609
Haemophilus parainfluenzae as a Rare Cause of Epidural Abscess: Case Report and Review Grace M. Auten, Charles S. Levy, and Margo A. Smith
From the Section of Infectious Diseases, Washington Hospital Center and George Washington University, Washington, D.C.
Haemophilus parainfluenzae is a pleomorphic, fastidious, gram-negative coccobacillus that has been recognized as an infrequent cause of invasive disease. It has been noted as a cause most often of endocarditis, but increasingly other diseases caused by this organism are being reported. We present what we believe to be the first report of a patient with an epidural abscess caused by H. parainjiuenzae.
Case Report A previously healthy 74-year-old man developed severe pain at the posterior base of his neck that was not relieved by change of position, warm compresses, or bed rest. After 4 days he presented at an outpatient emergency department, where a nonsteroidal, antiinflammatory agent was prescribed. On day 6 of his illness, the patient presented at Washington Hospital Center (Washington, D.C.) because of worsening pain and limited range of motion in his neck. The patient reported no history of fever, chills, night sweats, or weight loss. He had experienced no muscle weakness, sensory changes, or urinary or bowel incontinence. His medical history was significant for periodontal disease, and he had had a chronically abscessed tooth removed 2 weeks before admission. A neck injury 20 years earlier had required cervical foraminectomy and had caused intermittent neck pain. He reported an allergy to penicillin but was unable to remember the adverse reaction.
Received 29 May 1990; revised 7 September 1990. Reprints and correspondence: Dr. Charles S. Levy, Section of Infectious Diseases, Washington Hospital Center, 110 Irving Street NW, Washington, D.C. 20010-2975. Reviews of Infectious Diseases 1991;13:609-12 © 1991 by The University of Chicago. AU rights reserved. 0162-0886/91/1304-0035$02.00
The patient's vital signs were normal. There were no oral lesions, and the appearance of the site of the recently extracted tooth was unremarkable. A soft midsystolic heart murmur was noted. Except for limitation of the range of motion of his neck, the neurologic examination revealed no abnormalities. Roentgenograms of the cervical spine revealed degenerative changes in the fifth and sixth cervical vertebral (C5 and C6) areas; these included narrowing of the space between the disks, formation of osteophytes, and minimal retrograde spondylolisthesis. Exacerbation of degenerative cervical disease was presumed to be the cause of his symptoms. The patient was treated with analgesics and bed rest, but only minimal relief was achieved. A bone scan on the second hospital day indicated increased uptake in the lower cervical spine. That evening, the patient developed numbness and weakness in both arms and in his right leg. A myelogram revealed almost total occlusion of the thecal sac at the C6 level. A computed tomogram revealed an extensive anterior, extradural soft tissue mass from the C3 to C6 levels and posterior displacement of the spinal cord (figure 1). Laboratory studies of CSF samples obtained at the time of myelography revealed the following values: red blood cells, 12/mm3 ; white blood cells (WBCs), 188/mm 3 (82 % neutrophils, 14% lymphocytes, and 4% mononuclear cells); protein, 582 mg/dL; and glucose, 61 mg/dL. The patient's peripheral WBC count was 7,800/mm3 • A laminectomy was performed to remove an extensive anterior cervical epidural abscess. A gram stain revealed that the purulent material from the abscess contained many WBCs but no organisms. The patient was treated with vancomycin, tobramycin, and aztreonam. Cultures of the abscess revealed H. parainjiuenzae in pure culture; the organism was detected on chocolate agar after 24 hours of incubation. No microorganisms were recovered from the blood or CSF. An echocardiogram was negative for cardiac vegetations. Therapy with ampicillin was precluded by the patient's allergy to penicillin.
Downloaded from http://cid.oxfordjournals.org/ at Yale University on July 10, 2015
We report a case of epidural abscess due to Haemophilus parainfluenzae. This microorganism is a normal inhabitant of the upper respiratory tract that causes endocarditis and, rarely, other invasive infections. To the best of our knowledge, epidural abscess due to H. parainjluenzae has not been reported previously. A 74-year-old man presented with neck pain and subsequently developed incomplete quadriparesis. A cervical epidural abscess and vertebral osteomyelitis were detected by radiologic studies. Surgical drainage and antibiotic therapy resulted in resolution of the abscess and osteomyelitis,and the neurologic sequelae were minimal. Cultures of the purulent material from the abscess yielded H. parainfluenzae. Descriptions in the literature of infections caused by H. parainjluenzae and the antimicrobial agents used for treatment of these infections are reviewed.
610
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RID 1991;13 (July-August)
Table 1. Degree of susceptibility of H. parainfluenzae organisms isolated from an epidural abscess to various antibiotics, in terms of MIC. Antibiotic Ampicillin Gentamicin Tobramycin Chloramphenicol TMP-SMZ Ciproftoxacin Cefazolin Cefuroxime Ceftriaxone Aztreonam Rifampin Erythromycin
He was treated intravenously with trimethoprim-sulfamethoxazole (TMP-SMZ; 240 mg every 6 hours) and tobramycin (80 mg every 8 hours). The peak and trough bacteriostatic and bactericidal levels in serum were >1:64. Postoperatively, the patient experienced incomplete quadriparesis, and magnetic resonance imaging of the cervical spine revealed changes consistent with vertebral osteomyelitis and residual epidural abscess. He remained afebrile, and by the time of discharge on the 20th hospital day, his neurologic function was improving gradually. The use of tobramycin was discontinued after the first 2 weeks of therapy. After mild neutropenia was noted during the fifth week of therapy with TMPSMZ, oral ciprofloxacin (750 mg every 12 hours) was administered instead to complete 2 more weeks of therapy. Four months postoperatively, there was no evidence of recurrence and the patient's only residual neurologic deficit was tingling in his fingertips. The Centers for Disease Control (Atlanta) later confirmed that the causative organism was H. parainjluenzae. No (j-lactamase production was detected, and tests for MICs revealed that H. parainjluenzae was susceptible to all the antibiotics tested except for erythromycin (table 1).
Literature Review and Discussion Epidural abscess is an uncommon disease that can have devastating results, including paralysis or death. The causative organism is most often Staphylococcus aureus, but the disease can also be caused by other gram-positive cocci, gramnegative bacilli, Mycobacterium tuberculosis, and opportunis-
~0.12
2.0 2.0 1.0 ~0.03/0.6
~0.03
1.0 0.25 ~0.OO2 ~0.5
0.5 8.0
tic organisms [1, 2]. Two studies of epidural abscesses due to other Haemophilus species have been reported [2, 3]; to our knowledge, there are no previous reports of epidural abscess caused by H. parainjiuenzae. Our patient presented with severe neck pain and then developed vertebral osteomyelitis and neurologic deficits secondary to a cervical epidural abscess. Although a heart murmur was detected, the negative results of blood cultures and of an echocardiogram made a diagnosis of endocarditis unlikely. We presumed that the original source of the H. parainjiuenzae infection was his dental abscess and that hematogenous seeding of the cervical spine and subsequent extension of infection to the epidural space had occurred. Previous reviews of vertebral osteomyelitis and epidural abscess have described the pathogenesis of these infections as hematogenous seeding of the vertebral spine from a distant focus such as a skin infection, periodontal abscess, urinary tract infection, or other localized infection. The spread of infection can also occur solely through the veins, such as through Batson's plexus from the genitourinary tract to the lumbar spine. Progression of the vertebral infection can then lead to its extension to surrounding tissue such as the disk space, psoas muscle, and epidural space [1, 4]. Deep infections (such as endocarditis) due to Haemophilus species are frequently attributed to seeding from previous dental procedures, dental abscesses, or periodontal disease [5, 6]. H. parainjiuenzae is a normal inhabitant of the upper respiratory tract. It is a small, pleomorphic, gram-negative coccobacillus with specific growth requirements. It tends to be slow-growing and is strictly a parasite, in need of accessory factors for growth. This organism is identified by its requirement for V factor (or nicotinamide-adenine dinucleotide) and by its nonhemolytic growth on sheep blood agar [7]. Even with supplemented media, the organism may not become detectable for several days. In cases of endocarditis, the mean interval between performance of blood cultures and apparent growth of the organism has been reported to be 6.3 days in
Downloaded from http://cid.oxfordjournals.org/ at Yale University on July 10, 2015
Figure 1. A computed tomogram of the cervical spine revealed posterior displacement of the contrast-enhanced spinal cord (between arrows) by an anterior epidural abscess.
MIC (J,.Lg/mL)
RID 1991;13 (July-August)
Epidural Abscess Due to H. parainfluenzae
Conclusion H. parainfiuenzae is a rare cause of epidural abscess. Because of its fastidious nature, this microorganism can be a
cause of epidural abscess or vertebral osteomyelitis yet can be difficult to isolate in culture. Optimal use of culture techniques, i.e., selection of appropriate media and sufficient duration of incubation, should improve the chances of recovering this organism. A diagnosis of H. parairfiuenzae infection should be considered for any patient with signs and symptoms of an epidural abscess, especially when periodontal disease is evident. To facilitate treatment in such cases, confirmation of this rare cause of epidural abscess should always be obtained by means of culture. Acknowledgment The authors thank Zenaida N. Leong for manuscript preparation.
References 1. Verner EF, Musher DM. Spinal epidural abscess. Med Clin North Am 1985;69:375-84 2. Danner RL, Hartman BJ. Update of spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis 1987;9:265-74 3. Gaudin P, Zagala A, Juvin R, Le Bas JF, Brion JP, Chirossel JP, Stahl JP, Phelip X. Haemophilus aphrophilus epidural abscess studied by nuclear magnetic resonance. Ann Med Interne (Paris) 1989;140:68-9 4. Beltrani VP, Echols RM, Vedder DK. Vertebral osteomyelitis caused by Haemophilus infiuenzae. J Infect Dis 1987;156:391-4 5. Chunn CJ, Jones SR, McCutchan JA, YoungEl, Gilbert DN. Haemophilus parairfluenzae infective endocarditis. Medicine (Baltimore) 1977; 56:99-113 6. Julander I, Lindberg AA, Svanbom M. Haemophilus parainfluenzaean uncommon cause of septicemia and endocarditis. Scand J Infect Dis 1980;12:85-9 7. Hand WL. Haemophilus species. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, 1990:1729-33 8. Jemsek JG, Greenberg SB, Gentry LO, Welton DE, Mattox KL. Haemophilus parainfluenzae endocarditis: two cases and review of the literature in the past decade. Am J Med 1979;66:51-7 9. Blair DC, Walker W, Sodeman T, Pagano T. Bacterial endocarditis due to Haemophilus parainfluenzae. Chest 1977;71:146-9 10. Lynn DJ, Kane JG, Parker RH. Haemophilus parairfiuenzae and injiuenzaeendocarditis: a review of forty cases. Medicine (Baltimore) 1977; 56:115-28 11. Wort AJ. Haemophilus parainfluenzae meningitis. Canadian Medical Association Journal 1975;112:606-7 12. Oill PA, Chow AW, Guze LB. Adult baeteremic Haemophilus parainjiuenzae infections: seven reports of cases and a review of the literature. Arch Intern Med 1979;139:985-8 13. Trollfors B, Brorson J-E, Claesson B, Sandberg T. Invasive infections caused by Haemophilus species other than Haemophilus injiuenzae. Infection 1985;13:12-4 14. Raoult D, Drancourt M, Gallais H, Casanova P. Haemophilus parainjiuenzae meningitis in an adult with an inherited deficiency of the seventh component of complement. Arch Intern Med 1987;147:2214 15. Maller R, Ansehn S, Fryden A. Haemophilusparainfiuenzae infection of the central nervous system: a report on two infants. Scand J Infect Dis 1977;9:241-2 16. Warman ST, Reinitz E, Klein RS. Haemophilusparainjiuenzae septic arthritis in an adult. JAMA 1981;246:868-9 17. Hollin SA, Hayashi H, Gross Sw. Intracranial abscesses of odontogenic origin. Oral Surg Oral Med Oral PathoI1967;23:277-93
Downloaded from http://cid.oxfordjournals.org/ at Yale University on July 10, 2015
cases of left-sided infection and 8.5 days in cases of right-sided infection [8]. The most frequently reported infection caused by H. parainfluenzae is endocarditis. High rates of complications, including large vegetations, septic emboli, persistent fever, and persistent bacteremia, have been noted [5, 6, 8-10]. Other rarely reported deep infections due to H. parainfluenzae include meningitis [11-15], septicemia [13], empyema [13], epiglottitis [12, 13], septic arthritis [12, 16], brain abscess [13, 15, 17], pneumonia [12], peritonitis [18], urinary tract and genital infection [19-21], pharyngitis [12], and hepatic abscess [22]. H. parainfiuenzae previously has been reported as a cause of vertebral osteomyelitis of the lumbar region in one patient [23]. The authors of that report believed that the predisposing factor was the performance of a septoplasty 3 months before admission to the hospital for osteomyelitis and that bacteremia had been induced at the time of the operation. Other Haemophilus species were associated with two reported cases of epidural abscess. In a report from France, Haemophilus aphrophilus was documented as the cause of an epidural abscess in the thoracic spine of a previously healthy patient for whom there were no predisposing factors [3]. Another case due to an unspecified Haemophilus species has been reported, but no other clinical or microbiologic details are available [2]. Reported cases of vertebral osteomyelitis due to Haemophilus species but with no epidural abscess have been due most commonly to H. infiuenzae [4, 24, 25] and H. aphrophilus [26-31]. In reports of infection due to a Haemophilus species, difficulties in isolating the organism were frequently noted; cultures yielded either no growth or rare colonies of Haemophilus species, an occurrence suggestive of contamination of the culture. Repeated cultures were often required for diagnosis. Predisposing factors were frequently periodontal disease, upper respiratory tract infections, or genitourinary infections. H. parainfluenzae is generally susceptible in vitro to multiple antibiotics, but resistance to ampicillin (which is attributed to (j-Iactamase production) has been noted in up to 6% of clinical isolates [32, 33]. Administration of ampicillin with an aminoglycoside is generally recommended as therapy for infection due to {j-Iactamase-negative organisms. Cephalosporins, chloramphenicol, and TMP-SMZ have also been used successfully [5, 6, 8, 10, 34, 35]. However, even when therapy appears adequate in terms of bactericidal titers in serum and the results of in vitro susceptibility assays, therapeutic modalities fail frequently in the treatment of endocarditis [5, 8]. Fortunately, our patient's epidural abscess and vertebral osteomyelitis responded satisfactorily to surgical drainage and the antibiotics we chose for therapy.
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27. Farrington M, Eykyn SI, Walker M, Warren RE. Vertebralosteomyelitis due to coccobacilli of the HB group. BMI 1983;287:1658-60 28. Ho lL, Soukiasian S, Oh WH, Snydman DR. Haemophilus aphrophilus osteomyelitis. Am 1 Med 1984;76:159-61 29. Petty BG, Burrow CR, Robinson RA, Bulkley GB. Haemophilus aphrophilus meningitis followed by vertebral osteomyelitis and suppurative psoas abscess. Am J Med 1985;78:159-61 30. Gribble Ml, Hunter T. Haemophilus aphrophilus vertebral osteomyelitis: a case report and literature review. Diagn Microbial Infect Dis 1987;8:189-91 31. Houssiau FA, Huaux JP, De Deuxchaisnes CN. Haemophilus aphrophilus: a rare pathogen in vertebral osteomyelitis. Ann Rheum Dis 1987;46:248-50 32. Kauffman CA, Bergman AG, Hertz CS. Antimicrobial resistance of Haemophilus species in patients with chronic bronchitis. Am Rev Respir Dis 1979;120:1382-5 33. Mayo JB, McCarthy LR. Antimicrobial susceptibility of Haemophilus parairfiuenzae. Antimicrob Agents Chemother 1977;11:844-7 34. Calio AI, Cusumano S, Ullman RF, Tjio DY, Cunha BA. Haemophilus parainfiuenzae endocarditis. Heart Lung 1987;16:222-3 35. Smith PW, Chambers WA, Walker CA. Ampicillin-resistant Haemophilus parainfiuenzae endocarditis. Am J Med Sci 1979;278:173-6
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18. Gallant TE, Malinak LR, Gump DW, Mead PB. Haemophilus parainjluenzae peritonitis associated with an intrauterine contraceptive device. Am 1 Obstet Gynecol 1977;129:702-3 19. Blaylock BL, Baber S. Urinary tract infection caused by Haemophilus parairfiuenzae. Am 1 Clin Pathol 1980;73:285-7 20. Clairmont Gl, Zon LI, Groopman IE. Haemophilus parainjiuenzae prostatitis in a homosexual man with chronic lymphadenopathy syndrome and HTLV-III infection. Am 1 Med 1987;82:175-8 21. Sturm AW. Haemophilus injiuenzae and Haemophilus parainjiuenzae in nongonococcal urethritis. 1 Infect Dis 1986;153:165-7 22. Black CT, Kupferschmid IP, West KW, Grosfeld lL. Haemophilus parainjluenzae infections in children, with the report of a unique case. Rev Infect Dis 1988;10:342-6 23. Olk DG, Hamill RJ, Proctor PA. Case report: Haemophilus parainjluenzae vertebral osteomyelitis. Am 1 Med Sci 1987;294:114-6 24. Holzgang 1, Wehrli R, von Graevenitz A, Santanam P. Adult vertebral osteomyelitis caused by Haemophilus injiuenzae. Eur 1 Clin Microbiol 1984;3:261-2 25. Oill PA, Chow AW, Flood TP, Guze LB. Adult Haemophilus injiuenzae type B vertebral osteomyelitis. Clin Orthop 1978;136:253-6 26. Nahass RG, Cook S, Weinstein MP. Vertebral osteomyelitis due to Haemophilus aphrophilus: treatment with ceftriaxone. 1 Infect Dis 1989;159:811-2
RID 1991;13 (luly-August)
Haemophilus parainfluenzae as a Rare Cause of Epidural Abscess: Case Report and Review Grace M. Auten, Charles S. Levy, and Margo A. Smith
From the Section of Infectious Diseases, Washington Hospital Center and George Washington University, Washington, D.C.
Haemophilus parainfluenzae is a pleomorphic, fastidious, gram-negative coccobacillus that has been recognized as an infrequent cause of invasive disease. It has been noted as a cause most often of endocarditis, but increasingly other diseases caused by this organism are being reported. We present what we believe to be the first report of a patient with an epidural abscess caused by H. parainjiuenzae.
Case Report A previously healthy 74-year-old man developed severe pain at the posterior base of his neck that was not relieved by change of position, warm compresses, or bed rest. After 4 days he presented at an outpatient emergency department, where a nonsteroidal, antiinflammatory agent was prescribed. On day 6 of his illness, the patient presented at Washington Hospital Center (Washington, D.C.) because of worsening pain and limited range of motion in his neck. The patient reported no history of fever, chills, night sweats, or weight loss. He had experienced no muscle weakness, sensory changes, or urinary or bowel incontinence. His medical history was significant for periodontal disease, and he had had a chronically abscessed tooth removed 2 weeks before admission. A neck injury 20 years earlier had required cervical foraminectomy and had caused intermittent neck pain. He reported an allergy to penicillin but was unable to remember the adverse reaction.
Received 29 May 1990; revised 7 September 1990. Reprints and correspondence: Dr. Charles S. Levy, Section of Infectious Diseases, Washington Hospital Center, 110 Irving Street NW, Washington, D.C. 20010-2975. Reviews of Infectious Diseases 1991;13:609-12 © 1991 by The University of Chicago. AU rights reserved. 0162-0886/91/1304-0035$02.00
The patient's vital signs were normal. There were no oral lesions, and the appearance of the site of the recently extracted tooth was unremarkable. A soft midsystolic heart murmur was noted. Except for limitation of the range of motion of his neck, the neurologic examination revealed no abnormalities. Roentgenograms of the cervical spine revealed degenerative changes in the fifth and sixth cervical vertebral (C5 and C6) areas; these included narrowing of the space between the disks, formation of osteophytes, and minimal retrograde spondylolisthesis. Exacerbation of degenerative cervical disease was presumed to be the cause of his symptoms. The patient was treated with analgesics and bed rest, but only minimal relief was achieved. A bone scan on the second hospital day indicated increased uptake in the lower cervical spine. That evening, the patient developed numbness and weakness in both arms and in his right leg. A myelogram revealed almost total occlusion of the thecal sac at the C6 level. A computed tomogram revealed an extensive anterior, extradural soft tissue mass from the C3 to C6 levels and posterior displacement of the spinal cord (figure 1). Laboratory studies of CSF samples obtained at the time of myelography revealed the following values: red blood cells, 12/mm3 ; white blood cells (WBCs), 188/mm 3 (82 % neutrophils, 14% lymphocytes, and 4% mononuclear cells); protein, 582 mg/dL; and glucose, 61 mg/dL. The patient's peripheral WBC count was 7,800/mm3 • A laminectomy was performed to remove an extensive anterior cervical epidural abscess. A gram stain revealed that the purulent material from the abscess contained many WBCs but no organisms. The patient was treated with vancomycin, tobramycin, and aztreonam. Cultures of the abscess revealed H. parainjiuenzae in pure culture; the organism was detected on chocolate agar after 24 hours of incubation. No microorganisms were recovered from the blood or CSF. An echocardiogram was negative for cardiac vegetations. Therapy with ampicillin was precluded by the patient's allergy to penicillin.
Downloaded from http://cid.oxfordjournals.org/ at Yale University on July 10, 2015
We report a case of epidural abscess due to Haemophilus parainfluenzae. This microorganism is a normal inhabitant of the upper respiratory tract that causes endocarditis and, rarely, other invasive infections. To the best of our knowledge, epidural abscess due to H. parainjluenzae has not been reported previously. A 74-year-old man presented with neck pain and subsequently developed incomplete quadriparesis. A cervical epidural abscess and vertebral osteomyelitis were detected by radiologic studies. Surgical drainage and antibiotic therapy resulted in resolution of the abscess and osteomyelitis,and the neurologic sequelae were minimal. Cultures of the purulent material from the abscess yielded H. parainfluenzae. Descriptions in the literature of infections caused by H. parainjluenzae and the antimicrobial agents used for treatment of these infections are reviewed.
610
Auten, Levy, and Smith
RID 1991;13 (July-August)
Table 1. Degree of susceptibility of H. parainfluenzae organisms isolated from an epidural abscess to various antibiotics, in terms of MIC. Antibiotic Ampicillin Gentamicin Tobramycin Chloramphenicol TMP-SMZ Ciproftoxacin Cefazolin Cefuroxime Ceftriaxone Aztreonam Rifampin Erythromycin
He was treated intravenously with trimethoprim-sulfamethoxazole (TMP-SMZ; 240 mg every 6 hours) and tobramycin (80 mg every 8 hours). The peak and trough bacteriostatic and bactericidal levels in serum were >1:64. Postoperatively, the patient experienced incomplete quadriparesis, and magnetic resonance imaging of the cervical spine revealed changes consistent with vertebral osteomyelitis and residual epidural abscess. He remained afebrile, and by the time of discharge on the 20th hospital day, his neurologic function was improving gradually. The use of tobramycin was discontinued after the first 2 weeks of therapy. After mild neutropenia was noted during the fifth week of therapy with TMPSMZ, oral ciprofloxacin (750 mg every 12 hours) was administered instead to complete 2 more weeks of therapy. Four months postoperatively, there was no evidence of recurrence and the patient's only residual neurologic deficit was tingling in his fingertips. The Centers for Disease Control (Atlanta) later confirmed that the causative organism was H. parainjluenzae. No (j-lactamase production was detected, and tests for MICs revealed that H. parainjluenzae was susceptible to all the antibiotics tested except for erythromycin (table 1).
Literature Review and Discussion Epidural abscess is an uncommon disease that can have devastating results, including paralysis or death. The causative organism is most often Staphylococcus aureus, but the disease can also be caused by other gram-positive cocci, gramnegative bacilli, Mycobacterium tuberculosis, and opportunis-
~0.12
2.0 2.0 1.0 ~0.03/0.6
~0.03
1.0 0.25 ~0.OO2 ~0.5
0.5 8.0
tic organisms [1, 2]. Two studies of epidural abscesses due to other Haemophilus species have been reported [2, 3]; to our knowledge, there are no previous reports of epidural abscess caused by H. parainjiuenzae. Our patient presented with severe neck pain and then developed vertebral osteomyelitis and neurologic deficits secondary to a cervical epidural abscess. Although a heart murmur was detected, the negative results of blood cultures and of an echocardiogram made a diagnosis of endocarditis unlikely. We presumed that the original source of the H. parainjiuenzae infection was his dental abscess and that hematogenous seeding of the cervical spine and subsequent extension of infection to the epidural space had occurred. Previous reviews of vertebral osteomyelitis and epidural abscess have described the pathogenesis of these infections as hematogenous seeding of the vertebral spine from a distant focus such as a skin infection, periodontal abscess, urinary tract infection, or other localized infection. The spread of infection can also occur solely through the veins, such as through Batson's plexus from the genitourinary tract to the lumbar spine. Progression of the vertebral infection can then lead to its extension to surrounding tissue such as the disk space, psoas muscle, and epidural space [1, 4]. Deep infections (such as endocarditis) due to Haemophilus species are frequently attributed to seeding from previous dental procedures, dental abscesses, or periodontal disease [5, 6]. H. parainjiuenzae is a normal inhabitant of the upper respiratory tract. It is a small, pleomorphic, gram-negative coccobacillus with specific growth requirements. It tends to be slow-growing and is strictly a parasite, in need of accessory factors for growth. This organism is identified by its requirement for V factor (or nicotinamide-adenine dinucleotide) and by its nonhemolytic growth on sheep blood agar [7]. Even with supplemented media, the organism may not become detectable for several days. In cases of endocarditis, the mean interval between performance of blood cultures and apparent growth of the organism has been reported to be 6.3 days in
Downloaded from http://cid.oxfordjournals.org/ at Yale University on July 10, 2015
Figure 1. A computed tomogram of the cervical spine revealed posterior displacement of the contrast-enhanced spinal cord (between arrows) by an anterior epidural abscess.
MIC (J,.Lg/mL)
RID 1991;13 (July-August)
Epidural Abscess Due to H. parainfluenzae
Conclusion H. parainfiuenzae is a rare cause of epidural abscess. Because of its fastidious nature, this microorganism can be a
cause of epidural abscess or vertebral osteomyelitis yet can be difficult to isolate in culture. Optimal use of culture techniques, i.e., selection of appropriate media and sufficient duration of incubation, should improve the chances of recovering this organism. A diagnosis of H. parairfiuenzae infection should be considered for any patient with signs and symptoms of an epidural abscess, especially when periodontal disease is evident. To facilitate treatment in such cases, confirmation of this rare cause of epidural abscess should always be obtained by means of culture. Acknowledgment The authors thank Zenaida N. Leong for manuscript preparation.
References 1. Verner EF, Musher DM. Spinal epidural abscess. Med Clin North Am 1985;69:375-84 2. Danner RL, Hartman BJ. Update of spinal epidural abscess: 35 cases and review of the literature. Rev Infect Dis 1987;9:265-74 3. Gaudin P, Zagala A, Juvin R, Le Bas JF, Brion JP, Chirossel JP, Stahl JP, Phelip X. Haemophilus aphrophilus epidural abscess studied by nuclear magnetic resonance. Ann Med Interne (Paris) 1989;140:68-9 4. Beltrani VP, Echols RM, Vedder DK. Vertebral osteomyelitis caused by Haemophilus infiuenzae. J Infect Dis 1987;156:391-4 5. Chunn CJ, Jones SR, McCutchan JA, YoungEl, Gilbert DN. Haemophilus parairfluenzae infective endocarditis. Medicine (Baltimore) 1977; 56:99-113 6. Julander I, Lindberg AA, Svanbom M. Haemophilus parainfluenzaean uncommon cause of septicemia and endocarditis. Scand J Infect Dis 1980;12:85-9 7. Hand WL. Haemophilus species. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, 1990:1729-33 8. Jemsek JG, Greenberg SB, Gentry LO, Welton DE, Mattox KL. Haemophilus parainfluenzae endocarditis: two cases and review of the literature in the past decade. Am J Med 1979;66:51-7 9. Blair DC, Walker W, Sodeman T, Pagano T. Bacterial endocarditis due to Haemophilus parainfluenzae. Chest 1977;71:146-9 10. Lynn DJ, Kane JG, Parker RH. Haemophilus parairfiuenzae and injiuenzaeendocarditis: a review of forty cases. Medicine (Baltimore) 1977; 56:115-28 11. Wort AJ. Haemophilus parainfluenzae meningitis. Canadian Medical Association Journal 1975;112:606-7 12. Oill PA, Chow AW, Guze LB. Adult baeteremic Haemophilus parainjiuenzae infections: seven reports of cases and a review of the literature. Arch Intern Med 1979;139:985-8 13. Trollfors B, Brorson J-E, Claesson B, Sandberg T. Invasive infections caused by Haemophilus species other than Haemophilus injiuenzae. Infection 1985;13:12-4 14. Raoult D, Drancourt M, Gallais H, Casanova P. Haemophilus parainjiuenzae meningitis in an adult with an inherited deficiency of the seventh component of complement. Arch Intern Med 1987;147:2214 15. Maller R, Ansehn S, Fryden A. Haemophilusparainfiuenzae infection of the central nervous system: a report on two infants. Scand J Infect Dis 1977;9:241-2 16. Warman ST, Reinitz E, Klein RS. Haemophilusparainjiuenzae septic arthritis in an adult. JAMA 1981;246:868-9 17. Hollin SA, Hayashi H, Gross Sw. Intracranial abscesses of odontogenic origin. Oral Surg Oral Med Oral PathoI1967;23:277-93
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cases of left-sided infection and 8.5 days in cases of right-sided infection [8]. The most frequently reported infection caused by H. parainfluenzae is endocarditis. High rates of complications, including large vegetations, septic emboli, persistent fever, and persistent bacteremia, have been noted [5, 6, 8-10]. Other rarely reported deep infections due to H. parainfluenzae include meningitis [11-15], septicemia [13], empyema [13], epiglottitis [12, 13], septic arthritis [12, 16], brain abscess [13, 15, 17], pneumonia [12], peritonitis [18], urinary tract and genital infection [19-21], pharyngitis [12], and hepatic abscess [22]. H. parainfiuenzae previously has been reported as a cause of vertebral osteomyelitis of the lumbar region in one patient [23]. The authors of that report believed that the predisposing factor was the performance of a septoplasty 3 months before admission to the hospital for osteomyelitis and that bacteremia had been induced at the time of the operation. Other Haemophilus species were associated with two reported cases of epidural abscess. In a report from France, Haemophilus aphrophilus was documented as the cause of an epidural abscess in the thoracic spine of a previously healthy patient for whom there were no predisposing factors [3]. Another case due to an unspecified Haemophilus species has been reported, but no other clinical or microbiologic details are available [2]. Reported cases of vertebral osteomyelitis due to Haemophilus species but with no epidural abscess have been due most commonly to H. infiuenzae [4, 24, 25] and H. aphrophilus [26-31]. In reports of infection due to a Haemophilus species, difficulties in isolating the organism were frequently noted; cultures yielded either no growth or rare colonies of Haemophilus species, an occurrence suggestive of contamination of the culture. Repeated cultures were often required for diagnosis. Predisposing factors were frequently periodontal disease, upper respiratory tract infections, or genitourinary infections. H. parainfluenzae is generally susceptible in vitro to multiple antibiotics, but resistance to ampicillin (which is attributed to (j-Iactamase production) has been noted in up to 6% of clinical isolates [32, 33]. Administration of ampicillin with an aminoglycoside is generally recommended as therapy for infection due to {j-Iactamase-negative organisms. Cephalosporins, chloramphenicol, and TMP-SMZ have also been used successfully [5, 6, 8, 10, 34, 35]. However, even when therapy appears adequate in terms of bactericidal titers in serum and the results of in vitro susceptibility assays, therapeutic modalities fail frequently in the treatment of endocarditis [5, 8]. Fortunately, our patient's epidural abscess and vertebral osteomyelitis responded satisfactorily to surgical drainage and the antibiotics we chose for therapy.
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27. Farrington M, Eykyn SI, Walker M, Warren RE. Vertebralosteomyelitis due to coccobacilli of the HB group. BMI 1983;287:1658-60 28. Ho lL, Soukiasian S, Oh WH, Snydman DR. Haemophilus aphrophilus osteomyelitis. Am 1 Med 1984;76:159-61 29. Petty BG, Burrow CR, Robinson RA, Bulkley GB. Haemophilus aphrophilus meningitis followed by vertebral osteomyelitis and suppurative psoas abscess. Am J Med 1985;78:159-61 30. Gribble Ml, Hunter T. Haemophilus aphrophilus vertebral osteomyelitis: a case report and literature review. Diagn Microbial Infect Dis 1987;8:189-91 31. Houssiau FA, Huaux JP, De Deuxchaisnes CN. Haemophilus aphrophilus: a rare pathogen in vertebral osteomyelitis. Ann Rheum Dis 1987;46:248-50 32. Kauffman CA, Bergman AG, Hertz CS. Antimicrobial resistance of Haemophilus species in patients with chronic bronchitis. Am Rev Respir Dis 1979;120:1382-5 33. Mayo JB, McCarthy LR. Antimicrobial susceptibility of Haemophilus parairfiuenzae. Antimicrob Agents Chemother 1977;11:844-7 34. Calio AI, Cusumano S, Ullman RF, Tjio DY, Cunha BA. Haemophilus parainfiuenzae endocarditis. Heart Lung 1987;16:222-3 35. Smith PW, Chambers WA, Walker CA. Ampicillin-resistant Haemophilus parainfiuenzae endocarditis. Am J Med Sci 1979;278:173-6
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18. Gallant TE, Malinak LR, Gump DW, Mead PB. Haemophilus parainjluenzae peritonitis associated with an intrauterine contraceptive device. Am 1 Obstet Gynecol 1977;129:702-3 19. Blaylock BL, Baber S. Urinary tract infection caused by Haemophilus parairfiuenzae. Am 1 Clin Pathol 1980;73:285-7 20. Clairmont Gl, Zon LI, Groopman IE. Haemophilus parainjiuenzae prostatitis in a homosexual man with chronic lymphadenopathy syndrome and HTLV-III infection. Am 1 Med 1987;82:175-8 21. Sturm AW. Haemophilus injiuenzae and Haemophilus parainjiuenzae in nongonococcal urethritis. 1 Infect Dis 1986;153:165-7 22. Black CT, Kupferschmid IP, West KW, Grosfeld lL. Haemophilus parainjluenzae infections in children, with the report of a unique case. Rev Infect Dis 1988;10:342-6 23. Olk DG, Hamill RJ, Proctor PA. Case report: Haemophilus parainjluenzae vertebral osteomyelitis. Am 1 Med Sci 1987;294:114-6 24. Holzgang 1, Wehrli R, von Graevenitz A, Santanam P. Adult vertebral osteomyelitis caused by Haemophilus injiuenzae. Eur 1 Clin Microbiol 1984;3:261-2 25. Oill PA, Chow AW, Flood TP, Guze LB. Adult Haemophilus injiuenzae type B vertebral osteomyelitis. Clin Orthop 1978;136:253-6 26. Nahass RG, Cook S, Weinstein MP. Vertebral osteomyelitis due to Haemophilus aphrophilus: treatment with ceftriaxone. 1 Infect Dis 1989;159:811-2
RID 1991;13 (luly-August)
