JOURNAL OF CLINICAL MICROBIOLOGY, Feb. 1979, p. 299-300 0095-1137/79/02-0299/02$02.00/0
Vol. 9, No. 2
Liver Abscess Caused by Haemophilus paraphrohaemolyticus GEORGE W. DOUGLAS,* LARRY L. BUCK, AND CLIFFORD ROSEN Department of Pathology, Microbiology Laboratory, Berkshire Medical Center, Pittsfield, Massachusetts 01201 Received for publication 8 November 1978
Haemophilus paraphrohaemolyticus was isolated in pure culture from a liver abscess in a 73-year-old man. In 1971, Zinnemann et al. (5) studied 11 isolates of a V-dependent, hemolytic, C02-preferring Haemophilus species which they named Haemophilus paraphrohaemolyticus. Nine isolates were of upper respiratory tract origin, one was from skin, and the other was from the urethra of an adult male. Kilian (2) has recently proposed that this species should be included in his Haemophilus parainfluenzae biotype III. Most of his isolates were from the upper respiratory tract of humans. To our knowledge there have been no previous reports of this organism isolated from a liver abscess. We have chosen to use the terminology of Zinnemann (H. paraphrohaemolyticus), as that of Kilian has not yet been officially adopted. Our patient was a 73-year-old male construction worker who had right side pleuritic-type chest pain. He had been in good health until 1 month before his pertinent admission to the Berkshire Medical Center when he was admitted because of a large anterior wall myocardial infarct. At 10 days after infarct, he developed temperature spikes to -102°F (ca. 33.5°C) with right upper quadrant tendemess. Chest X-ray was negative, the gallbladder did not visualize with an oral cholecystogram, and liver ultrasound was normal. Blood cultures were negative (10 days), and sputum cultures were unremarkable. There was a mild transaminase elevation. Ampicillin, gentamicin, and clindamycin were prescribed, and the fever and tenderness resolved over the next 7 days. He was discharged on no medication. His latest admission occurred during the next week because of the pleuritic pain. There was no fever, chills, abdominal pain, or right upper quadrant tenderness. Liver function chemistry tests revealed an alkaline phosphatase level of 311 IU/liter (N = 35-115), a serum glutamic oxalacetic transaminase level of 96 IU/liter (N = 7-40), and a serum glutamic pyruvic transaminase level of 67 IU/liter (N = 5-24). Serum bilirubin, lactic dehydrogenase, and creatine phosphokinase were in our normal range. The peripheral leukocyte count was 6,300 with nor-
mal differential. A liver and spleen scan demonstrated a large filling defect in the right lobe of the liver; ultrasound confirmed a cystic mass. Percutaneous aspiration of the lesion yielded 25 ml of thick brownish yellow fluid, so the wound was widened and a drain was inserted. The patient was placed on clindamycin and gentamicin. A Gram stain of the aspirated material showed abundant pus and proteinaceous material and a few questionable pleomorphic gramnegative bacilli. Trichrome preparations were negative for protozoa. The organism was isolated in pure culture from the liver aspirate after overnight incubation on a chocolate agar plate in 10% C02-90% air. No growth was present on sheep blood agar plates incubated aerobically or anaerobically (GasPak) or on MacConkey agar. Colonies were of pinpoint size and translucent. Gram stain showed short, thin gram-negative bacilli. Betalactamase was negative by the acidometric method (4). This result, plus a presumptive identification of the isolate as Haemophilus, was promptly called to the attention of the clinicians. Previous antibiotics were stopped, and the patient was started on ampicillin. Drainage from the wound was sterile within 48 h. He was discharged 2 weeks after the aspiration was performed, asymptomatic and with normal liver function studies. Subcultures of the original isolate were made to chocolate agar plates incubated at 35°C aerobically in 10% C02-90% air and anaerobically (GasPak) and to a horse blood agar plate incubated in 10% C02-90% air. After 18 h, there was good growth on the plates incubated in C02-air or anaerobically and there were small zones of beta-hemolysis around the colonies grown on horse blood agar. There was no growth on the aerobic chocolate plate. The isolate grew on Trypticase soy agar (in C02-air) with V factor or X + V factor strips, but not with X factor alone. The V-factor requirement was confirmed by two successive Trypticase soy agar subcultures. The organism was catalase positive and oxidase negative. 299
300
J. CLIN. MICROBIOL.
NOTES
Because of the unusual source for a Haemophilus species and its C02 requirement for growth, we hesitated to identify the organism as H. parahaemolyticus and elected to perform additional tests. With Minitek-GC broth and Minitek disks, the organism produced acid from glucose, maltose, and sucrose, and it was o-nitrophenyl-fl-D-galactopyranoside positive. No acid production was noted from lactose, xylose, and mannitol. Indole was not detected with the organism in Minitek-GC broth. Nitrate was reduced to nitrite. A presumptive identification of H. paraphrohaemolyticus was made, and the organism was sent to the Center for Disease Control via the Massachusetts State Laboratory for confirmation. The Center for Disease Control agreed with this identification and noted that the isolate was also urease and ornithine decarboxylase positive. By disk diffusion, the Center for Disease Control demonstrated susceptibility of the organism to ampicillin, tetracycline, and chloramphenicol and confirmed its lack of betalactamase. Minimal inhibitory concentrations were not determined. Although, because of the nature of our clinical microbiology practice, we do not plan to incorporate all of the biochemical tests listed in Table 1 in our usual Haemophilus work-up, the isolation of the C02-dependent species has made us acutely aware of the existence of H. paraphrohaemolyticus and H. paraphrophilus. Sims (3) found that approximately 13% of haemophili from the normal oral cavity were CO2 dependent, V dependent, and hemolytic. Jones et al. (1) found that 65 to 75% of the nonhemolytic, Vdependent respiratory tract isolates in their clinical laboratory were CO2 dependent, i.e. H. paraphrophilus. In retrospect, our laboratory has isolated a C02-preferring Haemophilus from culposcopy fluid and one from a leg wound, which
TABLE 1. Biochemical tests Three Liver isolate
Test
of strains Zinnemann et
Eight
strains of Kilian (2)
al. (5)
Hemolysis CO2 improves growth V-factor requirement X-factor requirement Catalase Oxidase Indole Urease Nitrate to nitrite
O-Nitrophenyl-,f-D-
galactopyranoside Glucose, acid Lactose, acid Sucrose, acid Xylose, acid a V, Variable. bNT, Not tested.
+ + +
+ + +
+ + +
+ +
+ V + + NT
+
+ +
+ +
-
+ V V V
V
+
NTb V + +
we reported, perhaps erroneously, as H. parainfluenzae. LITERATURE CITED 1. Jones, R. N., J. Slepack, and J. Bigelow. 1976. Ampi-
2. 3.
4.
5.
cillin-resistant Haemophilus paraphrophilus laryngoepiglottitis. J. Clin. Microbiol. 4:405-407. Kilian, M. 1976. A taxonomic study of the genus Haemophilus, with the proposal of a new species. J. Gen. Microbiol. 93:9-62. Sims, W. 1970. Oral haemophili. J. Med. Microbiol. 3: 615-625. Thornsberry, C., and L. A. Kirven. 1974. Ampicillin resistance in Haemophilus influenzae as determined by a rapid test for beta-lactamase production. Antimicrob. Agents Chemother. 6:653-654. Zinnemann, K., K. B. Rogers, J. Frazer, and S. K. Devaraj. 1971. A haemolytic V-dependent C02-preferring Haemophilus species (Haemophilusparaphrohaemolyticus nov. spec.). J. Med. Microbiol. 4:139-143.
Vol. 9, No. 2
Liver Abscess Caused by Haemophilus paraphrohaemolyticus GEORGE W. DOUGLAS,* LARRY L. BUCK, AND CLIFFORD ROSEN Department of Pathology, Microbiology Laboratory, Berkshire Medical Center, Pittsfield, Massachusetts 01201 Received for publication 8 November 1978
Haemophilus paraphrohaemolyticus was isolated in pure culture from a liver abscess in a 73-year-old man. In 1971, Zinnemann et al. (5) studied 11 isolates of a V-dependent, hemolytic, C02-preferring Haemophilus species which they named Haemophilus paraphrohaemolyticus. Nine isolates were of upper respiratory tract origin, one was from skin, and the other was from the urethra of an adult male. Kilian (2) has recently proposed that this species should be included in his Haemophilus parainfluenzae biotype III. Most of his isolates were from the upper respiratory tract of humans. To our knowledge there have been no previous reports of this organism isolated from a liver abscess. We have chosen to use the terminology of Zinnemann (H. paraphrohaemolyticus), as that of Kilian has not yet been officially adopted. Our patient was a 73-year-old male construction worker who had right side pleuritic-type chest pain. He had been in good health until 1 month before his pertinent admission to the Berkshire Medical Center when he was admitted because of a large anterior wall myocardial infarct. At 10 days after infarct, he developed temperature spikes to -102°F (ca. 33.5°C) with right upper quadrant tendemess. Chest X-ray was negative, the gallbladder did not visualize with an oral cholecystogram, and liver ultrasound was normal. Blood cultures were negative (10 days), and sputum cultures were unremarkable. There was a mild transaminase elevation. Ampicillin, gentamicin, and clindamycin were prescribed, and the fever and tenderness resolved over the next 7 days. He was discharged on no medication. His latest admission occurred during the next week because of the pleuritic pain. There was no fever, chills, abdominal pain, or right upper quadrant tenderness. Liver function chemistry tests revealed an alkaline phosphatase level of 311 IU/liter (N = 35-115), a serum glutamic oxalacetic transaminase level of 96 IU/liter (N = 7-40), and a serum glutamic pyruvic transaminase level of 67 IU/liter (N = 5-24). Serum bilirubin, lactic dehydrogenase, and creatine phosphokinase were in our normal range. The peripheral leukocyte count was 6,300 with nor-
mal differential. A liver and spleen scan demonstrated a large filling defect in the right lobe of the liver; ultrasound confirmed a cystic mass. Percutaneous aspiration of the lesion yielded 25 ml of thick brownish yellow fluid, so the wound was widened and a drain was inserted. The patient was placed on clindamycin and gentamicin. A Gram stain of the aspirated material showed abundant pus and proteinaceous material and a few questionable pleomorphic gramnegative bacilli. Trichrome preparations were negative for protozoa. The organism was isolated in pure culture from the liver aspirate after overnight incubation on a chocolate agar plate in 10% C02-90% air. No growth was present on sheep blood agar plates incubated aerobically or anaerobically (GasPak) or on MacConkey agar. Colonies were of pinpoint size and translucent. Gram stain showed short, thin gram-negative bacilli. Betalactamase was negative by the acidometric method (4). This result, plus a presumptive identification of the isolate as Haemophilus, was promptly called to the attention of the clinicians. Previous antibiotics were stopped, and the patient was started on ampicillin. Drainage from the wound was sterile within 48 h. He was discharged 2 weeks after the aspiration was performed, asymptomatic and with normal liver function studies. Subcultures of the original isolate were made to chocolate agar plates incubated at 35°C aerobically in 10% C02-90% air and anaerobically (GasPak) and to a horse blood agar plate incubated in 10% C02-90% air. After 18 h, there was good growth on the plates incubated in C02-air or anaerobically and there were small zones of beta-hemolysis around the colonies grown on horse blood agar. There was no growth on the aerobic chocolate plate. The isolate grew on Trypticase soy agar (in C02-air) with V factor or X + V factor strips, but not with X factor alone. The V-factor requirement was confirmed by two successive Trypticase soy agar subcultures. The organism was catalase positive and oxidase negative. 299
300
J. CLIN. MICROBIOL.
NOTES
Because of the unusual source for a Haemophilus species and its C02 requirement for growth, we hesitated to identify the organism as H. parahaemolyticus and elected to perform additional tests. With Minitek-GC broth and Minitek disks, the organism produced acid from glucose, maltose, and sucrose, and it was o-nitrophenyl-fl-D-galactopyranoside positive. No acid production was noted from lactose, xylose, and mannitol. Indole was not detected with the organism in Minitek-GC broth. Nitrate was reduced to nitrite. A presumptive identification of H. paraphrohaemolyticus was made, and the organism was sent to the Center for Disease Control via the Massachusetts State Laboratory for confirmation. The Center for Disease Control agreed with this identification and noted that the isolate was also urease and ornithine decarboxylase positive. By disk diffusion, the Center for Disease Control demonstrated susceptibility of the organism to ampicillin, tetracycline, and chloramphenicol and confirmed its lack of betalactamase. Minimal inhibitory concentrations were not determined. Although, because of the nature of our clinical microbiology practice, we do not plan to incorporate all of the biochemical tests listed in Table 1 in our usual Haemophilus work-up, the isolation of the C02-dependent species has made us acutely aware of the existence of H. paraphrohaemolyticus and H. paraphrophilus. Sims (3) found that approximately 13% of haemophili from the normal oral cavity were CO2 dependent, V dependent, and hemolytic. Jones et al. (1) found that 65 to 75% of the nonhemolytic, Vdependent respiratory tract isolates in their clinical laboratory were CO2 dependent, i.e. H. paraphrophilus. In retrospect, our laboratory has isolated a C02-preferring Haemophilus from culposcopy fluid and one from a leg wound, which
TABLE 1. Biochemical tests Three Liver isolate
Test
of strains Zinnemann et
Eight
strains of Kilian (2)
al. (5)
Hemolysis CO2 improves growth V-factor requirement X-factor requirement Catalase Oxidase Indole Urease Nitrate to nitrite
O-Nitrophenyl-,f-D-
galactopyranoside Glucose, acid Lactose, acid Sucrose, acid Xylose, acid a V, Variable. bNT, Not tested.
+ + +
+ + +
+ + +
+ +
+ V + + NT
+
+ +
+ +
-
+ V V V
V
+
NTb V + +
we reported, perhaps erroneously, as H. parainfluenzae. LITERATURE CITED 1. Jones, R. N., J. Slepack, and J. Bigelow. 1976. Ampi-
2. 3.
4.
5.
cillin-resistant Haemophilus paraphrophilus laryngoepiglottitis. J. Clin. Microbiol. 4:405-407. Kilian, M. 1976. A taxonomic study of the genus Haemophilus, with the proposal of a new species. J. Gen. Microbiol. 93:9-62. Sims, W. 1970. Oral haemophili. J. Med. Microbiol. 3: 615-625. Thornsberry, C., and L. A. Kirven. 1974. Ampicillin resistance in Haemophilus influenzae as determined by a rapid test for beta-lactamase production. Antimicrob. Agents Chemother. 6:653-654. Zinnemann, K., K. B. Rogers, J. Frazer, and S. K. Devaraj. 1971. A haemolytic V-dependent C02-preferring Haemophilus species (Haemophilusparaphrohaemolyticus nov. spec.). J. Med. Microbiol. 4:139-143.
