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
322
Letters to the Editor
f r o m the pharynx. T r a n s i e n t E. coli bacteraemia m a y occur in healthy people during menstruation, after intra-oral manipulation or after tonsillectomy, but urinary tract or gastro-intestinal infections are the m o r e usual source. 3 T h e oropharynx harbours E. coli in 2 % of the normal population but does not provide a suitable environment for growth of the organisms. Chronically or severely ill patients however have increased colonization with G r a m - n e g a t i v e bacilli in the oropharynx and therefore are at greater risk of p u l m o n a r y infection by aspiration. 1 I n one published series of aerobic G r a m negative pneumonias one or m o r e serious chronic disease was present in every case. ~ T h e s e included chronic renal disease, diabetes mellitus, alcoholism, heart disease, lung disease, cancer, blood dyscrasia and immunosuppression, whilst other published series fail to clarify whether cases of p r i m a r y E. coli pneumonia were free of serious associated disease. 2' 5 T h e normal M C V and transient abnormality of liver function in our patient do not suggest chronic alcohol abuse. Escherichia coli lobar p n e u m o n i a occurring in a previously well patient is exceedingly rare and this case m a y be unique.
* Infectious Diseases Unit, t Bacteriology Laboratory, City Hospital, Greenbank Drive, Edinburgh, EHIo 5SB, Scotland, U.K.
J. Bligh* F . X . S . Emmanuel% M. E. Jones*:~
Address correspondence to: Dr M. E. Jones.
I. 2. 345.
References Pierce AK, Sanford JP. Aerobic Gram-negative bacillary pneumonias. Am Rev Respir Dis 1974; n o : 647-658. Dorff GJ, Rytel MW, Farmer SG, Scanlon G. Etiologies and characteristic features of pneumonias in a municipal hospital. Am J Med Sci 1973 ; 266: 349-358. Salomon PF, Tamlyn T T , Grieco MH. Escherichia coli pneumonia--case report. Am Rev Respir Dis 197o; I02: 248--257. Tillotson JR, Lerner AM. Characteristics of pneumonias caused by Escherichia coli. N Engl J Med 1967; 277: 115-122. Sullivan RJ, Dowdle WR, Marine WM, Hierholzer JC. Adult pneumonia in a general hospital. Arch Intern Med 1972; 129: 935-942.
Lactobacillus jensenii prosthetic valve endocarditis Accepted for publication IO May 199o Sir, M e m b e r s of the genus Lactobacillus are c o m m o n l y present in the gastro-intestinal and genito-urinary tracts and in the mouth, 1 yet serious disease attributable to these organisms is raref1-9 W e describe the first recorded case of prosthetic valve endocarditis due to Lactobacillus jensenii. A 6 I - y e a r - o l d male engineer presented in M a r c h 1989 with a 3 weeks' history of malaise, night sweats, intermittent fever and progressive dyspnoea. H e had suffered previous episodes of infective endocarditis in 1983 (with a Streptococcus sp., necessitating aortic valve replacement) ; in 1986 (no causative organism was identified); and in 1988 (due to Streptococcus faecalis serotype 9/19). Following the third episode of infection, all his teeth were extracted because of severe periodontal disease. Clinical examination revealed a low-grade fever, signs of mixed aortic valve disease and moderate enlargement of the liver and spleen. T h e haemoglobin concentration was 7 g / d l and the E S R was 40 m m in the first hour. F o u r sets of blood cultures (eight
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
322
Letters to the Editor
f r o m the pharynx. T r a n s i e n t E. coli bacteraemia m a y occur in healthy people during menstruation, after intra-oral manipulation or after tonsillectomy, but urinary tract or gastro-intestinal infections are the m o r e usual source. 3 T h e oropharynx harbours E. coli in 2 % of the normal population but does not provide a suitable environment for growth of the organisms. Chronically or severely ill patients however have increased colonization with G r a m - n e g a t i v e bacilli in the oropharynx and therefore are at greater risk of p u l m o n a r y infection by aspiration. 1 I n one published series of aerobic G r a m negative pneumonias one or m o r e serious chronic disease was present in every case. ~ T h e s e included chronic renal disease, diabetes mellitus, alcoholism, heart disease, lung disease, cancer, blood dyscrasia and immunosuppression, whilst other published series fail to clarify whether cases of p r i m a r y E. coli pneumonia were free of serious associated disease. 2' 5 T h e normal M C V and transient abnormality of liver function in our patient do not suggest chronic alcohol abuse. Escherichia coli lobar p n e u m o n i a occurring in a previously well patient is exceedingly rare and this case m a y be unique.
* Infectious Diseases Unit, t Bacteriology Laboratory, City Hospital, Greenbank Drive, Edinburgh, EHIo 5SB, Scotland, U.K.
J. Bligh* F . X . S . Emmanuel% M. E. Jones*:~
Address correspondence to: Dr M. E. Jones.
I. 2. 345.
References Pierce AK, Sanford JP. Aerobic Gram-negative bacillary pneumonias. Am Rev Respir Dis 1974; n o : 647-658. Dorff GJ, Rytel MW, Farmer SG, Scanlon G. Etiologies and characteristic features of pneumonias in a municipal hospital. Am J Med Sci 1973 ; 266: 349-358. Salomon PF, Tamlyn T T , Grieco MH. Escherichia coli pneumonia--case report. Am Rev Respir Dis 197o; I02: 248--257. Tillotson JR, Lerner AM. Characteristics of pneumonias caused by Escherichia coli. N Engl J Med 1967; 277: 115-122. Sullivan RJ, Dowdle WR, Marine WM, Hierholzer JC. Adult pneumonia in a general hospital. Arch Intern Med 1972; 129: 935-942.
Lactobacillus jensenii prosthetic valve endocarditis Accepted for publication IO May 199o Sir, M e m b e r s of the genus Lactobacillus are c o m m o n l y present in the gastro-intestinal and genito-urinary tracts and in the mouth, 1 yet serious disease attributable to these organisms is raref1-9 W e describe the first recorded case of prosthetic valve endocarditis due to Lactobacillus jensenii. A 6 I - y e a r - o l d male engineer presented in M a r c h 1989 with a 3 weeks' history of malaise, night sweats, intermittent fever and progressive dyspnoea. H e had suffered previous episodes of infective endocarditis in 1983 (with a Streptococcus sp., necessitating aortic valve replacement) ; in 1986 (no causative organism was identified); and in 1988 (due to Streptococcus faecalis serotype 9/19). Following the third episode of infection, all his teeth were extracted because of severe periodontal disease. Clinical examination revealed a low-grade fever, signs of mixed aortic valve disease and moderate enlargement of the liver and spleen. T h e haemoglobin concentration was 7 g / d l and the E S R was 40 m m in the first hour. F o u r sets of blood cultures (eight
