Letters to the Editor
334
8. Bailie WE, Stowe EC, Schmitt AM. Aerobic bacterial flora of oral and nasal fluids of canines with reference to bacteria associated with bites. J Clin Microbiol 1978; 7:223-23 I. 9. Westwell AG, Kerr K, Spencer MB, Hutchinson DN. DF-2 infection. Br Med.7 1989;
298:
I I 6 - I I7.
IO. Brook I. Human and animal bite infections..7 Family Practice 1989; 28: 713-718. I I. Graham DR, Band JD, Thornsberry C, Hollis DG, Weaver RE. Infections caused by Moraxella, Moraxella urethralis, Moraxella-like groups M-5 and M-6, and Kingella kingae in the United States, 1953-198o. Rev Infect Dis 199o; 12: 423-431. 12. Talan DA, Staatz D, Staatz A, Goldstein EJC, Overturf GD. Staphylococcus intermedius in canine gingiva and canine-inflicted human wound infections : laboratory characterization of a newly recognized zoonotic pathogen. J Clin Microbiol 1989 ; 27: 78-81. 13. Talan DA, Goldstein EJC, Staatz D, Overturf GD. Staphylococcus intermedius: clinical presentation of a new human pathogen. Ann Emerg Med 1989; I8:41o-413. 14. Hole S, Fossum K. Antibodies to staphylococcal DNases in sera from different animal species, including humans. J Clin Microbiol 1989; 27: 2444-2447. 15. Talan DA, Staatz D, Staatz A, Overturf GD. Frequency of Staphylococcus intermedius as human nasopharyngeal flora..7 Clin Microbiol 1989; 27: 2393.
Pasteurella h a e m o l y t i c a diagnosis questioned Accepted for publication 30 March 1992 Sir, We read with interest the case report of Pasteurella haemolytica endocarditis by Yaneza et al. 1 T h e y call attention to the fact that h u m a n infections due to P. haemolytica are rare and subsequently state that endocarditis caused by this organism has been reported only once before. However, in our opinion the authors do not offer sufficient documentation that the organism isolated from the patient's blood was P. haemolytica. A very short bacteriological description is given mentioning only that the Gram-negative coccobacilli found were identified as P. haemolytica by means of the A P I 20 N E system. N o further details are reported. T h e A P I 2o N E system is a commercial micromethod combining 20 tests for the identification of Gram-negative rods not belonging to the Enterobacteriaceae family, i.e. Pseudomonas, Moraxella, Pasteurella, Acinetobacter, Aeromonas etc. It has been shown previously to be a reliable method for identifying non-enteric rods in the genus Pseudomonas 2 and with some reservations usable also for routine identification of several other Gram-negative non-fermentative rods; s-5 but in our experience the system is not applicable to the family Pasteurellaceae. We recently tested a set of 30 strains belonging to this family, all of them previously extensively studied by conventional biochemical tests. With the A P I 20 N E system and the A P I Analytical Profile Index (4th edition, 199o), only three strains (two P. multocida and one P. aerogenes) could be correctly identified. Sixteen strains were misdiagnosed while the remaining I I , including two P. haemolytica isolates could not be identified as their numerical profile was not listed in the Analytical Profile Index. O f special interest in relation to the P. haemolytica case report is the observation that three strains belonging to the species Haemophilus aphrophilus or H. paraphrophilus were erroneously identified as P. haemolytica (with the note: ' g o o d identification'). T h e former two species are well-known aetiological agents of infective endocarditis. In addition, a Capnocytophaga isolate was wrongly identified as P. haemolytica (' good identification '), while one P. granulomatis strain was diagnosed as P. haemolytica on a low discriminatory level. Profiles for Haemophilus ducreyi and Actinobacillus actinomycetemcomitans were decoded as Pasteurella spp. or Pasteurella haemolytica (acceptable identification to genus level).
Letters to the Editor
335
In conclusion, we found the A P I 2o N E system unfit for use and often directly misleading when applied to organisms of the family Pasteurellaceae. T h i s makes the v a l i d i t y of the P. haemolytica diagnosis in the endocarditis case report highly questionable because other bacteriological characteristics that might have led to an unequivocal identification were not described. W h e n reporting unusual pathogens in unusual circumstances, we believe it is important to provide sufficient bacteriological details to make an evaluation of the diagnosis possible a n d / o r to submit the organism to a reference laboratory.
Department of Clinical Microbiology, Statens Seruminstitut, Artillerivej 5, D K - 2 3 o o Copenhagen S, Denmark
I. 2. 3. 4.
A. Lester J. 0. Jarlov H. Westh W. Frederiksen
References Yaneza AL, Jivan H, Kumari P, Togoo MS. Pasteurella haemolytica endocarditis. J Infect 1991 ; 23 : 65-67. Sogaard P, Gahrn-Hansen B, Hui-Ping Z, Frederiksen W. An investigation of three commercial methods for rapid identification of non-enteric Gram-negative rods. Acta Path Microbiol Immunol Scand Sect B 1986; 94: 357-363. Appelbaum PC, Leathers DJ. Evaluation of the Rapid N F T system for identification of Gram-negative, nonfermenting rods. J Clin Microbiol 1984; 2o: 730-734 . yon Graevenitz A, Zollinger-Iten J. Evaluation of pertinent parameters of a new identification system for non-enteric Gram-negative rods. Eur J Clin Microbiol 1985; 4: I08--I I2.
5. MartinR, SiavoshiF, McDougalDL. Comparison of Rapid N F T system and conventional methods for identification of non-saccharolytic Gram-negative bacteria. J Clin Microbiol 1986; 24: lO89-1o92.
Acute pyogenic P s e u d a l l e s c h e r i a boydii foot infection sequentially treated with m i c o n a z o l e and itraconazole Accepted for publication 8 April 1992 Sir, On 2 D e c e m b e r 1987 a 5 I - y e a r - o l d healthy male farmer stepped on to the prongs of a dung fork hidden in a pile of cow dung. T h e fork penetrated his Wellington boot and his foot. H e was given tetanus toxoid and co-amoxyclav tablets in casualty. T w o weeks later the foot was swollen and painful and two pieces of boot were removed f r o m beneath the scab of the entry wounds. N o fractures were seen on X - r a y and a swab of the pus did not grow any bacterial pathogens. T h e foot remained swollen and the patient was unable to walk and on 22 January a few small pieces of foreign material were discovered just under the skin. After their removal a below knee plaster was applied and the patient sent home. X - r a y of the foot before discharge revealed an area of rarefaction in the cuneiform bones and bases of the 2nd, 3rd and 4th metatarsal bones. By the 12 F e b r u a r y his foot was extremely painful and an X - r a y showed marked osteoporosis. H e was treated with flucloxacillin. T h e foot was explored again on the 23 F e b r u a r y when there was oedema of all soft tissues and a large quantity of yellowish fluid was seen. All the involved bones were soft and there was a small abscess cavity at the base of the 2nd metatarsal and cuneiform bones. Fungal elements resembling hyphae were seen and culture of the pus revealed woolly colonies, at first white, but becoming grey with a dark underside. Microscopically elliptical, spermshaped, single-celled conidia, borne singly from the tips of conidiophores, were seen.
334
8. Bailie WE, Stowe EC, Schmitt AM. Aerobic bacterial flora of oral and nasal fluids of canines with reference to bacteria associated with bites. J Clin Microbiol 1978; 7:223-23 I. 9. Westwell AG, Kerr K, Spencer MB, Hutchinson DN. DF-2 infection. Br Med.7 1989;
298:
I I 6 - I I7.
IO. Brook I. Human and animal bite infections..7 Family Practice 1989; 28: 713-718. I I. Graham DR, Band JD, Thornsberry C, Hollis DG, Weaver RE. Infections caused by Moraxella, Moraxella urethralis, Moraxella-like groups M-5 and M-6, and Kingella kingae in the United States, 1953-198o. Rev Infect Dis 199o; 12: 423-431. 12. Talan DA, Staatz D, Staatz A, Goldstein EJC, Overturf GD. Staphylococcus intermedius in canine gingiva and canine-inflicted human wound infections : laboratory characterization of a newly recognized zoonotic pathogen. J Clin Microbiol 1989 ; 27: 78-81. 13. Talan DA, Goldstein EJC, Staatz D, Overturf GD. Staphylococcus intermedius: clinical presentation of a new human pathogen. Ann Emerg Med 1989; I8:41o-413. 14. Hole S, Fossum K. Antibodies to staphylococcal DNases in sera from different animal species, including humans. J Clin Microbiol 1989; 27: 2444-2447. 15. Talan DA, Staatz D, Staatz A, Overturf GD. Frequency of Staphylococcus intermedius as human nasopharyngeal flora..7 Clin Microbiol 1989; 27: 2393.
Pasteurella h a e m o l y t i c a diagnosis questioned Accepted for publication 30 March 1992 Sir, We read with interest the case report of Pasteurella haemolytica endocarditis by Yaneza et al. 1 T h e y call attention to the fact that h u m a n infections due to P. haemolytica are rare and subsequently state that endocarditis caused by this organism has been reported only once before. However, in our opinion the authors do not offer sufficient documentation that the organism isolated from the patient's blood was P. haemolytica. A very short bacteriological description is given mentioning only that the Gram-negative coccobacilli found were identified as P. haemolytica by means of the A P I 20 N E system. N o further details are reported. T h e A P I 2o N E system is a commercial micromethod combining 20 tests for the identification of Gram-negative rods not belonging to the Enterobacteriaceae family, i.e. Pseudomonas, Moraxella, Pasteurella, Acinetobacter, Aeromonas etc. It has been shown previously to be a reliable method for identifying non-enteric rods in the genus Pseudomonas 2 and with some reservations usable also for routine identification of several other Gram-negative non-fermentative rods; s-5 but in our experience the system is not applicable to the family Pasteurellaceae. We recently tested a set of 30 strains belonging to this family, all of them previously extensively studied by conventional biochemical tests. With the A P I 20 N E system and the A P I Analytical Profile Index (4th edition, 199o), only three strains (two P. multocida and one P. aerogenes) could be correctly identified. Sixteen strains were misdiagnosed while the remaining I I , including two P. haemolytica isolates could not be identified as their numerical profile was not listed in the Analytical Profile Index. O f special interest in relation to the P. haemolytica case report is the observation that three strains belonging to the species Haemophilus aphrophilus or H. paraphrophilus were erroneously identified as P. haemolytica (with the note: ' g o o d identification'). T h e former two species are well-known aetiological agents of infective endocarditis. In addition, a Capnocytophaga isolate was wrongly identified as P. haemolytica (' good identification '), while one P. granulomatis strain was diagnosed as P. haemolytica on a low discriminatory level. Profiles for Haemophilus ducreyi and Actinobacillus actinomycetemcomitans were decoded as Pasteurella spp. or Pasteurella haemolytica (acceptable identification to genus level).
Letters to the Editor
335
In conclusion, we found the A P I 2o N E system unfit for use and often directly misleading when applied to organisms of the family Pasteurellaceae. T h i s makes the v a l i d i t y of the P. haemolytica diagnosis in the endocarditis case report highly questionable because other bacteriological characteristics that might have led to an unequivocal identification were not described. W h e n reporting unusual pathogens in unusual circumstances, we believe it is important to provide sufficient bacteriological details to make an evaluation of the diagnosis possible a n d / o r to submit the organism to a reference laboratory.
Department of Clinical Microbiology, Statens Seruminstitut, Artillerivej 5, D K - 2 3 o o Copenhagen S, Denmark
I. 2. 3. 4.
A. Lester J. 0. Jarlov H. Westh W. Frederiksen
References Yaneza AL, Jivan H, Kumari P, Togoo MS. Pasteurella haemolytica endocarditis. J Infect 1991 ; 23 : 65-67. Sogaard P, Gahrn-Hansen B, Hui-Ping Z, Frederiksen W. An investigation of three commercial methods for rapid identification of non-enteric Gram-negative rods. Acta Path Microbiol Immunol Scand Sect B 1986; 94: 357-363. Appelbaum PC, Leathers DJ. Evaluation of the Rapid N F T system for identification of Gram-negative, nonfermenting rods. J Clin Microbiol 1984; 2o: 730-734 . yon Graevenitz A, Zollinger-Iten J. Evaluation of pertinent parameters of a new identification system for non-enteric Gram-negative rods. Eur J Clin Microbiol 1985; 4: I08--I I2.
5. MartinR, SiavoshiF, McDougalDL. Comparison of Rapid N F T system and conventional methods for identification of non-saccharolytic Gram-negative bacteria. J Clin Microbiol 1986; 24: lO89-1o92.
Acute pyogenic P s e u d a l l e s c h e r i a boydii foot infection sequentially treated with m i c o n a z o l e and itraconazole Accepted for publication 8 April 1992 Sir, On 2 D e c e m b e r 1987 a 5 I - y e a r - o l d healthy male farmer stepped on to the prongs of a dung fork hidden in a pile of cow dung. T h e fork penetrated his Wellington boot and his foot. H e was given tetanus toxoid and co-amoxyclav tablets in casualty. T w o weeks later the foot was swollen and painful and two pieces of boot were removed f r o m beneath the scab of the entry wounds. N o fractures were seen on X - r a y and a swab of the pus did not grow any bacterial pathogens. T h e foot remained swollen and the patient was unable to walk and on 22 January a few small pieces of foreign material were discovered just under the skin. After their removal a below knee plaster was applied and the patient sent home. X - r a y of the foot before discharge revealed an area of rarefaction in the cuneiform bones and bases of the 2nd, 3rd and 4th metatarsal bones. By the 12 F e b r u a r y his foot was extremely painful and an X - r a y showed marked osteoporosis. H e was treated with flucloxacillin. T h e foot was explored again on the 23 F e b r u a r y when there was oedema of all soft tissues and a large quantity of yellowish fluid was seen. All the involved bones were soft and there was a small abscess cavity at the base of the 2nd metatarsal and cuneiform bones. Fungal elements resembling hyphae were seen and culture of the pus revealed woolly colonies, at first white, but becoming grey with a dark underside. Microscopically elliptical, spermshaped, single-celled conidia, borne singly from the tips of conidiophores, were seen.
