Letters to the Editor
319
deficiency m a y have allowed a usually innocent microbe to cause clinically significant illness. F u r t h e r studies are required to examine the pathogenic potential of this c o m m o n organism. W e consider that when there is protracted diarrhoea in immunodeficient patients in w h o m no other pathogen is found a therapeutic trial of metronidazole should be considered.
* Department of Tropical Medicine and Infection, t Department of Histopathology, Ruchill Hospital, Bilsland Drive, Glasgow G2o 9NB, U.K. References
Dilip Nathwani* P. H. M. MeWhinney* S. T. Green* J. D. B o y d t
I. McMillan A, Lee FD. Sigmoidoscopic and microscopic appearance of the rectal mucosa in homosexual men. Gut ~98I ; zz : Io35-ro4I. 2. Nielsen RH, Orholm N, Pedersen JO, Hovind-Hougen K, Teglbjaerg PS, Thaysen EH. Colorectal spirochaetosis : clinical significance of the infestation. Gastroenterology I985; 85 : 62-67.
Endocarditis caused by Veillonella d i s p a r Accepted for publication 3o April I99o Sir, Anaerobic bacteria are an u n c o m m o n cause of endocarditis. We wish to report a case of endocarditis caused by Veillonella dispar. T h e r e appear to be only two previous reports of endocarditis caused by Veillonellae. 1' ~ A 57-year-old with rheumatic heart disease was admitted to hospital with a 3 weeks' history of lethargy and anorexia. A Bjork-Shiley mitral valve replacement had been p e r f o r m e d 7 years previously. T h r e e weeks before admission, a gingival abscess had been treated by the family doctor with ampicillin. On examination, the patient was febrile (38 °C), had splinter haemorrhages, a grade 4 / 6 pansystolic apical m u r m u r and a grade 2/6 early diastolic m u r m u r at the left sternal edge. She was haemodynamically stable and there were no other signs of endocarditis. An echocardiogram indicated a m i n o r degree of aortic incompetence and a vegetation which was clearly seen on the mitral valve. Initial laboratory investigations revealed a mild n o r m o c h r o m i c normocytic anaemia with 2 % reticulocytes, a haemoglobin concentration of to'9 g / d l and a W B C count of I I'5 × Io9/1. T h e concentration of C-reactive protein was 6I mg/1. Red cells were not seen in the urine. A Veillonella species was isolated from six of seven sets of blood cultures taken over a period of 3 days. T h e identity of the organism was confirmed as V. dispar by the Public Health L a b o r a t o r y Service Anaerobe Reference U n i t at Luton. T h e organism was first isolated from the patient 48 h after her admission to hospital. T r e a t m e n t began with intravenous ampicillin z g 4 hourly and oral metronidazole 4oo m g three times daily. She initially responded and became afebrile while the concentration of C-reactive protein fell to 21 mg/1. T w o weeks after treatment started, however, the patient developed acute p u l m o n a r y oedema and fever. T h e previously noted diastolic m u r m u r was m o r e p r o n o u n c e d and a further echocardiogram appeared to reveal severe aortic incompetence but with good left ventricular function. T h e appearance of the mitral prosthesis suggested that it was tilted and this may have interfered with assessment of function of the aortic valve. Because of recurrent fever and a rising W B C count (I6"9 x IO9/1) oral clindamycin 450 mg, three times daily, was substituted for the previous regimen. Despite vigorous medical treatment, the cardiac
Letters to the Editor
320
failure did not respond and surgical intervention was deemed necessary. At operation, considerable dehiscence of the suture line of the mitral valve was noted and vegetations were present on the valve. T h e aortic valve, however, showed no evidence of vegetations and was not felt to be more than slightly incompetent. Both valves were replaced with St Judes prostheses. Veillonella dispar was not isolated from the excised valves despite prolonged incubation. Post-operatively the patient made an excellent recovery. Veillonella spp. are constituents of the normal flora of the oropharynx, gastrointestinal tract and vagina. T h e organisms are small anaerobic Gram-negative cocci which are seen in pairs, short chains and irregular masses. T h e y are relatively inert biochemically. 3 Most strains isolated from h u m a n beings are V. parvula, V. atypica or V. dispar and have in the past been regarded as being of low pathogenicity. T h e y have, however, been isolated in pure culture from patients with bacterial endocarditis, 1'2 sinusitis 4 and osteomyelitis. 5 In addition, Veillonella spp. have been reported in cases of pleuropulmonary infection, 6 pelvic abscess 7 and epididymo-orchitis. 8 T h e organisms have also been implicated in the pathogenesis of periodontal disease and in the case of our patient the antecedent history of gingival abscess would suggest that this was the likely source. 9 In vitro studies suggest that Veillonella spp. are susceptible to a wide range of commonly used antibiotics including penicillin, cephalosporins, clindamycin and metronidazole, l°'n Limited clinical experience suggests benzyl penicillin to be the drug of choice in most situations. T h e failure of ampicillin and metronidazole in our patient would therefore appear to be unusual. It is notable that in one of the two previously cited cases of endocarditis, 2 despite initial improvement, deteriorating valvular function necessitated surgical intervention. T h e organism was subsequently cultured from the excised valve. We would emphasise that anaerobes should not be forgotten as causes of endocarditis and that Veillonella spp., although rarely pathogenic, may in such circumstances prove to be remarkably aggressive. (We thank Dr J. G. Murtagh for permission to report this case.)
Anne C. Loughrey
Department of Bacteriology, City Hospital, Belfast,
Eng Wooi Chew
Department of Cardiology, City Hospital, Belfast, Northern Ireland, U.K.
Address correspondence to: Dr A. C. Loughrey, Department of Bacteriology, Royal Victoria Hospital, Grosvenor Road, Belfast BTI2 6BA, Northern Ireland, U.K.
References
L Loewe L, Rosenblatt P, Alture-Werber E. A refractory case of subacute bacterial endocarditis due to Veillonella gazogenes. Am Heart J I946; 32: 327-338. 2. Greaves WL, Kaiser AB. Endocarditis due to Veillonella alcalescens. South MedJ I984; 77: I2II--1212.
3. Rogosa M. Anaerobic Gram-negative cocci. In: Krieg NR, Holt JG, Eds. Bergey's manual of systematic bacteriology. Vol. I. Baltimore: Williams and Wilkins, I984: 68o-685. 4. Fredrich J, Brande A. Anaerobic infections of the paranasal sinuses. N Engl J Med I974: 290; I35-I37.
L e t t e r s to the E d i t o r
321
5. Barnhart RA, Weitekamp MR, Aber RC. Osteomyelitis caused by Veillonella. Am J Med I983 74: 902-904. 6. Bartlett JG, Finegold SM. Anaerobic pleuropulmonary infections. Medicine I972 ; 5I: 413-45o. 7- Bradford TW. Pelvic abscess associated with repeated recovery of Veillonella. Am J Obstet Gynecol I977; x29: 342-343. 8. Arrosagaray PM, Salas C, Morales M, Correas M, Barros JM, Cordon M L Bilateral abscessed orchiepididymitis associated with sepsis caused by Veillonella parvula and Clostridium perfringens. J Clin Microbiol I987; 25: i579-i58o. 9. Loesche W. Dental infections. In: Balows A, DeHaan RM, Dowell VR, Guze LB, Eds. Anaerobic bacteria, role in disease. Springfield, Illinois: Charles C Thomas, I974: 409-434. IO. Martin WJ, Gardner M, Washington JA. In vitro antimicrobial susceptibility of anaerobic bacteria isolated from clinical specimens. Antimicrob Agents Chemother I972 ; I: I48-I58. I I. Sutter VL, Finegold SM. Susceptibility of anaerobic bacteria to 23 antimicrobial agents. Antimicrob Agents Chemother I976; Io: 736-752.
E s c h e r i c h i a coli lobar pneumonia Accepted for publication 5 M a y I99O Sir, In recent years G r a m - n e g a t i v e bacilli have been increasingly recognised as a cause of p n e u m o n i a s although coliforms are a very rare cause of c o m m u n i t y - a c q u i r e d p n e u m o n i a in a young healthy patientfl We report a case of p r i m a r y Escherichia coli p n e u m o n i a in such a person. A 27-year-old male dock worker was admitted in I988 with a I5 h history of fever, rigors, vomiting, dyspnoea, right sided pleuritic pain and a cough productive of green bloodstained sputum. His past medical history included mild episodic asthma, penicillin allergy and transient intravenous drug abuse 7 years before. (He was H I V antibody-negative in I986). H e smoked 20 cigarettes a day and 'occasionally' drank alcohol. H e was febrile (38"5 °C), centrally cyanosed, tachypnoeic with a heart rate of I 4 o / m i n and a blood pressure of 70/30 m m / H g . T h e r e were signs of right lung base consolidation and the a b d o m e n was tender. T h e r e was no acute dental pathology although dental care had been neglected. Chest X - r a y on admission showed right lower lobe consolidation. His H b was I6"9 g/dl, M C V 89 fl, platelet count normal and W B C 2"9 X I09/l, (59 % neutrophils, 28 % lymphocytes, I4 % monocytes). Arterial blood gases showed marked hypoxaemia and his initial A L T was I23 IU/1 with a normal g a m m a G T . On day 20 of his illness both enzymes were transiently elevated but were normal at 3 months. H e was treated with intravenous ciprofloxacin and erythromycin and his condition improved within 24 h. Admission s p u t u m and blood cultures yielded a pure growth of E. coli sensitive to ciprofloxacin with a characteristic biochemical profile, the only atypical feature being a positive test for arginine dihydrolase. Pneumococcal antigen was not found in s p u t u m and blood. Legionella and viral serology, including H I V , was negative. T h e total W B C peaked on day 9 at I 6 ' 3 x IO9/1 (85"4% neutrophils, i i . 9 % lymphocytes, 2"7 % monocytes) and repeat radiology showed a small right pleural effusion and resolving pneumonia, H e was discharged on day I I and 6 weeks later was a s y m p t o m a t i c with a normal chest X-ray. T h e r e is little doubt that E. coli was the causative agent in our patient. Primary E. coli p n e u m o n i a s tend to present in patients with predisposing conditions as lower lobe b r o n c h o p n e u m o n i a , 2 but signs of lobar consolidation are rare. Escherichia coli (usually) invade alveoli either by bacteraemic spread or by aspiration
319
deficiency m a y have allowed a usually innocent microbe to cause clinically significant illness. F u r t h e r studies are required to examine the pathogenic potential of this c o m m o n organism. W e consider that when there is protracted diarrhoea in immunodeficient patients in w h o m no other pathogen is found a therapeutic trial of metronidazole should be considered.
* Department of Tropical Medicine and Infection, t Department of Histopathology, Ruchill Hospital, Bilsland Drive, Glasgow G2o 9NB, U.K. References
Dilip Nathwani* P. H. M. MeWhinney* S. T. Green* J. D. B o y d t
I. McMillan A, Lee FD. Sigmoidoscopic and microscopic appearance of the rectal mucosa in homosexual men. Gut ~98I ; zz : Io35-ro4I. 2. Nielsen RH, Orholm N, Pedersen JO, Hovind-Hougen K, Teglbjaerg PS, Thaysen EH. Colorectal spirochaetosis : clinical significance of the infestation. Gastroenterology I985; 85 : 62-67.
Endocarditis caused by Veillonella d i s p a r Accepted for publication 3o April I99o Sir, Anaerobic bacteria are an u n c o m m o n cause of endocarditis. We wish to report a case of endocarditis caused by Veillonella dispar. T h e r e appear to be only two previous reports of endocarditis caused by Veillonellae. 1' ~ A 57-year-old with rheumatic heart disease was admitted to hospital with a 3 weeks' history of lethargy and anorexia. A Bjork-Shiley mitral valve replacement had been p e r f o r m e d 7 years previously. T h r e e weeks before admission, a gingival abscess had been treated by the family doctor with ampicillin. On examination, the patient was febrile (38 °C), had splinter haemorrhages, a grade 4 / 6 pansystolic apical m u r m u r and a grade 2/6 early diastolic m u r m u r at the left sternal edge. She was haemodynamically stable and there were no other signs of endocarditis. An echocardiogram indicated a m i n o r degree of aortic incompetence and a vegetation which was clearly seen on the mitral valve. Initial laboratory investigations revealed a mild n o r m o c h r o m i c normocytic anaemia with 2 % reticulocytes, a haemoglobin concentration of to'9 g / d l and a W B C count of I I'5 × Io9/1. T h e concentration of C-reactive protein was 6I mg/1. Red cells were not seen in the urine. A Veillonella species was isolated from six of seven sets of blood cultures taken over a period of 3 days. T h e identity of the organism was confirmed as V. dispar by the Public Health L a b o r a t o r y Service Anaerobe Reference U n i t at Luton. T h e organism was first isolated from the patient 48 h after her admission to hospital. T r e a t m e n t began with intravenous ampicillin z g 4 hourly and oral metronidazole 4oo m g three times daily. She initially responded and became afebrile while the concentration of C-reactive protein fell to 21 mg/1. T w o weeks after treatment started, however, the patient developed acute p u l m o n a r y oedema and fever. T h e previously noted diastolic m u r m u r was m o r e p r o n o u n c e d and a further echocardiogram appeared to reveal severe aortic incompetence but with good left ventricular function. T h e appearance of the mitral prosthesis suggested that it was tilted and this may have interfered with assessment of function of the aortic valve. Because of recurrent fever and a rising W B C count (I6"9 x IO9/1) oral clindamycin 450 mg, three times daily, was substituted for the previous regimen. Despite vigorous medical treatment, the cardiac
Letters to the Editor
320
failure did not respond and surgical intervention was deemed necessary. At operation, considerable dehiscence of the suture line of the mitral valve was noted and vegetations were present on the valve. T h e aortic valve, however, showed no evidence of vegetations and was not felt to be more than slightly incompetent. Both valves were replaced with St Judes prostheses. Veillonella dispar was not isolated from the excised valves despite prolonged incubation. Post-operatively the patient made an excellent recovery. Veillonella spp. are constituents of the normal flora of the oropharynx, gastrointestinal tract and vagina. T h e organisms are small anaerobic Gram-negative cocci which are seen in pairs, short chains and irregular masses. T h e y are relatively inert biochemically. 3 Most strains isolated from h u m a n beings are V. parvula, V. atypica or V. dispar and have in the past been regarded as being of low pathogenicity. T h e y have, however, been isolated in pure culture from patients with bacterial endocarditis, 1'2 sinusitis 4 and osteomyelitis. 5 In addition, Veillonella spp. have been reported in cases of pleuropulmonary infection, 6 pelvic abscess 7 and epididymo-orchitis. 8 T h e organisms have also been implicated in the pathogenesis of periodontal disease and in the case of our patient the antecedent history of gingival abscess would suggest that this was the likely source. 9 In vitro studies suggest that Veillonella spp. are susceptible to a wide range of commonly used antibiotics including penicillin, cephalosporins, clindamycin and metronidazole, l°'n Limited clinical experience suggests benzyl penicillin to be the drug of choice in most situations. T h e failure of ampicillin and metronidazole in our patient would therefore appear to be unusual. It is notable that in one of the two previously cited cases of endocarditis, 2 despite initial improvement, deteriorating valvular function necessitated surgical intervention. T h e organism was subsequently cultured from the excised valve. We would emphasise that anaerobes should not be forgotten as causes of endocarditis and that Veillonella spp., although rarely pathogenic, may in such circumstances prove to be remarkably aggressive. (We thank Dr J. G. Murtagh for permission to report this case.)
Anne C. Loughrey
Department of Bacteriology, City Hospital, Belfast,
Eng Wooi Chew
Department of Cardiology, City Hospital, Belfast, Northern Ireland, U.K.
Address correspondence to: Dr A. C. Loughrey, Department of Bacteriology, Royal Victoria Hospital, Grosvenor Road, Belfast BTI2 6BA, Northern Ireland, U.K.
References
L Loewe L, Rosenblatt P, Alture-Werber E. A refractory case of subacute bacterial endocarditis due to Veillonella gazogenes. Am Heart J I946; 32: 327-338. 2. Greaves WL, Kaiser AB. Endocarditis due to Veillonella alcalescens. South MedJ I984; 77: I2II--1212.
3. Rogosa M. Anaerobic Gram-negative cocci. In: Krieg NR, Holt JG, Eds. Bergey's manual of systematic bacteriology. Vol. I. Baltimore: Williams and Wilkins, I984: 68o-685. 4. Fredrich J, Brande A. Anaerobic infections of the paranasal sinuses. N Engl J Med I974: 290; I35-I37.
L e t t e r s to the E d i t o r
321
5. Barnhart RA, Weitekamp MR, Aber RC. Osteomyelitis caused by Veillonella. Am J Med I983 74: 902-904. 6. Bartlett JG, Finegold SM. Anaerobic pleuropulmonary infections. Medicine I972 ; 5I: 413-45o. 7- Bradford TW. Pelvic abscess associated with repeated recovery of Veillonella. Am J Obstet Gynecol I977; x29: 342-343. 8. Arrosagaray PM, Salas C, Morales M, Correas M, Barros JM, Cordon M L Bilateral abscessed orchiepididymitis associated with sepsis caused by Veillonella parvula and Clostridium perfringens. J Clin Microbiol I987; 25: i579-i58o. 9. Loesche W. Dental infections. In: Balows A, DeHaan RM, Dowell VR, Guze LB, Eds. Anaerobic bacteria, role in disease. Springfield, Illinois: Charles C Thomas, I974: 409-434. IO. Martin WJ, Gardner M, Washington JA. In vitro antimicrobial susceptibility of anaerobic bacteria isolated from clinical specimens. Antimicrob Agents Chemother I972 ; I: I48-I58. I I. Sutter VL, Finegold SM. Susceptibility of anaerobic bacteria to 23 antimicrobial agents. Antimicrob Agents Chemother I976; Io: 736-752.
E s c h e r i c h i a coli lobar pneumonia Accepted for publication 5 M a y I99O Sir, In recent years G r a m - n e g a t i v e bacilli have been increasingly recognised as a cause of p n e u m o n i a s although coliforms are a very rare cause of c o m m u n i t y - a c q u i r e d p n e u m o n i a in a young healthy patientfl We report a case of p r i m a r y Escherichia coli p n e u m o n i a in such a person. A 27-year-old male dock worker was admitted in I988 with a I5 h history of fever, rigors, vomiting, dyspnoea, right sided pleuritic pain and a cough productive of green bloodstained sputum. His past medical history included mild episodic asthma, penicillin allergy and transient intravenous drug abuse 7 years before. (He was H I V antibody-negative in I986). H e smoked 20 cigarettes a day and 'occasionally' drank alcohol. H e was febrile (38"5 °C), centrally cyanosed, tachypnoeic with a heart rate of I 4 o / m i n and a blood pressure of 70/30 m m / H g . T h e r e were signs of right lung base consolidation and the a b d o m e n was tender. T h e r e was no acute dental pathology although dental care had been neglected. Chest X - r a y on admission showed right lower lobe consolidation. His H b was I6"9 g/dl, M C V 89 fl, platelet count normal and W B C 2"9 X I09/l, (59 % neutrophils, 28 % lymphocytes, I4 % monocytes). Arterial blood gases showed marked hypoxaemia and his initial A L T was I23 IU/1 with a normal g a m m a G T . On day 20 of his illness both enzymes were transiently elevated but were normal at 3 months. H e was treated with intravenous ciprofloxacin and erythromycin and his condition improved within 24 h. Admission s p u t u m and blood cultures yielded a pure growth of E. coli sensitive to ciprofloxacin with a characteristic biochemical profile, the only atypical feature being a positive test for arginine dihydrolase. Pneumococcal antigen was not found in s p u t u m and blood. Legionella and viral serology, including H I V , was negative. T h e total W B C peaked on day 9 at I 6 ' 3 x IO9/1 (85"4% neutrophils, i i . 9 % lymphocytes, 2"7 % monocytes) and repeat radiology showed a small right pleural effusion and resolving pneumonia, H e was discharged on day I I and 6 weeks later was a s y m p t o m a t i c with a normal chest X-ray. T h e r e is little doubt that E. coli was the causative agent in our patient. Primary E. coli p n e u m o n i a s tend to present in patients with predisposing conditions as lower lobe b r o n c h o p n e u m o n i a , 2 but signs of lobar consolidation are rare. Escherichia coli (usually) invade alveoli either by bacteraemic spread or by aspiration
