V.ol. 11, 1992
4. Canton R, Leon A, de la Fuente S, Carda P, Morales .V, Baquero F, Messeguer MA: Beta-lactamase producing Haemophilus influenzae as causative agent of a
liver abscess. European Journal of Clinical Microbiology and Infectious Diseases 1989, 8: 748-749. 5. Ferran M, Buti M, Gonzalez A, Boqu~ R, Esteban R, Guardia J: Pyogenicliver abscess by Haemophilus influenzae complicatinghydatid cysts. Infection 1986, 14: 197. 6. KUian M: Haemophilus. In: Lennette EH, Balows A, Hausler WJ, Shadomy HJ red): Manual of clinical microbiology. American Society for Microbiology. Washington, DC, 1985, p. 387-393. 7. M~graud F, B~b~ar C, Dabernat H, Deimas C: Haemophilus species in the human gastrointestinal tract. European Journal of Clinical Microbiologyand Infectious Diseases 1988, 7: 437-438. 8. Palmer GG: Haemophili in feces. Journal of Medical Microbiology 1981; 14: 147-150. 9. Morton D, WilliamsP: Characterizationof the outermembrane proteinsof Haemophilus parainfluenzae expressed under iron-sufficientand iron-restricted conditions. Journal of General Microbiology 1989, 135: 445--451. 10. Quentin R, Goudeau A, Wallace JR, Smith AL, Selander RK, Musser JM: Urogenital, maternal and neonatal isolates of Haemophilus influenzae: identification of unusually virulent serologically nontypable clone familiesand evidence for a new Haemophihts species. Journal of General Microbiology1990, 136: 1203-1209.
Serratiafonticola as an I n f e c t i o u s A g e n t A few weeks after Bollet et al. (1) had reported the first documented human infection due to Serratia fonticola, our laboratory was confronted With the isolation and identification of the very Same bacterium from pus. The organism was responsible for a severe infection of the right hand of a 39-year-old female patient. She had suffered an open fracture of the hand in a car accident. The WOund was subsequently debrided and treated locally with gentamicin. The entire lesion healed within a few days. Apart from a few colonies of Bacillus cereus, the primary plates were predominantly covered with Smooth colonies of Serratia fonticola. In the enrichment broth, Serratia fonticola again represented the major organism, in addition to some Colonies of Bacillus cereus and Staphylococcus aureus. In contrast to the bacterium isolated by Bollet et al., our strain developed a strong potatolike odor, a feature typical of some Serratia and Cedecea strains (2). In addition, it showed a
199
cocarde phenomenon which had been observed previously in Serratia marcescens and which is known to be induced by the cationic detergentlike activity of colistin (3). Our isolate showed excellent identification as
Serratiafonticota (97.7 % and 99.9 %) by the API 20E and API 50 CH systems (API System S.A., France), respectively. Except for positive reactions for both sucrose and cellobiose, our strain exhibited the same biochemical reactions as the organism described by Bollet et al. Additional biochemical tests provided by the API 50 CH system revealed that our strain was, furthermore, positive for fermentations of glycerol, ribose, Dxylose, galactose, D-fructose, D-mannose, dulcitol, inositol, cx-methyl-D-glucoside, N-acetylglucosamine, trehalose, D-raffinose, [3-gentiobiose, D-tagatose, D-arabitol, L-arabitol, gluconate, 2-keto-gluconate, 5-keto-gluconate and maltose. Negative reactions were observed for D-arabinose, L-xylose, l~-methyl-xyloside, Lsorbose, c~-ethyl-D-mannoside, amygdalin, inulin, melezitose, starch, glycogen, xylitol, Dturanose, D-lyxose, D-fucose and L-fucose. Compared with type strain ATCC 29844 (1), our isolate differed only in the utilization of cellobiose. It appears, furthermore, to be biochemically very similar to the strains described by Gavini et al. (4), Farmer et ai. (5) and MUller et al. (6). Most of these strains have been found either in water or bird feces, although a few were isolated from wounds (5) without their possible role as potential clinical pathogens recognized at that time. Antibiotic susceptibility of our strain was determined by the agar diffusion disk method according to the standard procedure of the National Committee for Clinical Laboratory Standards (7) using cation-supplemented Mueller-Hinton medium. The isolate was found to be susceptible to ciprofloxacin, cefoxitin, ceftazidime, ceftriaxone, gentamicin, netilmicin, tobramycin, piperaciIlin, imipenem and sulfamethoxazole-trimethoprim, but resistant to ampicillin, amoxicillin/clavulanic acid, cephalothin and cefamandole.
G.E. Pfyffer
Institute of Medical Microbiology, University of Ztirich, Gloriastrasse 32, 8028 Ztirich,Switzerland.
200
References 1, Bollet C, Gainnier M, Sainly J-M, Orhesser P, de Micco P: Serratia fonticola isolated from a leg abscess.
Journal of Clinical Microbiology 1991, 29: 834--835. 2. Galiois A, Grimont PAD: Pyrazines responsible for the potato-like odor produced by some Serratia and Cedecea strains. Applied Environmental Microbiology 1985, 50: 1048-1051. 3. Traub W: Polymyxin B-induced cocarde growth phenomenon of Serratia marcescens due to cationic detergent-like activity of polymyxin B. Chemotherapy 1982, 28: 363-368. 4. Gavini FB, Ferragut C, Izard D, Trinei PA, Lederc H, Lefebvre B, Mossel DAA: Serratiafontico/a, a new species from water. International Journal of Systematic Bacteriology 1979, 29: 92-101. 5. Farmer I11 J J, Davis BR, Hickman-Brenner FW, McWorther A, Huntley-Carter GP, Asbury MA, Riddle .C, Watzhen-Gardy HG, Elias C, Fanning GR, Steigerwalt AG, O'Hara CM, Morris GK, Smith PB, Brenner D J: Biochemical identification of new species and biogroups of Enterobacteriaceae isolated from clinical specimens. Journal of Clinical Microbiology 1985, 21: 46-76. 6. Miiller HE, Steigerwalt AG, Brenner D J: Isolation of Serratia fonticola from birds. Zentralblatt far Bakteriologic und Hygiene A, 1986, 261: 212-218. 7. National Committee for Clinical Laboratory Standards: Performance standards for antimicrobial disk susceptibility tests. Approved Standard M2-A4. 4th edition. NCCLS, Villanova, PA, 1990.
A C a s e o f Cellulitis, T h r o m b o p h l e b i t i s and B a c t e r e m i a C a u s e d by Salmonella G r o u p E
Non-typhoid Salmonella infection with extra-intestinal manifestations is a well recognized entity. In most cases it occurs in elderly and very young patients, and in subjects with immunosuppression (1). Soft tissues are an uncommon site of infection with Salmonella and to our knowledge only one case of venous system involvement has been reported (2). We report on a previously healthly patient who developed cellulitis of his lower left extremity along with saphenous thrombophlebitis and bacteremia caused by Salmonella group E serotype give. The 66-year-old man was admitted to our hospital because of fever. He had a two week history of pain and erythema in the left leg accompanied by fever and chills. He did not report any recent trauma. Cephradine 2 g per day and subsequently clindamycin 1.2 g per day p.o. were administered without improvement of the patient's condition,
Eur. J. Clin. Microbiol. Infect. Dis.
Physical examination showed an axillary temperature of 40.5 °, erythema, tenderness and two cutaneous abscesses on the lower third of the left leg. There were signs of thrombosis of the great saphenous vein extending up to the thigh. There was no crepitation. The laboratory results showed leucocytes: 10 x 10/1 with a shift of the left, AST 64 U/l, ALT 101 U/I. The reaction to the tuberculin test using 5 units measured 12 mm. Tests for HIV were negative. Chest X-rays and an E C G were normal. The cutaneous abscesses were excised and subsequently the arch of the great saphenous vein was ligated. The material obtained from the abscesses and the blood samples were cultured in aerobic and anaerobic media. All cultures grew a gram-negative rod identified biochemically (API 20E, Analytab Products, USA) as Salmonella and by agglutination with specific antisera as Salmonella group E, serotype give. It was sensitive to ampicillin, co-trimoxazole and chloramphenicol. The stool culture was negative. Ampicillin at a dosage of 12 g per day i.v. was administered for two weeks. The general condition of the patient improved, and the fever and inflamatory signs disappeared on the fifth day of treatment. Subsequently, amoxicillin at a dosage of 2 g per day p.o. was administered for one week. Six months after discharge the patient remained asymptomatic. Extraintestinal non-typhoid salmonellosis can occur in patients with decreased immune defences due to solid or haematotogical neoplasms, system lupus erythematosis, Sickle cell disease, AIDS or organ transplantation. Defects in cellmediated immunity and decreased levels of C2, C3, C4 and lgM have been reported (3, 4). In our patient the immunological status was not investigated, however no underlying diseases or predisposing conditions were apparent. The absence of gastrointestinal symptoms and negative stool cultures have been reported by Aguado et al. (5) in patients with metastatic sites of Salmonella infection which according to these authors could arise from a dormant focus in the reticuloendotelial system. Salmonella spreads mainly to the lungs, pleura, joints and arterio-vascular system, especially when damaged endothelium is present (1, 3). Involvement of the superficial venous system is exceptional. Only one case, also involving the lower left extremity in a patient with gastric adenocarcinoma, has been reported to our knowledge (2). We believe that thrombophlebitis in our patient
4. Canton R, Leon A, de la Fuente S, Carda P, Morales .V, Baquero F, Messeguer MA: Beta-lactamase producing Haemophilus influenzae as causative agent of a
liver abscess. European Journal of Clinical Microbiology and Infectious Diseases 1989, 8: 748-749. 5. Ferran M, Buti M, Gonzalez A, Boqu~ R, Esteban R, Guardia J: Pyogenicliver abscess by Haemophilus influenzae complicatinghydatid cysts. Infection 1986, 14: 197. 6. KUian M: Haemophilus. In: Lennette EH, Balows A, Hausler WJ, Shadomy HJ red): Manual of clinical microbiology. American Society for Microbiology. Washington, DC, 1985, p. 387-393. 7. M~graud F, B~b~ar C, Dabernat H, Deimas C: Haemophilus species in the human gastrointestinal tract. European Journal of Clinical Microbiologyand Infectious Diseases 1988, 7: 437-438. 8. Palmer GG: Haemophili in feces. Journal of Medical Microbiology 1981; 14: 147-150. 9. Morton D, WilliamsP: Characterizationof the outermembrane proteinsof Haemophilus parainfluenzae expressed under iron-sufficientand iron-restricted conditions. Journal of General Microbiology 1989, 135: 445--451. 10. Quentin R, Goudeau A, Wallace JR, Smith AL, Selander RK, Musser JM: Urogenital, maternal and neonatal isolates of Haemophilus influenzae: identification of unusually virulent serologically nontypable clone familiesand evidence for a new Haemophihts species. Journal of General Microbiology1990, 136: 1203-1209.
Serratiafonticola as an I n f e c t i o u s A g e n t A few weeks after Bollet et al. (1) had reported the first documented human infection due to Serratia fonticola, our laboratory was confronted With the isolation and identification of the very Same bacterium from pus. The organism was responsible for a severe infection of the right hand of a 39-year-old female patient. She had suffered an open fracture of the hand in a car accident. The WOund was subsequently debrided and treated locally with gentamicin. The entire lesion healed within a few days. Apart from a few colonies of Bacillus cereus, the primary plates were predominantly covered with Smooth colonies of Serratia fonticola. In the enrichment broth, Serratia fonticola again represented the major organism, in addition to some Colonies of Bacillus cereus and Staphylococcus aureus. In contrast to the bacterium isolated by Bollet et al., our strain developed a strong potatolike odor, a feature typical of some Serratia and Cedecea strains (2). In addition, it showed a
199
cocarde phenomenon which had been observed previously in Serratia marcescens and which is known to be induced by the cationic detergentlike activity of colistin (3). Our isolate showed excellent identification as
Serratiafonticota (97.7 % and 99.9 %) by the API 20E and API 50 CH systems (API System S.A., France), respectively. Except for positive reactions for both sucrose and cellobiose, our strain exhibited the same biochemical reactions as the organism described by Bollet et al. Additional biochemical tests provided by the API 50 CH system revealed that our strain was, furthermore, positive for fermentations of glycerol, ribose, Dxylose, galactose, D-fructose, D-mannose, dulcitol, inositol, cx-methyl-D-glucoside, N-acetylglucosamine, trehalose, D-raffinose, [3-gentiobiose, D-tagatose, D-arabitol, L-arabitol, gluconate, 2-keto-gluconate, 5-keto-gluconate and maltose. Negative reactions were observed for D-arabinose, L-xylose, l~-methyl-xyloside, Lsorbose, c~-ethyl-D-mannoside, amygdalin, inulin, melezitose, starch, glycogen, xylitol, Dturanose, D-lyxose, D-fucose and L-fucose. Compared with type strain ATCC 29844 (1), our isolate differed only in the utilization of cellobiose. It appears, furthermore, to be biochemically very similar to the strains described by Gavini et al. (4), Farmer et ai. (5) and MUller et al. (6). Most of these strains have been found either in water or bird feces, although a few were isolated from wounds (5) without their possible role as potential clinical pathogens recognized at that time. Antibiotic susceptibility of our strain was determined by the agar diffusion disk method according to the standard procedure of the National Committee for Clinical Laboratory Standards (7) using cation-supplemented Mueller-Hinton medium. The isolate was found to be susceptible to ciprofloxacin, cefoxitin, ceftazidime, ceftriaxone, gentamicin, netilmicin, tobramycin, piperaciIlin, imipenem and sulfamethoxazole-trimethoprim, but resistant to ampicillin, amoxicillin/clavulanic acid, cephalothin and cefamandole.
G.E. Pfyffer
Institute of Medical Microbiology, University of Ztirich, Gloriastrasse 32, 8028 Ztirich,Switzerland.
200
References 1, Bollet C, Gainnier M, Sainly J-M, Orhesser P, de Micco P: Serratia fonticola isolated from a leg abscess.
Journal of Clinical Microbiology 1991, 29: 834--835. 2. Galiois A, Grimont PAD: Pyrazines responsible for the potato-like odor produced by some Serratia and Cedecea strains. Applied Environmental Microbiology 1985, 50: 1048-1051. 3. Traub W: Polymyxin B-induced cocarde growth phenomenon of Serratia marcescens due to cationic detergent-like activity of polymyxin B. Chemotherapy 1982, 28: 363-368. 4. Gavini FB, Ferragut C, Izard D, Trinei PA, Lederc H, Lefebvre B, Mossel DAA: Serratiafontico/a, a new species from water. International Journal of Systematic Bacteriology 1979, 29: 92-101. 5. Farmer I11 J J, Davis BR, Hickman-Brenner FW, McWorther A, Huntley-Carter GP, Asbury MA, Riddle .C, Watzhen-Gardy HG, Elias C, Fanning GR, Steigerwalt AG, O'Hara CM, Morris GK, Smith PB, Brenner D J: Biochemical identification of new species and biogroups of Enterobacteriaceae isolated from clinical specimens. Journal of Clinical Microbiology 1985, 21: 46-76. 6. Miiller HE, Steigerwalt AG, Brenner D J: Isolation of Serratia fonticola from birds. Zentralblatt far Bakteriologic und Hygiene A, 1986, 261: 212-218. 7. National Committee for Clinical Laboratory Standards: Performance standards for antimicrobial disk susceptibility tests. Approved Standard M2-A4. 4th edition. NCCLS, Villanova, PA, 1990.
A C a s e o f Cellulitis, T h r o m b o p h l e b i t i s and B a c t e r e m i a C a u s e d by Salmonella G r o u p E
Non-typhoid Salmonella infection with extra-intestinal manifestations is a well recognized entity. In most cases it occurs in elderly and very young patients, and in subjects with immunosuppression (1). Soft tissues are an uncommon site of infection with Salmonella and to our knowledge only one case of venous system involvement has been reported (2). We report on a previously healthly patient who developed cellulitis of his lower left extremity along with saphenous thrombophlebitis and bacteremia caused by Salmonella group E serotype give. The 66-year-old man was admitted to our hospital because of fever. He had a two week history of pain and erythema in the left leg accompanied by fever and chills. He did not report any recent trauma. Cephradine 2 g per day and subsequently clindamycin 1.2 g per day p.o. were administered without improvement of the patient's condition,
Eur. J. Clin. Microbiol. Infect. Dis.
Physical examination showed an axillary temperature of 40.5 °, erythema, tenderness and two cutaneous abscesses on the lower third of the left leg. There were signs of thrombosis of the great saphenous vein extending up to the thigh. There was no crepitation. The laboratory results showed leucocytes: 10 x 10/1 with a shift of the left, AST 64 U/l, ALT 101 U/I. The reaction to the tuberculin test using 5 units measured 12 mm. Tests for HIV were negative. Chest X-rays and an E C G were normal. The cutaneous abscesses were excised and subsequently the arch of the great saphenous vein was ligated. The material obtained from the abscesses and the blood samples were cultured in aerobic and anaerobic media. All cultures grew a gram-negative rod identified biochemically (API 20E, Analytab Products, USA) as Salmonella and by agglutination with specific antisera as Salmonella group E, serotype give. It was sensitive to ampicillin, co-trimoxazole and chloramphenicol. The stool culture was negative. Ampicillin at a dosage of 12 g per day i.v. was administered for two weeks. The general condition of the patient improved, and the fever and inflamatory signs disappeared on the fifth day of treatment. Subsequently, amoxicillin at a dosage of 2 g per day p.o. was administered for one week. Six months after discharge the patient remained asymptomatic. Extraintestinal non-typhoid salmonellosis can occur in patients with decreased immune defences due to solid or haematotogical neoplasms, system lupus erythematosis, Sickle cell disease, AIDS or organ transplantation. Defects in cellmediated immunity and decreased levels of C2, C3, C4 and lgM have been reported (3, 4). In our patient the immunological status was not investigated, however no underlying diseases or predisposing conditions were apparent. The absence of gastrointestinal symptoms and negative stool cultures have been reported by Aguado et al. (5) in patients with metastatic sites of Salmonella infection which according to these authors could arise from a dormant focus in the reticuloendotelial system. Salmonella spreads mainly to the lungs, pleura, joints and arterio-vascular system, especially when damaged endothelium is present (1, 3). Involvement of the superficial venous system is exceptional. Only one case, also involving the lower left extremity in a patient with gastric adenocarcinoma, has been reported to our knowledge (2). We believe that thrombophlebitis in our patient
