I I6

Letters to the Editor

therefore have been responsible, as suggested by the presence of M protein, a virulence factor rarely seen in G G S .

* Department of Rheumatology and t Public Health Laboratory, St George's Hospital Medical School, Blackshaw Road, London S W I 7 oQT, U.K.

J . H . Tobias* P . Y . C . Lee3; F . E . Bruckner*

References I. Norden CW. In: Mandell GL, Douglas RG, Bennett JE, Eds. Principles and practice of infectious disease. Edinburgh: Churchill Livingstone, 199o: 922-930. 2. Hess OM, Youssef S, Luthy R, Seigenthaler W. Rezidivierende Sepsis mit Streptokokken der Lancefield-Gruppe G. Schweiz Med Wochenschr 198o: IiO: 129-13o. 3- Vartian C, Lerner PI, Shales DM, Gopalkrishna KV. Infections due to Lancefield group G streptococci. Medicine 1985; 64: 75-88.

Staphylococcus lugdunensis e n d o c a r d i t i s Accepted for publication 19 December 1991 Sir, We wish to present another case of endocarditis caused by Staphylococcus lugdunensis, adding to those previously reported. 1-3 A 59-year-old carpenter presented to the Accident and E m e r g e n c y D e p a r t m e n t with a short history of chest pain. His past medical history included a mitral valve replacement for rheumatic heart disease 13 years before; since then he had remained well. Closer questioning revealed an influenza-like illness 3 months before admission since when he had noticed occasional night sweats and fever. H e had no focal central nervous system signs or s y m p t o m s but he described experiencing intermittent short episodes of strange thought processes during the previous few months. H e had undergone cautery for nose-bleeds I year before but had no other recent surgery and he had no skin lesions. Total dental clearance had been p e r f o r m e d prior to mitral valve replacement in 1977 . On initial examination he was afebrile, normotensive and had a collapsing pulse. H e had no cutaneous stigmata of endocarditis. Auscultation was consistent with a prosthetic mitral valve, and an aortic stenotic m u r m u r was heard. T h e r e was no evidence of incompetence in either valve. Investigation showed a slightly raised W B C count of 12"2 x lO9/1 (75 % neutrophils), haemoglobin concentration of I 1.3 g/dl, and E S R of 86 m m in the first hour. S e r u m biochemistry and a chest X - r a y were normal. Blood cultures yielded G r a m - p o s i t i v e cocci in clusters after 24 h in both bottles. An urgent echocardiogram showed mild aortic stenosis but no vegetations were seen. A working diagnosis of prosthetic valve endocarditis was made and treatment was started with flucloxacillin 2 g 4 hourly and gentamicin 80 m g 12 hourly after taking further blood for culture. All six blood culture bottles yielded staphylococci after 24 h. T h e organism was Staphaurex (Wellcome) and Staphylase (Oxoid) negative; it was also tube-coagulase and slide-coagulase negative using h u m a n plasma. Identification by A P I - s t a p h was Staphylococcus warneri. T h e organism was sensitive by disc-diffusion methods to methicillin, penicillin, fusidic acid, erythromycin, trimethoprim, gentarnicin, vancomycin, chloramphenicol and rifampicin. T h e minimal inhibitory and minimal bactericidal concentration of penicillin was found to be 0"03 mg/1. T h e flucloxacillin was therefore changed to benzyl penicillin 1.2 g 4 hourly. T h e organism was subsequently identified as S. lugdunensis by the delayed positive D N A s e , and positive ornithine decarboxylase test. 4

Letters to the Editor Despite chemotherapy the patient developed aortic regurgitation and left ventricular failure which necessitated cardiac surgery. At operation active endocarditis involving both the prosthetic (Bjork-Shiley) mitral and native aortic valves was found. T h e non-coronary leaflet of the aortic valve had a large central perforation, and granulation tissue extended f r o m this down onto the anterior leaflet of the mitral valve. Both diseased valves were replaced but the patient died on the operating table. T h i s case again shows the aggressive nature of S. lugdunensis endocarditis: the patients reported by Walsh and Mounseyfl and by S m y t h et al. 1 recovered after emergency surgery. T w o of the three cases reported by Etienne et al. 2 died, one during emergency valve replacement. It also demonstrates the wisdom of the teaching that poor clinical progress in endocarditis is an indication for surgery rather than for altering the antibiotic therapy. Blood cultures f r o m our patient taken during treatment and cultures of the replaced heart valves were sterile, and the deterioration appeared to be due to perforation of one cusp of the valve : i.e. mechanical, not infective. As in m o s t of the previously described cases the source of the organism is unclear. A review by Herchline and Ayers 5 showed that S. lugdunensis could be isolated f r o m m a n y b o d y sites. T h e nose is an obvious source of staphylococci; however, the patient's nasal cautery had been p e r f o r m e d a year previously and 9 months before the onset of s y m p t o m s , m u c h longer than the usual ' i n c u b a t i o n p e r i o d ' of endocarditis. A m o r e likely hypothesis is that the organism gained entry through skin t r a u m a and his trade as a carpenter may be relevant. (We thank Dr S. J. Eykyn of UMDS, St Thomas' campus, for identifying the organism; and Dr R. Courtenay-Evans, Dr S. Joseph and Mr J. Pepper for permission to report their patient.)

Departments of *Microbiology and t Medicine Mayday Hospital, Croydon CR7 7 YE, U.K.

M. Sheppard* S. Jankowskit

References r. Smyth EG, Wright ED, Marples RP. New type of staphylococcal endocarditis. J Clin Pathol ~988; 4I: 8o9-8Io. 2. Etienne J, Pangon B, Leport C et al. Staphylococcus lugdunensis endocarditis. Lancet I989; i: 390. 3. Walsh B, Mounsey JP. Staphylococcus lugdunensis and endocarditis. J Clin Pathol r99o; 43: I7I. 4. Freney Jet al. Staphylococcus lugdunensissp. nov. and Staphylococcus schleiferi sp. nov., two species from human clinical specimens. Int J Syst Bacteriol I988 ; 38: I68-I72. 5- Herchline T, Ayers L. Occurrence of Staphylococcus lugdunensis in consecutive clinical cultures and relationship of isolation to infection. J Clin Microbiol I99I ; 29: 419-42r.

Single-dose ciprofloxacin for shigellosis in adults Accepted for publication I2 January 1992 Sir, Since the epidemic of bacillary dysentery caused by m u l t i - d r u g resistant Shigella dysenteriae type I in West Bengal, India, 1 in 1984, the disease has been an important cause of morbidity, mortality and hospitalisation in this region. A n u m b e r of clinical trials have shown that appropriate antibiotic therapy shortens the illness and the time during which Shigellae are excreted in the stool. Ampicillin and co-trimoxazole have been the drugs of choice but because of the appearance of resistance to these two agents, nalidixic acid has become the first line treatment. However, in recent years Shigella strains resistant to nalidixic acid have emerged f r o m different parts of the

Staphylococcus lugdunensis endocarditis.

I I6 Letters to the Editor therefore have been responsible, as suggested by the presence of M protein, a virulence factor rarely seen in G G S . *...
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