Streptococcus zooepidemicus cellulitis and bacteraemia in a renal transplant recipient M. J. McKeage Renal Registrar, Wellington Hospital, New Zealand
M. W. Humble Senior Lecturer in Clinical Microbiology, Wellington School of Medicine, New Zealand
R. B. I. Morrison Renal Physician, Wellington Hospital, New Zealand.
Abstract: A case of a renal transplant recipient with Streptococcus zooepidemiczcs (Lancefield group C) cellulitis and bacteraemia is described. Human infections with this organism are very rare and this is the first case report of cellulitis caused by S. zooepidemicus. While animals are the reservoir for most human infections, a source was not defined in this patient. (Aust NZ J Med 1990; 20: 177-178.) Key words: Streptococcus zooepidemicus, renal transplant, zoonosis.
Streptococcus zooepidemicus is a Lancefield group C streptococcus and is differentiated by biochemical tests from the other group C streptococci (S. dysguluctiue, S. equi and S. equisimilis). I Group C streptococci frequently cause disease in domestic animals, but human infections are rare.’ Only 118 cases of S. zooepidemicus human infection have been reported, and most have occurred in previously healthy people. Upper respiratory infections accounted for 89 of these 85 of which occurred during one epidemic.’ Poststreptococcal glomerulonephritis is a recognised complication,’ ’ 3 and transient disturbance of liver function may also Animals are the source of most human infections. Contaminated unpasteurised cow’s milk is the most common source and has caused three outbreaks.’ 3 3 Cases of poststreptococcal glomerulonephritis occurred in two of these This is the first case report of cellulitis caused by S. zooepidemicus and also the first account of S. zooepidemicus infection in a renal transplant recipient.
Relevant past history is that of presentation, in 1980, in end stage renal failure secondary to reflux nephropathy. After initial treatment with chronic ambulatory peritoneal dialysis and later home haemodialysis, he received a successful cadaveric renal transplant in 1983. At admission he was taking azathioprine 50 mg bd, prednisone 10 mg mane and laherolol 200 mg bd. O n examination he was jaundiced, febrile (38.5T) and had a tachycardia (1 I0imin). T h e jugular venous pressure was low ( 2 cm) and the blood pressure was 110/68 mmHg. T h e transplanted kidney felt normal. There was a large area of cellulitis over the anterior upper right thigh extending onto the abdominal wall. T h e right inguinal nodes were tender and enlarged. T h e healing laceration on the sole of the right foot did not appear infected. T h e peripheral blood white count was 5.1 x lOY/L(neutrophils 7670, lymphocytes 17%, monocytes 3% and basophils 4%). T h e serum creatinine was mildly raised at 0.18 mmol/L (previously stable at 0.13 mmollL), but the serum electrolytes were normal. T h e serum bilirubin was raised (153 pnol/L), the liver enzymes were normal (alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, gamma glutamyl transpeptidase), and the serum albumin was mildly reduced (34 glL). Two sets of blood cultures grew S. zooepidemicus (Lancefield group C), sensitive to penicillin and erythromycin. Swabs of the right foot laceration and a urine culture were sterile. UIine microscopy was normal. Acute and convalescent sera showed moderate elevation of antiDNAase B levels, 340 and 480 units respectively (n < 240 units), but the antistreptolysin 0 and antihyaluronidase levels were normal. H e was initially treated with penicillin G (two megaunits intravenously four hourly) and flucloxacillin (one gram intravenously ~
CASE REPORT X 40-year-old renal transplant patient presented with a two day hisrory of pain and redness in the right thigh, accompanied by fever, chills and lethargy. Two weeks earlier he had lacerated the sole of his right foot on broken glass. H e did not seek medical attention for this as it seemed to be healing. Three days hefore admission, while wearing open sandals, he visited a country pony club. ~
Reprinz requests 10: Dr M . McKeage, Todd Fnundation Fellow, Cancer Research Laboratory, Auckland School of Medicine, LJniversity of Auckland, Private Bag, Auckland, New Zealand.
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six hourly). He was rehydrated with normal saline. The flucloxacillin was stopped when the culture results became known. The fever, jaundice and cellulitis disappeared completely within 48 hours. He was discharged after three days, to take penicillin V (0.5 gram six hourly) for a further two weeks and has remained in good health.
DISCUSSION S. zooepidemicus is a common upper respiratory tract commensal in horses and is often associated with equine infections, most commonly septicaemia, abortion, abscesses and pneumonia.' Horses have been the source of human infection in four reported cases. One young woman developed pneumonia while caring for her sick horse.' Another developed meningitis and S. zooepidemicus was isolated from her horse's pharynx.I0 A horse trainer developed septic arthritis several days after taking cervical cultures from infertile mares without wearing gloves. One of the cervical cultures grew S. zooepidemicus." The fourth infection occurred in a pregnant woman who developed bacteraemia. She owned a racehorse with a tracheostomy which she cleared each morning. S. zooepidemicus was isolated from the tracheal This case report represents the first of cellulitis. ~ecretions.~ Although no direct route of transmission could be established, it is possible our patient acquired his infection at the pony club through contamination of the healing laceration on the exposed sole of his right foot. Accepted for publication: 24 July 1989
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References 1. Stamm AM, Cobbs CG. Group C streptococcal pneumonia, report of a fatal case and a review of the literature. Rev Infect Dis 1980; 2: 889-98. 2. Duca E, Teodorovici G, Radu C el al. A new nephritogenic streptococcus. J Hyg (Camb) 1969; 67: 691-8. 3. Barnham M, Thorton TJ, Lange K. Nephritis caused by Srreprococcus zooepidemicus (Lancefield group C). Lancet 1983; i: 945-8. 4. Kohler W, Cederburg A. Srreprococcus zooepidemicus (Group C Streptococci) as a cause of human disease. Scand J Infect Dis 1976; 8: 217-8. 5. Barnham M, Ljunggren A, McIntyre M. Human infection with S~reprococcuszooepidemicus (Lancefield group C): three case reports. Epidem Infect 1987; 98: 183-90. 6. Ghomeim A, Cooke EM. Serious infection caused by group C streptococci. J Clin Pathol 1980; 33: 188-90. 7. Mohr DN, Feist DJ, Washington JA, Hermans PE. Meningitis due to group C streptococcus in an adult. Mayo Clin Proc 1978; 53: 529-32. 8. Espinosa FH, Ryan WM, Vigil PL ef al. Group C streptococcal infections associated with eating homemade cheese - New Mexico. MMWR 1983; 32: 510-6. 9. Rose HD, Allen JR, Witte G. Srreprococcus zooepidemicus (group C ) pneumonia in a human. J Clin Microbiol 1980; 11: 76-8. 10. Low DE, Young MR, Harding GKM. Group C streptococcal meningitis in an adult. Probable acquisition from a horse. Arch Intern Med 1980; 140: 977-8. 11. Gorman PW, Collins DN. Group C streptococcal arthritis. A case report of equine transmission. Orthopedics 1987; 10: 615-6.
Aust NZ J Med 1990; 20
McKEAGE ET AL.
M. W. Humble Senior Lecturer in Clinical Microbiology, Wellington School of Medicine, New Zealand
R. B. I. Morrison Renal Physician, Wellington Hospital, New Zealand.
Abstract: A case of a renal transplant recipient with Streptococcus zooepidemiczcs (Lancefield group C) cellulitis and bacteraemia is described. Human infections with this organism are very rare and this is the first case report of cellulitis caused by S. zooepidemicus. While animals are the reservoir for most human infections, a source was not defined in this patient. (Aust NZ J Med 1990; 20: 177-178.) Key words: Streptococcus zooepidemicus, renal transplant, zoonosis.
Streptococcus zooepidemicus is a Lancefield group C streptococcus and is differentiated by biochemical tests from the other group C streptococci (S. dysguluctiue, S. equi and S. equisimilis). I Group C streptococci frequently cause disease in domestic animals, but human infections are rare.’ Only 118 cases of S. zooepidemicus human infection have been reported, and most have occurred in previously healthy people. Upper respiratory infections accounted for 89 of these 85 of which occurred during one epidemic.’ Poststreptococcal glomerulonephritis is a recognised complication,’ ’ 3 and transient disturbance of liver function may also Animals are the source of most human infections. Contaminated unpasteurised cow’s milk is the most common source and has caused three outbreaks.’ 3 3 Cases of poststreptococcal glomerulonephritis occurred in two of these This is the first case report of cellulitis caused by S. zooepidemicus and also the first account of S. zooepidemicus infection in a renal transplant recipient.
Relevant past history is that of presentation, in 1980, in end stage renal failure secondary to reflux nephropathy. After initial treatment with chronic ambulatory peritoneal dialysis and later home haemodialysis, he received a successful cadaveric renal transplant in 1983. At admission he was taking azathioprine 50 mg bd, prednisone 10 mg mane and laherolol 200 mg bd. O n examination he was jaundiced, febrile (38.5T) and had a tachycardia (1 I0imin). T h e jugular venous pressure was low ( 2 cm) and the blood pressure was 110/68 mmHg. T h e transplanted kidney felt normal. There was a large area of cellulitis over the anterior upper right thigh extending onto the abdominal wall. T h e right inguinal nodes were tender and enlarged. T h e healing laceration on the sole of the right foot did not appear infected. T h e peripheral blood white count was 5.1 x lOY/L(neutrophils 7670, lymphocytes 17%, monocytes 3% and basophils 4%). T h e serum creatinine was mildly raised at 0.18 mmol/L (previously stable at 0.13 mmollL), but the serum electrolytes were normal. T h e serum bilirubin was raised (153 pnol/L), the liver enzymes were normal (alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, gamma glutamyl transpeptidase), and the serum albumin was mildly reduced (34 glL). Two sets of blood cultures grew S. zooepidemicus (Lancefield group C), sensitive to penicillin and erythromycin. Swabs of the right foot laceration and a urine culture were sterile. UIine microscopy was normal. Acute and convalescent sera showed moderate elevation of antiDNAase B levels, 340 and 480 units respectively (n < 240 units), but the antistreptolysin 0 and antihyaluronidase levels were normal. H e was initially treated with penicillin G (two megaunits intravenously four hourly) and flucloxacillin (one gram intravenously ~
CASE REPORT X 40-year-old renal transplant patient presented with a two day hisrory of pain and redness in the right thigh, accompanied by fever, chills and lethargy. Two weeks earlier he had lacerated the sole of his right foot on broken glass. H e did not seek medical attention for this as it seemed to be healing. Three days hefore admission, while wearing open sandals, he visited a country pony club. ~
Reprinz requests 10: Dr M . McKeage, Todd Fnundation Fellow, Cancer Research Laboratory, Auckland School of Medicine, LJniversity of Auckland, Private Bag, Auckland, New Zealand.
S. ZOOEPIDEMICUS CELLL’LITIS
Aust NZ J Med 1990; 20
177
six hourly). He was rehydrated with normal saline. The flucloxacillin was stopped when the culture results became known. The fever, jaundice and cellulitis disappeared completely within 48 hours. He was discharged after three days, to take penicillin V (0.5 gram six hourly) for a further two weeks and has remained in good health.
DISCUSSION S. zooepidemicus is a common upper respiratory tract commensal in horses and is often associated with equine infections, most commonly septicaemia, abortion, abscesses and pneumonia.' Horses have been the source of human infection in four reported cases. One young woman developed pneumonia while caring for her sick horse.' Another developed meningitis and S. zooepidemicus was isolated from her horse's pharynx.I0 A horse trainer developed septic arthritis several days after taking cervical cultures from infertile mares without wearing gloves. One of the cervical cultures grew S. zooepidemicus." The fourth infection occurred in a pregnant woman who developed bacteraemia. She owned a racehorse with a tracheostomy which she cleared each morning. S. zooepidemicus was isolated from the tracheal This case report represents the first of cellulitis. ~ecretions.~ Although no direct route of transmission could be established, it is possible our patient acquired his infection at the pony club through contamination of the healing laceration on the exposed sole of his right foot. Accepted for publication: 24 July 1989
178
References 1. Stamm AM, Cobbs CG. Group C streptococcal pneumonia, report of a fatal case and a review of the literature. Rev Infect Dis 1980; 2: 889-98. 2. Duca E, Teodorovici G, Radu C el al. A new nephritogenic streptococcus. J Hyg (Camb) 1969; 67: 691-8. 3. Barnham M, Thorton TJ, Lange K. Nephritis caused by Srreprococcus zooepidemicus (Lancefield group C). Lancet 1983; i: 945-8. 4. Kohler W, Cederburg A. Srreprococcus zooepidemicus (Group C Streptococci) as a cause of human disease. Scand J Infect Dis 1976; 8: 217-8. 5. Barnham M, Ljunggren A, McIntyre M. Human infection with S~reprococcuszooepidemicus (Lancefield group C): three case reports. Epidem Infect 1987; 98: 183-90. 6. Ghomeim A, Cooke EM. Serious infection caused by group C streptococci. J Clin Pathol 1980; 33: 188-90. 7. Mohr DN, Feist DJ, Washington JA, Hermans PE. Meningitis due to group C streptococcus in an adult. Mayo Clin Proc 1978; 53: 529-32. 8. Espinosa FH, Ryan WM, Vigil PL ef al. Group C streptococcal infections associated with eating homemade cheese - New Mexico. MMWR 1983; 32: 510-6. 9. Rose HD, Allen JR, Witte G. Srreprococcus zooepidemicus (group C ) pneumonia in a human. J Clin Microbiol 1980; 11: 76-8. 10. Low DE, Young MR, Harding GKM. Group C streptococcal meningitis in an adult. Probable acquisition from a horse. Arch Intern Med 1980; 140: 977-8. 11. Gorman PW, Collins DN. Group C streptococcal arthritis. A case report of equine transmission. Orthopedics 1987; 10: 615-6.
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