50
Eur. J. Clin. Microbiol. Infect Dis.
dimetric. Journal of Antimicrobial Chemotherapy 1980, 6: 617--621. 14, Brown W J: National committee for clinical laboratory standards agar dilution susceptibility testing of anaerobic gram-negative bacteria. Antimicrobial Agents and Chemotherapy 1988, 32: 385-390. 15. Cuchural G J, Tally FP: Bacteroides fragilis: current susceptibilities, mechanisms of drug resistance, and principles of antimierobiat therapy. Drug Intelligence and Clinical Pharmacology 1986, 20: 567-573. 16. Tuner K, Lundqvist L, Nord CE: Characterization of a new I~-lactamase from Fusobaczerium nucleatum by substrate profiles and chromatofocusing patterns. Journal of Antimicrobial Chemotherapy 1985, 16: 23-
30.
17. Appelbaum PC: Anaerobic infections: non-sporeformers. In: Wentworth BB (ed.): Diagnostic procedures for bacterial infections. American Public Health Association, Washington, DC, 1987, p. 45-109. 18. Appelbaum PC, Jacobs MR, Spangler SK, Yamabe S: Comparative activity of ~-lactamase inhibitors YTR 830, clavulanate, and sulbactam combined with [~-lactams against [~-lactamase-producing anaerobes. Antimicrobial Agents and Chemotherapy 1986, 30: 789-791.
Erysopelothrix rhusiopathiae Endocarditis M. V e n d i t t i * , V. G e l f u s a , F. Castelli, C. B r a n d i m a r t e , P. S e r r a A case of Erysipelothrix rhusiopathiae endocarditis involving the aortic and mitral valves in a 70-year-old male farmer is reported. The onset of infection was insidious, with a five-month history of low grade fever, malaise and a 20 kg weight loss. The patient eventually developed severe heart failure requiring surgery and died postoperatively of Pseudomonas aeruginosa pneumonia. In vitro studies showed the isolate to be highly susceptible to penicillin, ciprofloxacin and ofloxacin, and resistant to vancomycin.
Erysipelothrix rhusiopathiae is a gram-positive bacillus which has long been recognized as pathogenic for animals and man (1, 2). In a recent extensive review of the literature, Gorby and Peacock (3) found that 49 cases of systemic infection with this organism have been reported over the past 15 years; 90 % were episodes of proven or presumed endocarditis. Alternatives Patologia Medica III, Univerisit~ La S~ipienza, Padiglione VII, Policlinico Umberto I, 00161 Rome, Italy.
to penicillin have seldom been used in therapy, and the MICs and MBCs of many antibiotics for Erisipelothrix rhusiopathiae are not widely known. We report a case of Erysipelothrix rhusiopathiae infection of the aortic and mitral valves and drug susceptibility data for the isolate recovered from our patient.
Case Report. On 2 January 1989 a 70-year-old male farmer was admitted to a community hospital with a five-month history of low grade fever, anorexia, malaise, low back pain and a weight loss of more than 20 kg. Two weeks before onset of the symptoms, he complained of an e.rythematous and slightly pruritic skin rash involving the left forearm which resolved spontaneously within a few days. On admission, the body temperature was 37.4 °C and physical examination revealed only a palpable spleen. There were neither audible heart murmurs nor cutaneous or mucosal stigmata of endocarditis. Laboratory investigations revealed a hematocrit of 26 %, a hemoglobin concentration of 8.3 g %, a leukocyte count of 4900 I.tl, and an ESR of 82 mm at 1 h. Urine analysis revealed microscopic hematuria. On day 7 after admission, i.v. chloramphenicol therapy (500 mg every 12 h) was started. On day 13 the patient developed leftsided hemiplegia which resolved spontaneously within 48 h. On day 18 the patient was afebrile, but complained of progressive dyspnea and orthopnea. On physical examination a grade III/VI diastolic heart murmur was heard over the left sternal border. Echocardiography revealed a vegetation 1 cm in diameter on the noncoronary cusp of the aortic valve. Another small vegetative lesion was seen on the posterior cusp of the mitral valve with fluttering of the anterior cusp. On day 24 the patient developed first degree atrioventricular block and i.m. cefotaxime (1 g every 8 h) was added to his therapy. Since the patient failed to respond to medical therapy, aortic and mitral valve replacement was judged to be mandatory. Surgery on day 28 revealed almost total destruction of the aortic cusp. Vegetations were seen on the noncoronary cusp of the aortic valve and on the mitral valve cusps. Therapy with i.v. teicoplanin (400 mg every 24 l't) and penicillin G (20 x 106 U every 24 h given by continuous infusion) was initiated during surgery soon after removal of the infected valves. The following day, two of the three blood cultures taken before surgery, and cultures of the removed aortic valve yielded a gram-positive bacterium that appeared at initial identification to be an alpha-hemolytic streptococcus. Ultimately, all the isolates were identified as Erysipelothrix rhusiopathiae by both standard methods (2) and by an automatic identification method (4) which includes 30 biochemical tests (Vitek System, McDonnell
Vol. 1, 1990
51
Douglas, USA). On the basis of results of in vitro susceptibility tests (Table 1), performed using a broth macrodilution technique (5), teicoplanin therapy was discontinued on day 37. Using a standardized method (6), serum bactericidal titers of 1:128-1:256 were found during penicillin therapy. Further blood cultures performed daily did not yield microbial growth. Nevertheless, the patient died on day 45 after admission as a consequence of bilateral Pseudomonas aeruginosa pneumonia. No signs of residual infective endocarditis were found at autopsy. Cultures of the removed prosthetic valves yieldes no microbial growth.
Discussion. Erysipelothrix rhusiopathiae, formerly known as Erysipelothrix insidiosa, is a grampositive, pleomorphic, facultatively anaerobic, non-motile, non-sporeforming, catalase-negative bacillus (1, 2, 3). Some colonies produce alphahemolysis on blood agar, and on primary isolation the organism may be erroneously identified as a viridans streptococcus (3, 7). After preliminary identification of an organism as a gram-positive rod, Erysipelothrix rhusiopathiae and Bacillus spp. can be distinguished by the absence and presence of spores, respectively. Unlike other non-sporeforming gram-positive bacilli (i.e. Listeria monocytogenes, Corynebacterium spp. and Lactobacillus spp.), ErysipeIothrix rhusiopathiae produces H2S on triplesugar iron agar. It is ubiquitous in nature, being isolated as a commensal or as a pathogen from a number of domestic and wild mammals in addition to birds and fish (1-3). Erysipelothrix rhusiopathiae infection in humans is often thus an occupational disease principally affecting people who have contact with animals or organic matter of animal origin (1-3). As was
Erysiopelothrix rhusiopathiae strain isolated from a patient with endo-
T a b l e 1: Antibiotic sensitivity of an
carditis. Antibiotic Penicillin Ampicillin Cefamandole Cefotaxime Erythromycin Trimethoprim! sulphamethoxazole Clindamycin Chloramphenicol Gentamicin Netilmicin Vancomycin Teicoplanin Ciprofloxacin Ofloxacin Pefloxacin
MIC (I.tg/ml) MBC (ixg/ml) _
Eur. J. Clin. Microbiol. Infect Dis.
dimetric. Journal of Antimicrobial Chemotherapy 1980, 6: 617--621. 14, Brown W J: National committee for clinical laboratory standards agar dilution susceptibility testing of anaerobic gram-negative bacteria. Antimicrobial Agents and Chemotherapy 1988, 32: 385-390. 15. Cuchural G J, Tally FP: Bacteroides fragilis: current susceptibilities, mechanisms of drug resistance, and principles of antimierobiat therapy. Drug Intelligence and Clinical Pharmacology 1986, 20: 567-573. 16. Tuner K, Lundqvist L, Nord CE: Characterization of a new I~-lactamase from Fusobaczerium nucleatum by substrate profiles and chromatofocusing patterns. Journal of Antimicrobial Chemotherapy 1985, 16: 23-
30.
17. Appelbaum PC: Anaerobic infections: non-sporeformers. In: Wentworth BB (ed.): Diagnostic procedures for bacterial infections. American Public Health Association, Washington, DC, 1987, p. 45-109. 18. Appelbaum PC, Jacobs MR, Spangler SK, Yamabe S: Comparative activity of ~-lactamase inhibitors YTR 830, clavulanate, and sulbactam combined with [~-lactams against [~-lactamase-producing anaerobes. Antimicrobial Agents and Chemotherapy 1986, 30: 789-791.
Erysopelothrix rhusiopathiae Endocarditis M. V e n d i t t i * , V. G e l f u s a , F. Castelli, C. B r a n d i m a r t e , P. S e r r a A case of Erysipelothrix rhusiopathiae endocarditis involving the aortic and mitral valves in a 70-year-old male farmer is reported. The onset of infection was insidious, with a five-month history of low grade fever, malaise and a 20 kg weight loss. The patient eventually developed severe heart failure requiring surgery and died postoperatively of Pseudomonas aeruginosa pneumonia. In vitro studies showed the isolate to be highly susceptible to penicillin, ciprofloxacin and ofloxacin, and resistant to vancomycin.
Erysipelothrix rhusiopathiae is a gram-positive bacillus which has long been recognized as pathogenic for animals and man (1, 2). In a recent extensive review of the literature, Gorby and Peacock (3) found that 49 cases of systemic infection with this organism have been reported over the past 15 years; 90 % were episodes of proven or presumed endocarditis. Alternatives Patologia Medica III, Univerisit~ La S~ipienza, Padiglione VII, Policlinico Umberto I, 00161 Rome, Italy.
to penicillin have seldom been used in therapy, and the MICs and MBCs of many antibiotics for Erisipelothrix rhusiopathiae are not widely known. We report a case of Erysipelothrix rhusiopathiae infection of the aortic and mitral valves and drug susceptibility data for the isolate recovered from our patient.
Case Report. On 2 January 1989 a 70-year-old male farmer was admitted to a community hospital with a five-month history of low grade fever, anorexia, malaise, low back pain and a weight loss of more than 20 kg. Two weeks before onset of the symptoms, he complained of an e.rythematous and slightly pruritic skin rash involving the left forearm which resolved spontaneously within a few days. On admission, the body temperature was 37.4 °C and physical examination revealed only a palpable spleen. There were neither audible heart murmurs nor cutaneous or mucosal stigmata of endocarditis. Laboratory investigations revealed a hematocrit of 26 %, a hemoglobin concentration of 8.3 g %, a leukocyte count of 4900 I.tl, and an ESR of 82 mm at 1 h. Urine analysis revealed microscopic hematuria. On day 7 after admission, i.v. chloramphenicol therapy (500 mg every 12 h) was started. On day 13 the patient developed leftsided hemiplegia which resolved spontaneously within 48 h. On day 18 the patient was afebrile, but complained of progressive dyspnea and orthopnea. On physical examination a grade III/VI diastolic heart murmur was heard over the left sternal border. Echocardiography revealed a vegetation 1 cm in diameter on the noncoronary cusp of the aortic valve. Another small vegetative lesion was seen on the posterior cusp of the mitral valve with fluttering of the anterior cusp. On day 24 the patient developed first degree atrioventricular block and i.m. cefotaxime (1 g every 8 h) was added to his therapy. Since the patient failed to respond to medical therapy, aortic and mitral valve replacement was judged to be mandatory. Surgery on day 28 revealed almost total destruction of the aortic cusp. Vegetations were seen on the noncoronary cusp of the aortic valve and on the mitral valve cusps. Therapy with i.v. teicoplanin (400 mg every 24 l't) and penicillin G (20 x 106 U every 24 h given by continuous infusion) was initiated during surgery soon after removal of the infected valves. The following day, two of the three blood cultures taken before surgery, and cultures of the removed aortic valve yielded a gram-positive bacterium that appeared at initial identification to be an alpha-hemolytic streptococcus. Ultimately, all the isolates were identified as Erysipelothrix rhusiopathiae by both standard methods (2) and by an automatic identification method (4) which includes 30 biochemical tests (Vitek System, McDonnell
Vol. 1, 1990
51
Douglas, USA). On the basis of results of in vitro susceptibility tests (Table 1), performed using a broth macrodilution technique (5), teicoplanin therapy was discontinued on day 37. Using a standardized method (6), serum bactericidal titers of 1:128-1:256 were found during penicillin therapy. Further blood cultures performed daily did not yield microbial growth. Nevertheless, the patient died on day 45 after admission as a consequence of bilateral Pseudomonas aeruginosa pneumonia. No signs of residual infective endocarditis were found at autopsy. Cultures of the removed prosthetic valves yieldes no microbial growth.
Discussion. Erysipelothrix rhusiopathiae, formerly known as Erysipelothrix insidiosa, is a grampositive, pleomorphic, facultatively anaerobic, non-motile, non-sporeforming, catalase-negative bacillus (1, 2, 3). Some colonies produce alphahemolysis on blood agar, and on primary isolation the organism may be erroneously identified as a viridans streptococcus (3, 7). After preliminary identification of an organism as a gram-positive rod, Erysipelothrix rhusiopathiae and Bacillus spp. can be distinguished by the absence and presence of spores, respectively. Unlike other non-sporeforming gram-positive bacilli (i.e. Listeria monocytogenes, Corynebacterium spp. and Lactobacillus spp.), ErysipeIothrix rhusiopathiae produces H2S on triplesugar iron agar. It is ubiquitous in nature, being isolated as a commensal or as a pathogen from a number of domestic and wild mammals in addition to birds and fish (1-3). Erysipelothrix rhusiopathiae infection in humans is often thus an occupational disease principally affecting people who have contact with animals or organic matter of animal origin (1-3). As was
Erysiopelothrix rhusiopathiae strain isolated from a patient with endo-
T a b l e 1: Antibiotic sensitivity of an
carditis. Antibiotic Penicillin Ampicillin Cefamandole Cefotaxime Erythromycin Trimethoprim! sulphamethoxazole Clindamycin Chloramphenicol Gentamicin Netilmicin Vancomycin Teicoplanin Ciprofloxacin Ofloxacin Pefloxacin
MIC (I.tg/ml) MBC (ixg/ml) _
