1060
Correspondence
Streptococcus pneumoniae Peritonitis Secondary to Genital Tract Infection in a Previously Healthy Woman SIR-Streptococcus pneumoniae peritonitis is a well-known entity described in the past century. It was a relatively common disease in the preantibiotic era; both reporting ofcases and severity of disease have declined during the past decades. It is usually associated with hepatic or cardiac ascites in adult patients and with nephrotic syndrome and appendicitis in children. Pneumococcal peritonitis can present either as a primary disease or secondary to adjacent or distant pneumococcal infections. We report the case of a previously healthy young woman who presented with bacteremic pneumococcal peritonitis arising from the genital tract in the absence oflocal factors predisposing to infection. A 31-year-old woman with a history of hysteropexy and appendectomy was admitted to our hospital complaining ofleukorrhea and hypogastric pain followed by foul-smelling metrorrhagia and sustained fever. The general physical examination showed no abnormalities, except for slight pallor and sweating. Her temperature initially was 38.2°C, increasing to 40.rC a few hours later. Pelvic examination revealed normal external genitalia, yellowish cervical exudate, and painful mobilization. Both adnexal areas were tender and firm. She had rebound tenderness over the suprapubic area. On admission, her white blood cell count was 17.35 X I09fL with 5%band forms. Abdominal and pelvic ultrasonography showed endometrial thickening, bi-
Correspondence: Dr. Javier Gomez Rodrigo, Infectious Diseases Unit, Hospital Severo Ochoa, Avenida de Orellana Sin Numero, Leganes, 28911Madrid, Spain.
Clinical Infectious Diseases 1992;15:1060-1 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1506-0034$02.00
and can be lethal. In our patient valvular function remained adequate. Although presumably bacteriologically cured, the patient died of neurological complications. The clinical course suggested an initial embolic event that led to cerebral infarction. The hemorrhage could have been due to an unrecognized mycotic aneurysm or, more likely, hemorrhage into tissue altered by ischemia and necrosis. Our patient was initially afebrile, as may be the case in endocarditis, especially in elderly patients. His course serves as a reminder that endocarditis should be considered in the differential diagnosis for patients who present with new neurological events.
Mary E. Wilson and Debra S. Shapiro Department ofMedicineand Division ofInfectious Diseases, Mount Auburn Hospital, Cambridge, Massachusetts
Reference I. Morris A, Guild 1. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains. Clin Infect Dis 1991;13:887-92.
lateral adnexal enlargement, and free fluid in Douglas' cul-desac. Laparoscopy was unsuccessful because of previous surgery, and a laparotomy was performed. At surgery purulent peritoneal fluid was obtained from the abdominal cavity and Douglas' culde-sac; the perihepatic area was free of infection. Both fallopian tubes were inflamed and purulent. On admission she was treated with iv ampicillin, clindamycin, and gentamicin; the patient's condition improved soon after surgery. On the second day, blood cultures yielded penicillin-sensitive S. pneumoniae, and therapy was changed to that with oral amoxycillin. The same organism was recovered from peritoneal fluid inoculated in aerobic Bactec, as well as from endometrial and endocervical samples. Gram-positive diplococci were seen in gram-stained preparations of the endometrial and endocervical specimens. Cultures yielded no other pathogens, and the urine culture and results of the direct fluorescence test of cervical specimens for Chlamydia were negative. The blood culture strain was identified as serotype 1. In 1990 Westh et al. [1] reported nine cases of pneumococcal peritonitis, along with seven cases of pneumococcal bartholinitis and one case of vulvovaginitis. In their review, they found reports of 27 cases published between 1938 and 1988. Most of the patients had local factors predisposing them to infection, mainly the use ofan intrauterine contraceptive device (IUD) or changes secondary to the postpartum or postabortion period. They pointed out the fact that mortality for this rare entity ranged from almost 85%in the preantibiotic era to 0 after 1963. Six months later, Christopher et al. [2] reported one case of pneumococcal peritonitis in a young woman who had undergone three previous cesarean sections. The diagnosis ofour case prompted a MEDLINE search of the English-language literature. We found four additional cases in Westh's review, two of them occurring in IUD-bearing women [3-6]. As previously suggested, pneumococcal pelviperitonitis may be an underreported entity. S. pneumoniae can easily be missed as "saprophy-
Downloaded from http://cid.oxfordjournals.org/ at University of New South Wales on August 3, 2015
the isolate was sensitive to penicillin, ampicillin, cephalothin, chloramphenicol, clindamycin, erythromycin, gentamicin, vancomycin, and tetracycline. Testing by the agar dilution method was not performed. The patient was initially given vancomycin. Treatment was changed to administration of penicillin and gentamicin when the sensitivity profile of the organism was complete. While the patient was receiving penicillin and gentamicin, his serum was bactericidal at a dilution of ~ 1:256. His hospital course was complicated by mild congestive heart failure that responded promptly to diuretics. His right hemiplegia remained unchanged. Approximately 3 weeks into his hospital course, the patient became unresponsive and developed total flaccid paralysis. Computed tomography showed hemorrhage into the area of the cerebral infarct. Although the patient completed 4 weeks of antibiotic therapy and repeated blood cultures were sterile, he remained comatose and died ....., 7 weeks postadmission after a massive gastrointestinal hemorrhage occurred. Permission for autopsy was refused. The case of our patient reinforces the findings of Morris and Guild [1] that C. pseudodiphtheriticum can infect native valves
CID 1992; 15 (December)
CID 1992; 15 (December)
J. Gomez Rodrigo, B. Padilla, A. Delgado-Iribarren, J. L. Dargallo, C. Pedroviejo, and J. Elviro Infectious Diseases Unit and Departments of Microbiology and Obstetrics. Hospital SeveroOchoa. Madrid. Spain
Cerebrospinal Fluid Adenosine Deaminase Levels in a Patient with Cryptococcal Meningitis SIR-The measurement of the adenosine deaminase activity (ADA) in CSF has been previously reported as a useful and reliable test for diagnosis oftuberculosis meningitis, and its specificity has been described to be as high as 99.4% [1]. Even in patients infected with human immunodeficiency virus (HIV), despite a selective depletion of blood T lymphocytes, raised ADA levels in CSF have been described as a helpful tool for diagnosing tuberculous meningitis [2]. There may be false-positive results, most often in cases of viral meningitis, although in a recent study of patients with bacterial meningitis due to Staphylococcus aureus and Streptococcus pneumoniae, ADA levels in CSF were significantly higher than normal and there were no differences between groups with bacterial and tuberculous meningitis [3]. Furthermore, opportunistic microorganisms other than Mycobacterium tuberculosis, such as Cryptococcus neoformans, may also produce meningitis in immunosuppressed patients. For the past 5 years, we have routinely measured CSF ADA levels, as described by Giusti [4], in patients with meningitis. In addition to patients with tuberculous meningitis, we have seen high CSF ADA levels in all those patients who are infected with HIV and who have cryptococcal meningitis in whom this parameter was measured (nine patients of 12; 75%). Among HIV-in-
Correspondence: Dr. Esteban Martinez, Department of Internal Medicine. Hospital de la Santa Creu i Sant Pau, Avda. Sant Antoni Maria Claret, 167,08025, Barcelona, Spain.
References I. Westh H, Skibsted L, Korner B. Streptococcus pneumoniae infections of the female genital tract and in the newborn child. Rev Infect Dis 1990;12:416-22. 2. Christopher GW, Hucker lA, White DW, Carter BL. Pneumococcal infections of the female genital tract. Rev Infect Dis 1990; 12:1203-4. 3. Bukovsky I, Neuman M, Ron-EI R, Langer R, Caspi E. Pneumococcal peritonitis in the presence of intra-uterine device-conservative treatment; a case report. Eur J Obstet Gynecol Reprod Bioi 1989;33:7982. 4. Goldman lA, Yeshaya A, Peleg D, Dekel A, Dicker D. Severe pneumococcal peritonitis complicating IUD: case report and review of the literature. Obstet Gynecol Surv 1986;41:672-4. 5. Muray JM, GalIi-Douani D, Ciraru-Vigneron N, BarrierJ. Pneumococcal peritonitis. An unusual diagnosis in gynecology. J Gynecol Obstet Bioi Reprod (Paris) 1982;11:829-32. 6. Browne MK, Cassie R. Spontaneous bacterial peritonitis during pregnancy. Case report. Br J Obstet Gynaecol 1981 ;88: I 158-60. 7. Fenoll A, Martin Bourgon C, Munoz R, Vicioso D, Casal J. Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates causing systemic infection in Spain, 1979-1989. Rev Infect Dis 1991;13:56-60.
fected patients, CSF ADA values were not significantly different between the group with tuberculous meningitis and the one with cryptococcal meningitis. CSF biochemical and cytological data from HIV-infected patients with cryptococcal meningitis are shown in table 1. The values for CSF ADA showed a close direct correlation with the number oflymphocytes in CSF (r = .689, P = .04). As far as we know, the association between cryptococcal meningitis and raised levels of CSF ADA has not been previously reported. There are at least two reasons. On the one hand, the incidence of cryptococcal meningitis is low, even among patients infected by HIV (4.5%; 12 of 269 patients with HIV infection diagnosed at our hospital), because it seems that severe immunosuppression is required (the mean CD4 lymphocyte count for our patients was 21 ± 13/mm 3, ranging from 3 to 47). Moreover, many laboratories do not routinely measure ADA levels in CSF. Although HIV-infected patients show a higher incidence of tuberculous meningitis than do non-HlV-infected patients [5], the former are also at risk for developing meningitis due to C. neoformans. Therefore, the previously described high specificity ofthe measurement ofADA in CSF for the diagnosis oftubercuTable 1. CSF biochemical and cytological data for nine infected patients with cryptococcal meningitis. Parameter Protein (g/L) Ratio ofCSF/blood glucose Leukocytes/mnr' * Adenosine deaminase (U/L)
Mean ± SD .64 ± .39 .44 ± .17 158 ± 167 14.7 ± 5.7 t
Range .08-1.5 .16-.73 20-426 8.2-25.2 t
* All the patients had a pleocytosis of lymphocytic predominance. t
The normal valve at our hospital is
Correspondence
Streptococcus pneumoniae Peritonitis Secondary to Genital Tract Infection in a Previously Healthy Woman SIR-Streptococcus pneumoniae peritonitis is a well-known entity described in the past century. It was a relatively common disease in the preantibiotic era; both reporting ofcases and severity of disease have declined during the past decades. It is usually associated with hepatic or cardiac ascites in adult patients and with nephrotic syndrome and appendicitis in children. Pneumococcal peritonitis can present either as a primary disease or secondary to adjacent or distant pneumococcal infections. We report the case of a previously healthy young woman who presented with bacteremic pneumococcal peritonitis arising from the genital tract in the absence oflocal factors predisposing to infection. A 31-year-old woman with a history of hysteropexy and appendectomy was admitted to our hospital complaining ofleukorrhea and hypogastric pain followed by foul-smelling metrorrhagia and sustained fever. The general physical examination showed no abnormalities, except for slight pallor and sweating. Her temperature initially was 38.2°C, increasing to 40.rC a few hours later. Pelvic examination revealed normal external genitalia, yellowish cervical exudate, and painful mobilization. Both adnexal areas were tender and firm. She had rebound tenderness over the suprapubic area. On admission, her white blood cell count was 17.35 X I09fL with 5%band forms. Abdominal and pelvic ultrasonography showed endometrial thickening, bi-
Correspondence: Dr. Javier Gomez Rodrigo, Infectious Diseases Unit, Hospital Severo Ochoa, Avenida de Orellana Sin Numero, Leganes, 28911Madrid, Spain.
Clinical Infectious Diseases 1992;15:1060-1 © 1992 by The University of Chicago. All rights reserved.
1058-4838/92/1506-0034$02.00
and can be lethal. In our patient valvular function remained adequate. Although presumably bacteriologically cured, the patient died of neurological complications. The clinical course suggested an initial embolic event that led to cerebral infarction. The hemorrhage could have been due to an unrecognized mycotic aneurysm or, more likely, hemorrhage into tissue altered by ischemia and necrosis. Our patient was initially afebrile, as may be the case in endocarditis, especially in elderly patients. His course serves as a reminder that endocarditis should be considered in the differential diagnosis for patients who present with new neurological events.
Mary E. Wilson and Debra S. Shapiro Department ofMedicineand Division ofInfectious Diseases, Mount Auburn Hospital, Cambridge, Massachusetts
Reference I. Morris A, Guild 1. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains. Clin Infect Dis 1991;13:887-92.
lateral adnexal enlargement, and free fluid in Douglas' cul-desac. Laparoscopy was unsuccessful because of previous surgery, and a laparotomy was performed. At surgery purulent peritoneal fluid was obtained from the abdominal cavity and Douglas' culde-sac; the perihepatic area was free of infection. Both fallopian tubes were inflamed and purulent. On admission she was treated with iv ampicillin, clindamycin, and gentamicin; the patient's condition improved soon after surgery. On the second day, blood cultures yielded penicillin-sensitive S. pneumoniae, and therapy was changed to that with oral amoxycillin. The same organism was recovered from peritoneal fluid inoculated in aerobic Bactec, as well as from endometrial and endocervical samples. Gram-positive diplococci were seen in gram-stained preparations of the endometrial and endocervical specimens. Cultures yielded no other pathogens, and the urine culture and results of the direct fluorescence test of cervical specimens for Chlamydia were negative. The blood culture strain was identified as serotype 1. In 1990 Westh et al. [1] reported nine cases of pneumococcal peritonitis, along with seven cases of pneumococcal bartholinitis and one case of vulvovaginitis. In their review, they found reports of 27 cases published between 1938 and 1988. Most of the patients had local factors predisposing them to infection, mainly the use ofan intrauterine contraceptive device (IUD) or changes secondary to the postpartum or postabortion period. They pointed out the fact that mortality for this rare entity ranged from almost 85%in the preantibiotic era to 0 after 1963. Six months later, Christopher et al. [2] reported one case of pneumococcal peritonitis in a young woman who had undergone three previous cesarean sections. The diagnosis ofour case prompted a MEDLINE search of the English-language literature. We found four additional cases in Westh's review, two of them occurring in IUD-bearing women [3-6]. As previously suggested, pneumococcal pelviperitonitis may be an underreported entity. S. pneumoniae can easily be missed as "saprophy-
Downloaded from http://cid.oxfordjournals.org/ at University of New South Wales on August 3, 2015
the isolate was sensitive to penicillin, ampicillin, cephalothin, chloramphenicol, clindamycin, erythromycin, gentamicin, vancomycin, and tetracycline. Testing by the agar dilution method was not performed. The patient was initially given vancomycin. Treatment was changed to administration of penicillin and gentamicin when the sensitivity profile of the organism was complete. While the patient was receiving penicillin and gentamicin, his serum was bactericidal at a dilution of ~ 1:256. His hospital course was complicated by mild congestive heart failure that responded promptly to diuretics. His right hemiplegia remained unchanged. Approximately 3 weeks into his hospital course, the patient became unresponsive and developed total flaccid paralysis. Computed tomography showed hemorrhage into the area of the cerebral infarct. Although the patient completed 4 weeks of antibiotic therapy and repeated blood cultures were sterile, he remained comatose and died ....., 7 weeks postadmission after a massive gastrointestinal hemorrhage occurred. Permission for autopsy was refused. The case of our patient reinforces the findings of Morris and Guild [1] that C. pseudodiphtheriticum can infect native valves
CID 1992; 15 (December)
CID 1992; 15 (December)
J. Gomez Rodrigo, B. Padilla, A. Delgado-Iribarren, J. L. Dargallo, C. Pedroviejo, and J. Elviro Infectious Diseases Unit and Departments of Microbiology and Obstetrics. Hospital SeveroOchoa. Madrid. Spain
Cerebrospinal Fluid Adenosine Deaminase Levels in a Patient with Cryptococcal Meningitis SIR-The measurement of the adenosine deaminase activity (ADA) in CSF has been previously reported as a useful and reliable test for diagnosis oftuberculosis meningitis, and its specificity has been described to be as high as 99.4% [1]. Even in patients infected with human immunodeficiency virus (HIV), despite a selective depletion of blood T lymphocytes, raised ADA levels in CSF have been described as a helpful tool for diagnosing tuberculous meningitis [2]. There may be false-positive results, most often in cases of viral meningitis, although in a recent study of patients with bacterial meningitis due to Staphylococcus aureus and Streptococcus pneumoniae, ADA levels in CSF were significantly higher than normal and there were no differences between groups with bacterial and tuberculous meningitis [3]. Furthermore, opportunistic microorganisms other than Mycobacterium tuberculosis, such as Cryptococcus neoformans, may also produce meningitis in immunosuppressed patients. For the past 5 years, we have routinely measured CSF ADA levels, as described by Giusti [4], in patients with meningitis. In addition to patients with tuberculous meningitis, we have seen high CSF ADA levels in all those patients who are infected with HIV and who have cryptococcal meningitis in whom this parameter was measured (nine patients of 12; 75%). Among HIV-in-
Correspondence: Dr. Esteban Martinez, Department of Internal Medicine. Hospital de la Santa Creu i Sant Pau, Avda. Sant Antoni Maria Claret, 167,08025, Barcelona, Spain.
References I. Westh H, Skibsted L, Korner B. Streptococcus pneumoniae infections of the female genital tract and in the newborn child. Rev Infect Dis 1990;12:416-22. 2. Christopher GW, Hucker lA, White DW, Carter BL. Pneumococcal infections of the female genital tract. Rev Infect Dis 1990; 12:1203-4. 3. Bukovsky I, Neuman M, Ron-EI R, Langer R, Caspi E. Pneumococcal peritonitis in the presence of intra-uterine device-conservative treatment; a case report. Eur J Obstet Gynecol Reprod Bioi 1989;33:7982. 4. Goldman lA, Yeshaya A, Peleg D, Dekel A, Dicker D. Severe pneumococcal peritonitis complicating IUD: case report and review of the literature. Obstet Gynecol Surv 1986;41:672-4. 5. Muray JM, GalIi-Douani D, Ciraru-Vigneron N, BarrierJ. Pneumococcal peritonitis. An unusual diagnosis in gynecology. J Gynecol Obstet Bioi Reprod (Paris) 1982;11:829-32. 6. Browne MK, Cassie R. Spontaneous bacterial peritonitis during pregnancy. Case report. Br J Obstet Gynaecol 1981 ;88: I 158-60. 7. Fenoll A, Martin Bourgon C, Munoz R, Vicioso D, Casal J. Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates causing systemic infection in Spain, 1979-1989. Rev Infect Dis 1991;13:56-60.
fected patients, CSF ADA values were not significantly different between the group with tuberculous meningitis and the one with cryptococcal meningitis. CSF biochemical and cytological data from HIV-infected patients with cryptococcal meningitis are shown in table 1. The values for CSF ADA showed a close direct correlation with the number oflymphocytes in CSF (r = .689, P = .04). As far as we know, the association between cryptococcal meningitis and raised levels of CSF ADA has not been previously reported. There are at least two reasons. On the one hand, the incidence of cryptococcal meningitis is low, even among patients infected by HIV (4.5%; 12 of 269 patients with HIV infection diagnosed at our hospital), because it seems that severe immunosuppression is required (the mean CD4 lymphocyte count for our patients was 21 ± 13/mm 3, ranging from 3 to 47). Moreover, many laboratories do not routinely measure ADA levels in CSF. Although HIV-infected patients show a higher incidence of tuberculous meningitis than do non-HlV-infected patients [5], the former are also at risk for developing meningitis due to C. neoformans. Therefore, the previously described high specificity ofthe measurement ofADA in CSF for the diagnosis oftubercuTable 1. CSF biochemical and cytological data for nine infected patients with cryptococcal meningitis. Parameter Protein (g/L) Ratio ofCSF/blood glucose Leukocytes/mnr' * Adenosine deaminase (U/L)
Mean ± SD .64 ± .39 .44 ± .17 158 ± 167 14.7 ± 5.7 t
Range .08-1.5 .16-.73 20-426 8.2-25.2 t
* All the patients had a pleocytosis of lymphocytic predominance. t
The normal valve at our hospital is
