Volume 89 Number 1
REFERENCES 1. Albright F, Butler AM, Hampton AO, and Smith P: Syndrome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty, N Engl J Med 216:727, 1937. 2. Moldawer M, and Rabin ER: Polyostotic fibrous dysplasia with thyrotoxicosis, Arch Intern Med 118:379, 1966. 3. Danon M, Robboy SL Kim S, Scully R, and Crawford JD: Cushing syndrome, sexual precocity and polyostotic fibrous dysplasia in infancy, J PEI~IATR87:917, 1975. 4. Scurry TM, Bicknell J, and Fajans SS: Polyostotic fibrous
Nonhemolytic group B streptococcal infections Martha H. Roe, M.T. (ASCP), James K. Todd, M.D.,* and Blaise E. Favara, M.D., Denver, Colo.
RECENT RECOGNITION of an increased incidence of
group B streptococcal infections in the newborn infant 1 has prompted an unresolved controversy over the necessity for and significance of screening cultures for this organism in gravid women or their newborn infants?, 3 A three-year survey of neonatal infections treated at The Children's Hospital of Denver revealed a significant proportion of infections due to nonhemolytic group B streptococci and questions the validity of culture methods which have accepted the absence of beta hemolysis as excluding the presence of this organism. METHODS The charts of all newborn infants (0 to 28 days of age) hospitalized at The Children's Hospital of Denver with documented streptococcal bacteremia from January, 1973, through December, 1975, were reviewed. All blood culture isolates from newborn infants growing grampositive cocci were originally identified using standard colony morphology, surface hemolysis on 5% sheep blood agar incubated aerobically, catalase reaction, bile-esculin hydrolysis, hippurate hydrolysis techniques, and group A immunofluorescence procedures? .~ Nonhemolytic strepFrom The Departments o f Pathology, Pediatrics, and Infectious Disease of The Children's Hospital o f Denver, and the University o f Colorado Medical Center. *Reprint address: The Children's Hospital of Denver, 1056 East Nineteenth Ave,, Denver, Colo. 80218.
B r i e f clinical and laboratory observations
75
dysplasia and acromegaly, Arch Intern Med 114:40, 1964. 5. DiGeorge AM: Albright syndrome: Is it coming of age? J PEDIATR87:1018, 1975. 6. Ehrig U, and Wilson DR: Fibrous dysplasia of bone and primary hyperparathyroidism, Ann Intern Med 77:234, 1972. 7. Lightner ES, Penny R, and Frasier SD: Growth hormone excess and sexual precocity in polyostotic fibrous dysplasia (McCune-Albright syndrome): Evidence for abnormal hypothalamic function, J PEDIATR87:922, 1975.
tococci hydrolyzing hippurate and presumptively identified as nonhemolytic group B streptococci were confirmed by biochemical methods and Lancefield typing 6 at the Center for Disease Control. The four patients with infections caused by nonhemolytic group B streptococci were compared to the seven patients with similar disease caused by beta hemolytic organisms during the same time period (1973-1975). The four nonhemolytic organisms originally confirmed as group B streptococci were compared biochemically and immunologically to beta hemolytic group B streptococci saved from a previous study, 1 using the following tests: catalase, ~ Optochin sensitivity, ~bacitracin sensitivity,4 bile-esculin growth and hydrolysis/ standard" and rapid 7 hippurate hydrolysis, CAMP test,~ counterimmunoelectrophoresis typing, '~ Lancefield typing (CDC), 6 6.5% sodium chloride growth, ~~ l% sugar fermentationsr ~ growth at 45~ 1~ Kirby-Bauer antibiotic susceptibility?1 and surface and subsurface hemolysis on aerobic and anaerobic 5% sheep and rabbit blood agar plates? RESULTS From January, 1973, through December, 1975, 11 newborn infants with blood cultures positive for group B streptococci were identified at The Children's Hospital of Denver. Of the 11, four (36%) had group B organisms which were not beta hemolytic on the surface of standard 5% sheep blood agar plates incubated aerobically. Clinical evaluation of these four newborn infants compared to the seven with classic beta hemolytic group B streptococcal disease revealed no major differences; the typical infant in each group was preterm with low birth weight and the rapid onset, frequently in the first few hours of life, of respiratory distress secondary to pneumonitis, which was often interpreted as hyaline membrane disease on chest roentgenogram. Three of the four newborn infants with nonhemolytic group B streptococcal disease died, as compared to four of the seven with typical beta hemolytic
76
Brief clinical and laboratory observations
The Journal of Pediatrics July 1976
Table I
Nonhemolytic strains Strains tested Subtype
Beta hemolytic strains
4 11 BI~(2), B~a(4),BH(1),
Bin(2) B~(2) Beta hemolysis (5% sheep or rabbit blood) Aerobic surface (24-72 hr) Aerobic subsurface (72 hr) Anaerobic (72 hr)
0/4 2/4 2/4
7/7 7/7 7/7
group B streptococci. Epidemiologic investigation of the patients with nonhemolytic strains demonstrated all cases to be sporadic with no evidence for a common source of exposure. The four initially nonhemolytic group B strains were compared biochemically and immunologically to seven strains (saved from a previous study 1) of beta hemolytic group B streptococci. All strains were gram-positive cocci in chains, catalase negative, Optochin resistant, bacitracin resistant, bile-esculin hydrolysis negative, hippurate hydrolysis positive, CAMP test positive, penicillin sensitive, and confirmed as group B by Lancefield typing and counterimmunoelectrophoresis, with no major differences in other biochemical reactions (no growth on 10 or 40% bile, growth at 45°C and in 6.5% NaC1, fermentation of sucrose, salicin, and trehalose but not lactose, and resistance to kanamycin). More extensive hemolysis testing (Table I) of the four strains consistently nonhemolytic on the surface of standard 5% sheep blood agar plates incubated aerobically showed two strains which ultimately produced beta hemolysis if pour plates were used or a prolonged (72 hours) anaerobic environment was maintained, while the other two remained nonhemolytic under all conditions. Similar reacting nonhemolytic group B streptococcal strains were isolated from the exposed surfaces (throat, skin) of each patient, as well as from the blood. COMMENT Due to the apparent increased incidence of group B streptococcal infections in newborn infants? -3 a number of investigators have recommended that gravid women or their newborn infants be routinely screened and treated for the presence of group B streptococci.1' 2 These recommendations have been accepted by many obstetricians (43%) in the Denver area, whose reference laboratories all rely on the presence of beta hemolysis to initially identify these organisms. At the same time, 36% of newborn
infants admitted at The Children's Hospital with group B streptococcal infections had strains which were not beta hemolytic on the surface of standard blood agar plates incubated aerobically and 18% remained nonhemolytic even if incubated for prolonged periods anaerobically. Other authors have demonstrated the occurrence of nonhemolytic group B streptococci,7, 1.~ and several have induced certain strains of group B streptococci in vitro to lose their abilities to hemolyze blood in an aerobic environment. 13 It would appear that such a loss would be related either to the absence of all hemolysin activity or to the loss of a surface hemolysin with the retention of oxygen labile hemolytic activity, as was demonstrated in two of our initially nonhemolytic strains. The occurrence of a large proportion (36%) of disease caused by nonhemolytic group B streptococci suggests that laboratories relying on beta hemolysis for initial detection of pathogenic strains may underestimate the number of patients colonized with this organism, especially if the cultures are not incubated anaerobically. Similar deceptively low isolation rates may result from failure to use selectively enriched media. 3 It is therefore recommended that laboratories providing cultures for the group B streptococcus on an epidemiologic, research, or service basis utilize selective enrichment procedures and further evaluate all streptococci, both hemolytic and nonhemolytic, with biochemical or immunologic methods more specific for the organism (hippurate hydrolysis, CAMP reaction, immunofluorescence).
REFERENCES
1. Franciosi RA, Knostman JD, and Zimmerman RA: Group B streptococcal neonatal and infant infections, J PEDIATR 82:707, 1973. 2. McCracken GH, Jr: Group B streptococci: The new challenge in neonatal infections, J PEDIATR82:703, 1973. 3. Baker CJ, and Barrett FF: Transmission of group B streptococci among parturient women and their neonates, J P~BIATR 83:919, 1973. 4. Lennette EH, et al, editors: Manual of clinical microbiology, ed 2, Washington, D.C., 1974, American Society for Clinical Microbiology. 5. Facklam RR: Presumptive identification of group A, B, and D. streptococci, Appl Microbiol 27:107, 1974. 6. Lancefield RC: Serological differentiation of human and other groups of hemolytic streptococci, J Exp Med 57:571, 1933. 7. Hwang M-N, and Ederer G: Rapid hippurate hydrolysis method for presumptive identification of group B streptococci, J Clin Microbiol 1:114, 1975. 8. Darling CL: Standardization and. evaluation of the CAMP reaction for the prompt, presumptive identification of Streptococcus agalactiae (Lance field group B) in clinical materials, J Clin Microbiol 1:171, 1975. 9. Dajani AS: Rapid identification of beta hemolytic strepto-
Volume 89 Number 1
Brief cfinical and laboratory observations
cocci by counterimmunoelectrophoresis, J Immunol 110:1702, 1973. 10. Wilkinson HW, Thacker LG, and Facklam RR: Nonhemolytic group B streptococci of human, bovine, and ichthyic origin, Infect Immun 7:496, 1973. 11. Standardized disc susceptibility test, Fed Register 37:20527, 1972.
Yersinia enterocolitica
infections in children Steve Kohl, M.D.,* Jay A. Jacobson, M.D., and Andr6 Nahmias, M.D., Atlanta, Ga.
Y E R S I N I A ENTEROCOLITICA is associated with several clinical syndromes. It has received increasing attention in recent years f r o m E u r o p e a n a n d C a n a d i a n physicians w h o regard it as a relatively c o m m o n cause o f gastroenteritis a n d severe a b d o m i n a l p a i n in c h i l d r e n in certain c o u n t r i e s . " A l t h o u g h several cases a n d a n o u t b r e a k h a v e b e e n r e p o r t e d f r o m the U n i t e d States? -8 the incidence o f Y. enterocolitica infections in this c o u n t r y is not known. D u r i n g a 6 - m o n t h p e r i o d in 1975, however, four c h i l d r e n with Y. enterocolitica infection were diagnosed in two A t l a n t a hospitals. T h e cases show t h a t the diagnosis can b e readily m a d e w h e n physicians a n d laboratory p e r s o n n e l suspect it.
CASE REPORTS Case 1. A 19-month-old white female was hospitalized with a one-day history of fever, coryza, and a seizure. Positive physical findings were irritability and fever of 41 °C. Hem atocrit value was 29%, white blood cell count 8,700/mm 3 with 11% bands, 50% polymorphonuclear leukocytes, 31% lymphocytes, 7% monocytes, and 1% eosinophils. Shortly after admission diarrhea began with green, watery, fonl-smelling, non-bloody stools. Ampicillin was administered for presumed shigellosis. Four days later a pink, macular rash with target lesions developed on the trunk and limbs. Because stool cultures were negative for Salmonella and Shigella, ampicillin was discontinued. Within the ensuing five From the Division of Infectious Disease and Immunology, Department of Pediatrics, Emory University School of Medicine, and Special Pathogens Branch, Bacterial Diseases Division, Bureau of Epidemiology, Center for Disease Control. Dr. Kohl is supported by Research FellowshipAward CA 05232-01 from the National Cancer Institute. *Reprint address: Department of Pediatrics, Emory University School of Medicine, 69 Butler Street, S.E., Atlanta, Ga. 30303.
77
12. Butter MNW, and de Moor CE: Streptococcus agalactiae as a cause of meningitis in the newborn, and of bacteremia in adults, Antonie van Leeuwenhoek 33:439, 1967. 13. Lancefield RC: Loss of the properties of hemolysin and pigment formation without change in immunological specificity in a strain of Streptococcus haemolyticus, J Exp Med 59:459, 1934.
days all symptoms resolved without specific therapy. During the patient's illness the possibility of yersiniosis was discussed with the laboratory and a second stool culture was submitted. Y. enterocolitica, resistant to ampicillin arid cephalothin and sensitive to chloramphenicol, tetracycline, kanamycin, and gentamicin, was recovered. The organism agglutinated with antisera to 0 factors 13 and 18. Case 2. A 19-month-old male cousin of Case 1 was seen with a four-day history of fever, green watery diarrhea and targetlike rash on the legs and abdomen. The temperature was 40~C with no other physical findings. The WBC was 14,800/mm 3 with many young forms and 6% eosinophils. Ampicillin therapy was prescribed for suspected otitis media. Within two days all symptoms resolved. A stool culture was obtained on a follow-up visit one month later because of the child's association with Case 1. Y. enterocolitica possessing 0 factors 13 and 18 was isolated.
Abbreviations used WBC: white blood count PMN: polymorphonuclear leukocytes
Case 3. A 4-year-old male presented with a 10-day history of fever, mild respiratory symptoms, and intermittent crampy lower abdominal pain unaccompanied by vomiting or diarrhea. His symptoms were unaffected by a four-day course of ampicillin administered in the week prior to admission. A temperature of 38.3°C was the only positive physical finding. The WBC was 24,900/mm 3 with 2% bands, 75% PMN, 15% lymphocytes, 8% monocytes, and 1% eosinophils. A stool culture grew Y. enterocolitica, sensitive to ampicillin, kanamycin, tetracycline, gentamicin, chloramphenicol, and colistin and resistant to cephalothin. Symptoms resolved over the following three days without specific antibiotic therapy. Case 4. A 3-month-old white female was transferred to an Atlanta hospital after in-patient evaluation at a local hospital failed to disclose the cause of her 21/i-month history of persistent diarrhea. The infant appeared chronically ill with an erythematous, scaly rash on her perineum; the abdomen was protuberant, and bowel sounds were absent. Body temperature was 37.2°C. The WBC was 13,000/ram ~ with 21% bands, 49% PMN, 25% lymphocytes, 5% monocytes, and 28,000 platelets/mm ~. Burr cells were seen on smear. Abdominal roentgenogram showed distended loops of bowel with air fluid levels. Laparotomy revealed matted loops of small bowel and purulent peritoneal fluid. A partial resection of the small bowel, ileostomy, and
REFERENCES 1. Albright F, Butler AM, Hampton AO, and Smith P: Syndrome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty, N Engl J Med 216:727, 1937. 2. Moldawer M, and Rabin ER: Polyostotic fibrous dysplasia with thyrotoxicosis, Arch Intern Med 118:379, 1966. 3. Danon M, Robboy SL Kim S, Scully R, and Crawford JD: Cushing syndrome, sexual precocity and polyostotic fibrous dysplasia in infancy, J PEI~IATR87:917, 1975. 4. Scurry TM, Bicknell J, and Fajans SS: Polyostotic fibrous
Nonhemolytic group B streptococcal infections Martha H. Roe, M.T. (ASCP), James K. Todd, M.D.,* and Blaise E. Favara, M.D., Denver, Colo.
RECENT RECOGNITION of an increased incidence of
group B streptococcal infections in the newborn infant 1 has prompted an unresolved controversy over the necessity for and significance of screening cultures for this organism in gravid women or their newborn infants?, 3 A three-year survey of neonatal infections treated at The Children's Hospital of Denver revealed a significant proportion of infections due to nonhemolytic group B streptococci and questions the validity of culture methods which have accepted the absence of beta hemolysis as excluding the presence of this organism. METHODS The charts of all newborn infants (0 to 28 days of age) hospitalized at The Children's Hospital of Denver with documented streptococcal bacteremia from January, 1973, through December, 1975, were reviewed. All blood culture isolates from newborn infants growing grampositive cocci were originally identified using standard colony morphology, surface hemolysis on 5% sheep blood agar incubated aerobically, catalase reaction, bile-esculin hydrolysis, hippurate hydrolysis techniques, and group A immunofluorescence procedures? .~ Nonhemolytic strepFrom The Departments o f Pathology, Pediatrics, and Infectious Disease of The Children's Hospital o f Denver, and the University o f Colorado Medical Center. *Reprint address: The Children's Hospital of Denver, 1056 East Nineteenth Ave,, Denver, Colo. 80218.
B r i e f clinical and laboratory observations
75
dysplasia and acromegaly, Arch Intern Med 114:40, 1964. 5. DiGeorge AM: Albright syndrome: Is it coming of age? J PEDIATR87:1018, 1975. 6. Ehrig U, and Wilson DR: Fibrous dysplasia of bone and primary hyperparathyroidism, Ann Intern Med 77:234, 1972. 7. Lightner ES, Penny R, and Frasier SD: Growth hormone excess and sexual precocity in polyostotic fibrous dysplasia (McCune-Albright syndrome): Evidence for abnormal hypothalamic function, J PEDIATR87:922, 1975.
tococci hydrolyzing hippurate and presumptively identified as nonhemolytic group B streptococci were confirmed by biochemical methods and Lancefield typing 6 at the Center for Disease Control. The four patients with infections caused by nonhemolytic group B streptococci were compared to the seven patients with similar disease caused by beta hemolytic organisms during the same time period (1973-1975). The four nonhemolytic organisms originally confirmed as group B streptococci were compared biochemically and immunologically to beta hemolytic group B streptococci saved from a previous study, 1 using the following tests: catalase, ~ Optochin sensitivity, ~bacitracin sensitivity,4 bile-esculin growth and hydrolysis/ standard" and rapid 7 hippurate hydrolysis, CAMP test,~ counterimmunoelectrophoresis typing, '~ Lancefield typing (CDC), 6 6.5% sodium chloride growth, ~~ l% sugar fermentationsr ~ growth at 45~ 1~ Kirby-Bauer antibiotic susceptibility?1 and surface and subsurface hemolysis on aerobic and anaerobic 5% sheep and rabbit blood agar plates? RESULTS From January, 1973, through December, 1975, 11 newborn infants with blood cultures positive for group B streptococci were identified at The Children's Hospital of Denver. Of the 11, four (36%) had group B organisms which were not beta hemolytic on the surface of standard 5% sheep blood agar plates incubated aerobically. Clinical evaluation of these four newborn infants compared to the seven with classic beta hemolytic group B streptococcal disease revealed no major differences; the typical infant in each group was preterm with low birth weight and the rapid onset, frequently in the first few hours of life, of respiratory distress secondary to pneumonitis, which was often interpreted as hyaline membrane disease on chest roentgenogram. Three of the four newborn infants with nonhemolytic group B streptococcal disease died, as compared to four of the seven with typical beta hemolytic
76
Brief clinical and laboratory observations
The Journal of Pediatrics July 1976
Table I
Nonhemolytic strains Strains tested Subtype
Beta hemolytic strains
4 11 BI~(2), B~a(4),BH(1),
Bin(2) B~(2) Beta hemolysis (5% sheep or rabbit blood) Aerobic surface (24-72 hr) Aerobic subsurface (72 hr) Anaerobic (72 hr)
0/4 2/4 2/4
7/7 7/7 7/7
group B streptococci. Epidemiologic investigation of the patients with nonhemolytic strains demonstrated all cases to be sporadic with no evidence for a common source of exposure. The four initially nonhemolytic group B strains were compared biochemically and immunologically to seven strains (saved from a previous study 1) of beta hemolytic group B streptococci. All strains were gram-positive cocci in chains, catalase negative, Optochin resistant, bacitracin resistant, bile-esculin hydrolysis negative, hippurate hydrolysis positive, CAMP test positive, penicillin sensitive, and confirmed as group B by Lancefield typing and counterimmunoelectrophoresis, with no major differences in other biochemical reactions (no growth on 10 or 40% bile, growth at 45°C and in 6.5% NaC1, fermentation of sucrose, salicin, and trehalose but not lactose, and resistance to kanamycin). More extensive hemolysis testing (Table I) of the four strains consistently nonhemolytic on the surface of standard 5% sheep blood agar plates incubated aerobically showed two strains which ultimately produced beta hemolysis if pour plates were used or a prolonged (72 hours) anaerobic environment was maintained, while the other two remained nonhemolytic under all conditions. Similar reacting nonhemolytic group B streptococcal strains were isolated from the exposed surfaces (throat, skin) of each patient, as well as from the blood. COMMENT Due to the apparent increased incidence of group B streptococcal infections in newborn infants? -3 a number of investigators have recommended that gravid women or their newborn infants be routinely screened and treated for the presence of group B streptococci.1' 2 These recommendations have been accepted by many obstetricians (43%) in the Denver area, whose reference laboratories all rely on the presence of beta hemolysis to initially identify these organisms. At the same time, 36% of newborn
infants admitted at The Children's Hospital with group B streptococcal infections had strains which were not beta hemolytic on the surface of standard blood agar plates incubated aerobically and 18% remained nonhemolytic even if incubated for prolonged periods anaerobically. Other authors have demonstrated the occurrence of nonhemolytic group B streptococci,7, 1.~ and several have induced certain strains of group B streptococci in vitro to lose their abilities to hemolyze blood in an aerobic environment. 13 It would appear that such a loss would be related either to the absence of all hemolysin activity or to the loss of a surface hemolysin with the retention of oxygen labile hemolytic activity, as was demonstrated in two of our initially nonhemolytic strains. The occurrence of a large proportion (36%) of disease caused by nonhemolytic group B streptococci suggests that laboratories relying on beta hemolysis for initial detection of pathogenic strains may underestimate the number of patients colonized with this organism, especially if the cultures are not incubated anaerobically. Similar deceptively low isolation rates may result from failure to use selectively enriched media. 3 It is therefore recommended that laboratories providing cultures for the group B streptococcus on an epidemiologic, research, or service basis utilize selective enrichment procedures and further evaluate all streptococci, both hemolytic and nonhemolytic, with biochemical or immunologic methods more specific for the organism (hippurate hydrolysis, CAMP reaction, immunofluorescence).
REFERENCES
1. Franciosi RA, Knostman JD, and Zimmerman RA: Group B streptococcal neonatal and infant infections, J PEDIATR 82:707, 1973. 2. McCracken GH, Jr: Group B streptococci: The new challenge in neonatal infections, J PEDIATR82:703, 1973. 3. Baker CJ, and Barrett FF: Transmission of group B streptococci among parturient women and their neonates, J P~BIATR 83:919, 1973. 4. Lennette EH, et al, editors: Manual of clinical microbiology, ed 2, Washington, D.C., 1974, American Society for Clinical Microbiology. 5. Facklam RR: Presumptive identification of group A, B, and D. streptococci, Appl Microbiol 27:107, 1974. 6. Lancefield RC: Serological differentiation of human and other groups of hemolytic streptococci, J Exp Med 57:571, 1933. 7. Hwang M-N, and Ederer G: Rapid hippurate hydrolysis method for presumptive identification of group B streptococci, J Clin Microbiol 1:114, 1975. 8. Darling CL: Standardization and. evaluation of the CAMP reaction for the prompt, presumptive identification of Streptococcus agalactiae (Lance field group B) in clinical materials, J Clin Microbiol 1:171, 1975. 9. Dajani AS: Rapid identification of beta hemolytic strepto-
Volume 89 Number 1
Brief cfinical and laboratory observations
cocci by counterimmunoelectrophoresis, J Immunol 110:1702, 1973. 10. Wilkinson HW, Thacker LG, and Facklam RR: Nonhemolytic group B streptococci of human, bovine, and ichthyic origin, Infect Immun 7:496, 1973. 11. Standardized disc susceptibility test, Fed Register 37:20527, 1972.
Yersinia enterocolitica
infections in children Steve Kohl, M.D.,* Jay A. Jacobson, M.D., and Andr6 Nahmias, M.D., Atlanta, Ga.
Y E R S I N I A ENTEROCOLITICA is associated with several clinical syndromes. It has received increasing attention in recent years f r o m E u r o p e a n a n d C a n a d i a n physicians w h o regard it as a relatively c o m m o n cause o f gastroenteritis a n d severe a b d o m i n a l p a i n in c h i l d r e n in certain c o u n t r i e s . " A l t h o u g h several cases a n d a n o u t b r e a k h a v e b e e n r e p o r t e d f r o m the U n i t e d States? -8 the incidence o f Y. enterocolitica infections in this c o u n t r y is not known. D u r i n g a 6 - m o n t h p e r i o d in 1975, however, four c h i l d r e n with Y. enterocolitica infection were diagnosed in two A t l a n t a hospitals. T h e cases show t h a t the diagnosis can b e readily m a d e w h e n physicians a n d laboratory p e r s o n n e l suspect it.
CASE REPORTS Case 1. A 19-month-old white female was hospitalized with a one-day history of fever, coryza, and a seizure. Positive physical findings were irritability and fever of 41 °C. Hem atocrit value was 29%, white blood cell count 8,700/mm 3 with 11% bands, 50% polymorphonuclear leukocytes, 31% lymphocytes, 7% monocytes, and 1% eosinophils. Shortly after admission diarrhea began with green, watery, fonl-smelling, non-bloody stools. Ampicillin was administered for presumed shigellosis. Four days later a pink, macular rash with target lesions developed on the trunk and limbs. Because stool cultures were negative for Salmonella and Shigella, ampicillin was discontinued. Within the ensuing five From the Division of Infectious Disease and Immunology, Department of Pediatrics, Emory University School of Medicine, and Special Pathogens Branch, Bacterial Diseases Division, Bureau of Epidemiology, Center for Disease Control. Dr. Kohl is supported by Research FellowshipAward CA 05232-01 from the National Cancer Institute. *Reprint address: Department of Pediatrics, Emory University School of Medicine, 69 Butler Street, S.E., Atlanta, Ga. 30303.
77
12. Butter MNW, and de Moor CE: Streptococcus agalactiae as a cause of meningitis in the newborn, and of bacteremia in adults, Antonie van Leeuwenhoek 33:439, 1967. 13. Lancefield RC: Loss of the properties of hemolysin and pigment formation without change in immunological specificity in a strain of Streptococcus haemolyticus, J Exp Med 59:459, 1934.
days all symptoms resolved without specific therapy. During the patient's illness the possibility of yersiniosis was discussed with the laboratory and a second stool culture was submitted. Y. enterocolitica, resistant to ampicillin arid cephalothin and sensitive to chloramphenicol, tetracycline, kanamycin, and gentamicin, was recovered. The organism agglutinated with antisera to 0 factors 13 and 18. Case 2. A 19-month-old male cousin of Case 1 was seen with a four-day history of fever, green watery diarrhea and targetlike rash on the legs and abdomen. The temperature was 40~C with no other physical findings. The WBC was 14,800/mm 3 with many young forms and 6% eosinophils. Ampicillin therapy was prescribed for suspected otitis media. Within two days all symptoms resolved. A stool culture was obtained on a follow-up visit one month later because of the child's association with Case 1. Y. enterocolitica possessing 0 factors 13 and 18 was isolated.
Abbreviations used WBC: white blood count PMN: polymorphonuclear leukocytes
Case 3. A 4-year-old male presented with a 10-day history of fever, mild respiratory symptoms, and intermittent crampy lower abdominal pain unaccompanied by vomiting or diarrhea. His symptoms were unaffected by a four-day course of ampicillin administered in the week prior to admission. A temperature of 38.3°C was the only positive physical finding. The WBC was 24,900/mm 3 with 2% bands, 75% PMN, 15% lymphocytes, 8% monocytes, and 1% eosinophils. A stool culture grew Y. enterocolitica, sensitive to ampicillin, kanamycin, tetracycline, gentamicin, chloramphenicol, and colistin and resistant to cephalothin. Symptoms resolved over the following three days without specific antibiotic therapy. Case 4. A 3-month-old white female was transferred to an Atlanta hospital after in-patient evaluation at a local hospital failed to disclose the cause of her 21/i-month history of persistent diarrhea. The infant appeared chronically ill with an erythematous, scaly rash on her perineum; the abdomen was protuberant, and bowel sounds were absent. Body temperature was 37.2°C. The WBC was 13,000/ram ~ with 21% bands, 49% PMN, 25% lymphocytes, 5% monocytes, and 28,000 platelets/mm ~. Burr cells were seen on smear. Abdominal roentgenogram showed distended loops of bowel with air fluid levels. Laparotomy revealed matted loops of small bowel and purulent peritoneal fluid. A partial resection of the small bowel, ileostomy, and
