Chlamydia pneumoniae Pneumonia with Pleural Effusion: Diagnosis by Culture MICHAELH. AUGENBRAUN,M.D., PATRICIAM. ROBLIN, M.s., LAURAJ. MANDEL,M.D., MARGARETR.HAMMERSCHLAG,M.D., Brooklyn, New York, JULIUSSCHACHTER,Ph.D., San Francisco, California
A case of Chkmydk pneumoniae pneumonia with pleural effusion in an otherwise healthy 19year-old man is described. Diagnosis was made by serologic means as well as by culture of both the nasopharynx and the pleural fluid. hlamydia pneumoniae has recently been desC ignated a species distinct from Chlamydia trachomatis and Chlamydia psittaci [l]. A number of studies have attributed various forms of respiratory tract disease to this pathogen, ranging from pharyngitis to pneumonia. The pneumonia is usually characterized by a mild to moderate interstitial process in otherwise normal adults. Most of these diagnoses have been based on serologic evidence of infection [2,3]. Few reports have appeared delineating clinical syndromes associated with this organism in which culture techniques have been used . Our laboratory has been studying the prevalence of this organism in our community . We report a case of community-acquired pneumonia caused by C. pneumoniae, characterized by a complicated and severe course, and documented by culture of the organism from the nasopharynx and pleural fluid as well as by concomitant serologic studies.
CASE REPORT A Is-year-old male college student presented to the hospital with a 2-week history of malaise, temperature to 37.8OC, severe right-sided pleuritic chest pain, nonproductive cough, sore throat, anorexia, and weight loss. His previous health had been excellent. Ten days before admission, his private physician prescribed oral cephalexin 500 mg, 4 times a day, which the patient took for 7 days without improvement. The right-sided pleuritic chest pain worsened, and the patient began to notice some shortness of breath. He was given erythromytin, which he discontinued after 3 doses due to gastrointestinal discomfort. The patient denied recent From the Division of Infectious Diseases, Departments of Medicine and Pediatrics, State University of New York Health Science Center at Brooklyn (MHA, PMR. LJM. MRH), Brooklyn, New York, and the Department of Laboratory Medicine, University of California, San Francisco (JS), San Francisco, California. Requests for reprints should be addressed to Michael H. Augenbraun, M.D.. Box 56, SUNY Health Science Center at Brooklyn, 450 Clarkson Avenue, Brooklyn, New York 11203. Manuscript submitted October 4, 1990, and accepted in revised form February 19. 1991.
travel. He owned no pets. There was no history of illegal drug use or of homosexual activity. He recalled no recent exposure to other individuals with respiratory tract symptoms. Due to his worsening symptoms, the patient was admitted to the hospital. On admission, his temperature was 339°C. The pulse was 120 beats/minute, blood pressure 130/82 mm Hg, and respiratory rate 24/minute. The pharynx was dry and erythematous. There were inspiratory wheezes and decreased breath sounds over the right, middle, and lower lung fields with egophony and dullness to percussion. There was also splinting. Mild tenderness to deep palpation was elicited in the right upper abdominal quadrant. Liver span was normal. There was no tenderness, guarding, or rebound. The white blood count was 14,700/mm3 with 83% segmented polymorphonuclear leukocytes and 0% band forms. Chest radiograph revealed right middle lobe consolidation with a patchy infiltrate in the right lower lobe. All routine chemistry results were normal except for a lactate dehydrogenase value of 487 U/L. Gram stain of sputum was nondiagnostic. Arterial blood gas study demonstrated an oxygen pressure of 64 mm Hg. Intravenous erythromycin, 1 g every 6 hours, was started. The patient’s temperature remained elevated, and a chest radiograph done 1*/z days later revealed a right pleural effusion (Figure 1). Thoracentesis was performed. Approximately 700 mL of free-flowing, straw-colored pleural fluid was removed with prompt symptomatic improvement. Laboratory analysis of the fluid revealed a red blood count of 50,000/mm3 and a white blood count of 27,500/mm3 with 75% polymorphonuclear leukocytes and 10% lymphocytes. Protein was 0.048 g/L, glucose 4.39 mmol/L, and pH 7.49. Gram stain, acid-fast stain, and routine bacterial cultures were negative. The patient continued to improve clinically. After 10 days, oral erythromycin was substituted, and the patient was discharged. He was subsequently lost to follow-up.
METHODS On admission, 2 nasopharyngeal swabs were obtained from the patient. Each swab was applied to a glass slide that was fixed with methanol and then stained with a Chlamydia genus-specific fluoresceintagged monoclonal antibody (Pathfinder Chlamydia October
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demonstratedC.pneumoniae-specific IgG and IgM antibody titers at 1:128and 1:16,respectively,in a serumsampleobtainedon the third day of hospitalization (approximately 18 days after symptom onset). Sera sent for Mycoplasma pneumoniae and Legionella pneumophila antibodieswerenegative. COMMENTS C. pneumoniae appearsto be responsiblemost commonly for a syndrome of mild to moderately severe pneumonia frequently accompanied by pharyngitis in otherwise healthy young adults. Graystonet al  cultured C. pneumoniae from the nasopharynxof 8 of 13 collegestudentswith pneumonia, bronchitis, and pharyngitis who had serologic evidenceof C. pneumoniae infection. All were seenat a student health center and none required hospitalization. In 1987,Marrie et al  reported serologicevidenceof C. pneumoniae infection in 18 of 301 (6%)casesof community-acquired pneumonia. These patients wereolder than had previously been seen and frequently had other underlying medical problems.All werehospitalized.Pleural effusions were describedin some of these patients, althoughculturesfor C. pneumoniae werenot done. Similarly, a retrospectivestudy of serafrom hospitalized patients in Seattle with pneumoniademonstrated that 10%had evidenceof C. pneumoniae Flgure 1. Chest radiograph of patient from second day of infection [S]. Pleural effusionswere noted but not hospitalization demonstrating moderate right-sided pleural cultured for this organism. effusion. The detection of C. pneumoniae by culture in both the pleural fluid and the nasopharynxof this CultureConfirmation System,KallestadDiagnostics, patient, alongwith the presenceof IgM antibodies, Chaska,Minn). Slides werethen examinedfor chla- strongly suggestsC. pneumoniae as the causative mydial elementarybodiesby fluorescentmicroscopy. agent of his respiratory illness. To our knowledge, Specimensof pleural fluid and nasopharyngeal this is the first casein which C, pneumoniae has swabs,the latter placedin sucrose-phosphate trans- beenisolatedfrom the pleural fluid. The finding of port media, wereinoculatedonto HeLa 229cell cul- this organism in an otherwise closed and sterile tureapretreatedwith DEAE-dextran.Thesewerecen- spacewould be highly unusualin any setting other trifuged at 1,7OOg, overlaidwith medium containing than C. pneumoniae pneumonia.The full spectrum 1.0cLg/mLof cycloheximide,andincubatedat 36OCfor of clinical illness due to C. pneumoniae, as well as 72 hours. The cultures were then confirmed as C. the prevalenceof asymptomaticinfection of the respneumoniae by dining with a C, pneumoniae-spepiratory tract, remains to be more clearly defined. c%c fluoreacein-tagged monoclonalantibody (WashingtonResearchFoundation,Seattle,Wash).Serologic studies were performed with the use of the REFERENCES Grayston J, Kuo C. Campbell L. Wang S. Chlamydia pneumoniae sp. nav. for microimmunofluorescence test with IgG andIgM con- 1.Chlamydia strain TWAR. Int J Syst Bact 1989; 39: 88-90. jugates.Antigensusedincludedelementarybodiesof 2. Marrie T, sp.Grayston J, Wang S, Kuo C. Pneumonia associated with the TWAR 15C. trachomatis serovars and the TW-163strain of strain. Ann Intern Med 1987; 106: 507-11. C. pneumoniae.
RESULTS The direct fluorescentantibodystainsof the nasopharyngealsmearswerepositive for chlamydial elementary bodies. Subsequentcultures of the nasopharyngealspecimens,aswell asthoseof the pleural fluid, contained C. pneumoniae. Serologicstudies 438
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3. Saikku P, Wang S. Kleemola M. Brander E, Rusanen E, Grayston J. An epidemic of mild pneumonia due to an unusual strain of Chlamydia psittaci. J Infect Dis 1985; 151: 832-9. 4. Grayston J, Kuo C, Wang S. Altman J. A new chlamydia strain TWAR, isolated in acute respiratory tract infections. N Engl J Med 1986; 315: 161-8. 5. Chirgwin K. Roblin P. Gelling M, Hammerschlag M, Schachter J. Infection with Chlamydia pneumoniae (TWAR) in Brooklyn. J Infect Dis 1991; 163: 757-61. 6. Grayston J, Diwan V, Cooney M, Wang S. Community and hospital-acquired pneumonia associated with Chlamydia TWAR infection demonstrated serologicaky. Arch Intern Med 1989; 149: 169-73.