376
Correspondence
CID 1992; 15 (August)
results of tests for human immunodeficiency virus, antinuclear and anti-DNA antibodies, and rheumatoid factor were negative. The results of immunoglobulin electrophoresis were normal, and Widal's and Weil-Felix tests were negative. A splenic 99mTc-sulfur colloid scan showed normal uptake. She needed a period of mechanical ventilation postoperatively and had an uneventful recovery. Pneumococcal bacteremia may rarely occur in immunocompetent individuals [1]. Functional hyposplenia, as described in cases of collagen vascular disease, may be a risk factor for invasive pneumococcal infections [2]. It was ruled out as a factor in our patient's case. In Oman falciparum malaria is endemic, and mild splenomegaly is common. However, functional hyposplenia due to "malaria spleen" has not been reported. Pneumococcal peritonitis may occur as an ascending infection from the vagina in young girls aged 2-10 years, but it is exceedingly rare in older females. In two recently described cases, the patients were undergoing continuous ambulatory peritoneal dialysis (CAPO) [3, 4], and both had episodes of bloody dialysate before developing peritonitis; this circumstance suggests retrograde menstruation as a possible pathogenetic mechanism. However, it is not known whether CAPO increases the risk of retrograde menstruation. An intrauterine device has also been implicated as a risk factor for young females [3, 4]. We
excluded this possibility in our patient's case on the basis of her medical history and the results of ultrasonography. Rarely, pneumococcal peritonitis may be associated with nephrotic syndrome [5]. Even in the absence of a recognized risk factor, S. pneumoniae should be considered a possible causative agent, particularly when the response to the initial broad-spectrum antimicrobial therapy is poor.
Recovery of Bordetella bronchiseptica from Patients
gradual clinical improvement, and he was discharged after 2 weeks of therapy. The patient returned several days later with complaints ofpersistent cough. Despite an additional 3 weeks of therapy with erythromycin followed by 6 months of therapy with ciprofloxacin, the patient continued to have intermittent bouts of nagging nocturnal cough, and cultures ofinduced sputa continued to yield B. bronchiseptica. Our case was noteworthy for the following reasons. First, although this patient was treated with erythromycin, the recommended therapy for infection with Bordetella [3], the patient remained symptomatic and the organism was not eradicated. Second, alternate therapy with ciprofloxacin, chosen because of apparent in vitro susceptibility, did not alleviate symptoms or eradicate the organism from this patient's respiratory tract. Although ciprofloxacin was effective in curing the symptoms in the patient with AIDS described by Decker and co-workers [2], subsequent cultures of respiratory specimens were not obtained for assessing eradication of the organism. The experience of Amador and colleagues was similar to our own: they also were unsuccessful in either alleviating clinical symptoms or eradicating B. bronchiseptica following 40 days of therapy with ciprofloxacin [I]. These observations support the previously observed poor correlation of in vitro susceptibility testing of B. bronchiseptica and clinical outcome [4, 5]. As a result of this case, we reviewed our laboratory records at San Francisco General Hospital to determine the clinical significance of isolation of B. bronchiseptica from respiratory specimens. Since 1986 we have recovered six isolates of B. bronchiseptica from six patients; four of the patients had AIDS, whereas
SIR-We read with great interest the two recent letters describing Bordetella bronchiseptica pneumonia in patients with AIDS [I, 2]. We observed a similar case in a 43-year-old man with AIDS who had Kaposi's sarcoma and recurrent pneumonia due to Pneumocystis carinii. He presented with a 2-month history of severe paroxysmal nocturnal cough. Bronchoscopy was performed, and rare P. carinii cysts were detected in bronchoalveolar lavage (BAL) fluid. No therapy was instituted; however, the patient was admitted to the hospital 1 week later because of a worsening cough. Therapy with intravenous pentamidine resulted in only mild clinical improvement. On the patient's third hospital day, the laboratory reported isolation of B. bronchiseptica from the BAL fluid obtained 10 days earlier. The organism displayed in vitro resistance to ampicillin, trimethoprim-sulfamethoxazole, tetracycline, and cefazolin, but it was susceptible to ceftazidime, aminoglycosides, piperacillin, ciprofloxacin, and imipenem/cilastatin. Erythromycin was added to the patient's therapeutic regimen, he showed
Correspondence: Dr. Valerie L. Ng, Clinical Laboratories, San Francisco General Hospital, 1001 Potrero Avenue, Building NH, Room 2M, San Francisco, California 94110.
Clinical Infectious Diseases 1992;15:376-7 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1502-0027$02.00
References I. Martinez E, Domingo P, Marcos A. Pneumococcal bacteraemia in immunocompetent adults. Lancet 1991;337:57. 2. Webster J, Williams BD, Smith AP, Hall M, Jessop JD. Systemic lupus erythematosus presenting as pneumococcal septicaemia and septic arthritis. Ann Rheum Dis 1990;49: 181-3. 3. Korzets A, Chagnac A, Ori Y, Zevin 0, Levi J. Pneumococcal peritonitis complicating CAPO-was the indwelling intrauterine device to blame? Clin Nephrol 1991;35:24-5. 4. Stuck A, Seiler A, Frey FJ. Peritonitis due to an intrauterine device in a patient on CAPO. Peritoneal Dialysis Bulletin 1986;6: 158-9. 5. Gorensek MJ, Lebel MH, Nelson JD. Peritonitis in children with nephrotic syndrome. Pediatrics 1988;81 :849-56.
Downloaded from http://cid.oxfordjournals.org/ at Indiana University Library on July 25, 2015
with AIDS
S. M. Tariq and T. P. Joseph Department ofMedicine, Sultan Qaboos University Hospital, Al-Khod, Muscat. Sultanate ofOman
CID 1992; 15 (August)
Correspondence
377
the other two did not have any risk factors for infection with the human immunodeficiency virus type I (HIV -I ). The four patients with AIDS had other serious pulmonary infections that were concomitantly present at the time of B. bronchiseptica isolation (two had P. carinii pneumonia, one had cytomegalovirus pneumonia, and one had pneumonia due to Pseudomonas species). Each of the four patients was treated with therapy specific for their pulmonic infectious disease (gentamicin for the Pseudomonas species infection, ganciclovir for the cytomegalovirus infection, and trimethoprim-sulfamethoxazole for the P. carinii infection). None of the four patients were treated with erythromycin. Symptoms ofchronic cough resolved during the course of therapy for all four individuals. (Since Bordetella is susceptible to trimethoprim-sulfamethoxazole [2], the bordetella infection in the two individuals with P. carinii pneumonia may have inadvertently been treated simultaneously.) Of the two patients who did not have risk factors for infection with HIV-I, one had an exacerbation of his chronic asthma and the other had pulmonary tuberculosis when B. bronchiseptica was recovered from respiratory specimens. The first individual's symptom of shortness of breath resolved spontaneously after appropriate therapy for asthma, and the second individual showed clinical improvement after institution of therapy for tuberculosis. Subsequent respiratory specimens were not submitted for bacterial culture from either individual. Severe pulmonary infection with B. bronchiseptica has primarily been reported to occur in immunocompromised patients [512]. Our retrospective experience is noteworthy in that two of our isolates were from individuals who were not obviously immunocompromised. Furthermore, our isolates obtained from four patients with AIDS did not appear to correlate with clinical infection since at least two of the patients recovered spontaneously without specific therapy for bordetella infection. Although we believe that the first patient's nagging persistent cough was attributable to incurable B. bronchiseptica infection, our retrospective experience coupled with a lack ofspecific clinical symptoms, laboratory values, or radiologic features of previously described cases of pulmonary disease due to B. bronchiseptica has
unfortunately demonstrated that the clinical significance of an isolate of B. bronchiseptica cannot always be readily assessed.
Fatal Measles Pneumonia in an Immunocompetent Patient-Case Report
before admission. The patient was treated with lithium carbonate, fluphenazine, and benztropine mesylate, and her condition improved. On hospital day 12, she had an oral temperature of 102"F. She was asymptomatic, and a physical examination was unremarkable. The patient's medications were discontinued, but she remained febrile. Two days later, exudative pharyngitis was noted, and therapy with oral penicillin V, 500 mg every 6 hours, was started. On the following day, an acneform facial rash developed, and administration of penicillin V was discontinued. A chest roentgenogram obtained later that day revealed diffuse bilateral reticulonodular infiltrates (figure I), and the patient was transferred to the medical center. The patient's oral temperature on admission was 103.4°F, and her respirations were 22/min. Lung fields were clear to auscultation. The leukocyte count was 5,600/mm 3, with an automated differential cell count of 95%granulocytes, 1%mononuclear cells, and 4%lymphocytes. An analysis ofarterial blood gas performed while the patient was breathing room air revealed a
Correspondence: Dr. Edward K. Chapnick, Division of Infectious Diseases, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, New York 11219. Clinical Infectious Diseases 1992;15:377-9 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1502-0028$02.00
Divisions ofInfectiousDiseases and Pulmonary Medicine, Departmentsof Medicine and Laboratory Medicine, University of California, San Francisco. and San Francisco GeneralHospital, San Francisco, California
References I. Amador C, Chiner E, Calpe JL, Ortiz de la Tabla V., Martinez C, Pasquau F. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:771-2. 2. Decker GR, Lavelle JP, Kuman PN, Pierce PF. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:1250-1. 3. Kurzynski TA, Boehm OM, Rott-Petri JA, Schell RF, Allison PE. Antimicrobial susceptibilities of Bordetella species isolated in a multicenter pertussis surveillance project. Antimicrob Agents Chemother 1988; 12:137-40. 4. Goodnow RA. Biology of Bordetella bronchiseptica. Microbiol Rev 1980;44:722-38. 5. Buggy BP, Brosius FC III, Bogin RM, Koller CA, Schaberg DR. Bordetella bronchiseptica pneumonia in a patient with chronic lymphocytic leukemia. South Med J 1987;80: 1187-9. 6. Ghosh HK, Tranter J. Bordetella bronchicanis(bronchiseptica) infection in man: review and a case report. J Clin PathoI1979;32:546-8. 7. Stoll DB, Murphey SA, BallasSK. Bordetella bronchiseptica infection in stage IV Hodgkin's disease. Postgrad Med J 1981;57:723-4. 8. Meis JF. van Griethuisjen AJ. Muytjen JL. Bordetella bronchiseptica bronchitis in an immunosuppressed patient. Eur J Clin Microbiol Infect Dis 1990;9: 366-7. 9. Chauncey JB. Schaberg DR. Interstitial pneumonia caused by Bordetella bronchiseptica in a heart transplant patient. Transplantation 1990;49:817-9. 10. Katzenstein DA. Ciofalo L. Jordan MC Bordetella bronchiseptica bacteremia. West J Med 1984; 140:96-8. II. Papasian CJ, Downs NJ. Talley RL, Romberger OJ, Hodges GR. Bordetella bronchiseptica bronchitis. J Clin MicrobioI1987;25:575-7. 12. Byrd LH, Anarna L, Gutkin M. et al. Bordetella bronchiseptica peritonitis associated with continuous ambulatory peritoneal dialysis. J Clin MicrobioI1981;14:232-3.
Downloaded from http://cid.oxfordjournals.org/ at Indiana University Library on July 25, 2015
SIR-There has been a dramatic increase in the incidence of measles in the past 2 years [I]. Pneumonia is a recognized complication and is known to cause fatalities in immunosuppressed patients, but there are only rare reports offatal measles pneumonia in immunocompetent adults [2]. We report such a case. A 32-year-old woman with a history of bipolar affective disorder was admitted to our psychiatric hospital because of mania. She was born in Puerto Rico and moved to New York IS years
Valerie L. Ng, John M. Boggs, Mary K. York, Jeffrey A. Golden, Harry Hollander, and W. Keith Hadley
Correspondence
CID 1992; 15 (August)
results of tests for human immunodeficiency virus, antinuclear and anti-DNA antibodies, and rheumatoid factor were negative. The results of immunoglobulin electrophoresis were normal, and Widal's and Weil-Felix tests were negative. A splenic 99mTc-sulfur colloid scan showed normal uptake. She needed a period of mechanical ventilation postoperatively and had an uneventful recovery. Pneumococcal bacteremia may rarely occur in immunocompetent individuals [1]. Functional hyposplenia, as described in cases of collagen vascular disease, may be a risk factor for invasive pneumococcal infections [2]. It was ruled out as a factor in our patient's case. In Oman falciparum malaria is endemic, and mild splenomegaly is common. However, functional hyposplenia due to "malaria spleen" has not been reported. Pneumococcal peritonitis may occur as an ascending infection from the vagina in young girls aged 2-10 years, but it is exceedingly rare in older females. In two recently described cases, the patients were undergoing continuous ambulatory peritoneal dialysis (CAPO) [3, 4], and both had episodes of bloody dialysate before developing peritonitis; this circumstance suggests retrograde menstruation as a possible pathogenetic mechanism. However, it is not known whether CAPO increases the risk of retrograde menstruation. An intrauterine device has also been implicated as a risk factor for young females [3, 4]. We
excluded this possibility in our patient's case on the basis of her medical history and the results of ultrasonography. Rarely, pneumococcal peritonitis may be associated with nephrotic syndrome [5]. Even in the absence of a recognized risk factor, S. pneumoniae should be considered a possible causative agent, particularly when the response to the initial broad-spectrum antimicrobial therapy is poor.
Recovery of Bordetella bronchiseptica from Patients
gradual clinical improvement, and he was discharged after 2 weeks of therapy. The patient returned several days later with complaints ofpersistent cough. Despite an additional 3 weeks of therapy with erythromycin followed by 6 months of therapy with ciprofloxacin, the patient continued to have intermittent bouts of nagging nocturnal cough, and cultures ofinduced sputa continued to yield B. bronchiseptica. Our case was noteworthy for the following reasons. First, although this patient was treated with erythromycin, the recommended therapy for infection with Bordetella [3], the patient remained symptomatic and the organism was not eradicated. Second, alternate therapy with ciprofloxacin, chosen because of apparent in vitro susceptibility, did not alleviate symptoms or eradicate the organism from this patient's respiratory tract. Although ciprofloxacin was effective in curing the symptoms in the patient with AIDS described by Decker and co-workers [2], subsequent cultures of respiratory specimens were not obtained for assessing eradication of the organism. The experience of Amador and colleagues was similar to our own: they also were unsuccessful in either alleviating clinical symptoms or eradicating B. bronchiseptica following 40 days of therapy with ciprofloxacin [I]. These observations support the previously observed poor correlation of in vitro susceptibility testing of B. bronchiseptica and clinical outcome [4, 5]. As a result of this case, we reviewed our laboratory records at San Francisco General Hospital to determine the clinical significance of isolation of B. bronchiseptica from respiratory specimens. Since 1986 we have recovered six isolates of B. bronchiseptica from six patients; four of the patients had AIDS, whereas
SIR-We read with great interest the two recent letters describing Bordetella bronchiseptica pneumonia in patients with AIDS [I, 2]. We observed a similar case in a 43-year-old man with AIDS who had Kaposi's sarcoma and recurrent pneumonia due to Pneumocystis carinii. He presented with a 2-month history of severe paroxysmal nocturnal cough. Bronchoscopy was performed, and rare P. carinii cysts were detected in bronchoalveolar lavage (BAL) fluid. No therapy was instituted; however, the patient was admitted to the hospital 1 week later because of a worsening cough. Therapy with intravenous pentamidine resulted in only mild clinical improvement. On the patient's third hospital day, the laboratory reported isolation of B. bronchiseptica from the BAL fluid obtained 10 days earlier. The organism displayed in vitro resistance to ampicillin, trimethoprim-sulfamethoxazole, tetracycline, and cefazolin, but it was susceptible to ceftazidime, aminoglycosides, piperacillin, ciprofloxacin, and imipenem/cilastatin. Erythromycin was added to the patient's therapeutic regimen, he showed
Correspondence: Dr. Valerie L. Ng, Clinical Laboratories, San Francisco General Hospital, 1001 Potrero Avenue, Building NH, Room 2M, San Francisco, California 94110.
Clinical Infectious Diseases 1992;15:376-7 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1502-0027$02.00
References I. Martinez E, Domingo P, Marcos A. Pneumococcal bacteraemia in immunocompetent adults. Lancet 1991;337:57. 2. Webster J, Williams BD, Smith AP, Hall M, Jessop JD. Systemic lupus erythematosus presenting as pneumococcal septicaemia and septic arthritis. Ann Rheum Dis 1990;49: 181-3. 3. Korzets A, Chagnac A, Ori Y, Zevin 0, Levi J. Pneumococcal peritonitis complicating CAPO-was the indwelling intrauterine device to blame? Clin Nephrol 1991;35:24-5. 4. Stuck A, Seiler A, Frey FJ. Peritonitis due to an intrauterine device in a patient on CAPO. Peritoneal Dialysis Bulletin 1986;6: 158-9. 5. Gorensek MJ, Lebel MH, Nelson JD. Peritonitis in children with nephrotic syndrome. Pediatrics 1988;81 :849-56.
Downloaded from http://cid.oxfordjournals.org/ at Indiana University Library on July 25, 2015
with AIDS
S. M. Tariq and T. P. Joseph Department ofMedicine, Sultan Qaboos University Hospital, Al-Khod, Muscat. Sultanate ofOman
CID 1992; 15 (August)
Correspondence
377
the other two did not have any risk factors for infection with the human immunodeficiency virus type I (HIV -I ). The four patients with AIDS had other serious pulmonary infections that were concomitantly present at the time of B. bronchiseptica isolation (two had P. carinii pneumonia, one had cytomegalovirus pneumonia, and one had pneumonia due to Pseudomonas species). Each of the four patients was treated with therapy specific for their pulmonic infectious disease (gentamicin for the Pseudomonas species infection, ganciclovir for the cytomegalovirus infection, and trimethoprim-sulfamethoxazole for the P. carinii infection). None of the four patients were treated with erythromycin. Symptoms ofchronic cough resolved during the course of therapy for all four individuals. (Since Bordetella is susceptible to trimethoprim-sulfamethoxazole [2], the bordetella infection in the two individuals with P. carinii pneumonia may have inadvertently been treated simultaneously.) Of the two patients who did not have risk factors for infection with HIV-I, one had an exacerbation of his chronic asthma and the other had pulmonary tuberculosis when B. bronchiseptica was recovered from respiratory specimens. The first individual's symptom of shortness of breath resolved spontaneously after appropriate therapy for asthma, and the second individual showed clinical improvement after institution of therapy for tuberculosis. Subsequent respiratory specimens were not submitted for bacterial culture from either individual. Severe pulmonary infection with B. bronchiseptica has primarily been reported to occur in immunocompromised patients [512]. Our retrospective experience is noteworthy in that two of our isolates were from individuals who were not obviously immunocompromised. Furthermore, our isolates obtained from four patients with AIDS did not appear to correlate with clinical infection since at least two of the patients recovered spontaneously without specific therapy for bordetella infection. Although we believe that the first patient's nagging persistent cough was attributable to incurable B. bronchiseptica infection, our retrospective experience coupled with a lack ofspecific clinical symptoms, laboratory values, or radiologic features of previously described cases of pulmonary disease due to B. bronchiseptica has
unfortunately demonstrated that the clinical significance of an isolate of B. bronchiseptica cannot always be readily assessed.
Fatal Measles Pneumonia in an Immunocompetent Patient-Case Report
before admission. The patient was treated with lithium carbonate, fluphenazine, and benztropine mesylate, and her condition improved. On hospital day 12, she had an oral temperature of 102"F. She was asymptomatic, and a physical examination was unremarkable. The patient's medications were discontinued, but she remained febrile. Two days later, exudative pharyngitis was noted, and therapy with oral penicillin V, 500 mg every 6 hours, was started. On the following day, an acneform facial rash developed, and administration of penicillin V was discontinued. A chest roentgenogram obtained later that day revealed diffuse bilateral reticulonodular infiltrates (figure I), and the patient was transferred to the medical center. The patient's oral temperature on admission was 103.4°F, and her respirations were 22/min. Lung fields were clear to auscultation. The leukocyte count was 5,600/mm 3, with an automated differential cell count of 95%granulocytes, 1%mononuclear cells, and 4%lymphocytes. An analysis ofarterial blood gas performed while the patient was breathing room air revealed a
Correspondence: Dr. Edward K. Chapnick, Division of Infectious Diseases, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, New York 11219. Clinical Infectious Diseases 1992;15:377-9 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1502-0028$02.00
Divisions ofInfectiousDiseases and Pulmonary Medicine, Departmentsof Medicine and Laboratory Medicine, University of California, San Francisco. and San Francisco GeneralHospital, San Francisco, California
References I. Amador C, Chiner E, Calpe JL, Ortiz de la Tabla V., Martinez C, Pasquau F. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:771-2. 2. Decker GR, Lavelle JP, Kuman PN, Pierce PF. Pneumonia due to Bordetella bronchiseptica in a patient with AIDS. Rev Infect Dis 1991;13:1250-1. 3. Kurzynski TA, Boehm OM, Rott-Petri JA, Schell RF, Allison PE. Antimicrobial susceptibilities of Bordetella species isolated in a multicenter pertussis surveillance project. Antimicrob Agents Chemother 1988; 12:137-40. 4. Goodnow RA. Biology of Bordetella bronchiseptica. Microbiol Rev 1980;44:722-38. 5. Buggy BP, Brosius FC III, Bogin RM, Koller CA, Schaberg DR. Bordetella bronchiseptica pneumonia in a patient with chronic lymphocytic leukemia. South Med J 1987;80: 1187-9. 6. Ghosh HK, Tranter J. Bordetella bronchicanis(bronchiseptica) infection in man: review and a case report. J Clin PathoI1979;32:546-8. 7. Stoll DB, Murphey SA, BallasSK. Bordetella bronchiseptica infection in stage IV Hodgkin's disease. Postgrad Med J 1981;57:723-4. 8. Meis JF. van Griethuisjen AJ. Muytjen JL. Bordetella bronchiseptica bronchitis in an immunosuppressed patient. Eur J Clin Microbiol Infect Dis 1990;9: 366-7. 9. Chauncey JB. Schaberg DR. Interstitial pneumonia caused by Bordetella bronchiseptica in a heart transplant patient. Transplantation 1990;49:817-9. 10. Katzenstein DA. Ciofalo L. Jordan MC Bordetella bronchiseptica bacteremia. West J Med 1984; 140:96-8. II. Papasian CJ, Downs NJ. Talley RL, Romberger OJ, Hodges GR. Bordetella bronchiseptica bronchitis. J Clin MicrobioI1987;25:575-7. 12. Byrd LH, Anarna L, Gutkin M. et al. Bordetella bronchiseptica peritonitis associated with continuous ambulatory peritoneal dialysis. J Clin MicrobioI1981;14:232-3.
Downloaded from http://cid.oxfordjournals.org/ at Indiana University Library on July 25, 2015
SIR-There has been a dramatic increase in the incidence of measles in the past 2 years [I]. Pneumonia is a recognized complication and is known to cause fatalities in immunosuppressed patients, but there are only rare reports offatal measles pneumonia in immunocompetent adults [2]. We report such a case. A 32-year-old woman with a history of bipolar affective disorder was admitted to our psychiatric hospital because of mania. She was born in Puerto Rico and moved to New York IS years
Valerie L. Ng, John M. Boggs, Mary K. York, Jeffrey A. Golden, Harry Hollander, and W. Keith Hadley
