Case Reports _ _ _ _ _ _ _ _ _ _ __ Neisseria meningitidis: A Cause of Nosocomial Pneumonia 1 2 •
REX V. BARNES, ALAN C. DOPP, HARRIS J. GELBERG, and JOSEPH SILVA, JR.
SUMMARY ____________________ ____________________ _____________ A 24-year-old man developed coma and many neurologic abnormalities for 2 weeks after ingesting phencyclidine. On admission, pulmonary aspiration occurred, for which he was given large doses of methylprednisolone, clindamycin, and gentamicin. These antimicrobial drugs were continued for 2 weeks until new pulmonary infiltrates were recognized. Neisseria meningitidis was subsequently isolated from cultures of conjunctival discharge, sputum, and blood and found to be resistant to clindamycin and gentamicin. N. meningitidis as a cause of nosocomial pneumonia in the setting of broad spectrum antimicrobial drugs is discussed.
Introduction
every 8 hours) was begun to cover organisms recognized to cause aspiration pneumonia. These antinized as a cause of bacterial pneumonia, except microbial drugs were continued for 14 days. Physical examination revealed a stuporous man in military populations during either influenza with flailing of the extremities but no seizures. The epidemics or adenoviral infections (1, 2). The rectal temperature was 104• F, pulse 100 beats per Qse reported here demonstrates that N. meninmin, blood pressure I84f84, and respiratory rate 20 gitidis is a respiratory pathogen that can cause breaths per min. The patient's pupils were mid-posinosocomial pneumonia and can be resistant to tion, equally reactive to light, and the funduscopic a popular regimen of "broad spectrum" anti- examination was normal. Diffuse rhonchi were presmicrobial drugs. ent in the chest without findings of consolidation. Heart sounds were normal. A neurologic examination revealed opisthotonos, decerebrate posturing, Ca•eReport A 24-year-old man was admitted for inappropriate hyperreflexia, bilateral ankle clonus, global nystagbehavior and thrashing of the extremities. The pa- mus, and extremity withdrawal to painful stimuli. The white blood cell count was 10,600 per mm3 tient was previously well but had recently purchased and injected an unknown quantity of phencyclidine. with 58 per cent segmented polymorphonuclear leuAspiration occurred during gastric lavage. He was kocytes, 26 per cent band neutrophils, and 16 per endotracheally intubated and given intravenous cent lymphocytes. Blood urea nitrogen, creatinine, methylprednisolone sodium succinate (one g twice serum electrolytes, urinalysis, and arterial blood gas in 2 days). Broad spectrum coverage with clindamy- analysis were normal. Serum salicylate was 1.1 mg cin (!100 mg every 6 hours) and gentamicin (80 mg per 100 ml, but barbiturates and glutethimide were undetected in serum. Phencyclidine was detected in (Received in original form August 19, 1974 and in blood and urine specimens. Cerebrospinal fluid was revised form November 15,1974) normal for cells, proteins, and glucose. Initial roentgenograms of the chest and skull and brain scan were 1 From the Department of Internal Medicine, Uninormal. An electroencephalogram revealed a mild, versity of Michigan Medical Center, Ann Arbor, diffuse abnormality. Sputum tested on admission and Mich. 48104. on the third, seventh, and tenth hospital days re2 Requests fot reprints should be addressed to Dr. vealed a mixed normal flora including alpha streptoJoseph Silva, Jr., X-resge ll, R6022, Division of Infec- cocci, a few Staphylococcus epidermidis and N. catious D~ses. Ann Arbor, Mieb. 48UM. tarrhalis. No N. meningitidis were isolated at any
Neisseria meningitidis is infrequently recog-
,\MERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME Ill, 1975
229
230
BARNES, DOPP, GELBERG, AND SILVA
Fig. l. A chest roentgenogram taken on the thirteenth hospital day reveals infiltrates in the right middle and lower lobes with partial atelectasis. time from these cultures. Repeated cultures of the blood obtained during this time were also negative. Gram stains of the sputum showed a few gram·positive cocci, occasional gram-negative rods, no polymorphonuclear leukocytes, and occasional squamous cells. The patient :remained comatose with the previously mentioned neurologic abnormalities for 2 weeks. Fever was hectic and intermittent to 102• F daily in spite of the antimicrobial treatment. Right lower and middle lobe infiltrates with atelectasis were noted on the thirteenth hospital day (figure 1). Three previous chest roentgenograms had been negative, but physical examination of the chest after 2 weeks showed consolidation over the right basilar lung field . A Gram stain of the sputum revealed many neutrophils and gram-negative cocci. N. meningitidis (Group B; determined by agglutination antisera) was subsequently cultured from conjunctival fluid and from one of 3 blood cultures taken on the thirteenth and fourteenth hospital days. Cultures of the sputum at this time also grew a pure culture of N. meningitidis with a few Pseudomonas organisms. The cerebrospinal fluid was again normal. Clindamycin and gentamicin were discontinued on the fourteenth hospital day, and cephalothin was begun (2 g intravenously every 6 hours). The patient became conscious again on the sixteenth hospital day with concurrent resolution of his pneumonia. Subsequent chest roentgenograms gradually became normal and the patient was discharged without residual
evidence of pulmonary or neurologic damage. The N . meningitidis showed the following minimal inhibitory concentrations as performed by the tube dilution method: penicillin (0.12 ILg per ml), clindamycin (25 ILg per ml), gentamicin (25 ILg per ml), and cephalothin (0.5 ILg per ml).
Discussion
Phencyclidine (Sernyl®, Sernylan®) is an animal tranquilizer that has gained popularity among drug users to induce a unique "body trip." This drug is called PCP on the street and is often confused with tetrahydrocannabinol (THC). Our patient admini$te:red to himself intravenously a large dose of phencyclidine that produced a prolonged coma and an alarming variety of b:rainstem and cortical abnormalities (3). This case illustrates that physicians should be prepared to support patients intoxicated with phencyclidine for 2 weeks or longer because the abnormalities can be completely :reversible. Clindamycin and gentamicin were given to provide broad spectrum coverage because the patient aspirated during gastric lavage. Such pneumonias are now :recognized to be caused frequently by aerobic and anaerobic gram-negative bacilli (4). A bacterial pneumonia developed 12 days later while the patient was still :re-
NEISSERIA MENINGITJDIS: A CAUSE OF NOSOCOMIAL PNEUMONIA
ceiving these drugs. Cultures of conjunctival discharge, sputum, and blood grew N. meningitidis. Colonization and then infection with N. meningitidis could have occurred in this patient because of the intubation, the corticosteroids, and the choice of antimicrobial drugs. No attempt was made to identify carriers of N. meningitidis because > 10 per cent of normal persons can carry this organism in their nasopharynx without manifesting systemic disease. We suspect the patient may have become colonized with N. meningitidis sometime after the tenth hospital day because 3 prior cultures of the sputum did not reveal N. meningitidis; however, N. meningitidis could also have been carried in his pharynx and been missed on cultures of the sputum and throat. The respiratory tracts of hospitalized patients are frequently colonized by gram-negative bacilli (5). Even so, this case qualifies as an example of nosocomial infection, defined as "one that develops in a patient after admission to a hospital. The infection was neither present nor in the incubation stage at the time of the patient's admission unless related to a previous hospitalization" (6). Results of the cultures were initially ignored in this patient because N. meningitidis was not considered a respiratory pathogen, although N. meningitidis can be a lethal respiratory pathogen (2). A culture of the sputum obtained by transtracheal a:tpiration might have facilitated an earlier diagnosis. Furthermore, the antimicrobial regimen of large doses of clindamycin and gentamicin was thought to provide adequate coverage. In vitro sensitivity studies showed that this organism was resistant to serum levels usually achieved with gentamicin and clindamycin; this agrees with previous data (7). As a general rule, penicillin is the choice for N. meningitidis infections, particularly if meningitis is pres-
231
ent; cephalosporins do not readily penetrate the meninges. However, cephalothin was instituted without this knowledge and because the patient rapidly improved, penicillin was not substituted. This case is unusual in that N. meningitidis pneumonia developed in a hospitalized patient while receiving broad spectrum antimicrobial drugs. Thus, physicians should be aware that N. meningitidis can be a cause of nosocomial pneumonia and resistant to a combination of dindamycin and gentamicin. References l. Putsch, R. W., Hamilton, J. D., and Wolinsky, E.:
2. !1.
4. 5.
6.
7.
Neisseria meningitidis, a respiratory pathogen? J Infect Dis, 1970,121, 48. Ellenbogen, C., Graybill, J. R., Silva, J., Homme, P. J.: Bacterial pneumonia complicating adenoviral pneumonia, Am J Med, 1974, 56, 169. Domino, E. F., and Luby, E. D.: Abnormal mental states induced by phencyclidine as a model of schizophrenia. Psychopathology and psychopharmacology, Proceedings of the Sixty-Second Annual Meeting of the American Psychopathological Association, Johns Hopkins University Press,l97!1, p. !17. Barlett, J. G., Gorbach, S. L., and Finegold, S. M.: The bacteriology of aspiration pneumonia, Am J Med, 1974, 46,202. Johanson, W. G., Pierce, A. K., Sanford, J. P., and Thomas, G. D.: Nosocomial respiratory infections with gram-negative bacilli, Ann Intern Med, 1974,77,701. Bennett, J. V., Scheckler, W. E., Maki, D. G., and Brachman, P. S.: Current national patterns, Proceedings of the International Conference on Nosocomial Infections, Center for Disease Control, August !1-6, 1970, p. 42. Devine, L. F., and Hagerman, C. R.: Spectra of susceptibility of Neisseria meningitidis to anti· microbial agents in vitro, Appl Microbiol, 1970,
19,!129.
REX V. BARNES, ALAN C. DOPP, HARRIS J. GELBERG, and JOSEPH SILVA, JR.
SUMMARY ____________________ ____________________ _____________ A 24-year-old man developed coma and many neurologic abnormalities for 2 weeks after ingesting phencyclidine. On admission, pulmonary aspiration occurred, for which he was given large doses of methylprednisolone, clindamycin, and gentamicin. These antimicrobial drugs were continued for 2 weeks until new pulmonary infiltrates were recognized. Neisseria meningitidis was subsequently isolated from cultures of conjunctival discharge, sputum, and blood and found to be resistant to clindamycin and gentamicin. N. meningitidis as a cause of nosocomial pneumonia in the setting of broad spectrum antimicrobial drugs is discussed.
Introduction
every 8 hours) was begun to cover organisms recognized to cause aspiration pneumonia. These antinized as a cause of bacterial pneumonia, except microbial drugs were continued for 14 days. Physical examination revealed a stuporous man in military populations during either influenza with flailing of the extremities but no seizures. The epidemics or adenoviral infections (1, 2). The rectal temperature was 104• F, pulse 100 beats per Qse reported here demonstrates that N. meninmin, blood pressure I84f84, and respiratory rate 20 gitidis is a respiratory pathogen that can cause breaths per min. The patient's pupils were mid-posinosocomial pneumonia and can be resistant to tion, equally reactive to light, and the funduscopic a popular regimen of "broad spectrum" anti- examination was normal. Diffuse rhonchi were presmicrobial drugs. ent in the chest without findings of consolidation. Heart sounds were normal. A neurologic examination revealed opisthotonos, decerebrate posturing, Ca•eReport A 24-year-old man was admitted for inappropriate hyperreflexia, bilateral ankle clonus, global nystagbehavior and thrashing of the extremities. The pa- mus, and extremity withdrawal to painful stimuli. The white blood cell count was 10,600 per mm3 tient was previously well but had recently purchased and injected an unknown quantity of phencyclidine. with 58 per cent segmented polymorphonuclear leuAspiration occurred during gastric lavage. He was kocytes, 26 per cent band neutrophils, and 16 per endotracheally intubated and given intravenous cent lymphocytes. Blood urea nitrogen, creatinine, methylprednisolone sodium succinate (one g twice serum electrolytes, urinalysis, and arterial blood gas in 2 days). Broad spectrum coverage with clindamy- analysis were normal. Serum salicylate was 1.1 mg cin (!100 mg every 6 hours) and gentamicin (80 mg per 100 ml, but barbiturates and glutethimide were undetected in serum. Phencyclidine was detected in (Received in original form August 19, 1974 and in blood and urine specimens. Cerebrospinal fluid was revised form November 15,1974) normal for cells, proteins, and glucose. Initial roentgenograms of the chest and skull and brain scan were 1 From the Department of Internal Medicine, Uninormal. An electroencephalogram revealed a mild, versity of Michigan Medical Center, Ann Arbor, diffuse abnormality. Sputum tested on admission and Mich. 48104. on the third, seventh, and tenth hospital days re2 Requests fot reprints should be addressed to Dr. vealed a mixed normal flora including alpha streptoJoseph Silva, Jr., X-resge ll, R6022, Division of Infec- cocci, a few Staphylococcus epidermidis and N. catious D~ses. Ann Arbor, Mieb. 48UM. tarrhalis. No N. meningitidis were isolated at any
Neisseria meningitidis is infrequently recog-
,\MERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME Ill, 1975
229
230
BARNES, DOPP, GELBERG, AND SILVA
Fig. l. A chest roentgenogram taken on the thirteenth hospital day reveals infiltrates in the right middle and lower lobes with partial atelectasis. time from these cultures. Repeated cultures of the blood obtained during this time were also negative. Gram stains of the sputum showed a few gram·positive cocci, occasional gram-negative rods, no polymorphonuclear leukocytes, and occasional squamous cells. The patient :remained comatose with the previously mentioned neurologic abnormalities for 2 weeks. Fever was hectic and intermittent to 102• F daily in spite of the antimicrobial treatment. Right lower and middle lobe infiltrates with atelectasis were noted on the thirteenth hospital day (figure 1). Three previous chest roentgenograms had been negative, but physical examination of the chest after 2 weeks showed consolidation over the right basilar lung field . A Gram stain of the sputum revealed many neutrophils and gram-negative cocci. N. meningitidis (Group B; determined by agglutination antisera) was subsequently cultured from conjunctival fluid and from one of 3 blood cultures taken on the thirteenth and fourteenth hospital days. Cultures of the sputum at this time also grew a pure culture of N. meningitidis with a few Pseudomonas organisms. The cerebrospinal fluid was again normal. Clindamycin and gentamicin were discontinued on the fourteenth hospital day, and cephalothin was begun (2 g intravenously every 6 hours). The patient became conscious again on the sixteenth hospital day with concurrent resolution of his pneumonia. Subsequent chest roentgenograms gradually became normal and the patient was discharged without residual
evidence of pulmonary or neurologic damage. The N . meningitidis showed the following minimal inhibitory concentrations as performed by the tube dilution method: penicillin (0.12 ILg per ml), clindamycin (25 ILg per ml), gentamicin (25 ILg per ml), and cephalothin (0.5 ILg per ml).
Discussion
Phencyclidine (Sernyl®, Sernylan®) is an animal tranquilizer that has gained popularity among drug users to induce a unique "body trip." This drug is called PCP on the street and is often confused with tetrahydrocannabinol (THC). Our patient admini$te:red to himself intravenously a large dose of phencyclidine that produced a prolonged coma and an alarming variety of b:rainstem and cortical abnormalities (3). This case illustrates that physicians should be prepared to support patients intoxicated with phencyclidine for 2 weeks or longer because the abnormalities can be completely :reversible. Clindamycin and gentamicin were given to provide broad spectrum coverage because the patient aspirated during gastric lavage. Such pneumonias are now :recognized to be caused frequently by aerobic and anaerobic gram-negative bacilli (4). A bacterial pneumonia developed 12 days later while the patient was still :re-
NEISSERIA MENINGITJDIS: A CAUSE OF NOSOCOMIAL PNEUMONIA
ceiving these drugs. Cultures of conjunctival discharge, sputum, and blood grew N. meningitidis. Colonization and then infection with N. meningitidis could have occurred in this patient because of the intubation, the corticosteroids, and the choice of antimicrobial drugs. No attempt was made to identify carriers of N. meningitidis because > 10 per cent of normal persons can carry this organism in their nasopharynx without manifesting systemic disease. We suspect the patient may have become colonized with N. meningitidis sometime after the tenth hospital day because 3 prior cultures of the sputum did not reveal N. meningitidis; however, N. meningitidis could also have been carried in his pharynx and been missed on cultures of the sputum and throat. The respiratory tracts of hospitalized patients are frequently colonized by gram-negative bacilli (5). Even so, this case qualifies as an example of nosocomial infection, defined as "one that develops in a patient after admission to a hospital. The infection was neither present nor in the incubation stage at the time of the patient's admission unless related to a previous hospitalization" (6). Results of the cultures were initially ignored in this patient because N. meningitidis was not considered a respiratory pathogen, although N. meningitidis can be a lethal respiratory pathogen (2). A culture of the sputum obtained by transtracheal a:tpiration might have facilitated an earlier diagnosis. Furthermore, the antimicrobial regimen of large doses of clindamycin and gentamicin was thought to provide adequate coverage. In vitro sensitivity studies showed that this organism was resistant to serum levels usually achieved with gentamicin and clindamycin; this agrees with previous data (7). As a general rule, penicillin is the choice for N. meningitidis infections, particularly if meningitis is pres-
231
ent; cephalosporins do not readily penetrate the meninges. However, cephalothin was instituted without this knowledge and because the patient rapidly improved, penicillin was not substituted. This case is unusual in that N. meningitidis pneumonia developed in a hospitalized patient while receiving broad spectrum antimicrobial drugs. Thus, physicians should be aware that N. meningitidis can be a cause of nosocomial pneumonia and resistant to a combination of dindamycin and gentamicin. References l. Putsch, R. W., Hamilton, J. D., and Wolinsky, E.:
2. !1.
4. 5.
6.
7.
Neisseria meningitidis, a respiratory pathogen? J Infect Dis, 1970,121, 48. Ellenbogen, C., Graybill, J. R., Silva, J., Homme, P. J.: Bacterial pneumonia complicating adenoviral pneumonia, Am J Med, 1974, 56, 169. Domino, E. F., and Luby, E. D.: Abnormal mental states induced by phencyclidine as a model of schizophrenia. Psychopathology and psychopharmacology, Proceedings of the Sixty-Second Annual Meeting of the American Psychopathological Association, Johns Hopkins University Press,l97!1, p. !17. Barlett, J. G., Gorbach, S. L., and Finegold, S. M.: The bacteriology of aspiration pneumonia, Am J Med, 1974, 46,202. Johanson, W. G., Pierce, A. K., Sanford, J. P., and Thomas, G. D.: Nosocomial respiratory infections with gram-negative bacilli, Ann Intern Med, 1974,77,701. Bennett, J. V., Scheckler, W. E., Maki, D. G., and Brachman, P. S.: Current national patterns, Proceedings of the International Conference on Nosocomial Infections, Center for Disease Control, August !1-6, 1970, p. 42. Devine, L. F., and Hagerman, C. R.: Spectra of susceptibility of Neisseria meningitidis to anti· microbial agents in vitro, Appl Microbiol, 1970,
19,!129.
