Journal of Infection (I99i) 23, 209-223 Letters
to the Editor
Streptococcus faecalis in neonatal infective endocarditis Accepted for publication 2 9 March I99 I Sir, Infective endocarditis in the neonate is rare and usually fatal. Reviews of case reports since the I95OS have shown that the major risks include admission to special care units and intravascular catheterisation, especially of the umbilical artery. 1-3 T h e aetiological agents most c o m m o n l y reported are Staphylococcus aureus and Staphylococcus epidermidis, although Streptococcus species of Lancefield groups B and C, Pseudomonas aeruginosa, Serratia marcescens and Candida spp. have also been recorded. 1-4 We wish to report an unusual case of neonatal endocarditis caused by Streptococcus faecalis in a baby in a special care unit and who did not have a ' long line' intravascular catheter in situ. T h e patient was born at 29 weeks of gestation, the first of female twins. She was admitted to the special care unit for assisted ventilation. Fluids and feeding were given entirely via peripheral intravenous cannulae. T h e infant became unwell and developed an intermittent systolic m u r m u r . Initial echocardiograms were equivocal. Blood culture yielded S. faecalis sensitive to ampicillin which failed to clear the infection despite 7- and I4-day courses of the drug given intravenously together with netilmicin. Subsequent urine analysis revealed microscopical haematuria and further echocardiograms showed progressive mitral valve regurgitation with thickening of the valve. Despite the absence of other peripheral stigmata, a diagnosis of infective endocarditis was made. W h e n a further blood culture again yielded S. faecalis, ampicillin with netilmicin was given intravenously for 6 weeks because of the high ampicillin M I C (I.o mg/1) and M B C (4"0 mg/1) against the organism. Subsequent echocardiograms revealed vegetations on the mitral leaflets compatible with infective endocarditis. T h e infant made good progress and later blood cultures remained negative. Typically, neonatal endocarditis is caused by Staphylococcus species 1-~ and is strongly associated with ' l o n g - l i n e ' intravascular catheters. ~-3 Although S. faecalis is a c o m m o n cause of neonatal bacteraemia 5 and of adult infective endocarditis and is found in 4 % cases of childhood endocarditis, 6 it has not been associated previously with neonatal endocarditis. In a recently reported series 2 of neonatal endocarditis association with ' l o n g - l i n e ' intravascular catheters, especially umbilical artery catheters, was present in all cases. T h e absence of a ' l o n g - l i n e ' intravenous catheter in our patient is unusual in the aetiology of this disease. Even in the absence of major risk factors, we feel that neonatal infective endocarditis should be considered in neonates in special care units and who develop recurrent bacteraemia. F u r t h e r m o r e , serial echocardiograms should be p e r f o r m e d to aid diagnosis.
Public Health Laboratory, West Norwich Hospital, Bowthorpe Road, Norwich, Norfolk, U.K. Department of Paediatrics, Norfolk and Norwich Hospital, St Stephens Road, Norwich, Norfolk, U.K.
S. S. Soo
D. L. Bosman
Letters to the Editor
2IO
References I. Oelberg DG, Fisher DJ, Gross DM, Denson SE, Adcock EW. Endocarditis in high-risk neonates. Paediatrics I983; 7x (3): 392-397. 2. Noel GJ, O'Loughlin JE, Edelson PJ. Neonatal Staphylococcus epidermidis. Right-sided endocarditis. Description of five catheterized infants. Paediatrics I988; 82 (2): 234-239. 3. Millard DD, Shulman ST. The changing spectrum of neonatal endocarditis. Clin Perinatol I988; x5 (3): 587-608. 4. O'Callaghan C, McDougall P. Infective endocarditis in neonates. Arch Dis Child I988; 63 :
53-57.
5. Musker DM. Enterococcus species and group D streptococcus. In: Mandell, Douglas, Bennett, Eds. Principles and practice of infectious disease I99o: I55O-I554. 6. Gersony WM, Hordof AJ. Infective endocarditis and disease of the pericardium. Paediatr Clin I978; 25 (4): 831-846.
Mycoplasma horninis i n f e c t i o n o f a b r e a s t p r o s t h e s i s Accepted for publication II February x99x Sir,
Mycoplasma hominis is often isolated f r o m the uro-genital tract and has been associated with a wide variety of clinical conditions. 1 W e wish to report a case of M. hominis infection in a breast prosthesis. W e are not aware of Mycoplasma species having been isolated in similar circumstances. A 38-year-old w o m a n underwent bilateral subcutaneous m a s t e c t o m y with insertion of silicone gel-filled implants for persistent mastalgia and nipple discharge. T h e operation was uneventful. F o u r weeks later, however, the patient was readmitted to hospital complaining of malaise and headaches during the previous 8 days. She was febrile (38 °C) and had a raised W B C count (I5"3 x Io9/1). T h e r e had been a serous discharge f r o m the left breast and fluid had collected under the right prosthesis. Some of this fluid was aspirated and sent for culture. After 48 h anaerobic incubation, a heavy pure growth of translucent, non-haemolytic pinpoint colonies was obtained on blood agar. Subculture on 20 % serum agar showed the classical ' f r i e d - e g g ' colonies of a Mycoplasma species. T h e organism was later identified as M. hominis, being sensitive to chloramphenicol and tetracycline but resistant to erythromycin by disc sensitivity testing. Neither Mycoplasma hominis nor other m o r e usual pathogens were isolated f r o m superficial w o u n d swabs. Both breast prostheses were removed and the patient was treated with tetracycline and metronidazole. T h e wounds healed and the patient was discharged f r o m hospital. Recovery of a heavy pure growth of M. hominis f r o m the breast aspirate, as well as failure to isolate any other pathogens both f r o m the aspirate and f r o m the skin, suggest that M. hominis played a pathogenic role in this patient. T h e presence of silicone implants p r e s u m a b l y predisposed to the infection. Mycoplasma pneumoniae is a wellrecognised pathogen of the respiratory tract and has also been implicated in m a n y other conditions. Mycoplasma hominis is known to colonise the adult uro-genital tract. It has been implicated in non-gonococcal urethritis, pelvic inflammatory disease 2 and p o s t - p a r t u m fever. 3 I n addition, there is a wide variety of uro-genital conditions to which M. hominis infection has been tentatively linked. W o u n d infections of the sternum with M. hominis have been described 4 although colonisation alone m a y have been difficult to exclude. T h e presence of this organism in such an unusual site led us to speculate on its origin. I m p l a n t a t i o n at the time of operation or post-operatively was possible. I f this had happened, M. hominis would probably have been isolated f r o m the superficial
to the Editor
Streptococcus faecalis in neonatal infective endocarditis Accepted for publication 2 9 March I99 I Sir, Infective endocarditis in the neonate is rare and usually fatal. Reviews of case reports since the I95OS have shown that the major risks include admission to special care units and intravascular catheterisation, especially of the umbilical artery. 1-3 T h e aetiological agents most c o m m o n l y reported are Staphylococcus aureus and Staphylococcus epidermidis, although Streptococcus species of Lancefield groups B and C, Pseudomonas aeruginosa, Serratia marcescens and Candida spp. have also been recorded. 1-4 We wish to report an unusual case of neonatal endocarditis caused by Streptococcus faecalis in a baby in a special care unit and who did not have a ' long line' intravascular catheter in situ. T h e patient was born at 29 weeks of gestation, the first of female twins. She was admitted to the special care unit for assisted ventilation. Fluids and feeding were given entirely via peripheral intravenous cannulae. T h e infant became unwell and developed an intermittent systolic m u r m u r . Initial echocardiograms were equivocal. Blood culture yielded S. faecalis sensitive to ampicillin which failed to clear the infection despite 7- and I4-day courses of the drug given intravenously together with netilmicin. Subsequent urine analysis revealed microscopical haematuria and further echocardiograms showed progressive mitral valve regurgitation with thickening of the valve. Despite the absence of other peripheral stigmata, a diagnosis of infective endocarditis was made. W h e n a further blood culture again yielded S. faecalis, ampicillin with netilmicin was given intravenously for 6 weeks because of the high ampicillin M I C (I.o mg/1) and M B C (4"0 mg/1) against the organism. Subsequent echocardiograms revealed vegetations on the mitral leaflets compatible with infective endocarditis. T h e infant made good progress and later blood cultures remained negative. Typically, neonatal endocarditis is caused by Staphylococcus species 1-~ and is strongly associated with ' l o n g - l i n e ' intravascular catheters. ~-3 Although S. faecalis is a c o m m o n cause of neonatal bacteraemia 5 and of adult infective endocarditis and is found in 4 % cases of childhood endocarditis, 6 it has not been associated previously with neonatal endocarditis. In a recently reported series 2 of neonatal endocarditis association with ' l o n g - l i n e ' intravascular catheters, especially umbilical artery catheters, was present in all cases. T h e absence of a ' l o n g - l i n e ' intravenous catheter in our patient is unusual in the aetiology of this disease. Even in the absence of major risk factors, we feel that neonatal infective endocarditis should be considered in neonates in special care units and who develop recurrent bacteraemia. F u r t h e r m o r e , serial echocardiograms should be p e r f o r m e d to aid diagnosis.
Public Health Laboratory, West Norwich Hospital, Bowthorpe Road, Norwich, Norfolk, U.K. Department of Paediatrics, Norfolk and Norwich Hospital, St Stephens Road, Norwich, Norfolk, U.K.
S. S. Soo
D. L. Bosman
Letters to the Editor
2IO
References I. Oelberg DG, Fisher DJ, Gross DM, Denson SE, Adcock EW. Endocarditis in high-risk neonates. Paediatrics I983; 7x (3): 392-397. 2. Noel GJ, O'Loughlin JE, Edelson PJ. Neonatal Staphylococcus epidermidis. Right-sided endocarditis. Description of five catheterized infants. Paediatrics I988; 82 (2): 234-239. 3. Millard DD, Shulman ST. The changing spectrum of neonatal endocarditis. Clin Perinatol I988; x5 (3): 587-608. 4. O'Callaghan C, McDougall P. Infective endocarditis in neonates. Arch Dis Child I988; 63 :
53-57.
5. Musker DM. Enterococcus species and group D streptococcus. In: Mandell, Douglas, Bennett, Eds. Principles and practice of infectious disease I99o: I55O-I554. 6. Gersony WM, Hordof AJ. Infective endocarditis and disease of the pericardium. Paediatr Clin I978; 25 (4): 831-846.
Mycoplasma horninis i n f e c t i o n o f a b r e a s t p r o s t h e s i s Accepted for publication II February x99x Sir,
Mycoplasma hominis is often isolated f r o m the uro-genital tract and has been associated with a wide variety of clinical conditions. 1 W e wish to report a case of M. hominis infection in a breast prosthesis. W e are not aware of Mycoplasma species having been isolated in similar circumstances. A 38-year-old w o m a n underwent bilateral subcutaneous m a s t e c t o m y with insertion of silicone gel-filled implants for persistent mastalgia and nipple discharge. T h e operation was uneventful. F o u r weeks later, however, the patient was readmitted to hospital complaining of malaise and headaches during the previous 8 days. She was febrile (38 °C) and had a raised W B C count (I5"3 x Io9/1). T h e r e had been a serous discharge f r o m the left breast and fluid had collected under the right prosthesis. Some of this fluid was aspirated and sent for culture. After 48 h anaerobic incubation, a heavy pure growth of translucent, non-haemolytic pinpoint colonies was obtained on blood agar. Subculture on 20 % serum agar showed the classical ' f r i e d - e g g ' colonies of a Mycoplasma species. T h e organism was later identified as M. hominis, being sensitive to chloramphenicol and tetracycline but resistant to erythromycin by disc sensitivity testing. Neither Mycoplasma hominis nor other m o r e usual pathogens were isolated f r o m superficial w o u n d swabs. Both breast prostheses were removed and the patient was treated with tetracycline and metronidazole. T h e wounds healed and the patient was discharged f r o m hospital. Recovery of a heavy pure growth of M. hominis f r o m the breast aspirate, as well as failure to isolate any other pathogens both f r o m the aspirate and f r o m the skin, suggest that M. hominis played a pathogenic role in this patient. T h e presence of silicone implants p r e s u m a b l y predisposed to the infection. Mycoplasma pneumoniae is a wellrecognised pathogen of the respiratory tract and has also been implicated in m a n y other conditions. Mycoplasma hominis is known to colonise the adult uro-genital tract. It has been implicated in non-gonococcal urethritis, pelvic inflammatory disease 2 and p o s t - p a r t u m fever. 3 I n addition, there is a wide variety of uro-genital conditions to which M. hominis infection has been tentatively linked. W o u n d infections of the sternum with M. hominis have been described 4 although colonisation alone m a y have been difficult to exclude. T h e presence of this organism in such an unusual site led us to speculate on its origin. I m p l a n t a t i o n at the time of operation or post-operatively was possible. I f this had happened, M. hominis would probably have been isolated f r o m the superficial
