989 the general condition of the patient was good. T h e r e was some wasting of the right quadriceps muscle and gross restriction of all m o v e m e n t s of the right hip, which were painful. T h e t e m p e r a t u r e was 38 °C, the blood pressure I 7 o / 9 o and the pulse 8o/min. N o abnormality was found in other systems. L a b o r a t o r y investigations showed a W B C of 11"58 x lO9/1 (neutrophils lO'27 x lO9/1, lymphocytes 0'63 x lO9/1, monocytes 0"65 x lO9/1, basophils 0-02 x lO9/1). T h e R B C count and M C V were normal. T h e E S R was 32 m m / h . S e r u m biochemistry and liver function tests were normal. C-reactive protein was 9o'o mg/1. T h e R. A. Latex test was negative. A preliminary diagnosis, of septic arthritis of the right hip joint was made. It was aspirated under general anaesthesia and about 60 ml of pus were sent for culture and sensitivity tests. Microscopy showed pus cells + + + but no organisms were seen. T h e hip was put on traction and cefuroxime 75o m g IV was started pending the results of bacterial examination. Culture of the pus grew L. monocytogenes, sensitive to ampicillin, t r i m e t h o p r i m , penicillin and e r y t h r o m y c i n but resistant to cephalexin and cefuroxime. Blood cultures were negative. T h e organism was sent to the Central Public Health L a b o r a t o r y ( C P H L ) and was confirmed as L. monocytogenes serovar i,
Letters to the Editor
f r o m the pharynx. T r a n s i e n t E. coli bacteraemia m a y occur in healthy people during menstruation, after intra-oral manipulation or after tonsillectomy, but urinary tract or gastro-intestinal infections are the m o r e usual source. 3 T h e oropharynx harbours E. coli in 2 % of the normal population but does not provide a suitable environment for growth of the organisms. Chronically or severely ill patients however have increased colonization with G r a m - n e g a t i v e bacilli in the oropharynx and therefore are at greater risk of p u l m o n a r y infection by aspiration. 1 I n one published series of aerobic G r a m negative pneumonias one or m o r e serious chronic disease was present in every case. ~ T h e s e included chronic renal disease, diabetes mellitus, alcoholism, heart disease, lung disease, cancer, blood dyscrasia and immunosuppression, whilst other published series fail to clarify whether cases of p r i m a r y E. coli pneumonia were free of serious associated disease. 2' 5 T h e normal M C V and transient abnormality of liver function in our patient do not suggest chronic alcohol abuse. Escherichia coli lobar p n e u m o n i a occurring in a previously well patient is exceedingly rare and this case m a y be unique.
* Infectious Diseases Unit, t Bacteriology Laboratory, City Hospital, Greenbank Drive, Edinburgh, EHIo 5SB, Scotland, U.K.
J. Bligh* F . X . S . Emmanuel% M. E. Jones*:~
Address correspondence to: Dr M. E. Jones.
I. 2. 345.
References Pierce AK, Sanford JP. Aerobic Gram-negative bacillary pneumonias. Am Rev Respir Dis 1974; n o : 647-658. Dorff GJ, Rytel MW, Farmer SG, Scanlon G. Etiologies and characteristic features of pneumonias in a municipal hospital. Am J Med Sci 1973 ; 266: 349-358. Salomon PF, Tamlyn T T , Grieco MH. Escherichia coli pneumonia--case report. Am Rev Respir Dis 197o; I02: 248--257. Tillotson JR, Lerner AM. Characteristics of pneumonias caused by Escherichia coli. N Engl J Med 1967; 277: 115-122. Sullivan RJ, Dowdle WR, Marine WM, Hierholzer JC. Adult pneumonia in a general hospital. Arch Intern Med 1972; 129: 935-942.
Lactobacillus jensenii prosthetic valve endocarditis Accepted for publication IO May 199o Sir, M e m b e r s of the genus Lactobacillus are c o m m o n l y present in the gastro-intestinal and genito-urinary tracts and in the mouth, 1 yet serious disease attributable to these organisms is raref1-9 W e describe the first recorded case of prosthetic valve endocarditis due to Lactobacillus jensenii. A 6 I - y e a r - o l d male engineer presented in M a r c h 1989 with a 3 weeks' history of malaise, night sweats, intermittent fever and progressive dyspnoea. H e had suffered previous episodes of infective endocarditis in 1983 (with a Streptococcus sp., necessitating aortic valve replacement) ; in 1986 (no causative organism was identified); and in 1988 (due to Streptococcus faecalis serotype 9/19). Following the third episode of infection, all his teeth were extracted because of severe periodontal disease. Clinical examination revealed a low-grade fever, signs of mixed aortic valve disease and moderate enlargement of the liver and spleen. T h e haemoglobin concentration was 7 g / d l and the E S R was 40 m m in the first hour. F o u r sets of blood cultures (eight
Letters to the Editor
323
bottles) grew a presumptive Streptococcus sp. A diagnosis of infective endocarditis was made. T h e M I C and M B C of ampicillin in respect of the organism were o'25 rag/1 and 8 mg/1 respectively, both reducing to 0.007 mg/1 on the addition of 5 rag/1 netilmicin to each tube of the tests. T h e patient responded well to a 6 weeks' course of these two antibiotics. In view of the repeated episodes of endocarditis, the patient was investigated for possible sources of bacteraemia. Tests for faecal occutt blood were positive on several occasions. Colonoscopic examination, under additional vancomycin cover, revealed multiple polyps containing areas of carcinoma in situ. Cardiac catheterisation had previously demonstrated an aneurysm at the root of the aorta. T h e patient is now awaiting aortic root replacement and a hemicolectomy. T h e presumptive Streptococcus sp. could not be identified by standard methods and was referred to the Streptococcus Reference Unit, Central Public Health Laboratory ( C P H L ) , Colindale, L o n d o n . Similar difficulties were encountered at the Reference U n i t ; the organism was finally identified as L. jensenii by the Miscellaneous Identification Unit, C P H L . Infective endocarditis due to other species of lactobacilli has been r e p o r t e d ? -~ T h o s e patients at greatest risk typically have pre-existing valvular disease, recent dental manipulation or infection, or are intravenous drug abusers. ~ T h e use of an aminoglycoside in addition to a fl-lactam antibiotic in serious infections with these organisms is recommended by some authors since this combination is often synergistic in vitro. 7-11 Our experience tends to support this approach. Vancomycin is a useful alternative agent in treating Gram-positive infections. Even so, resistance to vancomycin among lactobacilli has been reported, and sensitivity to this agent cannot be assumed, r' 11.1~ (We thank Dr M. R. Stephens for permission to report this case and Dr G. Colman for his assistance.)
* Department of Medical Microbiology, ~.Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff CF4 4 X W , Wales
M . C . Atkins* L. Nicolsont G. A. J. Harrison* A. Paull*
:~National Collection of Type Cultures, Division of Hospital Infection, Central Public Health Laboratory, Colindale, London N W 9 5EQ, U.K.
H. Malnick:~ D. Morrison~
References i. Parker MT. Streptococcus and Lactobacillus. In: Wilson G, Miles A, Parker MT, Eds. Topley and Wilson's Principles of Bacteriology, Virology and Immunity, z, Systematic Bacteriology. 7th ed. London: Edward Arnold; i983: I74-zi7. 2. Sussman JI, Baron EJ, Goldberg SM, Kaplan MH, Pizzario RA. Clinical manifestations and therapy of Lactobacillus endocarditis : report of a case and review of the literature. Rev Infect Dis I986; 8 (5): 771-776. 3. Thangkhiew I, Gunstone RF. Association of Lactobacillus plantarum with endocarditis. J Infect I988; I6:304-305. 4. Tenenbaum MJ, Warner JF. Lactobacillus casei endocarditis. Ann Intern Med I974; 8z: 539. 5. Naude WD, Swanepoel A, Bohmer RH, Bolding E. Endocarditis caused by Lactobacillus casei s rhamnosus. A case report. S Afr MedJ I988; 73 (Io): 6Iz-614.
324
Letters to the Editor
6. Golledge C. Vancomycin resistant lactobacilli, ff Hosp Infect 1988; I I : 292-295. 7. Bayer AS, Chow AW, Betts SD, Guze LB. Lactobacillaemia--report of nine cases. Am J Med 1978; 64: 8o8-813. 8. Rahman M. Chest infestion caused by Lactobacillus casei ss rhamnosus. Br Medff 1982 ; 284 : 471-472. 9. Allison D, Galloway A. Empyema of the gallbladder due to Lactobacillus casei, ff Infect 1988; 17: 191. IO. Bayer AS, Chow AW, Morrison JO, Guze LB. Bactericidal synergy between pencillin or ampicillin and aminoglycosides against antibiotic tolerant lactobacilli. Antimicrob Agents Chemother 198o; I7: 359-363. I I. Holliman RE, Bone GP. Vancomycin resistance of clinical isolates of lactobacilli. J Infect I988; I6: 279-283. 12. Colman G, Efstratiou A. Vancomycin resistant leuconostocs, lactobacilli and now pediococci, ff Hosp Infect 1987; IO: 1-3.
S e p t i c arthritis due to L i s t e r i a m o n o c y t o g e n e s Accepted for publication 23 M a y 199o Sir, T h e r e have been only a few reported cases of septic arthritis caused by Listeria monocytogenes 1-4 and in these the patients were i m m u n o - c o m p r o m i s e d or had an underlying disease. We had recently a case of septic arthritis due to L. monocytogenes in a patient who had undergone revision of the right hip 2 years before but who had no apparent immunological abnormality. T h e patient was a 73-year-old m a n admitted to the hospital in S e p t e m b e r I989 with a painful right hip and thigh. T h e pain was sudden in onset 24 h before admission and he was unable to walk or m o v e his right leg. His past history was not significant except that in August I986 he had revision of the right hip replacement. In January 1988 he developed a left hemiparesis following a cerebro-vascular accident. At that time he fell and then noticed discomfort in the right leg. T h e pain was sometimes severe but of short duration. H e was examined in July 1988 when some restriction of m o v e m e n t was found but there was no discomfort on axial pressure. X - r a y showed satisfactory position of the prosthesis apart from the trochanteric osteotomy which had not united. On examination following admission in S e p t e m b e r I989 the general condition of the patient was good. T h e r e was some wasting of the right quadriceps muscle and gross restriction of all m o v e m e n t s of the right hip, which were painful. T h e t e m p e r a t u r e was 38 °C, the blood pressure I 7 o / 9 o and the pulse 8o/min. N o abnormality was found in other systems. L a b o r a t o r y investigations showed a W B C of 11"58 x lO9/1 (neutrophils lO'27 x lO9/1, lymphocytes 0'63 x lO9/1, monocytes 0"65 x lO9/1, basophils 0-02 x lO9/1). T h e R B C count and M C V were normal. T h e E S R was 32 m m / h . S e r u m biochemistry and liver function tests were normal. C-reactive protein was 9o'o mg/1. T h e R. A. Latex test was negative. A preliminary diagnosis, of septic arthritis of the right hip joint was made. It was aspirated under general anaesthesia and about 60 ml of pus were sent for culture and sensitivity tests. Microscopy showed pus cells + + + but no organisms were seen. T h e hip was put on traction and cefuroxime 75o m g IV was started pending the results of bacterial examination. Culture of the pus grew L. monocytogenes, sensitive to ampicillin, t r i m e t h o p r i m , penicillin and e r y t h r o m y c i n but resistant to cephalexin and cefuroxime. Blood cultures were negative. T h e organism was sent to the Central Public Health L a b o r a t o r y ( C P H L ) and was confirmed as L. monocytogenes serovar i,
