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the second course of antibiotics and have remained well. T h e duration of follow-up ranged from 8-24 months. Possible explanations for the early relapse may be inadequate duration of therapy, inadequate dose of the drug used or the emergence of resistant bacteria. Resistance of B. melitensis to ciprofloxacin has been reportedfl and a similar problem may have occurred in our patients. U n h a p p i l y we were unable to document bacteriological relapse during the second clinical illness and such a possibility remains hypothetical. In the light of these findings the efficacy of ofloxacin in the treatment of brucellosis remains unproven. F u t u r e studies, however, are warranted in the light of the reported in vitro activity of the drug against the organism. Such studies should be guided by the M I C of ofloxacin for local isolates and should increase the duration of chemotherapy.

Najwa Khuri-Bulos Kandil Shaker

Faculty of Medicine, University of Jordan, Amman, Jordan References

i. Bosch J, Linares J, Lopez de Goioechea et al. In vitro activity of ciprofloxacin, ceftriaxone and five other antimicrobial agents against 95 strains of Brueella rnelitemis. J Antirnicrob Chemother 1986; 17: 459-46I. 2. Khan MY, Dizon M, Kiel FK. Comparative in vitro activities of ofloxacin, difloxacin, ciprofloxacin and other selected antimicrobial agents against Brucella melitensis. Antimicrob Agents Chemother 1989; 33: 14o9-14IO. 3. A1-Sibai MB, Qadri SMH. Development of ciprofloxacin resistance in Brucella melitensis. J Antimicrob Chemother 199o; 25: 3o2-3o3.

S t r e p t o c o c c u s s u i s s e p t i c a e m i a p r e s e n t i n g as s e v e r e acute gastro-enteritis Accepted for publication 2I September 199o Sir, Streptococcus suis is a zoonotic pathogen which m a y cause meningitis, arthritis and septicaemia in pigs and, rarely, meningitis or septicaemia in h u m a n beings.1 I report here on a patient who presented with severe acute gastro-enteritis and from whose blood S. suis was isolated. A 43-year-old previously healthy p i g - f a r m e r ' s wife was referred to the Infectious Diseases U n i t at Seacroft Hospital with suspected severe acute gastro-enteritis. She presented several hours after the sudden onset of vomiting, diarrhoea (profuse, loose, b r o w n motions without blood) and fever. She had no headache or pain in the neck or back. A short time earlier, she had been working in close contact with pigs, helping the piglets to suckle the sows, but had not sustained any wounds, lacerations or abrasions. On examination she was unwell, with shock, cyanosis and a temperature of 38 °C. T h e r e was no meningism, rash or joint swelling, and abdominal examination was unremarkable. A full blood examination showed the following: haemoglobin 14"4 g / d l ; white cell count 2 × Iog/l with 7 8 % neutrophils; platelet count 118 x I&/1. S e r u m creatinine concentration was I 6 I # m o l / 1 . Arterial blood analysis showed the following: haemoglobin saturation 9I % ; pO2 7"8 kPa; pCO~ 3"7 kPa; bicarbonate 2o retool/l, base excess - 7 retool/l; p H 7"4- Blood was taken for culture. A chest radiograph was clear.

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Letters to the Editor

Oxygen was given by a face mask. T h e patient was resuscitated with intravenous h u m a n albumen solution. She remained hypotensive despite adequate restoration of circulating blood volume as measured by a central venous pressure line. Suspected septicaemia was treated with intravenous cefuroxime and metronidazole. Blood cultures subsequently grew S. suis and treatment with antibiotics was changed to intravenous gentamicin and ampicillin, chosen for their synergistic effect. Faecal cultures were negative. Diarrhoea resolved after 3 days and the patient ultimately made a complete recovery despite having developed p u l m o n a r y oedema, disseminated intravascular coagulation and jaundice of a mixed cholestatic/hepatitic type. Gentamicin was discontinued after 9 days and ampicillin after I2 days. T h e patient was discharged h o m e i6 days after admission. H u m a n infections with S. suis arise mostly in persons having contact with pigs or raw pork and usually present as meningitis or septicaemia. 2' ~ Vomiting and diarrhoea may accompany streptococcal sel0ticaemia. ~ Diarrhoea as an accompaniment of S. suis septicaemia has been described in Holland 2 and H o n g Kong. 5 T h i s case, in the U . K . , shows the importance of bearing in mind the possibility of S. suis septicaemia in a person in an at-risk occupation who presents with severe acute gastro-enteritis. (I thank Dr H. Pullen, Consultant Physician in Infectious Diseases, Seacroft Hospital, Leeds, for permission to report this case.)

D. Maher

Department of Infectious Diseases, Seacroft Hospital, York Road, Leeds L S I 4 6UH, U.K.

References I. Dickie AS, Bremner DA, Wong PY, Worth JD, Robertson ID. Streptococcus suis bacteraemia. N Z Med J I987; IOO (835) : 677-678. 2. Zanen HC, Engel HWB. Porcine streptococci causing meningitis and septicaemia in man. Lancet I975; i: I286-I288. 3. Twort CHC. Group R streptococcal meningitis (Streptococcus suis type II): a new industrial disease? Br Med J x98I ; 28z: 523-524 . 4. Duma RJ, Weinberg AN, Medrek TF, Kunz LJ. Streptococcal infections. A bacteriologic and clinical study of streptococcal bacteraemia. Medicine I969 ; 48 (2): 87-I27. 5. Oo KT, Chan J. The epidemic of group-R streptococcal (Streptococcus suis) meningitis and septicaemia in Hong Kong. J Hong Kong Med Assoc I985; 37:I34-I36.

Ciprofloxacin and C l o s t r i d i u m difficile-associated diarrhoea Accepted for publication I4 November I99o Sir, Having read with interest the paper by Hillman et al., 1 on ciprofloxacin and Clostridium difficile-associated diarrhoea, we wish to make the following comments. T h e first concerns the statement that the most sensitive method for establishing the presence of C. difficile is by detecting cytotoxin in a cell culture assay. In our experience, detection of cytotoxin has never been more sensitive than culture of the organism for establishing the presence of C. difficile. 2 T h e inability of Hillman et al., 1 to isolate C. difficile from faecal specimens, despite the presence of cytotoxin, most probably relates to the concentration of antibiotics in their selective medium. Use of the Oxoid C. difficile supplement in the r e c o m m e n d e d manner results in final

Streptococcus suis septicaemia presenting as severe acute gastro-enteritis.

Letters to the Editor 303 the second course of antibiotics and have remained well. T h e duration of follow-up ranged from 8-24 months. Possible exp...
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