Letters
Septic Arthritis due to Oligella urethralis Except for ophthalmic infections, Moraxella Species are uncommon causes of disease. In particular, septic arthritis has been described on rare OCcasions. We report a case of Oligella urethralis (formerly Moraxella urethralis) infectious arthritis in a patient hospitalized in a surgical unit. An 83-year-old man was hospitalized in a surgical unit for rectum adenocarcinoma. Five weeks later the patient had a fever of 39.8 °C and refused to Walk. Examination at this time revealed that the right knee was warm, tender, greater in circumference than the left knee but not erythematous. Laboratory data included a white blood cell count of 14,000/mm 3 with 70 % neutrophils and 30 % lymphocytes. The erythrocyte sedimentation rate (Westergren) was 60 mm in the first hour. Radiographs of the right knee showed signs of chondrocalcinosis. Blood cultures performed at this time remained sterile. Purulent material was aspirated from the knee. It had poor clot formation and contained 210,000 white blood cells/mm3; 97 % were neutrophils. Direct examination was negative. OligeUa urethralis grew in pure culture, > 300 cfu per plate, on chocolate agar plates, incubated aerobically during 48 hours at 37 °C. No viral cultures were performed. Cultures of urine, pharynx, and conjunctiva revealed no pathogens. The patient was immediately treated with intravenous amoxicillin (1 g every 12 hours). Fever defervesced within 24 hours. Antibiotic therapy was Continued for three weeks. A control articular aspiration performed at 48 hours did not yield any bacteria. Upon examination three weeks later the patient was free of symptoms. The genus Oligella has been recently removed from the genus Moraxella on the basis of DNArRNA hybridizations and serological data (1). Two species have been delineated: Oligella urethralis (to accomodate Moraxella urethralis) and Oligella ureolytica. The genus Oligella shares COmmon properties with the genus Moraxella: gram-negative coccobacilli, strictly aerobic, Oxidase positive, non-saccharolytic. The strain isolated in this reported case had the following characteristics: gram-negative diplobacilli, nonmotile, oxidase and catalase positive, growth with little colonies on 5 % horse blood agar at 30 °C, 37 °C and slightly at 40 °C (after 48 hOUrs), growth on MacConkey agar, growth on Thayer Martin selective medium for Neisseria, Utilization of citrate, acetate and ethanol as the Sole sources of carbon, gamma-glutamyl transferase quickly positive, non-saccharolytic, urea
Vol. 11. No. 2
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on Christensen medium negative, gelatin and serum liquefaction negative, nitrate and nitrite are not reduced (nitrite reduction was tested by incubation for six days in 0.05 and 0.001% nitrite). The nitrite reductase of Oligella urethralis is generally positive, but discrepant characteristics have been mentioned in the literature (1). Antimicrobial susceptibility measured by the disk agar diffusion method showed that our strain was susceptible to ampicillin, anmxicillin/clavulanic acid, cephalosporins, aminoglycosides, minocyclin, pefloxacin, erythromycin and trimethoprim-sulfamethoxazole and resistant to lincomycin. The MICs were not determined. Cases of infectious arthritis caused by Moraxella species are rare. Only five cases have been reported in the last 20 years. Schonholtz and Scott (2) described one case of purulent arthritis of the knee diagnosed by arthroscopic synovial biopsy and culture with isolation of Moraxella osloensis. In another report, Rosenbaum et al. (3) described a case of septic arthritis clinically mimicking disseminated gonococcaemia with associated gonococcal arthritis, due to Moraxella species. Spahr (4) reported isolation of Moraxella species of a knee with indolent infectious arthritis. Feigin et al. (5) described a case of fulminant Moraxella infectious arthritis with an associated vaginal discharge. Montplaisir et al. (6) speculated that the Moraxella identified in a post-traumatic arthritis (initially presenting as pseudomonas septic arthritis) was a ned-opportunistic organism. Our observation is the first case reported of Oligella urethralis infectious arthritis. This case show that infectious arthritis clinically mimicking gonococcal arthritis may be caused by Oligella urethral& an opportunistic bacteria. Although its morphology is slightly different from Neisseria gonorrhoeae, growth may occur on Thayer Martin selective medium. The age of the patient and underlying predisposing factors (in this case rectum adenocarcinoma) may contribute to the pathogenicity of this strain. R. M e s n a r d 1. J.M Sire 1 EY. D o n n i o 1 J.Y. R i o u 2 J.L. Avril 1 a Laboratoire de Bact6riologie-Virologie, H6pital Pont. chaillou, 35033 Renncs Cedex, France. 2 Unit6 des Neisscria, Centre National de R6f6rence des M6ningocoques et Neisseria Apparent6es, Institut Pasteur, 28 rue du Docteur Roux, 75724Paris Cedex, France.
196
References 1. Rossau R, Kersters K, Falsen E, Jantzen E, Segers P, Union A, Nehls L, De Ley J: Oligella, a new genus including Oligella urethralis comb. nov. (formerly Moraxella urethral&) and Oligella ureotytica sp. nov. (formerly CDC group IVe): relationship to Taylorella
2. 3.
4. 5. 6.
equigenitalis and related taxa. International Journal of Sytematic Bacteriology 1987, 37: 198-210. Schonholtz GJ, Scott WO: Moraxella septic arthritis of the knee joint: a case report. Arthroscopy 1986, 2: 96--97. Rosenbaum J, Lieberman DH, Katz WA: Moraxella infectious arthritis: first report in an adult. Annals of the Rheumatic Diseases 1980, 39: 184-185. Spahr RC: Septic arthritis due to Moraxella species. Journal of Pediatrics 1975, 86: 310. Feigin RD, San Joaquin V, Middlelkemp JN: Septic arthritis due to Moraxella osloensis. Journal of Pediatrics 1969, 75: 116-117. Montplaisir S, Auger P, Marlineau B: Post-traumatic arthritis caused by Pseudomonas aeruginosa et Morgrella lwoffi: identification and pathogenic role of Moraxella. L'Union Medicaledu Canada 1971, I00: 1762-1766.
A C a s e ofPropionibacterium acnes Spinal Osleomyelitis
Propionibacterium acnes, previously known as Corynebacterium aches or Corynebacterium parvum, is a pleomorphic, gram-positive anaerobic or microaerophilic organism often recovered from epithelial surfaces of humans (1). Propionibacterium acnes has also commonly been isolated from blood cultures, most often as a contaminant. In the past the organism has been thought to have no intrinsic pathogenicity for humans although there have been some reports of infections due to Propionibacterium acnes, particularly in patients with vascular and orthopedic prosthetic implants (2-6). In addition, it has been isolated from wound infections as part of a mixed flora, and may play a sigmficant role in the pathogenesis of acne (7). In this report we describe a case of spinal osteomyelitis caused by Propionibacteriurn aches.
A 23-year-old woman with known mitral valve prolapse and aortic regurgitation (Marfan-like syndrome) and anamnestic evidence of streptococcal endocarditis (three years earlier) was admitted to our unit because of intermittent, lowgrade fever with chills and malaise. A change in heart murmur was documented and echocardio-
Eur. J. Clin. Microbiol. Infect. Dis.
graphy showed an increase in the pre-existing aortic regurgitation. Three blood cultures were performed, and in one case Propionibacterium acnes was isolated. A four-week course of teicoplanin (400 mg/day i.v.) was administered according to in vitro sensitivity tests to treat the presumed endocarditis. Therapy was apparently successful and the patient was discharged and remained well for a period of three months, after which she developed increasing non-radiating lower back pain, and low-grade fever with ESR values of 70 mm/h and normal WBC and differential. The patient was readmitted to hospital. A first X-ray did not identify bone lesions but subsequent tomographic scan and radionuclide studies were indicative of a spinal osteomylitis at L3-L4. A cytologic examination of two different fineneedle biopsies, performed under X-ray guide, revealed the exclusive presence of granulocytes, while Propionibacterium acnes was isolated from both specimens. The same microorganism was present in all of 6 blood cultures, but growth was slow and required 12 days' incubation. A six-week course of antimicrobial therapy with rifampicin (900 mg/day by i.v. infusion) plus trimethoprimsulfamethoxazole (160-800 mg b.i.d, po) was completed and followed by three courses of a three-week oral treatment (same drugs and dosages), separated by one-week intervals. Therapy was well tolerated by the patient and resulted in defervescence within 48 hours, progressive decrease of lumbar pain and normalisation of ESR in 28 days. Two years after presentation the patient was symptom-free, had a normal range of movement in her lumbar spine, and radiological evidence showed almost complete recovery with chronic sclerosis of the anatomic lesion. Propionibacterium acnes is an uncommon cause of osteomyelitis, and as it is a component of normal skin flora, establishing its pathogenicity may be difficult. Further difficulties derive from the prolonged incubation time needed (range 5 clays to 2 weeks) for identification (1). Most bone infections previously ascribed to Propionibacterium acnes or Propionibacterium sp. were associated with surgical or invasive procedures (1-6), and Propionibacterium acnes was rarely isolated in pure cultures (1-3, 8). In a recent review of the literature (3) it was reported that, among 17 patients affected by osteomyelitis, four had spinal osteomyelitis and in two a surgery-related predisposing condition was present. Our patient was untypical as most of the previously described cases have been diagnosed in men. Furthermore, she developed osteomylitis without invasive proce-
Septic Arthritis due to Oligella urethralis Except for ophthalmic infections, Moraxella Species are uncommon causes of disease. In particular, septic arthritis has been described on rare OCcasions. We report a case of Oligella urethralis (formerly Moraxella urethralis) infectious arthritis in a patient hospitalized in a surgical unit. An 83-year-old man was hospitalized in a surgical unit for rectum adenocarcinoma. Five weeks later the patient had a fever of 39.8 °C and refused to Walk. Examination at this time revealed that the right knee was warm, tender, greater in circumference than the left knee but not erythematous. Laboratory data included a white blood cell count of 14,000/mm 3 with 70 % neutrophils and 30 % lymphocytes. The erythrocyte sedimentation rate (Westergren) was 60 mm in the first hour. Radiographs of the right knee showed signs of chondrocalcinosis. Blood cultures performed at this time remained sterile. Purulent material was aspirated from the knee. It had poor clot formation and contained 210,000 white blood cells/mm3; 97 % were neutrophils. Direct examination was negative. OligeUa urethralis grew in pure culture, > 300 cfu per plate, on chocolate agar plates, incubated aerobically during 48 hours at 37 °C. No viral cultures were performed. Cultures of urine, pharynx, and conjunctiva revealed no pathogens. The patient was immediately treated with intravenous amoxicillin (1 g every 12 hours). Fever defervesced within 24 hours. Antibiotic therapy was Continued for three weeks. A control articular aspiration performed at 48 hours did not yield any bacteria. Upon examination three weeks later the patient was free of symptoms. The genus Oligella has been recently removed from the genus Moraxella on the basis of DNArRNA hybridizations and serological data (1). Two species have been delineated: Oligella urethralis (to accomodate Moraxella urethralis) and Oligella ureolytica. The genus Oligella shares COmmon properties with the genus Moraxella: gram-negative coccobacilli, strictly aerobic, Oxidase positive, non-saccharolytic. The strain isolated in this reported case had the following characteristics: gram-negative diplobacilli, nonmotile, oxidase and catalase positive, growth with little colonies on 5 % horse blood agar at 30 °C, 37 °C and slightly at 40 °C (after 48 hOUrs), growth on MacConkey agar, growth on Thayer Martin selective medium for Neisseria, Utilization of citrate, acetate and ethanol as the Sole sources of carbon, gamma-glutamyl transferase quickly positive, non-saccharolytic, urea
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195
on Christensen medium negative, gelatin and serum liquefaction negative, nitrate and nitrite are not reduced (nitrite reduction was tested by incubation for six days in 0.05 and 0.001% nitrite). The nitrite reductase of Oligella urethralis is generally positive, but discrepant characteristics have been mentioned in the literature (1). Antimicrobial susceptibility measured by the disk agar diffusion method showed that our strain was susceptible to ampicillin, anmxicillin/clavulanic acid, cephalosporins, aminoglycosides, minocyclin, pefloxacin, erythromycin and trimethoprim-sulfamethoxazole and resistant to lincomycin. The MICs were not determined. Cases of infectious arthritis caused by Moraxella species are rare. Only five cases have been reported in the last 20 years. Schonholtz and Scott (2) described one case of purulent arthritis of the knee diagnosed by arthroscopic synovial biopsy and culture with isolation of Moraxella osloensis. In another report, Rosenbaum et al. (3) described a case of septic arthritis clinically mimicking disseminated gonococcaemia with associated gonococcal arthritis, due to Moraxella species. Spahr (4) reported isolation of Moraxella species of a knee with indolent infectious arthritis. Feigin et al. (5) described a case of fulminant Moraxella infectious arthritis with an associated vaginal discharge. Montplaisir et al. (6) speculated that the Moraxella identified in a post-traumatic arthritis (initially presenting as pseudomonas septic arthritis) was a ned-opportunistic organism. Our observation is the first case reported of Oligella urethralis infectious arthritis. This case show that infectious arthritis clinically mimicking gonococcal arthritis may be caused by Oligella urethral& an opportunistic bacteria. Although its morphology is slightly different from Neisseria gonorrhoeae, growth may occur on Thayer Martin selective medium. The age of the patient and underlying predisposing factors (in this case rectum adenocarcinoma) may contribute to the pathogenicity of this strain. R. M e s n a r d 1. J.M Sire 1 EY. D o n n i o 1 J.Y. R i o u 2 J.L. Avril 1 a Laboratoire de Bact6riologie-Virologie, H6pital Pont. chaillou, 35033 Renncs Cedex, France. 2 Unit6 des Neisscria, Centre National de R6f6rence des M6ningocoques et Neisseria Apparent6es, Institut Pasteur, 28 rue du Docteur Roux, 75724Paris Cedex, France.
196
References 1. Rossau R, Kersters K, Falsen E, Jantzen E, Segers P, Union A, Nehls L, De Ley J: Oligella, a new genus including Oligella urethralis comb. nov. (formerly Moraxella urethral&) and Oligella ureotytica sp. nov. (formerly CDC group IVe): relationship to Taylorella
2. 3.
4. 5. 6.
equigenitalis and related taxa. International Journal of Sytematic Bacteriology 1987, 37: 198-210. Schonholtz GJ, Scott WO: Moraxella septic arthritis of the knee joint: a case report. Arthroscopy 1986, 2: 96--97. Rosenbaum J, Lieberman DH, Katz WA: Moraxella infectious arthritis: first report in an adult. Annals of the Rheumatic Diseases 1980, 39: 184-185. Spahr RC: Septic arthritis due to Moraxella species. Journal of Pediatrics 1975, 86: 310. Feigin RD, San Joaquin V, Middlelkemp JN: Septic arthritis due to Moraxella osloensis. Journal of Pediatrics 1969, 75: 116-117. Montplaisir S, Auger P, Marlineau B: Post-traumatic arthritis caused by Pseudomonas aeruginosa et Morgrella lwoffi: identification and pathogenic role of Moraxella. L'Union Medicaledu Canada 1971, I00: 1762-1766.
A C a s e ofPropionibacterium acnes Spinal Osleomyelitis
Propionibacterium acnes, previously known as Corynebacterium aches or Corynebacterium parvum, is a pleomorphic, gram-positive anaerobic or microaerophilic organism often recovered from epithelial surfaces of humans (1). Propionibacterium acnes has also commonly been isolated from blood cultures, most often as a contaminant. In the past the organism has been thought to have no intrinsic pathogenicity for humans although there have been some reports of infections due to Propionibacterium acnes, particularly in patients with vascular and orthopedic prosthetic implants (2-6). In addition, it has been isolated from wound infections as part of a mixed flora, and may play a sigmficant role in the pathogenesis of acne (7). In this report we describe a case of spinal osteomyelitis caused by Propionibacteriurn aches.
A 23-year-old woman with known mitral valve prolapse and aortic regurgitation (Marfan-like syndrome) and anamnestic evidence of streptococcal endocarditis (three years earlier) was admitted to our unit because of intermittent, lowgrade fever with chills and malaise. A change in heart murmur was documented and echocardio-
Eur. J. Clin. Microbiol. Infect. Dis.
graphy showed an increase in the pre-existing aortic regurgitation. Three blood cultures were performed, and in one case Propionibacterium acnes was isolated. A four-week course of teicoplanin (400 mg/day i.v.) was administered according to in vitro sensitivity tests to treat the presumed endocarditis. Therapy was apparently successful and the patient was discharged and remained well for a period of three months, after which she developed increasing non-radiating lower back pain, and low-grade fever with ESR values of 70 mm/h and normal WBC and differential. The patient was readmitted to hospital. A first X-ray did not identify bone lesions but subsequent tomographic scan and radionuclide studies were indicative of a spinal osteomylitis at L3-L4. A cytologic examination of two different fineneedle biopsies, performed under X-ray guide, revealed the exclusive presence of granulocytes, while Propionibacterium acnes was isolated from both specimens. The same microorganism was present in all of 6 blood cultures, but growth was slow and required 12 days' incubation. A six-week course of antimicrobial therapy with rifampicin (900 mg/day by i.v. infusion) plus trimethoprimsulfamethoxazole (160-800 mg b.i.d, po) was completed and followed by three courses of a three-week oral treatment (same drugs and dosages), separated by one-week intervals. Therapy was well tolerated by the patient and resulted in defervescence within 48 hours, progressive decrease of lumbar pain and normalisation of ESR in 28 days. Two years after presentation the patient was symptom-free, had a normal range of movement in her lumbar spine, and radiological evidence showed almost complete recovery with chronic sclerosis of the anatomic lesion. Propionibacterium acnes is an uncommon cause of osteomyelitis, and as it is a component of normal skin flora, establishing its pathogenicity may be difficult. Further difficulties derive from the prolonged incubation time needed (range 5 clays to 2 weeks) for identification (1). Most bone infections previously ascribed to Propionibacterium acnes or Propionibacterium sp. were associated with surgical or invasive procedures (1-6), and Propionibacterium acnes was rarely isolated in pure cultures (1-3, 8). In a recent review of the literature (3) it was reported that, among 17 patients affected by osteomyelitis, four had spinal osteomyelitis and in two a surgery-related predisposing condition was present. Our patient was untypical as most of the previously described cases have been diagnosed in men. Furthermore, she developed osteomylitis without invasive proce-
