238
Letters to the Editor
on 2I S e p t e m b e r x99I administration of imipenem ceased. By 23 N o v e m b e r I 9 9 I , the child was well and weighed 2-I6 kg. Overall, the child received 20 platelet transfusions and 29 blood transfusions to a total of 462 ml. M i x e d hyperbilirubinaemia (50 % direct) developed with elevated blood concentrations of liver enzymes which then fell slowly (Table I). T h e blood urea concentration was raised during the acute illness but that of creatinine remained normal throughout. Hepatitis B and C as well as ' T O R C H ' serological tests were all negative. T h e M I C s of amikacin, aztreonam, ciprofloxacin and i m i p e n e m in relation to the strain of Klebsiella sp. were I6, > 32, o'I25 and 0"5 rag/1 respectively. Ciprofloxacin did not appear as effective as imipenem. T h e latter may have contributed to the hepatitis but there were other possible causes including those arising from multiple transfusions. We conclude that the persistence of Klebsiella infection was catheterassociated and that administration of i m i p e n e m through the central venous line eliminated the organism f r o m the catheter.
Department of Medical Microbiology, Faculty of Medicine and Health Sciences, UAE University, P.O. Box I7666, Al-Ain, UAE
C. Stewart Goodwin Herbert Nsanze Bryan W. Worsley
Special Care Baby Unit, Tawam Hospital, P.O. Box x5z58, Al-Ain, UAE
Elizabeth Varady Janet Topley References
Begue PC, Baron S, Challier JS, Fontaine JL, Lasfargues G. Pharmacokinetic and clinical evaluation of impinem/cilastatin in children and neonates. Stand J Infect Dis I987; 52 (suppl) : 40-45 . A fatal case of pneumococcal
cellulitis
Accepted for publication I7 February I992 Sir,
Streptococcus pneumoniae is a rare cause of adult cellulitis. T h e r e are only nine previously reported cases, which have been summarised by Peters et al. 1 We wish to record an additional fatal case, in which the autopsy findings suggest that the cellulitis was the p r i m a r y event and was followed by septicaemia. A 73-year-old female presented with a 4 day history of stiffness of the left shoulder, and oedema of the arm. She had previously been well, but had a past history of tuberculosis and left thoracotomy and lobectomy in I963. On admission the patient was apyrexial, with oedema of the left a r m and axillary tenderness, but no evidence of skin abrasion. T h e W B C count was 2"0 x io9/1. T h e r e was mild renal impairment, with serum urea of I9"9 mmol/1 and creatinine of I75 #mol/1. I n view of the clinical findings, a preliminary diagnosis of axillary vein thrombosis was made and the patient anticoagulated. T w o days later there was an acute episode of dyspnoea and shock, and resuscitation attempts were unsuccessful. N e c r o p s y revealed an oedematous left a r m with bluish discoloration. Several bullae were present on the inner arm near to the axilla, each up to 2"5 cm in diameter and containing dark b r o w n fluid. N o skin abrasion was identified, and the old thoracotomy scar was not inflamed. Dissection of the soft tissue of the u p p e r arm revealed m u c h interstitial oedema fluid and a small collection of pus deep in the axilla. T h e r e was no
Letters to the Editor
239
evidence of venous thrombosis. T h e lungs were moderately oedematous with basal congestion, but p n e u m o n i a was not present. T h e liver appeared fibrotic and nodular; microscopically this proved to be nodular regenerative hyperplasia. T h e spleen was enlarged (weight 380 g) and was soft. T h e left kidney showed hydronephrosis with evidence of previous pyelonephritis. T h e left ureter appeared normal, indicating that previous obstruction had occurred at the left pelvi-ureteric junction. T h e r e were no other significant post mortem findings. Culture of fluid from skin bullae and of splenic tissue yielded a heavy p u r e growth of S. pneumoniae, sensitive to penicillin and erythromycin. Culture of the axillary pus was negative. O u r case is the third recorded example of fatal pneumococcal cellulitis. Previously described fatalities were in the U.S.A. ; one was a young male drug addict 2 and the other an elderly female with macroglobulinaemiafl We have good evidence based on the autopsy findings, that in our case the septicaemia was secondary to a p r i m a r y cellulitis, as no internal source of infection was identified and only one area of skin and soft tissue was affected. T h i s is in contrast to the most recent previously reported case in which the cellulitis was multifocal in a patient who had active rheumatoid arthritis. In that instance the skin manifestation was p r e s u m e d to be secondary to pneumococcaemia. 1 O u r case also highlights the diagnostic difficulties which m a y arise, as the bullae only became p r o n o u n c e d terminally, the patient was apyrexial, and the W B C count was not raised. Consequently no antibiotic therapy was administered. Six of the nine previous patients had underlying disease which m a y have c o m p r o m i s e d i m m u n e function. However, in our case none of the pathological findings was considered likely to predispose to the development of the pneumococcal cellulitis, which seems to have arisen de novo. (We wish to thank Dr N. A. Irvine for permission to report this case.)
* Department of Histopathology and t Public Health Laboratory, The lpswich Hospital, Heath Road, Ipswich, Suffolk IP4 5PD, U.K.
A. J. Molyneux* P. A. Judd* P. H. Jonest
References I. Peters NS, Eykyn SJ, Rudd AG. Pneumococcal cellulitis: a rare manifestation of pneumococcaemia in adults, ff Infect I989; I9: 57-59. 2. Lewis RJ, Richmond AS, McGrory JP. Cellulitis in drug addicts, ffAMA 1975; 232: 54-55. 3. Milstein P, Gleckman R. Pneumococcal erysipelas. Am J Med 1975 ; 59:293-296.
Letters to the Editor
on 2I S e p t e m b e r x99I administration of imipenem ceased. By 23 N o v e m b e r I 9 9 I , the child was well and weighed 2-I6 kg. Overall, the child received 20 platelet transfusions and 29 blood transfusions to a total of 462 ml. M i x e d hyperbilirubinaemia (50 % direct) developed with elevated blood concentrations of liver enzymes which then fell slowly (Table I). T h e blood urea concentration was raised during the acute illness but that of creatinine remained normal throughout. Hepatitis B and C as well as ' T O R C H ' serological tests were all negative. T h e M I C s of amikacin, aztreonam, ciprofloxacin and i m i p e n e m in relation to the strain of Klebsiella sp. were I6, > 32, o'I25 and 0"5 rag/1 respectively. Ciprofloxacin did not appear as effective as imipenem. T h e latter may have contributed to the hepatitis but there were other possible causes including those arising from multiple transfusions. We conclude that the persistence of Klebsiella infection was catheterassociated and that administration of i m i p e n e m through the central venous line eliminated the organism f r o m the catheter.
Department of Medical Microbiology, Faculty of Medicine and Health Sciences, UAE University, P.O. Box I7666, Al-Ain, UAE
C. Stewart Goodwin Herbert Nsanze Bryan W. Worsley
Special Care Baby Unit, Tawam Hospital, P.O. Box x5z58, Al-Ain, UAE
Elizabeth Varady Janet Topley References
Begue PC, Baron S, Challier JS, Fontaine JL, Lasfargues G. Pharmacokinetic and clinical evaluation of impinem/cilastatin in children and neonates. Stand J Infect Dis I987; 52 (suppl) : 40-45 . A fatal case of pneumococcal
cellulitis
Accepted for publication I7 February I992 Sir,
Streptococcus pneumoniae is a rare cause of adult cellulitis. T h e r e are only nine previously reported cases, which have been summarised by Peters et al. 1 We wish to record an additional fatal case, in which the autopsy findings suggest that the cellulitis was the p r i m a r y event and was followed by septicaemia. A 73-year-old female presented with a 4 day history of stiffness of the left shoulder, and oedema of the arm. She had previously been well, but had a past history of tuberculosis and left thoracotomy and lobectomy in I963. On admission the patient was apyrexial, with oedema of the left a r m and axillary tenderness, but no evidence of skin abrasion. T h e W B C count was 2"0 x io9/1. T h e r e was mild renal impairment, with serum urea of I9"9 mmol/1 and creatinine of I75 #mol/1. I n view of the clinical findings, a preliminary diagnosis of axillary vein thrombosis was made and the patient anticoagulated. T w o days later there was an acute episode of dyspnoea and shock, and resuscitation attempts were unsuccessful. N e c r o p s y revealed an oedematous left a r m with bluish discoloration. Several bullae were present on the inner arm near to the axilla, each up to 2"5 cm in diameter and containing dark b r o w n fluid. N o skin abrasion was identified, and the old thoracotomy scar was not inflamed. Dissection of the soft tissue of the u p p e r arm revealed m u c h interstitial oedema fluid and a small collection of pus deep in the axilla. T h e r e was no
Letters to the Editor
239
evidence of venous thrombosis. T h e lungs were moderately oedematous with basal congestion, but p n e u m o n i a was not present. T h e liver appeared fibrotic and nodular; microscopically this proved to be nodular regenerative hyperplasia. T h e spleen was enlarged (weight 380 g) and was soft. T h e left kidney showed hydronephrosis with evidence of previous pyelonephritis. T h e left ureter appeared normal, indicating that previous obstruction had occurred at the left pelvi-ureteric junction. T h e r e were no other significant post mortem findings. Culture of fluid from skin bullae and of splenic tissue yielded a heavy p u r e growth of S. pneumoniae, sensitive to penicillin and erythromycin. Culture of the axillary pus was negative. O u r case is the third recorded example of fatal pneumococcal cellulitis. Previously described fatalities were in the U.S.A. ; one was a young male drug addict 2 and the other an elderly female with macroglobulinaemiafl We have good evidence based on the autopsy findings, that in our case the septicaemia was secondary to a p r i m a r y cellulitis, as no internal source of infection was identified and only one area of skin and soft tissue was affected. T h i s is in contrast to the most recent previously reported case in which the cellulitis was multifocal in a patient who had active rheumatoid arthritis. In that instance the skin manifestation was p r e s u m e d to be secondary to pneumococcaemia. 1 O u r case also highlights the diagnostic difficulties which m a y arise, as the bullae only became p r o n o u n c e d terminally, the patient was apyrexial, and the W B C count was not raised. Consequently no antibiotic therapy was administered. Six of the nine previous patients had underlying disease which m a y have c o m p r o m i s e d i m m u n e function. However, in our case none of the pathological findings was considered likely to predispose to the development of the pneumococcal cellulitis, which seems to have arisen de novo. (We wish to thank Dr N. A. Irvine for permission to report this case.)
* Department of Histopathology and t Public Health Laboratory, The lpswich Hospital, Heath Road, Ipswich, Suffolk IP4 5PD, U.K.
A. J. Molyneux* P. A. Judd* P. H. Jonest
References I. Peters NS, Eykyn SJ, Rudd AG. Pneumococcal cellulitis: a rare manifestation of pneumococcaemia in adults, ff Infect I989; I9: 57-59. 2. Lewis RJ, Richmond AS, McGrory JP. Cellulitis in drug addicts, ffAMA 1975; 232: 54-55. 3. Milstein P, Gleckman R. Pneumococcal erysipelas. Am J Med 1975 ; 59:293-296.
