Letters to the Editor
205
method. 2 T h e m i n i m u m inhibitory concentration obtained for fluconazole was 5o mg/1 and those for ketoconazole and itraconazole were less than I mg/1. Fluconazole resistance has been described in disseminated C. glabrata infection and in ketoconazole-resistant C. albicans species isolated from patients with chronic mucocutaneous candidosis. 3,4 I n view of the continuing improvement in life expectancy of patients with A I D S , may we expect the emergence of resistant strains of C. albicans in patients on long term antifungal prophylaxis ? We feel that clinicians should be aware that a C. albicans resistant to fluconazole but sensitive to ketoconazole has now been isolated from a patient with A I D S. (We would like to thank Pfizer Central Research for their assistance.)
* Department of GU Medicine, St Mary's Hospital af Department of Mycology, St Mary's Hospital Medical School London W2 I N Y , U.K.
V . S . Kitchen* M. Savaget J. R. W. Harris*
References
i. Mau S, Salamone FR, Muller RJ, Polsky BW. Trimetrexate, gancyclovir, foscarnet and fluconazole-investigational drugs used in the management of AIDS. Hosp Pharm I989; 24 : 209-215. 2. Odds FC, Abbott AB, Pye G, Troke PF. Improved method for the estimation of antifungal inhibitory concentrations against Candida sp. based on azole/antibiotic interactions. J Med Vet Mycol I986; 24: 3o5-3II. 3. Warnock DW, Burke J, Cope NJ, Johnson EM, von Fraunhofer NA, Williams EW. Fluconazole resistance in Candida glabrata. Lancet I988; ii: I3IO. 4. Smith KJ, Warnock DW, Kennedy CTC, Johnson EM. Azole resistance in Candida albicans. J Med Vet Mycol I986; 24: I33-I44.
Cerebrospinal
fluid shunt infection: an unusual case
Accepted for publication 24 July I99O Sir, Cerebrospinal fluid shunt infections are an important cause of morbidity and mortality. A mortality rate of up to 3 1 % has been reported.1 Most shunt infections are caused by coagulase-negative staphylococci, 2 with Staphylococcus aureus as the second most frequent pathogen. We wish to report an unusual case of a shunt infection with Neisseria gonorrhoeae. A I7-year-old-girl with a ventriculo-peritoneal shunt following an episode of meningitis in infancy presented with I2 h history of acute abdominal pain. On examination the area over the abdominal insertion of the shunt was tender, with an overlying cellulitis extending to mid-sternal level. T h e patient was afebrile and there were no signs of meningitis. T h e peripheral W B C count was raised (I6"I x Iog); all other tested haematological parameters were normal. A diagnosis of shunt infection was made and the shunt was removed in theatre and sent for culture. It was not t h o u g h t necessary to replace it at the time. T h e patient was started empirically on broad-spectrum antibiotic therapy consisting of intravenous penicillin, flucloxacillin, gentamicin and metronidazole, to which she responded rapidly. On the following day a heavy pure growth of N. gonorrhoeae was cultured from the abdominal end of the shunt, with a scanty growth of the same organism from the ventricular end. Because of the POssibility of polymicrobial pelvic infection, antibiotic therapy was changed to
206
Letters to the Editor
intravenous penicillin and metronidazole, with oral tetracycline to cover Chlamydia trachomatis and Myocoplasma hominis. Further questioning revealed numerous recent sexual partners. Endocervical and high vaginal swabs grew no organisms of significance, but the patient had by then received antibiotic therapy for 2 days; serological tests for syphilis were negative. T h e patient recovered fully from the infection. Gonococcal infection is a cause of morbidity among young females. Ascending infection occurs in lO-2O % of those with endocervical gonorrhoea. 3 Gonococcal meningitis is well-documented 4 and gonococcal cellulitis, although rare, has been noted affecting the o r b i t ) T o our knowledge, only one other case of gonococcal shunt infection has been reported. 6 This presented, not as a typical shunt infection, but as fetal ventriculitis after a ventriculoamniotic shunt, inserted transabdominally into a 27-week fetus in utero, became infected as a result of amnionitis following premature rupture of the membranes. It is interesting to note that in our patient infection occurred on the fourth day of the menstrual cycle, when menstrual blood may reflux through the fallopian tubes to enter the peritoneal cavity, 3 providing a portal of entry for the infecting organism. T h e authors believe that this case is unique in its presentation. It constitutes a reminder that sexually transmitted diseases are c o m m o n although they may present in an unusual manner.
Departments of Medical Microbiology and Neurosurgery, Royal Hallamshire Hospital, Sheffield SIO 2JF, U.K.
I . A . Burnett K. Denton J. Sutcliffe
References I. Waiters BC, Hoffman HJ, Hendrick EB, Humphreys RP. Cerebrospinal fluid shunt infection: influence on management and subsequent outcome. J Neurosurg 1984; 6o: ioi4-IO2I. 2. Schoenbaum SC, Gardner P, Shillito J. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations and therapy. J Infect Dis I975 ; 13I(5) : 543-552. 3. Eschenbach DA. Acute pelvic inflammatory disease: etiology risk factors and pathogenesis. Clin Obstet Gynaecol 1976; 19(1): 147-168. 4- Sayeed Z, Bhadun V, Howell E, Mayers H. Gonococcal meningitis. JAMA 1972; 219(13): 173o-1731 . 5. Frazier J, Miller J, Picketing L. Orbital cellulitis due to Neisseria gonorrhoeae in an enucleated socket. Arch Opthalmol 1979; 97: 2345. 6. Bland R, Nelson L, Meis P, Weaver R, Abramsom J. Gonococcal ventriculitis associated with ventriculoamniotic shunt placement. Am J Obstet Gynecol 1983 ; 147(7): 781-784.
Low rate of vaginal carriage of Listeria monocytogenes
Accepted for publication 24 July 199o Sir, Asymptomatic carriage of Listeria species in the h u m a n gut is common, 1 since these organisms are ubiquitous in nature 2 and, in particular, are present in various foods. Furthermore, it is c o m m o n knowledge that the female genital tract may harbour gut flora and, in some cases of neonatal listeriosis, vaginal carriage of Listeria monocytogenes has been demonstrated in the mothers. We therefore attempted to recover these organisms from high vaginal swabs taken from both pregnant and non-pregnant w o m e n of reproductive age.
205
method. 2 T h e m i n i m u m inhibitory concentration obtained for fluconazole was 5o mg/1 and those for ketoconazole and itraconazole were less than I mg/1. Fluconazole resistance has been described in disseminated C. glabrata infection and in ketoconazole-resistant C. albicans species isolated from patients with chronic mucocutaneous candidosis. 3,4 I n view of the continuing improvement in life expectancy of patients with A I D S , may we expect the emergence of resistant strains of C. albicans in patients on long term antifungal prophylaxis ? We feel that clinicians should be aware that a C. albicans resistant to fluconazole but sensitive to ketoconazole has now been isolated from a patient with A I D S. (We would like to thank Pfizer Central Research for their assistance.)
* Department of GU Medicine, St Mary's Hospital af Department of Mycology, St Mary's Hospital Medical School London W2 I N Y , U.K.
V . S . Kitchen* M. Savaget J. R. W. Harris*
References
i. Mau S, Salamone FR, Muller RJ, Polsky BW. Trimetrexate, gancyclovir, foscarnet and fluconazole-investigational drugs used in the management of AIDS. Hosp Pharm I989; 24 : 209-215. 2. Odds FC, Abbott AB, Pye G, Troke PF. Improved method for the estimation of antifungal inhibitory concentrations against Candida sp. based on azole/antibiotic interactions. J Med Vet Mycol I986; 24: 3o5-3II. 3. Warnock DW, Burke J, Cope NJ, Johnson EM, von Fraunhofer NA, Williams EW. Fluconazole resistance in Candida glabrata. Lancet I988; ii: I3IO. 4. Smith KJ, Warnock DW, Kennedy CTC, Johnson EM. Azole resistance in Candida albicans. J Med Vet Mycol I986; 24: I33-I44.
Cerebrospinal
fluid shunt infection: an unusual case
Accepted for publication 24 July I99O Sir, Cerebrospinal fluid shunt infections are an important cause of morbidity and mortality. A mortality rate of up to 3 1 % has been reported.1 Most shunt infections are caused by coagulase-negative staphylococci, 2 with Staphylococcus aureus as the second most frequent pathogen. We wish to report an unusual case of a shunt infection with Neisseria gonorrhoeae. A I7-year-old-girl with a ventriculo-peritoneal shunt following an episode of meningitis in infancy presented with I2 h history of acute abdominal pain. On examination the area over the abdominal insertion of the shunt was tender, with an overlying cellulitis extending to mid-sternal level. T h e patient was afebrile and there were no signs of meningitis. T h e peripheral W B C count was raised (I6"I x Iog); all other tested haematological parameters were normal. A diagnosis of shunt infection was made and the shunt was removed in theatre and sent for culture. It was not t h o u g h t necessary to replace it at the time. T h e patient was started empirically on broad-spectrum antibiotic therapy consisting of intravenous penicillin, flucloxacillin, gentamicin and metronidazole, to which she responded rapidly. On the following day a heavy pure growth of N. gonorrhoeae was cultured from the abdominal end of the shunt, with a scanty growth of the same organism from the ventricular end. Because of the POssibility of polymicrobial pelvic infection, antibiotic therapy was changed to
206
Letters to the Editor
intravenous penicillin and metronidazole, with oral tetracycline to cover Chlamydia trachomatis and Myocoplasma hominis. Further questioning revealed numerous recent sexual partners. Endocervical and high vaginal swabs grew no organisms of significance, but the patient had by then received antibiotic therapy for 2 days; serological tests for syphilis were negative. T h e patient recovered fully from the infection. Gonococcal infection is a cause of morbidity among young females. Ascending infection occurs in lO-2O % of those with endocervical gonorrhoea. 3 Gonococcal meningitis is well-documented 4 and gonococcal cellulitis, although rare, has been noted affecting the o r b i t ) T o our knowledge, only one other case of gonococcal shunt infection has been reported. 6 This presented, not as a typical shunt infection, but as fetal ventriculitis after a ventriculoamniotic shunt, inserted transabdominally into a 27-week fetus in utero, became infected as a result of amnionitis following premature rupture of the membranes. It is interesting to note that in our patient infection occurred on the fourth day of the menstrual cycle, when menstrual blood may reflux through the fallopian tubes to enter the peritoneal cavity, 3 providing a portal of entry for the infecting organism. T h e authors believe that this case is unique in its presentation. It constitutes a reminder that sexually transmitted diseases are c o m m o n although they may present in an unusual manner.
Departments of Medical Microbiology and Neurosurgery, Royal Hallamshire Hospital, Sheffield SIO 2JF, U.K.
I . A . Burnett K. Denton J. Sutcliffe
References I. Waiters BC, Hoffman HJ, Hendrick EB, Humphreys RP. Cerebrospinal fluid shunt infection: influence on management and subsequent outcome. J Neurosurg 1984; 6o: ioi4-IO2I. 2. Schoenbaum SC, Gardner P, Shillito J. Infections of cerebrospinal fluid shunts: epidemiology, clinical manifestations and therapy. J Infect Dis I975 ; 13I(5) : 543-552. 3. Eschenbach DA. Acute pelvic inflammatory disease: etiology risk factors and pathogenesis. Clin Obstet Gynaecol 1976; 19(1): 147-168. 4- Sayeed Z, Bhadun V, Howell E, Mayers H. Gonococcal meningitis. JAMA 1972; 219(13): 173o-1731 . 5. Frazier J, Miller J, Picketing L. Orbital cellulitis due to Neisseria gonorrhoeae in an enucleated socket. Arch Opthalmol 1979; 97: 2345. 6. Bland R, Nelson L, Meis P, Weaver R, Abramsom J. Gonococcal ventriculitis associated with ventriculoamniotic shunt placement. Am J Obstet Gynecol 1983 ; 147(7): 781-784.
Low rate of vaginal carriage of Listeria monocytogenes
Accepted for publication 24 July 199o Sir, Asymptomatic carriage of Listeria species in the h u m a n gut is common, 1 since these organisms are ubiquitous in nature 2 and, in particular, are present in various foods. Furthermore, it is c o m m o n knowledge that the female genital tract may harbour gut flora and, in some cases of neonatal listeriosis, vaginal carriage of Listeria monocytogenes has been demonstrated in the mothers. We therefore attempted to recover these organisms from high vaginal swabs taken from both pregnant and non-pregnant w o m e n of reproductive age.
