CID 1992; 15 (December)
Correspondence
Native Valve Endocarditis Due to Corynebacterium pseudodiphtheriticum SIR-We would like to add the case of another patient with native valve endocarditis due to Corynebacterium pseudodiphtheriticum to the series described by Morris and Guild [1]. An 82-year-old man collapsed while walking and was admitted to the hospital with new right-sided weakness. The family reported that the patient had previously been active and in good health. He apparently had complained of fatigue for 2 weeks before admission; this fatigue was associated with myalgias, back pain, and weakness that began 5 days before admission. An echocardiogram 18 months earlier had revealed aortic regurgitation. His only medication was a Chinese herbal preparation. On physical examination he was drowsy but afebrile. His
Correspondence: Dr. Mary Wilson, Department of Medicine and Division of Infectious Diseases, Mount Auburn Hospital, 330 Mount Auburn Street, Cambridge, Massachusetts 02238. Clinical Infectious Diseases 1992;15:1059-60 © 1992 by The Universityof Chicago. All rights reserved. 1058-4838/92/1506-0032$02.00
David T. Dennis, Grant L. Campbell, and Thomas J. Quan Division of Vector-Borne Infectious Diseases, National Centerfor Infectious Diseases, Centersfor DiseaseControl, Fort Collins, Colorado References I. Berger BW, Johnson RC, Kodner C, Coleman L. Cultivation of Borrelia burgdorferi from erythema migrans lesions and perilesional skin. J Clin MicrobioI1992;30:359-61. 2. Wormser GP, Forseter G, Cooper D, et al. Use ofa novel technique of cutaneous lavage for diagnosis of Lyme disease associated with erythema migrans. JAMA 1992;268:1311-3. 3. Preac-Mursic V, Wilske B, Schierz G. European Borrelia burgdorferi isolated from humans and ticks: culture conditions and antibiotic susceptibility. Zentralbl Bakteriol Mikrobiol Hyg [AJ 1986; 263: 112-8. 4. Barbour AG. Laboratory aspects of Lyme borreliosis. Clin Microbiol Rev 1988;1:399-414. 5. Hughes CA, Kodner CB, Johnson RC. DNA analysis of Borrelia burgdorferi NCH-I, the first northcentral U.S. human Lyme disease isolate. J Clin Microbiol 1992;30:698-703. 6. Steere AC, Grodzicki RL, Kornblatt AN, et al. The spirochetal etiology of Lyme disease. N Engl J Med 1983;308:733-40. 7. Rawlings JA, Fournier PY. Teltow GJ. Isolation of Borrelia spirochetes from patients in Texas. J Clin MicrobioI1987;25: 1148-50. 8. Lastavica CC, Wilson ML, Berardi YP. Spielman A, Deblinger RD. Rapid emergence of a focal epidemic of Lyme disease in coastal Massachusetts. N Engl J Med 1989;320: 134-7. 9. Coan ME, Stiller D. Ixodes dammini (Acari: Ixodidae) in Maryland, USA, and a preliminary survey for Babesia microti. J Med Entomol 1986;23:446-53. 10. Amerasinghe FP, Breisch NL, Azad AF, et al. Distribution, density, and Lyme disease spirochete infection in Ixodes dammini (Acari: Ixodidae) on white-tailed deer in Maryland. J Med EntomoI1992;29:5461. II. Thambidurai RM. Grigor JK, Horman JT, Israel E. Lyme disease: epidemiological characteristics in Maryland, 1984-1986. Maryland Med J 1988;37:465-7.
blood pressure was 160/64 mm Hg, and his pulse was 40/min and regular. He had systolic and diastolic murmurs. Coarse rhonchi were heard bilaterally. His liver and spleen were not enlarged on palpation or percussion. He had no mucocutaneous stigmata of endocarditis. He had a left facial droop and flaccid right hemiplegia. On admission, laboratory values included a hematocrit of 34.5% and a white blood cell count of 12,300/ mm"; the serum electrolyte level was normal, and creatinine clearance was 1.2 mg/dL. The erythrocyte sedimentation rate was 49 mrn/h. An electrocardiogram showed a 2: 1atrioventricular block and no acute ischemic changes. Changes noted on computed tomography of the head were consistent with an early left-sided cerebral infarct. A transthoracic echocardiogram was interpreted as showing moderate aortic insufficiency, mild mitral regurgitation, and mild tricuspid regurgitation. No definite vegetations were noted. All seven sets of cultures of blood drawn during the first 3 days became positive for a gram-positive bacillus, later identified as C. pseudodiphtheriticum, after intervals ranging from 1 to 4 days. Identification was confirmed by the State Laboratory Institute of the Massachusetts Department of Public Health. With use of the disk diffusion method, it was determined that
Downloaded from http://cid.oxfordjournals.org/ at University of Exeter on July 19, 2015
obvious partial central clearing at the site of the tick bite. He had no constitutional symptoms or arthritis and did not exhibit neurological or cardiac signs of Lyme disease. A 4-mm punch biopsy specimen of the skin lesion was obtained on 15 July when the lesion was ,...." 15 em in diameter; the biopsy specimen was placed in 4.5 mL of'Barbour-Stoenner-Kelly (BSK) medium and shipped overnight to the Centers for Disease Control (Diagnostic and Reference Laboratory, Bacterial Zoonoses Branch, Division ofVector-Borne Infectious Diseases, Fort Collins, Colorado). The patient was treated with doxycycline at a dose of 200 mg twice a day for 3 days; the dosage was then decreased to 100 mg twice a day for 3 weeks. Clinical recovery was rapid and complete. The culture of the skin biopsy specimen yielded B. burgdorferi. Four cultures in BSK medium of blood collected at the same time as the skin biopsy specimen were negative for spirochetes. An enzyme immunoassay ofserum drawn on 5 September was performed using a whole-cell sonicate of the B31 strain of the organism (optical density ratio, O. 19; positive cutoff, 1.00); this test was negative, suggesting that the prompt antibiotic treatment had aborted an antibody response [8]. The presence of I. dammini, the principal vector of B. burgdorferi in the eastern and north central United States, was first recognized in Maryland in 1980-1981 when it was collected from Assateague Island [9]. By 1989, I. dammini ticks that were infected with B. burgdorferi had been shown to be well established in many areas of the state, including Prince Georges County [10]. Human cases of Lyme disease have been reported from Maryland since the early 1980s [11]. To help establish the true geographic distribution of B. burgdorferi in the United States, we encourage clinicians to attempt to isolate this organism from patients (particularly from their skin lesions). This is especially important in states where human cases of the disease have been reported but a cycle of transmission of B. burgdorferi in nature has not been documented.
1059
1060
Correspondence
Streptococcus pneumoniae Peritonitis Secondary to Genital Tract Infection in a Previously Healthy Woman SIR-Streptococcus pneumoniae peritonitis is a well-known entity described in the past century. It was a relatively common disease in the preantibiotic era; both reporting ofcases and severity of disease have declined during the past decades. It is usually associated with hepatic or cardiac ascites in adult patients and with nephrotic syndrome and appendicitis in children. Pneumococcal peritonitis can present either as a primary disease or secondary to adjacent or distant pneumococcal infections. We report the case of a previously healthy young woman who presented with bacteremic pneumococcal peritonitis arising from the genital tract in the absence oflocal factors predisposing to infection. A 31-year-old woman with a history of hysteropexy and appendectomy was admitted to our hospital complaining ofleukorrhea and hypogastric pain followed by foul-smelling metrorrhagia and sustained fever. The general physical examination showed no abnormalities, except for slight pallor and sweating. Her temperature initially was 38.2°C, increasing to 40.rC a few hours later. Pelvic examination revealed normal external genitalia, yellowish cervical exudate, and painful mobilization. Both adnexal areas were tender and firm. She had rebound tenderness over the suprapubic area. On admission, her white blood cell count was 17.35 X I09fL with 5%band forms. Abdominal and pelvic ultrasonography showed endometrial thickening, bi-
Correspondence: Dr. Javier Gomez Rodrigo, Infectious Diseases Unit, Hospital Severo Ochoa, Avenida de Orellana Sin Numero, Leganes, 28911Madrid, Spain.
Clinical Infectious Diseases 1992;15:1060-1 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1506-0034$02.00
and can be lethal. In our patient valvular function remained adequate. Although presumably bacteriologically cured, the patient died of neurological complications. The clinical course suggested an initial embolic event that led to cerebral infarction. The hemorrhage could have been due to an unrecognized mycotic aneurysm or, more likely, hemorrhage into tissue altered by ischemia and necrosis. Our patient was initially afebrile, as may be the case in endocarditis, especially in elderly patients. His course serves as a reminder that endocarditis should be considered in the differential diagnosis for patients who present with new neurological events.
Mary E. Wilson and Debra S. Shapiro Department ofMedicineand Division ofInfectious Diseases, Mount Auburn Hospital, Cambridge, Massachusetts
Reference I. Morris A, Guild 1. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains. Clin Infect Dis 1991;13:887-92.
lateral adnexal enlargement, and free fluid in Douglas' cul-desac. Laparoscopy was unsuccessful because of previous surgery, and a laparotomy was performed. At surgery purulent peritoneal fluid was obtained from the abdominal cavity and Douglas' culde-sac; the perihepatic area was free of infection. Both fallopian tubes were inflamed and purulent. On admission she was treated with iv ampicillin, clindamycin, and gentamicin; the patient's condition improved soon after surgery. On the second day, blood cultures yielded penicillin-sensitive S. pneumoniae, and therapy was changed to that with oral amoxycillin. The same organism was recovered from peritoneal fluid inoculated in aerobic Bactec, as well as from endometrial and endocervical samples. Gram-positive diplococci were seen in gram-stained preparations of the endometrial and endocervical specimens. Cultures yielded no other pathogens, and the urine culture and results of the direct fluorescence test of cervical specimens for Chlamydia were negative. The blood culture strain was identified as serotype 1. In 1990 Westh et al. [1] reported nine cases of pneumococcal peritonitis, along with seven cases of pneumococcal bartholinitis and one case of vulvovaginitis. In their review, they found reports of 27 cases published between 1938 and 1988. Most of the patients had local factors predisposing them to infection, mainly the use ofan intrauterine contraceptive device (IUD) or changes secondary to the postpartum or postabortion period. They pointed out the fact that mortality for this rare entity ranged from almost 85%in the preantibiotic era to 0 after 1963. Six months later, Christopher et al. [2] reported one case of pneumococcal peritonitis in a young woman who had undergone three previous cesarean sections. The diagnosis ofour case prompted a MEDLINE search of the English-language literature. We found four additional cases in Westh's review, two of them occurring in IUD-bearing women [3-6]. As previously suggested, pneumococcal pelviperitonitis may be an underreported entity. S. pneumoniae can easily be missed as "saprophy-
Downloaded from http://cid.oxfordjournals.org/ at University of Exeter on July 19, 2015
the isolate was sensitive to penicillin, ampicillin, cephalothin, chloramphenicol, clindamycin, erythromycin, gentamicin, vancomycin, and tetracycline. Testing by the agar dilution method was not performed. The patient was initially given vancomycin. Treatment was changed to administration of penicillin and gentamicin when the sensitivity profile of the organism was complete. While the patient was receiving penicillin and gentamicin, his serum was bactericidal at a dilution of ~ 1:256. His hospital course was complicated by mild congestive heart failure that responded promptly to diuretics. His right hemiplegia remained unchanged. Approximately 3 weeks into his hospital course, the patient became unresponsive and developed total flaccid paralysis. Computed tomography showed hemorrhage into the area of the cerebral infarct. Although the patient completed 4 weeks of antibiotic therapy and repeated blood cultures were sterile, he remained comatose and died ....., 7 weeks postadmission after a massive gastrointestinal hemorrhage occurred. Permission for autopsy was refused. The case of our patient reinforces the findings of Morris and Guild [1] that C. pseudodiphtheriticum can infect native valves
CID 1992; 15 (December)
Correspondence
Native Valve Endocarditis Due to Corynebacterium pseudodiphtheriticum SIR-We would like to add the case of another patient with native valve endocarditis due to Corynebacterium pseudodiphtheriticum to the series described by Morris and Guild [1]. An 82-year-old man collapsed while walking and was admitted to the hospital with new right-sided weakness. The family reported that the patient had previously been active and in good health. He apparently had complained of fatigue for 2 weeks before admission; this fatigue was associated with myalgias, back pain, and weakness that began 5 days before admission. An echocardiogram 18 months earlier had revealed aortic regurgitation. His only medication was a Chinese herbal preparation. On physical examination he was drowsy but afebrile. His
Correspondence: Dr. Mary Wilson, Department of Medicine and Division of Infectious Diseases, Mount Auburn Hospital, 330 Mount Auburn Street, Cambridge, Massachusetts 02238. Clinical Infectious Diseases 1992;15:1059-60 © 1992 by The Universityof Chicago. All rights reserved. 1058-4838/92/1506-0032$02.00
David T. Dennis, Grant L. Campbell, and Thomas J. Quan Division of Vector-Borne Infectious Diseases, National Centerfor Infectious Diseases, Centersfor DiseaseControl, Fort Collins, Colorado References I. Berger BW, Johnson RC, Kodner C, Coleman L. Cultivation of Borrelia burgdorferi from erythema migrans lesions and perilesional skin. J Clin MicrobioI1992;30:359-61. 2. Wormser GP, Forseter G, Cooper D, et al. Use ofa novel technique of cutaneous lavage for diagnosis of Lyme disease associated with erythema migrans. JAMA 1992;268:1311-3. 3. Preac-Mursic V, Wilske B, Schierz G. European Borrelia burgdorferi isolated from humans and ticks: culture conditions and antibiotic susceptibility. Zentralbl Bakteriol Mikrobiol Hyg [AJ 1986; 263: 112-8. 4. Barbour AG. Laboratory aspects of Lyme borreliosis. Clin Microbiol Rev 1988;1:399-414. 5. Hughes CA, Kodner CB, Johnson RC. DNA analysis of Borrelia burgdorferi NCH-I, the first northcentral U.S. human Lyme disease isolate. J Clin Microbiol 1992;30:698-703. 6. Steere AC, Grodzicki RL, Kornblatt AN, et al. The spirochetal etiology of Lyme disease. N Engl J Med 1983;308:733-40. 7. Rawlings JA, Fournier PY. Teltow GJ. Isolation of Borrelia spirochetes from patients in Texas. J Clin MicrobioI1987;25: 1148-50. 8. Lastavica CC, Wilson ML, Berardi YP. Spielman A, Deblinger RD. Rapid emergence of a focal epidemic of Lyme disease in coastal Massachusetts. N Engl J Med 1989;320: 134-7. 9. Coan ME, Stiller D. Ixodes dammini (Acari: Ixodidae) in Maryland, USA, and a preliminary survey for Babesia microti. J Med Entomol 1986;23:446-53. 10. Amerasinghe FP, Breisch NL, Azad AF, et al. Distribution, density, and Lyme disease spirochete infection in Ixodes dammini (Acari: Ixodidae) on white-tailed deer in Maryland. J Med EntomoI1992;29:5461. II. Thambidurai RM. Grigor JK, Horman JT, Israel E. Lyme disease: epidemiological characteristics in Maryland, 1984-1986. Maryland Med J 1988;37:465-7.
blood pressure was 160/64 mm Hg, and his pulse was 40/min and regular. He had systolic and diastolic murmurs. Coarse rhonchi were heard bilaterally. His liver and spleen were not enlarged on palpation or percussion. He had no mucocutaneous stigmata of endocarditis. He had a left facial droop and flaccid right hemiplegia. On admission, laboratory values included a hematocrit of 34.5% and a white blood cell count of 12,300/ mm"; the serum electrolyte level was normal, and creatinine clearance was 1.2 mg/dL. The erythrocyte sedimentation rate was 49 mrn/h. An electrocardiogram showed a 2: 1atrioventricular block and no acute ischemic changes. Changes noted on computed tomography of the head were consistent with an early left-sided cerebral infarct. A transthoracic echocardiogram was interpreted as showing moderate aortic insufficiency, mild mitral regurgitation, and mild tricuspid regurgitation. No definite vegetations were noted. All seven sets of cultures of blood drawn during the first 3 days became positive for a gram-positive bacillus, later identified as C. pseudodiphtheriticum, after intervals ranging from 1 to 4 days. Identification was confirmed by the State Laboratory Institute of the Massachusetts Department of Public Health. With use of the disk diffusion method, it was determined that
Downloaded from http://cid.oxfordjournals.org/ at University of Exeter on July 19, 2015
obvious partial central clearing at the site of the tick bite. He had no constitutional symptoms or arthritis and did not exhibit neurological or cardiac signs of Lyme disease. A 4-mm punch biopsy specimen of the skin lesion was obtained on 15 July when the lesion was ,...." 15 em in diameter; the biopsy specimen was placed in 4.5 mL of'Barbour-Stoenner-Kelly (BSK) medium and shipped overnight to the Centers for Disease Control (Diagnostic and Reference Laboratory, Bacterial Zoonoses Branch, Division ofVector-Borne Infectious Diseases, Fort Collins, Colorado). The patient was treated with doxycycline at a dose of 200 mg twice a day for 3 days; the dosage was then decreased to 100 mg twice a day for 3 weeks. Clinical recovery was rapid and complete. The culture of the skin biopsy specimen yielded B. burgdorferi. Four cultures in BSK medium of blood collected at the same time as the skin biopsy specimen were negative for spirochetes. An enzyme immunoassay ofserum drawn on 5 September was performed using a whole-cell sonicate of the B31 strain of the organism (optical density ratio, O. 19; positive cutoff, 1.00); this test was negative, suggesting that the prompt antibiotic treatment had aborted an antibody response [8]. The presence of I. dammini, the principal vector of B. burgdorferi in the eastern and north central United States, was first recognized in Maryland in 1980-1981 when it was collected from Assateague Island [9]. By 1989, I. dammini ticks that were infected with B. burgdorferi had been shown to be well established in many areas of the state, including Prince Georges County [10]. Human cases of Lyme disease have been reported from Maryland since the early 1980s [11]. To help establish the true geographic distribution of B. burgdorferi in the United States, we encourage clinicians to attempt to isolate this organism from patients (particularly from their skin lesions). This is especially important in states where human cases of the disease have been reported but a cycle of transmission of B. burgdorferi in nature has not been documented.
1059
1060
Correspondence
Streptococcus pneumoniae Peritonitis Secondary to Genital Tract Infection in a Previously Healthy Woman SIR-Streptococcus pneumoniae peritonitis is a well-known entity described in the past century. It was a relatively common disease in the preantibiotic era; both reporting ofcases and severity of disease have declined during the past decades. It is usually associated with hepatic or cardiac ascites in adult patients and with nephrotic syndrome and appendicitis in children. Pneumococcal peritonitis can present either as a primary disease or secondary to adjacent or distant pneumococcal infections. We report the case of a previously healthy young woman who presented with bacteremic pneumococcal peritonitis arising from the genital tract in the absence oflocal factors predisposing to infection. A 31-year-old woman with a history of hysteropexy and appendectomy was admitted to our hospital complaining ofleukorrhea and hypogastric pain followed by foul-smelling metrorrhagia and sustained fever. The general physical examination showed no abnormalities, except for slight pallor and sweating. Her temperature initially was 38.2°C, increasing to 40.rC a few hours later. Pelvic examination revealed normal external genitalia, yellowish cervical exudate, and painful mobilization. Both adnexal areas were tender and firm. She had rebound tenderness over the suprapubic area. On admission, her white blood cell count was 17.35 X I09fL with 5%band forms. Abdominal and pelvic ultrasonography showed endometrial thickening, bi-
Correspondence: Dr. Javier Gomez Rodrigo, Infectious Diseases Unit, Hospital Severo Ochoa, Avenida de Orellana Sin Numero, Leganes, 28911Madrid, Spain.
Clinical Infectious Diseases 1992;15:1060-1 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1506-0034$02.00
and can be lethal. In our patient valvular function remained adequate. Although presumably bacteriologically cured, the patient died of neurological complications. The clinical course suggested an initial embolic event that led to cerebral infarction. The hemorrhage could have been due to an unrecognized mycotic aneurysm or, more likely, hemorrhage into tissue altered by ischemia and necrosis. Our patient was initially afebrile, as may be the case in endocarditis, especially in elderly patients. His course serves as a reminder that endocarditis should be considered in the differential diagnosis for patients who present with new neurological events.
Mary E. Wilson and Debra S. Shapiro Department ofMedicineand Division ofInfectious Diseases, Mount Auburn Hospital, Cambridge, Massachusetts
Reference I. Morris A, Guild 1. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains. Clin Infect Dis 1991;13:887-92.
lateral adnexal enlargement, and free fluid in Douglas' cul-desac. Laparoscopy was unsuccessful because of previous surgery, and a laparotomy was performed. At surgery purulent peritoneal fluid was obtained from the abdominal cavity and Douglas' culde-sac; the perihepatic area was free of infection. Both fallopian tubes were inflamed and purulent. On admission she was treated with iv ampicillin, clindamycin, and gentamicin; the patient's condition improved soon after surgery. On the second day, blood cultures yielded penicillin-sensitive S. pneumoniae, and therapy was changed to that with oral amoxycillin. The same organism was recovered from peritoneal fluid inoculated in aerobic Bactec, as well as from endometrial and endocervical samples. Gram-positive diplococci were seen in gram-stained preparations of the endometrial and endocervical specimens. Cultures yielded no other pathogens, and the urine culture and results of the direct fluorescence test of cervical specimens for Chlamydia were negative. The blood culture strain was identified as serotype 1. In 1990 Westh et al. [1] reported nine cases of pneumococcal peritonitis, along with seven cases of pneumococcal bartholinitis and one case of vulvovaginitis. In their review, they found reports of 27 cases published between 1938 and 1988. Most of the patients had local factors predisposing them to infection, mainly the use ofan intrauterine contraceptive device (IUD) or changes secondary to the postpartum or postabortion period. They pointed out the fact that mortality for this rare entity ranged from almost 85%in the preantibiotic era to 0 after 1963. Six months later, Christopher et al. [2] reported one case of pneumococcal peritonitis in a young woman who had undergone three previous cesarean sections. The diagnosis ofour case prompted a MEDLINE search of the English-language literature. We found four additional cases in Westh's review, two of them occurring in IUD-bearing women [3-6]. As previously suggested, pneumococcal pelviperitonitis may be an underreported entity. S. pneumoniae can easily be missed as "saprophy-
Downloaded from http://cid.oxfordjournals.org/ at University of Exeter on July 19, 2015
the isolate was sensitive to penicillin, ampicillin, cephalothin, chloramphenicol, clindamycin, erythromycin, gentamicin, vancomycin, and tetracycline. Testing by the agar dilution method was not performed. The patient was initially given vancomycin. Treatment was changed to administration of penicillin and gentamicin when the sensitivity profile of the organism was complete. While the patient was receiving penicillin and gentamicin, his serum was bactericidal at a dilution of ~ 1:256. His hospital course was complicated by mild congestive heart failure that responded promptly to diuretics. His right hemiplegia remained unchanged. Approximately 3 weeks into his hospital course, the patient became unresponsive and developed total flaccid paralysis. Computed tomography showed hemorrhage into the area of the cerebral infarct. Although the patient completed 4 weeks of antibiotic therapy and repeated blood cultures were sterile, he remained comatose and died ....., 7 weeks postadmission after a massive gastrointestinal hemorrhage occurred. Permission for autopsy was refused. The case of our patient reinforces the findings of Morris and Guild [1] that C. pseudodiphtheriticum can infect native valves
CID 1992; 15 (December)
