CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASES Single Case Report
Pasteurella multocida Endocarditis SHIRIL M. HOMBAL, M.D., AND HOSOON P. DINCSOY, M.D.
Pasleurella multocida is a small gram-negative coccobacillus, which is part of the normal flora of dogs, cats, and many other animals. Human infection with P. multocida is uncommon and in most cases infection has been attributed to animal-derived trauma or contact with secretions of animals.'2 In most reported cases, systemic infection occurred in patients with underlying diseases.' P. multocida endocarditis is very rare and only several clinically diagnosed case reports have appeared in the literature.3"7 We report autopsyfindingsof a patient with autosomal dominant polycystic kidney disease who died of P. multocida septicemia and endocarditis.
history was significant because the patient had a sister who has polycystic kidney disease. On physical examination, he was alert but incoherent and agitated. His temperature was 37 °C, pulse was 98 beats per minute, and blood pressure was 88 mmHg and palpatory. He was tachypneic and had bibasilar rales. Cardiovascular examination was unremarkable. The abdomen was distended with bilateral soft masses. Lower extremities showed bilateral dry, scaly superficial ulcers. Initial laboratory data were significant for white blood cell counts, 19 X 109/L with 84% polys and 6% bands; hemoglobin, 150 g/L (15 g%); blood urea nitrogen, 25.5 mmol/L (71 mg/dL): creatinine concentration, 1,000 /imol/L (13 mg/dL); calcium, 2.3 mmol/L (9.2 mg/dL); aspartate aminotransferase, 42 IU/L; alanine aminotransferase, 72 IU/L; serum alkaline phosphatase, 177 IU/L; serum bilirubin, 25.6 MOI/L (1.5 mg/ dL); and serum potassium, 6.6 mmol/L (6.6 mg/dL). Chest x-ray and electrocardiogram did not show significant abnormalities. In the few hours after admission he became more hypotensive (blood CASE REPORT pressure, 50 mmHg and palpatory) and febrile (temperature 38 °C) with chills and rigor. He was treated with intravenous fluids. Gentamycin and A 61-year-old man was brought to North Shore University Hospital vancomycin were started empirically, awaiting blood culture reports. after being found unresponsive on the bathroom floor. The patient was However, his condition deteriorated rapidly and he died approximately known to have autosomal-dominant polycystic kidney disease and to 16 hours after admission. Information obtained from the family indicated have been dependent on hemodialysis since 1979. Other medical probthat the patient had a dog that used to lick his leg ulcers. lems included chronic hypotension, calcification of aortic valve annulus At autopsy, kidneys weighed 3,500 g each and displayed typical features demonstrated by an echocardiogram in 1985, and peripheral vascular of autosomal-dominant polycystic kidney disease, associated with cysts disease diagnosed by aortogram in 1989 with superficial leg ulcers. Family involving liver, seminal vesicles, and epididymis. The heart, weighing 500 g, revealed bisinus-bicuspid aortic valve with marked fibrocalcific, nodular deformity of the cusps. The right cusp of the aortic valve showed a minute vegetation (Fig. 1). Sections of the aortic valve showed extensive From the Department of Laboratories, North Shore University Hos-acute valvulitis (Fig. 2) and multiple clumps of bacteria (Fig. 3) that pital-Cornell University Medical College, Manhasset, New York. were gram negative. Other autopsyfindingsincluded acute cholangitis, Received October 23, 1991; revised manuscript accepted for publihepatic necrosis, and acute splenitis, which were attributed to sepsis and cation April 10, 1992. septic shock. Address reprint requests to Dr. Hosoon P. Dincsoy: Department of Antemortem and postmortem blood cultures grew colonies of bacteria; Laboratories, North Shore University Hospital, Manhasset, New York the isolates were identified as gram-negative nonmotile, coccobacilli that 11030. 565
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
quired via licking of leg ulcers by his pet dog, establishing an animal-related causal relationship. Because P. multocida is a very common flora of many animals, infection with this organism probably occurs more frequently than is commonly appreciated. High index of suspicion and early diagnosis, especially in immunocompromised patients, are warranted because the disease is potentially life threatening, yet is a readily treatable infection. (Key words: Pasteurella multocida; Infective endocarditis; Polycystic kidney disease) Am J Clin Pathol 1992; 98:565-568
Human infection with Pasteurella multocida is the leading cause of animal bite wound infection. Life-threatening infection may occur in patients with a variety of underlying disorders and an immunocompromised state. Infective endocarditis with P. multocida is very rare and only a few clinically diagnosed cases have been reported. Described here is an autopsy case of a 61-yearold man with polycystic kidney disease who had P. multocida bacteremia and acute infective endocarditis with multiple bacterial clumps involving bicuspid aortic valve. The organisms were gram negative. Apparently the sepsis with P. multocida was ac-
566
CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASES Single Case Report
FlG. 2 (lower). Photomicrograph of aortic valve showing acute valvulitis (hematoxylin and eosin, X450).
were catalase positive, oxidase positive, and fermented glucose without gas production. In addition, using APT20E system and other standard biochemical methods, the isolates were identified as P. mullocida.
DISCUSSION In the case described here, the infection with P. mullocida was probably acquired when his dog licked his leg ulcers. P. mullocida has been isolated from the digestive system or respiratory tract in 70% to 90% of cats and 50% to 66% of dogs.2 In recent years, an increasing incidence
of animal-related human infections with P. mullocida have been reported.',2-8'9 Immunocompromised patients appear to be at greater risk of developing life-threatening systemic disease; the underlying diseases associated with immunocompromised state include cirrhosis, neoplasia, chronic pulmonary disease, rheumatoid arthritis, and various other disorders.1"12 To our knowledge, our patient is the first case of polycystic kidney disease with P. mullocida septicemia. The overall mortality rate in P. mullocida bacteremia has been reported to be 31%.'
A.J.C.P. • December 1992
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
FIG. 1 (upper). Gross photograph of heart showing minute vegetation (arrowhead) on the right cusp of aortic valve.
HOMBAL AND DINCSOY Pasteurella multocida Endocarditis
aortic regurgitation among 11 cases of polycystic renal disease. None of these four patients had infective endocarditis. P. multocida is sensitive to penicillin, ampicillin, carbenicillin, tetracyclines, and chloramphenicol. Penicillin is the drug of choice. Penicillin resistance, however, has been reported in a few human cases. 1516 Human infection with P. multocida probably occurs more frequently than is commonly appreciated. A high index of suspicion and early diagnosis are warranted because it is a potentially serious but readily treatable infection, especially in immunocompromised patients. REFERENCES 1. Raffi F, Barrier J, Baron D, Drugeon H, Nicolas F. Pasteurella multocida bacteremia: Report of thirteen cases over twelve years and review of the literature. Scand J Infec Dis 1987; 19:385-393. 2. Weber DJ, Wolfson JS, Swartz MN, Hooper D. Pasteurella multocida infections. Report of thirty-four cases and review of literature. Medicine 1984;63:133-153. 3. Singh CP, Spurrel JRR. Pasteurella multocida endocarditis. Br Med J 1983;286:1862-1863. 4. Lehmann V, Knotsen SB, Ragnhildstveit F, Skagseth E, Solberg C. Endocarditis caused by Pasteurella multocida. Scand J Inf Dis 1977;9:247-248. 5. Gump DW, Holden RA. Endocarditis caused by a new species of Pasteurella. Ann Int Med 1972;76:275-278. 6. Phillips I, Midgley J, Lapage SP. Endocarditis due to a Pasteurella multocida-like organism. East Afr Med J 1970;47:440-444. 7. Tucker DN, Slotnick IJ, King EO. et al. Endocarditis caused by a Pasteurella-like organism. N Engl J Med 1962;267:913-916. 8. Frances DP, Holmes MA, Brandon G. Pasteurella multocida. In-
Vol. 98 • No. 6
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P. multocida endocarditis is exceedingly rare, and in a series of 13 cases of P. multocida bacteremia reported by Raffi and associates,1 there was no case of endocarditis, and a review of 82 cases of published reports of P. multocida bacteremia revealed only 3 cases of endocarditis. Review of the English-language literature yielded eight cases of endocarditis caused by P. multocida,3,4 a new species of Pasteurella,5 and a P. multocida-like organism.6-7 The clinical diagnosis of endocarditis in these reports was established on the basis of positive blood cultures and appropriate clinical criteria in all cases. In the case reported by Lehmann and co-workers,4 after resection of the infected aortic valve and implantation of a prosthesis, the patient recovered; bacteriologic examination of the excised valve, however, was negative for P. multocida. Of the four cases of endocarditis reported by Tucker and others,7 one patient died; the aortic valve, examined during autopsy, grew Enterococcus and Clostridia. Thus our patient appears to be the only case in which histologic examination of the aortic cusp revealed the presence of bacteria with associated acute valvulitis and blood cultures taken before and after death yielded pure growth of P. multocida. The bicuspid aortic valve in our patient appears to be a predisposing factor for infective endocarditis. Cardiovascular abnormalities in patients with polycystic disease have been reported in the literature.13'14 Leier and others' 3 reported four patients with bicuspid aortic valves and
567
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9. 10. 11. 12.
CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASES Single Case Report
fections after domestic animal bites and scratches. JAMA 1975;233:42-45. Nadler JP, Freedman MS, Berger SA. Pasteurella multocida septicemia. NY State J Med 1979;79:1581-1583. Stein AA, Fialk MA, Blevins A, Armstrong D. Pasteurella multocida septicemia. Experience at a cancer hospital. JAMA 1983; 249: 508-509. Gerding DN, Khan MY, Ewing JW, Hall W. Pasteurella multocida peritonitis in hepatic cirrhosis with ascites. Gastroenterology 1976;70:413-415. Jacobson JA, Miner P, Duffy O. Pasteurella multocida bacteremia associated with peritonitis and cirrhosis. Am J Gastroenterol 1977;68:489-491.
13. Leier CV, Baker PB, Kilman JW, Wooley C. Cardiovascular abnormalities associated with adult polycystic kidney disease. Ann IntMed 1984;100:683-688. 14. Hossack KF, Leddy CL, Johnson AM, Schrier R, Gabow P. Echocardiographyfindingsin autosomal dominant polycystic kidney disease. N Engl J Med 1988;319:902-912. 15. Ellis RH. Pasteurella septica infection in respiratory disease. Torax 1967;22:79-87. 16. Spagnuolo PJ, Friedman RI. Penicillin sensitivity of invasive and non-invasive Pasteurella multocida. J Antimicrob Chemother 1979;5:324-325.
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
A.J.C.P. • December 1992
Pasteurella multocida Endocarditis SHIRIL M. HOMBAL, M.D., AND HOSOON P. DINCSOY, M.D.
Pasleurella multocida is a small gram-negative coccobacillus, which is part of the normal flora of dogs, cats, and many other animals. Human infection with P. multocida is uncommon and in most cases infection has been attributed to animal-derived trauma or contact with secretions of animals.'2 In most reported cases, systemic infection occurred in patients with underlying diseases.' P. multocida endocarditis is very rare and only several clinically diagnosed case reports have appeared in the literature.3"7 We report autopsyfindingsof a patient with autosomal dominant polycystic kidney disease who died of P. multocida septicemia and endocarditis.
history was significant because the patient had a sister who has polycystic kidney disease. On physical examination, he was alert but incoherent and agitated. His temperature was 37 °C, pulse was 98 beats per minute, and blood pressure was 88 mmHg and palpatory. He was tachypneic and had bibasilar rales. Cardiovascular examination was unremarkable. The abdomen was distended with bilateral soft masses. Lower extremities showed bilateral dry, scaly superficial ulcers. Initial laboratory data were significant for white blood cell counts, 19 X 109/L with 84% polys and 6% bands; hemoglobin, 150 g/L (15 g%); blood urea nitrogen, 25.5 mmol/L (71 mg/dL): creatinine concentration, 1,000 /imol/L (13 mg/dL); calcium, 2.3 mmol/L (9.2 mg/dL); aspartate aminotransferase, 42 IU/L; alanine aminotransferase, 72 IU/L; serum alkaline phosphatase, 177 IU/L; serum bilirubin, 25.6 MOI/L (1.5 mg/ dL); and serum potassium, 6.6 mmol/L (6.6 mg/dL). Chest x-ray and electrocardiogram did not show significant abnormalities. In the few hours after admission he became more hypotensive (blood CASE REPORT pressure, 50 mmHg and palpatory) and febrile (temperature 38 °C) with chills and rigor. He was treated with intravenous fluids. Gentamycin and A 61-year-old man was brought to North Shore University Hospital vancomycin were started empirically, awaiting blood culture reports. after being found unresponsive on the bathroom floor. The patient was However, his condition deteriorated rapidly and he died approximately known to have autosomal-dominant polycystic kidney disease and to 16 hours after admission. Information obtained from the family indicated have been dependent on hemodialysis since 1979. Other medical probthat the patient had a dog that used to lick his leg ulcers. lems included chronic hypotension, calcification of aortic valve annulus At autopsy, kidneys weighed 3,500 g each and displayed typical features demonstrated by an echocardiogram in 1985, and peripheral vascular of autosomal-dominant polycystic kidney disease, associated with cysts disease diagnosed by aortogram in 1989 with superficial leg ulcers. Family involving liver, seminal vesicles, and epididymis. The heart, weighing 500 g, revealed bisinus-bicuspid aortic valve with marked fibrocalcific, nodular deformity of the cusps. The right cusp of the aortic valve showed a minute vegetation (Fig. 1). Sections of the aortic valve showed extensive From the Department of Laboratories, North Shore University Hos-acute valvulitis (Fig. 2) and multiple clumps of bacteria (Fig. 3) that pital-Cornell University Medical College, Manhasset, New York. were gram negative. Other autopsyfindingsincluded acute cholangitis, Received October 23, 1991; revised manuscript accepted for publihepatic necrosis, and acute splenitis, which were attributed to sepsis and cation April 10, 1992. septic shock. Address reprint requests to Dr. Hosoon P. Dincsoy: Department of Antemortem and postmortem blood cultures grew colonies of bacteria; Laboratories, North Shore University Hospital, Manhasset, New York the isolates were identified as gram-negative nonmotile, coccobacilli that 11030. 565
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
quired via licking of leg ulcers by his pet dog, establishing an animal-related causal relationship. Because P. multocida is a very common flora of many animals, infection with this organism probably occurs more frequently than is commonly appreciated. High index of suspicion and early diagnosis, especially in immunocompromised patients, are warranted because the disease is potentially life threatening, yet is a readily treatable infection. (Key words: Pasteurella multocida; Infective endocarditis; Polycystic kidney disease) Am J Clin Pathol 1992; 98:565-568
Human infection with Pasteurella multocida is the leading cause of animal bite wound infection. Life-threatening infection may occur in patients with a variety of underlying disorders and an immunocompromised state. Infective endocarditis with P. multocida is very rare and only a few clinically diagnosed cases have been reported. Described here is an autopsy case of a 61-yearold man with polycystic kidney disease who had P. multocida bacteremia and acute infective endocarditis with multiple bacterial clumps involving bicuspid aortic valve. The organisms were gram negative. Apparently the sepsis with P. multocida was ac-
566
CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASES Single Case Report
FlG. 2 (lower). Photomicrograph of aortic valve showing acute valvulitis (hematoxylin and eosin, X450).
were catalase positive, oxidase positive, and fermented glucose without gas production. In addition, using APT20E system and other standard biochemical methods, the isolates were identified as P. mullocida.
DISCUSSION In the case described here, the infection with P. mullocida was probably acquired when his dog licked his leg ulcers. P. mullocida has been isolated from the digestive system or respiratory tract in 70% to 90% of cats and 50% to 66% of dogs.2 In recent years, an increasing incidence
of animal-related human infections with P. mullocida have been reported.',2-8'9 Immunocompromised patients appear to be at greater risk of developing life-threatening systemic disease; the underlying diseases associated with immunocompromised state include cirrhosis, neoplasia, chronic pulmonary disease, rheumatoid arthritis, and various other disorders.1"12 To our knowledge, our patient is the first case of polycystic kidney disease with P. mullocida septicemia. The overall mortality rate in P. mullocida bacteremia has been reported to be 31%.'
A.J.C.P. • December 1992
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
FIG. 1 (upper). Gross photograph of heart showing minute vegetation (arrowhead) on the right cusp of aortic valve.
HOMBAL AND DINCSOY Pasteurella multocida Endocarditis
aortic regurgitation among 11 cases of polycystic renal disease. None of these four patients had infective endocarditis. P. multocida is sensitive to penicillin, ampicillin, carbenicillin, tetracyclines, and chloramphenicol. Penicillin is the drug of choice. Penicillin resistance, however, has been reported in a few human cases. 1516 Human infection with P. multocida probably occurs more frequently than is commonly appreciated. A high index of suspicion and early diagnosis are warranted because it is a potentially serious but readily treatable infection, especially in immunocompromised patients. REFERENCES 1. Raffi F, Barrier J, Baron D, Drugeon H, Nicolas F. Pasteurella multocida bacteremia: Report of thirteen cases over twelve years and review of the literature. Scand J Infec Dis 1987; 19:385-393. 2. Weber DJ, Wolfson JS, Swartz MN, Hooper D. Pasteurella multocida infections. Report of thirty-four cases and review of literature. Medicine 1984;63:133-153. 3. Singh CP, Spurrel JRR. Pasteurella multocida endocarditis. Br Med J 1983;286:1862-1863. 4. Lehmann V, Knotsen SB, Ragnhildstveit F, Skagseth E, Solberg C. Endocarditis caused by Pasteurella multocida. Scand J Inf Dis 1977;9:247-248. 5. Gump DW, Holden RA. Endocarditis caused by a new species of Pasteurella. Ann Int Med 1972;76:275-278. 6. Phillips I, Midgley J, Lapage SP. Endocarditis due to a Pasteurella multocida-like organism. East Afr Med J 1970;47:440-444. 7. Tucker DN, Slotnick IJ, King EO. et al. Endocarditis caused by a Pasteurella-like organism. N Engl J Med 1962;267:913-916. 8. Frances DP, Holmes MA, Brandon G. Pasteurella multocida. In-
Vol. 98 • No. 6
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
P. multocida endocarditis is exceedingly rare, and in a series of 13 cases of P. multocida bacteremia reported by Raffi and associates,1 there was no case of endocarditis, and a review of 82 cases of published reports of P. multocida bacteremia revealed only 3 cases of endocarditis. Review of the English-language literature yielded eight cases of endocarditis caused by P. multocida,3,4 a new species of Pasteurella,5 and a P. multocida-like organism.6-7 The clinical diagnosis of endocarditis in these reports was established on the basis of positive blood cultures and appropriate clinical criteria in all cases. In the case reported by Lehmann and co-workers,4 after resection of the infected aortic valve and implantation of a prosthesis, the patient recovered; bacteriologic examination of the excised valve, however, was negative for P. multocida. Of the four cases of endocarditis reported by Tucker and others,7 one patient died; the aortic valve, examined during autopsy, grew Enterococcus and Clostridia. Thus our patient appears to be the only case in which histologic examination of the aortic cusp revealed the presence of bacteria with associated acute valvulitis and blood cultures taken before and after death yielded pure growth of P. multocida. The bicuspid aortic valve in our patient appears to be a predisposing factor for infective endocarditis. Cardiovascular abnormalities in patients with polycystic disease have been reported in the literature.13'14 Leier and others' 3 reported four patients with bicuspid aortic valves and
567
568
9. 10. 11. 12.
CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASES Single Case Report
fections after domestic animal bites and scratches. JAMA 1975;233:42-45. Nadler JP, Freedman MS, Berger SA. Pasteurella multocida septicemia. NY State J Med 1979;79:1581-1583. Stein AA, Fialk MA, Blevins A, Armstrong D. Pasteurella multocida septicemia. Experience at a cancer hospital. JAMA 1983; 249: 508-509. Gerding DN, Khan MY, Ewing JW, Hall W. Pasteurella multocida peritonitis in hepatic cirrhosis with ascites. Gastroenterology 1976;70:413-415. Jacobson JA, Miner P, Duffy O. Pasteurella multocida bacteremia associated with peritonitis and cirrhosis. Am J Gastroenterol 1977;68:489-491.
13. Leier CV, Baker PB, Kilman JW, Wooley C. Cardiovascular abnormalities associated with adult polycystic kidney disease. Ann IntMed 1984;100:683-688. 14. Hossack KF, Leddy CL, Johnson AM, Schrier R, Gabow P. Echocardiographyfindingsin autosomal dominant polycystic kidney disease. N Engl J Med 1988;319:902-912. 15. Ellis RH. Pasteurella septica infection in respiratory disease. Torax 1967;22:79-87. 16. Spagnuolo PJ, Friedman RI. Penicillin sensitivity of invasive and non-invasive Pasteurella multocida. J Antimicrob Chemother 1979;5:324-325.
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
A.J.C.P. • December 1992
