Correspondence
1162
rable duration, iodoquinol is relatively inexpensive, both drugs are well tolerated and have efficacy rates comparable to that of diloxanide furoate, and both paromomycin and iodoquinol are easier to obtain in the United States.
James B. McAuley and Dennis D. Juranek Parasitic Disease Branch, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia References
Reply additional discussion of luminal agents by Drs. McAuley and Juranek is very helpful, and I agree with their assessment that no one drug is definitely superior to the others. The clear-cut indication for the use of one of these agents is to eradicate luminal cysts from patients who have been treated for amebic colitis or amebic liver abscess. Since most laboratories do not yet cultivate Entamoeba histolytica and cannot determine whether asymptomatic cyst passers are colonized with pathogenic or nonpathogenic zymodemes, these individuals should probably be treated with luminal agents as well. More practical methods of differentiating pathogenic and nonpathogenic strains of E. histolytica should be available in the future, and many of these patients will not require treatment. Most asymptomatic cyst passers in North America harbor nonpathogenic strains [ 1 ], and there is no evidence that these ameba can SIR-The
4. Suchak NG, Satoskar RS, Sheth UK. Entamide furoate in the treatment of intestinal amoebiasis. Am J Trop Med Hyg 1962;1 1:330-2. 5. Woodruff AW, Bell S. The evaluation of amoebicides. Trans R Soc Trop Med Hyg 1967;61:435-9. 6. Carter CH, Bayles A, Thompson PE. Effects of paromomycin sulfate in man against Entamoeba histolytica and other intestinal protozoa. Am J Trop Med Hyg 1968;11:448-51. 7. Courtney KO, Thompson PE, Hodgkinson R, Fitzsimmons JR. Paromomycin as a therapeutic substance for intestinal amebiasis and bacterial enteritis. In: Antibiotics annual 1959-1960. New York: Antibiotica, 1960;304-9. 8. Wolfe MS. Nondysenteric intestinal amebiasis treatment with diloxanide furoate. JAMA 1973;224:1601-4. 9. Keusch GT, Troncale FJ, Buchanan RD. Malabsorption due to paromomycin. Arch Intern Med 1970;125:273-6. 10. Kean BH. The treatment of amebiasis: a recurrent agony. JAMA 1976;235:501.
cause disease, even in severely immunocompromised patients with AIDS [2]. The use of paromomycin for the treatment of "intestinal amebiasis that is mild to moderately symptomatic" is more problematic. The available published information on its efficacy was gathered before the recognition of nonpathogenic E. histolytica, and the symptoms of some of these patients undoubtedly were caused by other enteropathogens. Since mild-to-moderate intestinal amebiasis can progress to severe and even life-threatening disease, it seems risky to use an agent of uncertain or lesser efficacy in treating symptomatic patients with parasitological or serological evidence of amebiasis. While the use of metronidazole during pregnancy is undesirable, there is much greater experience with metronidazole than with paromomycin, a drug of uncertain absorption and with unknown effects on the fetus.
Sharon L. Reed Division of Infectious Diseases, UCSD Medical Center, San Diego, California References
Correspondence: Dr. Sharon L. Reed, Division of Infectious Diseases, UCSD Medical Center, 225 Dickinson Street, San Diego, California 921038416. Clinical Infectious Diseases 1992;14:1162 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1405-0023$02.00
Leg Abscess Caused by Weeksella zoohelcum following a Dog Bite taxonomic study performed by Holmes et al. [1] in 1986 on 30 bacterial strains, previously designated as CDC
SIR-The
Correspondence: Dr. J. Reina, Clinical Microbiology Service, Hospital Son Dureta, 07014-Palma de Mallorca, Spain. Clinical Infectious Diseases 1992;14:1162-3 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1405-0024$02.00
1. Proctor EM, Wong Q, Yang J, Keystone JS. The electrophoretic isoenzyme patterns of strains of Entamoeba histolytica isolated in two major cities in Canada. Am J Trop Med Hyg 1987;37:296-301. 2. Reed SL, Wessel DW, Davis CE. Entamoeba histolytica infection and AIDS. Am J Med 1991;90:269-71.
group IIj, demonstrated that this group of bacteria constituted a homogeneous taxon; therefore, this group was considered a new species that could be included in the genus Weeksella, previously described by Holmes et al. [2], and it was designated Weeksella zoohelcum. Unlike Weeksella virosa, the other species included in this genus (it is isolated preferentially from the human genitourinary tract [3-5]), most strains of W. zoohelcum have been isolated from human wounds caused by bites of various animals [1,6]. The principal pathology associated with this microorganism seems to be infections secondary to animal bites. We describe a patient with a leg abscess caused by W. zoohelcum.
Downloaded from http://cid.oxfordjournals.org/ at New York University on September 6, 2015
1. Reed SL. Amebiasis: an update. Clin Infect Dis 1992;14:385-91. 2. American Academy of Pediatrics Committee on Drugs. Blindness and neuropathy from diiodohydroxyquin-like drugs. Pediatrics 1974; 54:378-9. 3. Botero DR. Treatment of acute and chronic intestinal amoebiasis with entamide furoate. Trans R Soc Trop Med Hyg 1964;58:419-21.
CID 1992;14 (May)
CID 1992;14 (May)
Correspondence
association with other infectious processes. Bracis et al. [8] described a case of meningitis due to CDC group IIj in a child that occurred following a dog bite. Noell et al. [9] described a case of septicemia in a diabetic woman. The woman's condition was associated with continuous contact with her cat. Holmes et al. [1] performed a taxonomic study covering strains isolated from other specimens (e.g., sputum, spinal fluid, and blood) that were obtained from humans. At present no specific antibiotic treatment is recommended for infections caused by W. zoohelcum. However, given the high degree of this organism's susceptibility to most antimicrobial agents (e.g., )3-lactam agents, aminoglycosides, tetracycline, sulfonamides, and quinolones), patients can be treated with agents that have demonstrated efficacy against strains isolated from animals [8]. Noell et al. [9] treated patients who had septicemia with cefotaxime. We also treated our patient with cefotaxime, and our patient's successful outcome supports the drug's clinical efficacy. Nevertheless, it is essential to perform antibiotic susceptibility studies for all clinical isolates until more epidemiological information regarding W. zoohelcum is available.
J. Reina and N. Borrell Clinical Microbiology Service, Hospital Son Dureta, Palma de Mallorca, Spain
References 1. Holmes B, Steigerwalt AG, Weaver RE, Brenner DJ. Weeksella zoohelcum sp. nov. (formerly group IIj) from human clinical specimens. Systematic Applied Microbiology 1986;8:191-6. 2. Holmes B, Steigerwalt AG, Weaver RE, Brenner DJ. Weeksella virosa gen. nov., sp. nov. (formerly group IV) found in human clinical specimens. Systematic Applied Microbiology 1986;8:185-90. 3. Mardy C, Holmes B. Incidence of vaginal Weeksella virosa (formerly group IIf). J Clin Pathol 1988;41:21 1-4. 4. Reina J, Gil J, Alomar P. Isolation of Weeksella virosa (formerly group 'If) from a vaginal sample. Eur J Clin Microbiol Infect Dis 1989;8:569-70. 5. Reina J, Gil J, Salva F, Gomez J, Alomar P. Microbiological characteristics of Weeksella virosa (formerly CDC group I1f) isolated from the human genitourinary tract. J Clin Microbiol 1990;28:2357-9. 6. Saphir DA, Carter GR. Gingival flora of the dog with special reference to bacteria associated with bites. J Clin Microbiol 1976;3:344-9. 7. Bailie WE, Stow EC, Schmitt EC. Aerobic bacterial flora of oral and nasal fluids of canines with reference to bacteria associated with bites. J Clin Microbiol 1978;7:223-31. 8. Bracis R, Seibers K, Julien RM. Meningitis caused by group IIj following a dog bite. West J Med 1979;131:438-40. 9. Noell F, Gorce MF, Garde C, Bizet C. Isolation of Weeksella zoohelcum in septicaemia [letter]. Lancet 1989;2:332.
Downloaded from http://cid.oxfordjournals.org/ at New York University on September 6, 2015
A 10-year-old boy presented to the emergency department with an abscess in the back of the right leg that had formed as the result of a wound caused by a dog bite 6 days previously. The patient was afebrile and had no signs of sepsis at presentation. The abscess was surgically debrided, prophylaxis for tetanus was administered, and treatment with cefotaxime (1 g every 12 hours) was initiated. Samples from the abscess were sent for microbiological study. The wound healed well after treatment with antiseptic washes and topical application of nitrofurazone. The patient was discharged from the hospital 5 days after admission. The sample was plated on blood, chocolate, MacConkey, and Schaedler agars as well as thioglycollate broth and incubated at 37°C for 18-24 hours. Subsequent examination of the plates revealed abundant growth of smooth, translucent, butyrous colonies only on the blood and chocolate agar plates. The colonies consisted of nonmotile, oxidase- and catalase-positive, gramnegative bacilli. The microorganism was biochemically identified with use of the API 20E and API 20NE systems (Biomerieux, France). The organism produced only urease and indol; it did not grow on MacConkey agar in the presence of 4% NaCl or hydrolyze polysorbate 80 and esculin, findings that led to the definitive identification of the organism as W. zoohelcum [1]. At the same time, slight growth of lactose- and oxidase-negative colonies, later identified as Serratia marcescens by conventional biochemical tests [7], was seen in the MacConkey medium. Antibiotic susceptibility was studied with use of the broth microdilution test. The microorganism was susceptible to ampicillin (MIC, 4 Ag/mL); ampicillin/clavulanic acid (MIC,
1162
rable duration, iodoquinol is relatively inexpensive, both drugs are well tolerated and have efficacy rates comparable to that of diloxanide furoate, and both paromomycin and iodoquinol are easier to obtain in the United States.
James B. McAuley and Dennis D. Juranek Parasitic Disease Branch, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia References
Reply additional discussion of luminal agents by Drs. McAuley and Juranek is very helpful, and I agree with their assessment that no one drug is definitely superior to the others. The clear-cut indication for the use of one of these agents is to eradicate luminal cysts from patients who have been treated for amebic colitis or amebic liver abscess. Since most laboratories do not yet cultivate Entamoeba histolytica and cannot determine whether asymptomatic cyst passers are colonized with pathogenic or nonpathogenic zymodemes, these individuals should probably be treated with luminal agents as well. More practical methods of differentiating pathogenic and nonpathogenic strains of E. histolytica should be available in the future, and many of these patients will not require treatment. Most asymptomatic cyst passers in North America harbor nonpathogenic strains [ 1 ], and there is no evidence that these ameba can SIR-The
4. Suchak NG, Satoskar RS, Sheth UK. Entamide furoate in the treatment of intestinal amoebiasis. Am J Trop Med Hyg 1962;1 1:330-2. 5. Woodruff AW, Bell S. The evaluation of amoebicides. Trans R Soc Trop Med Hyg 1967;61:435-9. 6. Carter CH, Bayles A, Thompson PE. Effects of paromomycin sulfate in man against Entamoeba histolytica and other intestinal protozoa. Am J Trop Med Hyg 1968;11:448-51. 7. Courtney KO, Thompson PE, Hodgkinson R, Fitzsimmons JR. Paromomycin as a therapeutic substance for intestinal amebiasis and bacterial enteritis. In: Antibiotics annual 1959-1960. New York: Antibiotica, 1960;304-9. 8. Wolfe MS. Nondysenteric intestinal amebiasis treatment with diloxanide furoate. JAMA 1973;224:1601-4. 9. Keusch GT, Troncale FJ, Buchanan RD. Malabsorption due to paromomycin. Arch Intern Med 1970;125:273-6. 10. Kean BH. The treatment of amebiasis: a recurrent agony. JAMA 1976;235:501.
cause disease, even in severely immunocompromised patients with AIDS [2]. The use of paromomycin for the treatment of "intestinal amebiasis that is mild to moderately symptomatic" is more problematic. The available published information on its efficacy was gathered before the recognition of nonpathogenic E. histolytica, and the symptoms of some of these patients undoubtedly were caused by other enteropathogens. Since mild-to-moderate intestinal amebiasis can progress to severe and even life-threatening disease, it seems risky to use an agent of uncertain or lesser efficacy in treating symptomatic patients with parasitological or serological evidence of amebiasis. While the use of metronidazole during pregnancy is undesirable, there is much greater experience with metronidazole than with paromomycin, a drug of uncertain absorption and with unknown effects on the fetus.
Sharon L. Reed Division of Infectious Diseases, UCSD Medical Center, San Diego, California References
Correspondence: Dr. Sharon L. Reed, Division of Infectious Diseases, UCSD Medical Center, 225 Dickinson Street, San Diego, California 921038416. Clinical Infectious Diseases 1992;14:1162 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1405-0023$02.00
Leg Abscess Caused by Weeksella zoohelcum following a Dog Bite taxonomic study performed by Holmes et al. [1] in 1986 on 30 bacterial strains, previously designated as CDC
SIR-The
Correspondence: Dr. J. Reina, Clinical Microbiology Service, Hospital Son Dureta, 07014-Palma de Mallorca, Spain. Clinical Infectious Diseases 1992;14:1162-3 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1405-0024$02.00
1. Proctor EM, Wong Q, Yang J, Keystone JS. The electrophoretic isoenzyme patterns of strains of Entamoeba histolytica isolated in two major cities in Canada. Am J Trop Med Hyg 1987;37:296-301. 2. Reed SL, Wessel DW, Davis CE. Entamoeba histolytica infection and AIDS. Am J Med 1991;90:269-71.
group IIj, demonstrated that this group of bacteria constituted a homogeneous taxon; therefore, this group was considered a new species that could be included in the genus Weeksella, previously described by Holmes et al. [2], and it was designated Weeksella zoohelcum. Unlike Weeksella virosa, the other species included in this genus (it is isolated preferentially from the human genitourinary tract [3-5]), most strains of W. zoohelcum have been isolated from human wounds caused by bites of various animals [1,6]. The principal pathology associated with this microorganism seems to be infections secondary to animal bites. We describe a patient with a leg abscess caused by W. zoohelcum.
Downloaded from http://cid.oxfordjournals.org/ at New York University on September 6, 2015
1. Reed SL. Amebiasis: an update. Clin Infect Dis 1992;14:385-91. 2. American Academy of Pediatrics Committee on Drugs. Blindness and neuropathy from diiodohydroxyquin-like drugs. Pediatrics 1974; 54:378-9. 3. Botero DR. Treatment of acute and chronic intestinal amoebiasis with entamide furoate. Trans R Soc Trop Med Hyg 1964;58:419-21.
CID 1992;14 (May)
CID 1992;14 (May)
Correspondence
association with other infectious processes. Bracis et al. [8] described a case of meningitis due to CDC group IIj in a child that occurred following a dog bite. Noell et al. [9] described a case of septicemia in a diabetic woman. The woman's condition was associated with continuous contact with her cat. Holmes et al. [1] performed a taxonomic study covering strains isolated from other specimens (e.g., sputum, spinal fluid, and blood) that were obtained from humans. At present no specific antibiotic treatment is recommended for infections caused by W. zoohelcum. However, given the high degree of this organism's susceptibility to most antimicrobial agents (e.g., )3-lactam agents, aminoglycosides, tetracycline, sulfonamides, and quinolones), patients can be treated with agents that have demonstrated efficacy against strains isolated from animals [8]. Noell et al. [9] treated patients who had septicemia with cefotaxime. We also treated our patient with cefotaxime, and our patient's successful outcome supports the drug's clinical efficacy. Nevertheless, it is essential to perform antibiotic susceptibility studies for all clinical isolates until more epidemiological information regarding W. zoohelcum is available.
J. Reina and N. Borrell Clinical Microbiology Service, Hospital Son Dureta, Palma de Mallorca, Spain
References 1. Holmes B, Steigerwalt AG, Weaver RE, Brenner DJ. Weeksella zoohelcum sp. nov. (formerly group IIj) from human clinical specimens. Systematic Applied Microbiology 1986;8:191-6. 2. Holmes B, Steigerwalt AG, Weaver RE, Brenner DJ. Weeksella virosa gen. nov., sp. nov. (formerly group IV) found in human clinical specimens. Systematic Applied Microbiology 1986;8:185-90. 3. Mardy C, Holmes B. Incidence of vaginal Weeksella virosa (formerly group IIf). J Clin Pathol 1988;41:21 1-4. 4. Reina J, Gil J, Alomar P. Isolation of Weeksella virosa (formerly group 'If) from a vaginal sample. Eur J Clin Microbiol Infect Dis 1989;8:569-70. 5. Reina J, Gil J, Salva F, Gomez J, Alomar P. Microbiological characteristics of Weeksella virosa (formerly CDC group I1f) isolated from the human genitourinary tract. J Clin Microbiol 1990;28:2357-9. 6. Saphir DA, Carter GR. Gingival flora of the dog with special reference to bacteria associated with bites. J Clin Microbiol 1976;3:344-9. 7. Bailie WE, Stow EC, Schmitt EC. Aerobic bacterial flora of oral and nasal fluids of canines with reference to bacteria associated with bites. J Clin Microbiol 1978;7:223-31. 8. Bracis R, Seibers K, Julien RM. Meningitis caused by group IIj following a dog bite. West J Med 1979;131:438-40. 9. Noell F, Gorce MF, Garde C, Bizet C. Isolation of Weeksella zoohelcum in septicaemia [letter]. Lancet 1989;2:332.
Downloaded from http://cid.oxfordjournals.org/ at New York University on September 6, 2015
A 10-year-old boy presented to the emergency department with an abscess in the back of the right leg that had formed as the result of a wound caused by a dog bite 6 days previously. The patient was afebrile and had no signs of sepsis at presentation. The abscess was surgically debrided, prophylaxis for tetanus was administered, and treatment with cefotaxime (1 g every 12 hours) was initiated. Samples from the abscess were sent for microbiological study. The wound healed well after treatment with antiseptic washes and topical application of nitrofurazone. The patient was discharged from the hospital 5 days after admission. The sample was plated on blood, chocolate, MacConkey, and Schaedler agars as well as thioglycollate broth and incubated at 37°C for 18-24 hours. Subsequent examination of the plates revealed abundant growth of smooth, translucent, butyrous colonies only on the blood and chocolate agar plates. The colonies consisted of nonmotile, oxidase- and catalase-positive, gramnegative bacilli. The microorganism was biochemically identified with use of the API 20E and API 20NE systems (Biomerieux, France). The organism produced only urease and indol; it did not grow on MacConkey agar in the presence of 4% NaCl or hydrolyze polysorbate 80 and esculin, findings that led to the definitive identification of the organism as W. zoohelcum [1]. At the same time, slight growth of lactose- and oxidase-negative colonies, later identified as Serratia marcescens by conventional biochemical tests [7], was seen in the MacConkey medium. Antibiotic susceptibility was studied with use of the broth microdilution test. The microorganism was susceptible to ampicillin (MIC, 4 Ag/mL); ampicillin/clavulanic acid (MIC,
