Letters to the Editor
26 5
References I. Simonsen JN, Cameron DW, Gakinya MN et al. HIV infection among men with sexually transmitted diseases. NEJM; 319 (5): 274-278. 2. Waugh MA. Chancroid and HIV. Br MedJ 1989; 298: 321. 3. Mindel A. Chancroid. Br MedJ 1989; 298: 64-65. 4- Piot P, Laga M. Genital ulcers, other sexually transmitted diseases, and the sexual transmission of HIV. Br Med J 1989; 298: 623-624.
An u n u s u a l p r e s e n t a t i o n o f s a l m o n e l l a i n f e c t i o n Accepted for publication 18 December 1989 Sir, Although salmonella bone infection is known to occur in patients with sickle cell disease it is very rare in individuals who are otherwise healthy. We describe such a case. A 55-year-old Caucasian male first presented to his doctor with anterior chest pain in 1987. At that time all investigations were negative. H e presented again in October of the same year with a swelling over the manubriosternal junction which he thought had developed during the previous 2 to 3 months. Although there was a small area of erythema and scaling of the skin, there had never been any discharge, nor was there significant pain or tenderness to suggest an acute infection. His doctor prescribed flucloxaciUin for 28 days but the condition did not improve. W h e n first seen by a Consultant Orthopaedic Surgeon in January 1988 there was a firm diffuse swelling, tender but not fluctuant, over the u p p e r part of the sternum. T h e r e was no tenderness over the spine and no pain on compression of the body of the sternum or rib cage. Review of previous X-rays suggested periosteal reaction at the manubriosternal junction with a suggestion of substernal soft tissue thickening. A further X - r a y of the sternum and chest now showed the same sort of localised reaction in the manubriosternal join region as before. T h e r e was no increase in the shadowing within the chest substernally and no expansion or destruction of the sternum or m a n u b r i u m . H e was advised to continue with flucloxacillin. H e was seen again z weeks later because he felt ill and the swelling was more inflamed. On examination there was a large area of inflammation with a suggestion of fluctuation. A minute amount of pus was aspirated which was sent for microscopy, culture, including AFB, and antibiotic susceptibility tests. Salmonella brandenburg sensitive to amoxycillin, co-trimoxazole, chloramphenicol and ciprofloxacin was isolated. T h e patient was treated with amoxycillin 5o0 mg t.d.s, for 3 weeks after which, on examination, there was less swelling, erythema and tenderness. T h e dose was reduced to 25o m g t.d.s, for a further 6 weeks, at the end of which time he had completely recovered. Although the patient did not give any history of diarrhoea or of travel abroad, it is possible that he carried this salmonella in his gut before haematogenous spread occurred. A stool culture sent after salmonella had been isolated from the abscess was however negative. Salmonella bone infection in patients with sickle cell disease is well known. 1 M o r e o v e r Salmonella paratyphi A has been isolated from bone m a r r o w alone when the organisms were sequestrated there following inappropriate antibiotic therapy in a patient returning f r o m abroad with pyrexia of unknown originfl Infection of the
Letters to the Editor
266
surgical site with non typhoidal salmonella following total hip replacement, though rare, has also been well documented. 3 However, our case was unusual because there was no history of any predisposing factors. Therefore the portal of entry of this microorganism, its dissemination and sequestration remain speculative though presumably the focus of infection was the gut from which there was haematogenous spread. (We thank Mrs M. White for her typing.)
B. Chattopadhyay J. D. Jeremiah G. Sadler
Roding Hospital, Roding Lane South, Ilford, Essex IG4 5PZ, U.K. References
i. Barrett-Connor E. Bacterial infection and sickle cell anaemia: analysis of 25o infections in I66 patients and a review of the literature. Medicine I971 ; 5o: 97-I I2. 2. Knowles GK, Murphy MFG. Paratyphoid A fever diagnosed from bone marrow culture after indiscriminate antibiotic treatment. BMJ I979; I" 384. 3. Samra Y, Shaked Y, Maier MK. Non typhoid salmonellosis in patients with total hip replacement: report of four cases and review of the literature. Rev Infect Dis I986; 8" 978-983.
Acute a c t i n o m y c o t i c osteomyelitis o f the skull with subdural e m p y e m a
Accepted for publication 19 December I989 Sir, We read with interest your recent editorial and correspondence on actinomycosis. 1'2 We would like to report an atypical case of actinomycotic osteomyelitis of the skull with subdural empyema. T h i s in itself is extremely rare. However, this case also demonstrates that this infection may present in an acute fashion without any apparent p r i m a r y focus. A 48-year-old coal-face worker was admitted with a 7 day history of frontal headache and malaise. On the day of admission he was noted by his work-mates to be drowsy and disorientated. H e had had middle ear disease as a child but not since. On examination he was drowsy and pyrexial (38"5 °C) with a tachycardia of i o o / m i n . H e was restless and had some neck stiffness, could obey commands but was unable to speak. T h e r e were no other focal neurological signs. His teeth were neglected but there was no evidence of cervicofacial infection. Investigation revealed a peripheral W B C of z I x IO9/1. C S F contained I35 x io ~ white cells/1 (all lymphocytes), with a glucose of 3"6 mmol/1 (blood glucose 5"7 mmol/1) and protein of o'3 g/1. Skull X - r a y d e m o n strated partial obliteration of the right frontal sinus and erosion of the skull vault in the right frontal region. A C T scan showed in addition a subdural fluid collection, most marked in the right sub-frontal region. T h e patient was taken to theatre where burr holes revealed grossly diseased bone, which was removed, and subdural pus, which was drained. Microscopy of the pus demonstrated Gram-positive branching bacilli. Actinomyces viscosus and Fusobacterium nucleatum were cultured. Antimicrobial therapy was with benzylpenicillin, chloramphenicol and metronidazole initially, followed by benzylpenicillin alone. An E N T surgeon examined the patient and explored the frontal and ethmoidal sinuses at surgery, but no focus of infection was found. T h e patient made an uneventful recovery. Actinomycotic osteomyelitis of the skull with C N S involvement is extremely rare
26 5
References I. Simonsen JN, Cameron DW, Gakinya MN et al. HIV infection among men with sexually transmitted diseases. NEJM; 319 (5): 274-278. 2. Waugh MA. Chancroid and HIV. Br MedJ 1989; 298: 321. 3. Mindel A. Chancroid. Br MedJ 1989; 298: 64-65. 4- Piot P, Laga M. Genital ulcers, other sexually transmitted diseases, and the sexual transmission of HIV. Br Med J 1989; 298: 623-624.
An u n u s u a l p r e s e n t a t i o n o f s a l m o n e l l a i n f e c t i o n Accepted for publication 18 December 1989 Sir, Although salmonella bone infection is known to occur in patients with sickle cell disease it is very rare in individuals who are otherwise healthy. We describe such a case. A 55-year-old Caucasian male first presented to his doctor with anterior chest pain in 1987. At that time all investigations were negative. H e presented again in October of the same year with a swelling over the manubriosternal junction which he thought had developed during the previous 2 to 3 months. Although there was a small area of erythema and scaling of the skin, there had never been any discharge, nor was there significant pain or tenderness to suggest an acute infection. His doctor prescribed flucloxaciUin for 28 days but the condition did not improve. W h e n first seen by a Consultant Orthopaedic Surgeon in January 1988 there was a firm diffuse swelling, tender but not fluctuant, over the u p p e r part of the sternum. T h e r e was no tenderness over the spine and no pain on compression of the body of the sternum or rib cage. Review of previous X-rays suggested periosteal reaction at the manubriosternal junction with a suggestion of substernal soft tissue thickening. A further X - r a y of the sternum and chest now showed the same sort of localised reaction in the manubriosternal join region as before. T h e r e was no increase in the shadowing within the chest substernally and no expansion or destruction of the sternum or m a n u b r i u m . H e was advised to continue with flucloxacillin. H e was seen again z weeks later because he felt ill and the swelling was more inflamed. On examination there was a large area of inflammation with a suggestion of fluctuation. A minute amount of pus was aspirated which was sent for microscopy, culture, including AFB, and antibiotic susceptibility tests. Salmonella brandenburg sensitive to amoxycillin, co-trimoxazole, chloramphenicol and ciprofloxacin was isolated. T h e patient was treated with amoxycillin 5o0 mg t.d.s, for 3 weeks after which, on examination, there was less swelling, erythema and tenderness. T h e dose was reduced to 25o m g t.d.s, for a further 6 weeks, at the end of which time he had completely recovered. Although the patient did not give any history of diarrhoea or of travel abroad, it is possible that he carried this salmonella in his gut before haematogenous spread occurred. A stool culture sent after salmonella had been isolated from the abscess was however negative. Salmonella bone infection in patients with sickle cell disease is well known. 1 M o r e o v e r Salmonella paratyphi A has been isolated from bone m a r r o w alone when the organisms were sequestrated there following inappropriate antibiotic therapy in a patient returning f r o m abroad with pyrexia of unknown originfl Infection of the
Letters to the Editor
266
surgical site with non typhoidal salmonella following total hip replacement, though rare, has also been well documented. 3 However, our case was unusual because there was no history of any predisposing factors. Therefore the portal of entry of this microorganism, its dissemination and sequestration remain speculative though presumably the focus of infection was the gut from which there was haematogenous spread. (We thank Mrs M. White for her typing.)
B. Chattopadhyay J. D. Jeremiah G. Sadler
Roding Hospital, Roding Lane South, Ilford, Essex IG4 5PZ, U.K. References
i. Barrett-Connor E. Bacterial infection and sickle cell anaemia: analysis of 25o infections in I66 patients and a review of the literature. Medicine I971 ; 5o: 97-I I2. 2. Knowles GK, Murphy MFG. Paratyphoid A fever diagnosed from bone marrow culture after indiscriminate antibiotic treatment. BMJ I979; I" 384. 3. Samra Y, Shaked Y, Maier MK. Non typhoid salmonellosis in patients with total hip replacement: report of four cases and review of the literature. Rev Infect Dis I986; 8" 978-983.
Acute a c t i n o m y c o t i c osteomyelitis o f the skull with subdural e m p y e m a
Accepted for publication 19 December I989 Sir, We read with interest your recent editorial and correspondence on actinomycosis. 1'2 We would like to report an atypical case of actinomycotic osteomyelitis of the skull with subdural empyema. T h i s in itself is extremely rare. However, this case also demonstrates that this infection may present in an acute fashion without any apparent p r i m a r y focus. A 48-year-old coal-face worker was admitted with a 7 day history of frontal headache and malaise. On the day of admission he was noted by his work-mates to be drowsy and disorientated. H e had had middle ear disease as a child but not since. On examination he was drowsy and pyrexial (38"5 °C) with a tachycardia of i o o / m i n . H e was restless and had some neck stiffness, could obey commands but was unable to speak. T h e r e were no other focal neurological signs. His teeth were neglected but there was no evidence of cervicofacial infection. Investigation revealed a peripheral W B C of z I x IO9/1. C S F contained I35 x io ~ white cells/1 (all lymphocytes), with a glucose of 3"6 mmol/1 (blood glucose 5"7 mmol/1) and protein of o'3 g/1. Skull X - r a y d e m o n strated partial obliteration of the right frontal sinus and erosion of the skull vault in the right frontal region. A C T scan showed in addition a subdural fluid collection, most marked in the right sub-frontal region. T h e patient was taken to theatre where burr holes revealed grossly diseased bone, which was removed, and subdural pus, which was drained. Microscopy of the pus demonstrated Gram-positive branching bacilli. Actinomyces viscosus and Fusobacterium nucleatum were cultured. Antimicrobial therapy was with benzylpenicillin, chloramphenicol and metronidazole initially, followed by benzylpenicillin alone. An E N T surgeon examined the patient and explored the frontal and ethmoidal sinuses at surgery, but no focus of infection was found. T h e patient made an uneventful recovery. Actinomycotic osteomyelitis of the skull with C N S involvement is extremely rare
