BRIEF REPORTS
METHOD
ANTIBODIES TO BORNA DISEASE VIRUS IN
SUBACUTE SCLEROSING PANENCEPHALITIS
Serdal Güngör, MD,* Banu Anlar, MD,* Nuri Turan, PhD,†
Hüseyin Yılmaz, PhD,† Chris R. Helps, PhD,‡
and Dave A. Harbour, PhD‡
Abstract: Mechanisms causing persistence and reactivation of mea-
sles virus in subacute sclerosing panencephalitis (SSPE) are un-
known. Borna disease virus (BDV) frequently causes latent or
persistent infection in the nervous system. We investigated a possi-
ble association of these viruses in SSPE. Although BDV seroposi-
tivity was similar in SSPE and control groups, SSPE patients with
high antibodies to BDV had earlier and more rapid disease. The
findings suggest that BDV might be involved in the course, but not
in the etiopathogenesis, of SSPE.
Accepted for publication March 3, 2005.
From the *Department of Pediatric Neurology, Hacettepe University Faculty
of Medicine, Ankara, Turkey; the †Department of Microbiology, Faculty
of Veterinary Medicine, Istanbul University, Istanbul, Turkey; and the
‡University of Bristol Veterinary School Molecular and Cellular Biol-
ogy, Bristol, United Kingdom
Dr Güngör’s current affiliation is the Department of Pediatric Neurology,
Inönü University Faculty of Medicine, Malatya, Turkey.
E-mail banlar@hacettepe.edu.tr. Reprints not available.
Copyright © 2005 by Lippincott Williams & Wilkins
DOI: 10.1097/01.inf.0000178307.70429.75
T he pathogenesis of subacute sclerosing panencephalitis (SSPE),
a disease that manifests several years after acute measles virus
(MV) infection, is unknown. Viral, environmental and host factors
facilitating the persistence of MV or its activation from a latent state
have been investigated. No evidence of impaired host immunity has
been demonstrated in SSPE patients.1 SSPE is more frequent among
children who had measles before 2 years if age and in rural
populations. Geographic and temporal changes in certain features of
SSPE, such as the duration of latent period, age of onset, or rate of
progression suggest a possible role for environmental factors in its
manifestations.2,3
Among these factors, infection with other viruses can con-
tribute to the establishment of latent or persistent infection by
several possible mechanisms: suppression of immunity; alterations
in tissue pH or permeability; increased expression of adhesion
molecules or cytokines; usage of available viral enzymes or pro-
moter sequences; or inhibition of apoptosis. In particular, neuro-
tropic viruses with a predilection for latency are potential associates.
Borna disease virus (BDV) shares these features with MV and
is found in many warm blooded animals and in psychiatric patients.
We investigated the presence of antibodies to BDV (aBDV) and the
association between BDV infection and clinical course in a group of
children with SSPE.
MATERIALS AND METHODS
Patients. The diagnosis of SSPE was made by: (1) clinical signs and
symptoms; (2) electroencephalographic findings; (3) cerebrospinal
fluid measles antibody titers. All patients met the 3 criteria. Clinical
stages were defined as: stage 1, psychointellectual symptoms; stage
2, stereotyped attacks; stage 3, bedridden; inconsistent or absent
responses to stimuli. The pretreatment clinical course was classified
as rapidly progressive when the Neurologic Disability Index in-
creased ⬎30% per month.4,5
Control cases were patients with nonprogressive, noninfec-
tious neurologic disorders (epilepsy, headache, cerebral palsy), from
the same geographic area and same rural versus urban distribution.
The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
Synthesis of Recombinant p40 Protein. The p40 gene of a BDV
isolated from a horse was cloned and expressed using the Baculo-
virus expression system as described previously.6 Recombinant
Baculovirus-infected sf9 cells were harvested 72 hours after infec-
tion. Recombinant hexahistidine-tagged p40 was purified in nickel-
agarose under natural conditions. The purity and specificity of this
protein were tested by sodium dodecyl sulfate-polyacrylamide gel
electrophoresis and immunoblotting.6
Standardization of Enzyme-Linked Immunosorbent Assay (ELISA).
Two-fold dilutions of p40 protein, starting from 10 ␮g/mL, were
used to coat the ELISA plates. Positive test sera were used at
dilutions from 1/20 to 1/1280. These experiments showed the
optimal concentration of p40 proteins as 5 ␮g/mL and the optimal
dilution of serum as 1/40. Human sera were therefore tested at this
dilution.
Application of ELISA. SSPE and control sera were stored at –20°C
until tested. ELISA plates were coated with 5 ␮g/mL p40 protein
and incubated overnight at 4°C. After blocking with phosphate-
buffered saline-0.05% Tween 20 with 5% fat-free dry milk for 1
hour at room temperature (RT), positive control and study sera,
diluted 1/40 in blocking buffer, were applied to wells (1 hour, RT).
Secondary antibody, rabbit anti-human IgG-alkaline phosphatase-
conjugated, was applied at a dilution of 1/1000 for 1 hour of
incubation at RT. All incubations were followed by 4 rinses with
phosphate-buffered saline-0.05% Tween 20. p-Nitrophenyl phos-
phate, 1 mg/mL in alkaline phosphatase buffer (0.1 M glycine, 1
mM MgCl2, 1 mM ZnCl2, pH 10.4) was added to plates, which were
read at 405 nm after 30 minutes. Each serum was tested in antigen-
coated and noncoated wells to measure the background optical
density. Sera that read at least 2-fold values compared with back-
ground were considered positive.7 Low, moderate or high positive
titers were defined by optical density values between 90 and 100,
100 and 200 and ⬎200, respectively.
Statistical analysis was conducted via the ␹2 and t tests for
independent samples.
RESULTS
The SSPE group (n ⫽ 174; ages 5–15 years; mean, 6.4 ⫾ 2.8
years), and the control group (n ⫽ 174; ages 5–15 years; mean,
6.8 ⫾ 2.3 years) were similar in age and sex distribution.
The rate of seropositivity was 22.4% (39 of 174) in SSPE and
22.5% (39 of 173) in control groups (P ⬎ 0.05). aBDV-positive
cases in both groups were of similar age and area of residence
(P ⬎ 0.05). More SSPE boys than control subjects were aBDV-
positive (P ⬍ 0.001).
In the SSPE group, aBDV-positive and -negative cases did
not differ in age of onset, age at testing, sex, rural versus urban
residence, symptoms and course of disease (Table).
aBDV-positive sera were highly positive in 9 (23.1%), mod-
erately positive in 28 (71.8%) and low positive in 2 (5.1%) SSPE
cases. Patients with high aBDV had earlier onset (P ⬍ 0.05) and
significantly more rapid course than others (P ⬍ 0.005) (Table 1).
DISCUSSION
BDV is mainly found in warm blooded animals and causes
noncytolytic, persistent infection in the central nervous system. The
resulting phenotype is age-dependent, ranging from an asymptom-
atic state to developmental abnormalities or meningoencephalitis.
An association of BDV with psychiatric disorders in humans has
been reported, although with some controversy.8,9 Certain features
of SSPE such as long latency period, increased frequency in rural
833
Shah et al The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005

TABLE 1. Features of SSPE Cases According to aBDV Status

Age at Age at Age at

Serology M:F (%) Course (% Rapid) Rural/Urban (%) Area (East/West) (%)
Test (yr) Onset (yr) Measles (mo)

aBDV-positive 6.8 ⫾ 2.9 6.1 ⫾ 2.9 18.4 ⫾ 10.8 61.5/38.5 38.5 56.6/43.6 53.8/46.2
aBDV-negative 6.2 ⫾ 2.9 5.9 ⫾ 2.9 20.0 ⫾ 18.8 79.2/20.8 45.5 41.7/58.3 41.7/58.3
P ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05 ⬎0.05
High aBDV 5.4 ⫾ 2.9 4.2 ⫾ 2.5 18.8 ⫾ 13.9 88.9/11.1 77.8 66.7/33.3 66.7/33.3
Moderate aBDV 7.0 ⫾ 2.8 6.4 ⫾ 2.8 17.8 ⫾ 9.8 53.6/46.4 25.0 50.0/50.0 46.4/53.6
P ⬎0.05 ⬍0.05 ⬎0.05 ⬎0.05 ⬍0.005 ⬎0.05 ⬎0.05

populations and after MV infections at young age, and the presence
of behavioral symptoms imply a possible connection with BDV.
Our study did not support an association of BDV with SSPE
or with its behavioral or neuropsychiatric symptoms. On the other
hand, high titer BDV antibodies concurred with earlier onset and
faster progression of SSPE. Rybakowski et al10 found a similar
result in psychiatric patients; those with the disorder for a period
shorter than 1 year had a higher BDV seropositivity rate, suggesting
BDV as an activator or initiator. BDV infections are not likely to
cause direct neuronal destruction but rather to trigger alterations in
neurotransmitters, cytokines, chemokines, nitric oxide or neuronal
apoptosis, contributing to cell damage. These mechanisms might
explain the early and rapid course of SSPE in patients with high
titers of aBDV. Alternatively an association secondary to the course
of SSPE can be speculated; rapidly progressing SSPE cases can
synthesize more antibodies because of immune stimulation. How-
ever, our studies with other viruses did not show such an association,
arguing against a general immune system activation in such cases.11
This is the first serologic study in humans in Turkey to detect
antibodies to BDV. The 22% rate of seropositivity in control cases
does not reflect the general population, but a certain region and age
group matched for region and age to the SSPE group. This high rate
of seropositivity suggests that further studies in the general popula-
tion are warranted. The use of only a single BDV antigen nucleo-
protein (p40) is a limitation of our study, but most seropositivity in
humans is against p40 nucleoprotein.9 Although the optimal meth-
odology for BDV detection has not been defined, serology is
currently most widely used. The diagnostic value of reverse
transcription-polymerase chain reaction-based tests is questioned
because of the low correlation of BDV RNA detection and antibody
positivity in blood. On the other hand, human aBDV of low avidity
might cross-react or form immune complexes with plasma antigens.8
Therefore the ELISA method should be complemented with West-
ern blotting. For clinical studies, a highly sensitive “screening” test
followed by a highly specific confirmatory test would be of signif-
icant benefit.
Our hypothesis that BDV promotes latency or triggers reac-
tivation of MV in SSPE is not supported by these results. The earlier
onset and more rapid course of SSPE in patients with high titers of
aBDV might indicate a contribution of BDV to the course and tissue
damage in SSPE.
ACKNOWLEDGMENTS
We thank Dr A. T. Reder, University of Chicago, for his input
in the study.
REFERENCES
1. Aysun S, Sanal O, Renda Y, et al. Cell mediated immunity in patients
with subacute sclerosing panencephalitis. Brain Dev. 1984;6:391–396.
2. Bojinova VS, Dimova PS, Belopitova LD, et al. Clinical and epidemi-
ological characteristics of subacute sclerosing panencephalitis in Bul-
garia during the past 25 years (1978 –2002). Eur J Paediatr Neurol.
2004;8:89 –94.
3. Anlar B, Köse G, Gürer Y, Altunbasak S, Haspolat S, Okan M.
Changing epidemiological features of subacute sclerosing panencepha-
litis. Infection. 2001;29:192–195.
4. Dyken PR, Swift A, DuRant RH. Long-term follow-up of patients with
subacute sclerosing panencephalitis treated with inosiplex. Ann Neurol.
1982;11:359 –363.
5. Yalaz K, Anlar B, Oktem F, et al. Intraventricular interferon and oral
inosiplex in the treatment of subacute sclerosing panencephalitis. Neu-
rology. 1992;42:488 – 491.
6. Bode L, Ludwig H. Borna disease virus infection, a human mental-
health risk. Clin Microbiol Rev. 2003;16:534 –545.
7. Yilmaz H, Helps CR, Turan N, Uysal A, Harbour DA. Detection of
antibodies to Borna disease virus (BDV) in Turkish horse sera using
recombinant p40. Arch Virol. 2002;147:429 – 435.
8. Helps CR, Turan N, Bilal T, Harbour DA, Yilmaz H. Detection of
antibodies to Borna disease virus in Turkish cats by using recombinant
p40. Vet Rec. 2001;149:647– 650.
9. Schwemmle M. Borna disease virus infection in psychiatric patients: are
we on the right track? Lancet Infect Dis. 2001;1:46 –52.
10. Rybakowski F, Sawada T, Yamaguchi K. Borna disease virus-reactive
antibodies and recent-onset psychiatric disorders. Eur Psychiatry. 2001;
16:191–192.
11. Anlar B, Pinar A, Anlar FY, et al. Viral studies in the cerebrospinal fluid
in subacute sclerosing panencephalitis. J Infect. 2002;44:176 –180.
STAPHYLOCOCCUS AUREUS AS A RISK FACTOR FOR
BLOODSTREAM INFECTION IN CHILDREN WITH
POSTOPERATIVE MEDIASTINITIS
Samir S. Shah, MD,*†储††
Ebbing Lautenbach, MD, MPH, MSCE,储#**††
Caroline B. Long, MD,* Sarah Tabbutt, MD,‡
J. William Gaynor, MD,§ Warren B. Bilker, PhD,储**††
and Louis M. Bell, MD*†¶
Abstract: Bloodstream infection (BSI) complicates postoperative
mediastinitis in ⬎50% of cases. In this retrospective cohort study
from 1995–2003, postoperative mediastinitis caused by Staphylo-
coccus aureus was an independent risk factor for the development of
BSI (adjusted odds ratio, 6.4; 95% confidence interval, 1.4 –29.3).
Postoperative mediastinitis caused by S. aureus has a higher intrinsic
risk of being complicated by BSI than mediastinitis caused by other
pathogens.
Key Words: surgical site infection, bacteremia, epidemiology,
Staphylococcus aureus
Accepted for publication March 3, 2005.
From the Divisions of *General Pediatrics, †Infectious Diseases, ‡Cardiol-
ogy and §Cardiothoracic Surgery and the 㛳Department of Infection
Control, The Children’s Hospital of Philadelphia, and the ¶Center for
Clinical Epidemiology and Biostatistics, the #Division of Infectious
Diseases of the Department of Medicine, the **Department of Biosta-

834 © 2005 Lippincott Williams & Wilkins

The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
tistics and Epidemiology and the ‡‡Center for Education and Research
on Therapeutics, University of Pennsylvania School of Medicine, Phil-
adelphia, PA
Supported by the Surgical Infections Postdoctoral Research Fellowship
sponsored by the Society for Healthcare Epidemiology of America and
GlaxoSmithKline (to Dr Shah), Public Health Service grant DK-
02987-01 of the National Institutes of Health (to Dr Lautenbach), in part
by the Agency for Healthcare Research and Quality Centers for Education
and Research on Therapeutics cooperative agreement (U18-HS10399).
Presented in part at the 2004 annual meetings of the Society for Healthcare
Epidemiology of America (April 17–20, 2004, Philadelphia, PA) and the
Infectious Diseases Society of America (September 30 –October 3, 2004,
Boston, MA).
Dr Long’s current affiliation is Babies and Children’s Hospital, New York,
NY.
Address for reprints: Dr Samir S. Shah, Division of Infectious Diseases, The
Children’s Hospital of Philadelphia (North Campus, Room 1526), 34th
Street and Civic Center Boulevard, Philadelphia, PA 19104. Fax 215-
590-0426; E-mail shahs@email.chop.edu.
DOI: 10.1097/01.inf.0000176615.77854.7a
M ediastinitis complicates median sternotomy in up to 4% of
cases.1 In a previous study,1 we found that the rate of con-
current bloodstream infection (BSI) in children with mediastinitis
was 53% (95% confidence interval, 38 – 69%). Smaller series of
children with mediastinitis have also reported high rates of concur-
rent BSI.2– 4
Factors predisposing to concurrent BSI in children with
postoperative mediastinitis are not known. In adults, the isolation of
Staphylococcus aureus from a wound culture is associated with an
increased risk of BSI complicating surgical site infection.5– 8 The
objective of this study was to identify risk factors for concurrent BSI
in children who develop postoperative mediastinitis.
METHODS
Study Design and Setting. This was a retrospective cohort study
conducted at the Children’s Hospital of Philadelphia, an urban
tertiary care children’s hospital where ⬃450 median sternotomies
are performed each year. The institutional review board of the
Children’s Hospital of Philadelphia approved this study.
Participants. Children, from birth to 18 years of age, who developed
mediastinitis after median sternotomy between January 1, 1995 and
December 1, 2003 were included in the study.
Study Definitions. Mediastinitis was defined as infection involving
the mediastinum or sternum that met the Centers for Disease Control
and Prevention criteria for organ/space surgical site infection.9 In
addition, patients must have had at least one of the following: (1)
purulent discharge in the mediastinum requiring surgical debride-
ment; (2) positive mediastinal cultures; or (3) sternal instability with
positive blood cultures. Concurrent BSI was defined as isolation of
the same organism from blood culture as from the mediastinum in
the 48 hours preceding or following the diagnosis of mediastinitis.
Case Finding. Potential study subjects were identified by reviewing
3 primary data sources: (1) active surveillance records for medias-
tinitis provided by the Department of Infection Control; (2) surgical
database maintained by the Division of Cardiothoracic Surgery; (3)
hospital discharge records using the International Classification of
Diseases, 9th revision, discharge diagnosis code for mediastinitis
(519.2). Medical records of potential study subjects were reviewed
to identify those who met the case definition for mediastinitis.
Data Collection and Statistical Analysis. The following information
was collected through review of inpatient medical records: sex;
patient age at surgery; underlying cardiac defect; associated chro-
mosomal abnormalities; and antibiotic use from hospitalization until
© 2005 Lippincott Williams & Wilkins
Bacteremia and Mediastinitis
diagnosis of infection. Intraoperative variables collected included
the type of surgical procedure, requirement for deep hypothermic
circulatory arrest and duration of circulatory arrest, cardiopulmonary
bypass and operation. Postoperative variables collected included
time to onset of mediastinitis after surgery, tissue and blood culture
results, requirement for extracorporeal membranous oxygenation,
duration of hospitalization, duration of intensive care unit stay,
requirement for delayed sternal closure or postoperative sternal
reexploration and the presence of thoracostomy tubes, endotracheal
tubes, intracardiac intravascular catheters and central venous catheters.
Data were analyzed using STATA version 8.0 (Stata Corp.,
College Station, TX). Continuous variables were compared across 2
groups, BSI versus no BSI, with the Wilcoxon rank sum test.
Categoric variables were compared via either the ␹2 test or Fisher’s
exact test. Stratified analysis was performed to identify potential
effect modifiers and confounders. Multivariable logistic regression
was performed to determine factors associated with BSI. Building of
the multivariable model began with inclusion of the variable for
mediastinitis caused by S. aureus (versus mediastinitis caused by
any other pathogen) based on our a priori hypothesis of an associ-
ation between S. aureus mediastinitis and concurrent BSI. Other
variables were then considered for inclusion in the multivariable
model as important risk factors if they were found to be associated
with BSI on univariate analysis (P ⬍ 0.20). In addition, risk factors
were considered for inclusion in the model if they were involved in
confounding. These variables remained in the final multivariable
model if their inclusion in the model resulted in a 15% or greater
change in the effect size of the primary association of interest (ie, the
association between S. aureus mediastinitis and concurrent BSI).
Statistical significance was determined a priori as a 2-tailed P value
of ⬍0.05. In this cohort study, odds ratios (OR) are reported for the
bivariate analysis to facilitate comparison with the adjusted OR
presented in the multivariable model. A 95% confidence interval
(CI) was calculated for the OR to evaluate the precision of the
estimate of the effect. For variables with a prevalence of at least 20%
and an ␣ level of 0.05, we could detect an OR of 3.0 with 80%
statistical power.
RESULTS
Seventy-two potential subjects were identified through review
of the primary data sources. All patient charts were available for
review. Twenty-nine patients were diagnosed with superficial sternal
wound infections and therefore were excluded from further study;
the remaining 43 patients met criteria for mediastinitis. As described
previously, 23 patients (53.5%) were female.1 The median patient
age at the time of operation was 32 days (interquartile range, 5
days–9 months).1 Infection occurred a median 11 days (interquartile
range, 6 –19 days) after surgery.1 Positive blood cultures occurred
before the diagnosis of mediastinitis in 10 (43%) patients, on the
same day as the diagnosis of mediastinitis in 11 (48%) patients and
after the diagnosis of mediastinitis in 2 (9%) patients. There were no
differences in sex or in age at the time of operation between those
with and without concurrent BSI. However, on bivariate analysis
children with concurrent BSI received fewer days of antibiotic
treatment before infection and had intracardiac intravascular cathe-
ters in for a shorter duration than those without BSI (Table 1).
Delayed sternal closure was less likely in those with concurrent BSI
than in those without concurrent BSI (Table 1). The risk of concur-
rent BSI was greater in those with mediastinitis caused by S. aureus
(Table 1).
Mediastinitis caused by S. aureus was an independent risk
factor for the development of BSI (adjusted OR, 6.4; 95% CI
1.4 –29.3; P ⫽ 0.016). The duration of antibiotic use was included in
the model as a confounder of the relationship between S. aureus
835
Shah et al The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005

TABLE 1. Bivariate Analysis of Risk Factors for Concurrent Bloodstream Infection in Children With Mediastinitis*

Variable Bloodstream Infection No Bloodstream Infection Odds Ratio P

Preoperative/intraoperative variables
Duration of operation (h) 3 (2.4 – 4.4) 3 (3.7–5.45) —† 0.17
Duration of circulatory arrest (min) 49 (35.5– 60.5) 41.5 (27.5– 47.5) — 0.26
Chromosome or syndromic abnormality 6/23 (26.1) 3/20 (15.0) 2.0 (0.34 –14.18)† 0.37
Deep hypothermic intraoperative circulatory arrest 12/23 (52.2) 12/20 (60.0) 0.73 (0.22–2.40) 0.61
Duration of preoperative hospitalization (d) 2 (1–5) 1.5 (0.5– 6) — 0.61
Age at operation (d) 32 (4 – 402) 69.5 (5–226) — 0.83
Postoperative variables
Staphylococcus aureus mediastinitis 17/23 (73.9) 5/20 (25.0) 8.50 (2.21–32.72) 0.001
Duration of antibiotics preceding infection (d) 3 (1–11) 12 (6.5–16) — 0.002
Intracardiac catheter duration (d) 3 (2–11) 9 (6 –12) — 0.04
Delayed sternal closure 3/23 (13.0) 8/20 (40.0) 0.23 (0.05– 0.96) 0.04
Duration of cardiopulmonary bypass (min) 85 (61–116) 111 (88 –167) — 0.06
Endotracheally intubated at time of infection 6/23 (26.1) 10/19 (52.6) 0.32 (0.09 –1.13) 0.08
Chest tube present at time of infection 2/23 (8.7) 5/20 (25.0) 0.29 (0 –1.49) 0.15
Sternal reexploration preceding infection 7/23 (30.4) 10/20 (50.0) 0.44 (0.13–1.49) 0.19
Infection onset (d after operation) 13 (6 –21) 9.5 (4.5–14.5) — 0.23
Polymicrobial mediastinitis 4/23 (17.4) 2/20 (10.0) 1.89 (0.35–9.91) 0.49
*Information presented in columns 2 and 3 as median (interquartile range) or number (percent).
†
—, not applicable.
Numbers in parentheses, 95% CI.

mediastinitis and concurrent BSI (adjusted OR, 1.0; 95% CI 0.9 –
1.0; P ⫽ 0.45). In the multivariable model, after adjusting for S.
aureus, the association of BSI with other variables, including de-
layed sternal closure and intracardiac intravascular catheter duration,
was no longer significant.
DISCUSSION
Our study demonstrates that postoperative mediastinitis
caused by S. aureus has a higher intrinsic risk of being complicated
by BSI than postoperative mediastinitis caused by other organisms.
Other variables, often associated with the development of medias-
tinitis, did not alter the risk of concurrent BSI.
A high rate of BSI (63% to 71%) in patients with S. aureus
mediastinitis has been reported in adults undergoing median ster-
notomy.7,8 The association of postoperative BSI with S. aureus
surgical site infection has also been noted after other surgical
procedures. Petti et al5 found that BSI developed in 16% of adult
patients with either incisional or organ/space infections caused by S.
aureus; cardiovascular procedures accounted for only 7.4% of all
surgical procedures. In their study, patients with S. aureus isolated
from surgical site infection were more than twice as likely to have
postoperative BSI than did patients with surgical site infections
caused by other organisms; additional risk factors for BSI were not
identified.
This study had several limitations. We did not have adequate
statistical power to detect relatively small differences in some
variables, if they were present, between the 2 groups. We presumed
that the surgical site infection was the source of BSI. It is possible
that mediastinitis in some patients developed as a consequence of
hematogenous dissemination after primary S. aureus BSI. Retro-
spectively, we cannot determine whether a patient’s initial symp-
toms were caused by mediastinitis or by bloodstream infection. The
timing of blood and mediastinal cultures may not accurately reflect
the underlying pathogenesis because blood cultures are relatively
easy to obtain and because the timing of mediastinal culture may
depend on other factors such as patient stability. In a study by
Gottlieb et al,6 21 (91%) of 23 patients developing S. aureus BSI
after sternotomy had or subsequently developed mediastinitis.
Fowler et al10 evaluated the clinical utility of blood cultures in
identifying mediastinitis. Blood cultures were obtained a median of
3 days before the diagnosis of mediastinitis. Patients with S. aureus
BSI were significantly more likely to have mediastinitis than did
patients without S. aureus BSI (likelihood ratio, 25; 95% CI 14.7–
44.4).10 Meanwhile BSI attributable to other organisms did not alter
the pretest suspicion for mediastinitis.
Regardless of whether BSI precedes or follows the develop-
ment of mediastinitis in an individual patient, effective prevention
measures are required because S. aureus BSI is associated with high
morbidity, mortality and cost.11 In the absence of other identifiable
risk factors for BSI among patients with mediastinitis, preoperative
interventions to decrease the incidence of S. aureus mediastinitis
might be an appropriate focus. Few data are available about the
source of S. aureus isolates causing surgical site infections in
children. Ruef et al12 reported a cluster of 6 children with deep
sternal wound infections after cardiac surgery; 4 patients had nasal
carriage of the same strain isolated from their wound. Weber et al13
reported a cluster of 4 children with S. aureus sternal wound
infections after cardiac surgery; 3 patients were infected with the
epidemic strain. A significant proportion of the operating room
(25%) and intensive care unit (11%) staff were colonized with the
epidemic strain. No additional cases were identified after the epi-
demic strain was eradicated from colonized staff members.
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a case-control study covering a seven-year period in Santander, Spain.
Clin Infect Dis. 1995;20:272–279.
9. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emorie TG. CDC
definitions of nosocomial surgical site infections, 1992: a modification of
CDC definitions of surgical wound infections. Infect Control Hosp
Epidemiol. 1992;13:606 – 608.
10. Fowler VG Jr., Kaye KS, Simel DL, et al. Staphylococcus aureus
bacteremia after median sternotomy: clinical utility of blood culture
results in the indentification of postoperative mediastinitis. Circulation.
2003;108:73–78.
11. Rubin RJ, Harrington CA, Poon A, Dietrich K, Greene JA, Moiduddin
A. The economic impact of Staphylococcus aureus infection in New
York City hospitals. Emerg Infect Dis. 1999;5:9 –17.
12. Ruef C, Fanconi S, Nadal D. Sternal wound infections after heart
operations in pediatric patients associated with nasal carriage of Staph-
ylococcus aureus. J Thorac Cardiovasc Surg. 1996;112:81– 86.
13. Weber S, Herwaldt LA, McNutt LA, et al. An outbreak of Staphylococ-
cus aureus in a pediatric cardiothoracic surgery unit. Infect Control Hosp
Epidemiol. 2002;23:77– 81.
BURKHOLDERIA GLADIOLI OSTEOMYELITIS IN
ASSOCIATION WITH CHRONIC GRANULOMATOUS
DISEASE: CASE REPORT AND REVIEW
Bobby L. Boyanton Jr., MD, MT(ASCP),‡
Lenora M. Noroski, MD,* Hari Reddy, DO,*
Megan K. Dishop, MD,†‡ M. John Hicks, MD, DDS, PhD,†‡
James Versalovic, MD, PhD,†‡ and Edina H. Moylett, MD*
Abstract: We describe a case of insidious small bone osteomyelitis
and soft tissue abscess with Burkholderia gladioli in a 6-year-old
Caucasian boy with chronic granulomatous disease. DNA sequenc-
ing of the 16S ribosomal RNA gene confirmed the bacterial identi-
fication. Clinical cure was achieved with a combination of antimi-
crobial therapy and surgical debridement. A review of infections
caused by Burkholderia spp., other than Burkholderia cepacia
complex, in pediatric patients with chronic granulomatous disease is
provided.
Key Words: Burkholderia gladioli, osteomyelitis, chronic
granulomatous disease, pyrosequencing, molecular diagnostics,
DNA sequencing
Accepted for publication March 4, 2005.
From the *Section of Allergy and Immunology, Department of Pediatrics,
and the †Department of Pathology, Texas Children’s Hospital, and the
‡Department of Pathology, Baylor College of Medicine, Houston, TX
E-mail jxversal@texaschildrenshospital.org. Reprints not available.
DOI: 10.1097/01.inf.0000177285.44374.dc
B urkholderia gladioli (basonym, Pseudomonas gladioli or
Pseudomonas marginata) was originally described in 1924 as a
phytopathogen of gladioli and other flowers.1 Initially isolated from
the sputa of patients with cystic fibrosis,2 B. gladioli has been
associated with various infections in patients with cystic fibrosis3,4
and has contributed to worsening of pulmonary function.4 Among
patients with chronic granulomatous disease (CGD), B. gladioli
infections were initially documented in 1995.5 Ensuing reports have
confirmed B. gladioli as an opportunistic pathogen primarily causing
infections in patients with underlying immunocompromise, such as
in acquired immunodeficiency syndrome,6 liver and lung transplant
recipients6 – 8 and patients with diabetes mellitus.6
© 2005 Lippincott Williams & Wilkins
This article includes the first description of a case of B.
gladioli osteomyelitis, confirmed by molecular methods in a patient
with CGD. A review of the current English language literature for
additional cases of Burkholderia infections, caused by organisms
other than B. cepacia complex, in association with underlying CGD
was performed. The current case and similar examples highlight the
possible role of Burkholderia spp. (not Burkholderia cepacia com-
plex) as important pathogens among pediatric patients with CGD
and possibly other defects of innate immunity.
CASE REPORT
A 6-year-old Caucasian boy with X-linked CGD (male sib-
ling with CGD died in infancy, documented maternal carrier status)
receiving prophylactic interferon-␥, itraconazole and dicloxacillin
presented to the immunology clinic with left foot pain of ⬃6 weeks
duration. Past medical history was significant for Nocardia aster-
oides pneumonia. Four weeks before presentation, his parents noted
an intermittent limp. No fever or recent trauma was reported. After
apparent improvement, recurrence of symptoms during the week
before presentation prompted evaluation. Physical examination dis-
closed an afebrile patient with a significant limp during ambulation.
Edema was present in an area overlying the left fourth and fifth
metatarsal bones. Additionally increased skin temperature and point
tenderness were localized to the diaphysis of the left fourth meta-
tarsal bone. The remainder of the physical examination was unre-
markable.
Laboratory studies revealed a white blood cell count of
5160/␮L (52% neutrophils, 2% band forms, 40% lymphocytes,
4% monocytes, 2% eosinophils); hemoglobin 11.1 g/dL; platelets
377,000/␮L; elevated erythrocyte sedimentation rate at 51 mm/h and
C-reactive protein 1.9 mg/dL (normal, ⬍1 mg/dL). Radiographs of
the left foot revealed new periosteal reaction along the shaft of the
left fourth metatarsal bone. Magnetic resonance imaging, performed
at an outside institution, revealed extensive marrow replacement and
marked adjacent soft tissue swelling. Surgical evaluation of the
affected area revealed intact bone with surrounding gray/mucoid
drainage. Blood, bone and soft tissue cultures were sterile. Patho-
logic evaluation of the bony specimens revealed intact bone without
acute inflammation or granuloma formation. The patient was dis-
charged home on a 4-week course of empiric intravenous clin-
damycin.
Two weeks later, there was no clinical change; but at 4 weeks,
localized disease progression was evident with a 3-cm indurated,
erythematous area with a localized purulent abscess overlying the
base of the left fourth metatarsal bone.
Laboratory evaluation showed an erythrocyte sedimentation
rate of 56 mm/h and C-reactive protein of 2.5 mg/dL. Repeat
magnetic resonance imaging revealed extensive high signal abnor-
mality on T2-weighted images through multiple muscle and fascial
planes overlying and communicating with the diaphysis of the left
fourth metatarsal bone with periosteal and medullary cavity involve-
ment. Abnormally high signal intensity extended to the plantar
aspect of the foot, with evidence of probable neurovascular involve-
ment and avascular necrosis of the affected metatarsal bone.
Histopathologic evaluation of the soft tissue and bone re-
vealed necrotizing granulomatous inflammation. No microorgan-
isms were identified with special stains. Multiple samples of bone
and soft tissue were submitted for culture. Two blood cultures were
sterile. Postoperatively the patient was treated with empiric therapy
with vancomycin, amikacin and ceftazidime. Four days later, cata-
lase-positive, oxidase-negative, Gram-negative rods were isolated
from 4 of 5 surgically obtained samples. The organisms were
ultimately identified as B. gladioli by DNA sequencing. The isolate
was susceptible to gentamicin, amikacin, ticarcillin/clavulanate and
837
Boyanton et al The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005

ciprofloxacin with minimum inhibitory concentrations of 0.5, 0.25,
16/2 and ⱕ0.125 ␮g/mL, respectively. The patient completed 8
weeks of intravenous ticarcillin/clavulanate and gentamicin therapy
followed by oral ciprofloxacin (serum inhibitory titer, 1/32; serum
bactericidal titer, 1/16) for 12 months. Plain films of the left foot
assessed at 6 and 12 months after the initial presentation revealed
complete absence of the left fourth metatarsal diaphysis without new
destructive changes.
ORGANISM IDENTIFICATION
The isolate was cultured from 4 of 5 surgically obtained bone
and soft tissue specimens from the left foot. Bacteriologic culture on
MacConkey’s agar and sheep blood agar plates incubated at 37°C
under routine conditions yielded a catalase-positive, oxidase-nega-
tive, Gram-negative rod. Initial biochemical analysis with an auto-
mated Vitek and manual API 20E identification system (Vitek-GNI
card, software version 9.01, and API 20E, both from bioMérieux,
Durham, NC) failed to identify the organism. The manual API 20NE
(bioMérieux) identification system provided a presumptive identifi-
cation as B. cepacia complex. Because of the atypical biochemical
and antimicrobial susceptibility profiles of the isolate, DNA pyro-
sequencing was performed with primers that recognize conserved
sites within the V1 and V3 regions of the 16S ribosomal RNA
(rRNA) genes.9 B. gladioli was the only organism that yielded 100%
DNA sequence identity in both the V1 and V3 regions of interest
when the Ribosomal Database Project (version 9.25) was queried.
The second ranked organism, Propionivibrio dicarboxylicus,
yielded 71% DNA sequence identity in the V3 region. Conventional
DNA sequencing of the 16S rRNA genes by capillary electrophore-
sis provided definitive confirmation of B. gladioli.
DISCUSSION
We present the first description of a case of B. gladioli
osteomyelitis confirmed by molecular methods in a patient with
CGD. Clinical cure was achieved with combination antimicrobial
therapy and aggressive surgical debridement. This case presents
challenges inherent in the isolation and identification of Gram-
negative bacilli that are members of the Burkholderia genus.
A literature search was performed of Medline (December 12,
2004) with Burkholderia gladioli, Pseudomonas gladioli, Burkhold-
eria cepacia, Pseudomonas cepacia, Burkholderia pseudomallei,
Pseudomonas pseudomallei, Pseudomonas marginata, chronic gran-
ulomatous disease and osteomyelitis as key words. All references
from selected publications were reviewed. In addition to the current
case, 5 other cases were included and summarized in Table 1. Our
case represents the sixth documented case of Burkholderia spp. (not
B. cepacia complex) organisms causing infections in CGD patients,
(B. gladioli, 4; B. pseudomallei, 2) reported in the English language
literature (Table 1). A variety of clinical scenarios have now been
described including sepsis,5,10 pneumonia,5 embolic disease,10 me-
lioidosis,11 mediastinitis/adenitis12 and osteomyelitis.11 The mode
of disease pathogenesis in each of the reported cases remains
unclear; however, it is presumed that colonization of the respiratory
tract precedes bone or soft tissue infections. All patients in prior
studies were male, reflecting the predominant X-linked pattern of
inheritance and increased severity of disease among patients with
X-linked CGD. The majority of patients were managed only with
antibiotic therapy, with clinical cures reported in 5 of 6 patients
(83%). No patient with B. gladioli infection was treated with a
cephalosporin, reflecting the typical resistance pattern of B. gladioli
to cephalosporins.6
All patients with B. gladioli infection were cured; 1 patient
with B. pseudomallei infection of the mediastinum died after com-
pletion of a 6-week course of intravenous therapy. He was receiving
suppressive oral therapy at the time, and no autopsy details were
available.
B. gladioli may be an emerging pathogen in CGD patients and
other immunocompromised hosts. This organism is probably under-
reported by clinical microbiology laboratories because of its fastid-
ious nature and difficulty in distinguishing it from members of the

TABLE 1. Patients With CGD and Various Burkholderia Infections (Excluding Burkholderia cepacia Complex)

Age (yr)/ Burkholderia Clinical Antibiotics

Reference Year CGD Diagnosis Treatment Outcome
Sex spp. Diagnosis Duration

11 1971 3/M NR Burkholderia Melioidosis, Medical CMP, KAN, 5 wk, CC

pseudomallei osteomyelitis SUL (po), 15 mo
关NR兴*
5 1995 34/M AR/p47phox Burkholderia Pneumonia Medical AMP/SUL, CC
gladioli 关lung兴 TMP-SMX (iv),
1 mo, TMP-SMX,
AMX/SUL,
duration NR
5 1995 22/M XL/gp91phox Burkholderia Pneumonia, Medical CIP, GT (iv), CC
gladioli bacteremia duration NR
关sputum and
blood兴
10 1996 5/M NR Burkholderia Septicemia Medical CIP, GT (iv), 10 d CC
gladioli 关blood and
pustular
fluid兴
12 1998 11/M XL/gp91phox Burkholderia Lymphadenitis, Medical IMI, DOX (iv), 6 wk; Died
pseudomallei mediastinitis CFX, DOX (po),
关lymph node兴 duration NR
CR 2004 6/M XL/gp91phox† Burkholderia Osteomyelitis Medical and TIC/CLV, GT, 10 wk; CC
gladioli 关bone and soft surgical CIP (po), 6 m
tissue兴
*Information in brackets, source of isolate.
†
Genotype assumed on the basis of family history.
CR indicates current report; NR, not reported; AR, autosomal recessive; XL, X-linked; p47phox and gp91phox, specific subunit mutations within the nicotinamide adenine dinucleotide
phosphate oxidase system; CMP, chloramphenicol; KAN, kanamycin; SUL, sulfa drug; po, orally; AMP/SUL, ampicillin-sulbactam; TMP-SMX, trimethoprim-sulfamethoxazole; iv,
intravenous; AMX/SUL, amoxicillin-sulbactam; CIP, ciprofloxacin; GT, gentamicin; IMI, imipenem; DOX, doxycycline; CFX, cefixime; TIC/CLV, ticarcillin/clavulanate; CC, clinical cure.

838 © 2005 Lippincott Williams & Wilkins

The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
B. cepacia complex by current manual and automated identification
systems. Advances in molecular technology enable definitive
identification of B. gladioli, including the ability to distinguish
B. gladioli from the more widely encountered organisms of the
B. cepacia complex.9,13 B. gladioli and B. cepacia complex organ-
isms are discriminated on the basis of the genetic diversity within
the 16S rRNA genes.13 The primers designed for distinguishing
between B. gladioli and B. cepacia complex organisms facilitate the
generation of amplicons of different sizes that do not cross-react
with other Burkholderia (B. pseudomallei and B. mallei) species. As
demonstrated in this study, DNA sequencing of the 16S rRNA genes
also distinguishes B. gladioli from other Burkholderia species.
The management of osteoarticular infections in patients with
CGD can be very challenging.14 Because initial attempts to isolate
a pathogen were unproductive, our patient was unsuccessfully
treated with empiric antistaphylococcal antibiotic therapy. Empiric
antistaphylococcal treatment has been suggested for the manage-
ment of patients with CGD and concomitant osteomyelitis without a
specific isolate.14 In addition to organism-specific antibiotic therapy,
our patient required extensive surgical debridement to resolve the
infectious process. In the report by Sponsellar et al,14 initial anti-
microbial management alone was unsuccessful in 12 of 14 cases;
however, extensive surgical debridement in combination with anti-
microbial therapy was successful in the treatment of 7 of 8 cases.
The susceptibility patterns usually differ between B. gladioli
and B. cepacia complex organisms. B. gladioli is typically suscep-
tible to aminoglycosides and resistant to ampicillin or first, second
and third generation cephalosporins; B. cepacia complex organisms
are usually resistant to aminoglycosides but susceptible to fluoro-
quinolones and antipseudomonal cephalosporins.6 The antimicrobial
susceptibility pattern of our isolate was consistent with that expected
for B. gladioli, and the patient was successfully treated with a
combination of surgical debridement and appropriate antimicrobial
therapy with ticarcillin/clavulanate and gentamicin.
ACKNOWLEDGMENTS
We thank R. A. Luna for assistance with pyrosequencing and
V. J. P. Gotting for administrative assistance.
REFERENCES
1. McCulloch L. A leaf and corm disease of gladioli caused by Bacterium
marginatum. J Agric Res. 1924;29:159 –177.
2. Christenson JC, Welch DF, Mukwaya G, Muszynski MJ, Weaver RE,
Brenner DJ. Recovery of Pseudomonas gladioli from respiratory tract
specimens of patients with cystic fibrosis. J Clin Microbiol. 1989;27:
270 –273.
3. Jones AM, Stanbridge TN, Isalska BJ, Dodd ME, Webb AK.
Burkholderia gladioli: recurrent abscesses in a patient with cystic
fibrosis. J Infect. 2001;42:69 –71.
4. Barker PM, Wood RE, Gilligan PH. Lung infection with Burkholderia
gladioli in a child with cystic fibrosis: acute clinical and spirometric
deterioration. Pediatr Pulmonol. 1997;23:123–125.
5. Ross JP, Holland SM, Gill VJ, DeCarlo ES, Gallin JI. Severe. Burk-
holderia (Pseudomonas) gladioli infection in chronic granulomatous
disease: report of two successfully treated cases. Clin Infect Dis. 1995;
21:1291–1293.
6. Graves M, Robin T, Chipman AM, Wong J, Khashe S, Janda JM. Four
additional cases of Burkholderia gladioli infection with microbiological
correlates and review. Clin Infect Dis. 1997;25:838 – 842.
7. Kanj SS, Tapson V, Davis RD, Madden J, Browning I. Infections in
patients with cystic fibrosis following lung transplantation. Chest. 1997;
112:924 –930.
8. Khan SU, Gordon SM, Stillwell PC, Kirby TJ, Arroliga AC. Empyema
and bloodstream infection caused by Burkholderia gladioli with cystic
fibrosis after lung transplantation. Pediatr Infect Dis. 1996;15:637– 639.
© 2005 Lippincott Williams & Wilkins
TMP-SMX Susceptibilities in Otitis
9. Jonasson J, Olofsson M, Monstein HJ. Classification, identification and
subtyping of bacteria based on pyrosequencing and signature matching
of 16S rDNA fragments. APMIS. 2002;110:263–272.
10. Hoare S, Cant AJ. Chronic granulomatous disease presenting as severe
sepsis due to Burkholderia gladioli. Clin Infect Dis. 1996;23:411.
11. Tarlow MJ, Lloyd J. Melioidosis and chronic granulomatous disease.
Proc R Soc Med. 1971;64:19 –20.
12. Dorman SE, Gill VJ, Gallin JI, Holland SM. Burkholderia pseudomallei
infection in a Puerto Rican patient with chronic granulomatous disease:
case report and review of occurrences in the Americas. Clin Infect Dis.
1998;26:889 – 894.
13. Ferroni A, Sermet-Gaudelus I, Abachin E, et al. Use of 16S rRNA gene
sequencing for identification of nonfermenting Gram-negative bacilli
recovered from patients attending a single cystic fibrosis center. J Clin
Microbiol. 2002;40:3793–3797.
14. Sponseller PD, Malech HL, McCarthy EF, Horowitz SF, Jaffe G, Gallin
JI. Skeletal involvement in children who have chronic granulomatous
disease. J Bone Joint Surg Am. 1991;73:37–51.
ACTIVITY OF TRIMETHOPRIM-SULFAMETHOXAZOLE
AGAINST MIDDLE EAR FLUID PATHOGENS
OBTAINED FROM COSTA RICAN CHILDREN
WITH OTITIS MEDIA
Adriano Arguedas, MD,*† Hernan Sierra, MD,*
Carolina Soley, MD,* Silvia Guevara, MD,* and
Eduardo Brilla, MQC‡
Abstract: For many years, trimethoprim-sulfamethoxazole (TMP-
SMX) has been recommended as an alternative antimicrobial agent
for the treatment of children with otitis media (OM). This study
analyzed the in vitro activity of TMP-SMX against respiratory
pathogens obtained from middle ear fluid of Costa Rican children
6 – 60 months of age with acute OM, recurrent OM, therapeutic
failures and acute OM at risk for having a resistant pathogen.
Between 2002 and 2003, a total of 124 middle ear fluid bacterial
isolates were analyzed and compared with historic data from 1992 to
1997. A significant increase in the number of TMP-SMX Strepto-
coccus pneumoniae (P ⫽ 0.00008)- and Haemophilus influenzae
(P ⫽ 0.04)-resistant strains was observed during 2002–2003 when
compared with strains from 1992–1997.
Key Words: trimethoprim-sulfamethoxazole, acute otitis media,
middle ear fluid
Accepted for publication March 10, 2005.
From *Instituto de Atención Pediátrica, †Universidad de Ciencias Médicas, and
‡Laboratorio Centro de Investigaciones Médicas, San José, Costa Rica
E-mail aarguedas@ped.net. Reprints not available.
DOI: 10.1097/01.inf.0000177286.40817.10
O titis media (OM) is one of the most common infections in
young children and the most common indication for antimi-
crobial use in this age group.1,2 For many years, trimethoprim-
sulfamethoxazole (TMP-SMX) has been recommended as an alter-
native for the treatment of children with OM in different parts of the
world, including Latin America.2– 4 The widespread use of antibi-
otics in children can promote antimicrobial resistance; this has
become a public health issue. Previous reports analyzing the middle
ear fluid (MEF) microbiology in Costa Rican children with OM have
shown an important increase in the number of penicillin-nonsuscep-
tible Streptococcus pneumoniae isolates, particularly those isolates
obtained from children with recurrent OM (ROM) and therapeutic
failure OM (FOM).5 Although TMP-SMX is widely used in Latin
America for the treatment of respiratory, gastrointestinal and urinary
tract infections, data on the current susceptibility pattern of this
agent against respiratory pathogens are scarce and are needed to
make scientifically driven antimicrobial recommendations.
839
Arguedas et al The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
The aim of the current analysis was to determine the in vitro
activity of TMP-SMX against MEF pathogens obtained from Costa
Rican children with OM between 2002 and 2003 and compare these
results to those obtained by our group in 1992 and 1997.2
METHODS
As part of 3 drug efficacy clinical trials performed between 2002
and 2003, Costa Rican children 6 – 60 months of age with OM were
considered candidates for the analysis. One of the trials included
patients with AOM at low risk of having a resistant MEF pathogen
(AOM patients), and the other 2 trials included patients with ROM
and/or FOM or AOM patients at risk for having an MEF-resistant
pathogen (AOM at risk) defined as having an OM episode with at least
1 of the following risk factors: age 24 months or younger; first OM
episode at 6 months of age or younger; day-care attendance; frequent
contact with children 14 years of age or younger; or antimicrobial
exposure in the previous 90 days. The following definitions were used
for the analysis of the patients in this study: AOM, signs and symptoms
of OM for ⱕ72 hours; ROM, history of ⱖ3 episodes of OM in the
previous 6 months or ⱖ4 episodes in the previous 12 months, including
the current episode; and FOM, persistent signs and symptoms of OM
within ⱖ72 hours of appropriate antimicrobial therapy or an OM
episode occurring within 7 days of the last dose of an antibiotic
prescribed for a previous OM episode.
Diagnostic tympanocentesis was performed in all patients
who had an intact tympanic membrane according to our standard
procedures.2 When a patient presented a perforated tympanic mem-
brane, removal and drainage of the ear canal material was done, and
deep aspiration of the MEF material was attempted. All samples
were immediately placed in transport medium (Copan Diagnostics
Inc., Corona, CA) and transferred to the local research laboratory for
processing.
MEF aspirates were inoculated onto blood agar, chocolate
agar, MacConkey’s agar and manitol salt agar at 37°C in a 5% CO2
environment for 18 –72 hours at the Centro de Investigaciones
Clı́nicas Laboratory. At the time bacterial growth was documented,
identification was performed by standard procedures.6 For the pur-
poses of this study, susceptibility testing was analyzed for S. pneu-
moniae and H. influenzae only.
Following the recommended methodology by the Clinical and
Laboratory Standards Institute, TMP-SMX Kirby-Bauer susceptibil-
ity was tested in every MEF isolate. The E-test was the susceptibility
test used for the historic data from period 1992–1997 (PDM Epsi-
lometer; AB Biodisk, Solna, Sweden). Interpretation of the suscepti-
bility reports as susceptible, intermediate or resistant strains was done
according to Clinical and Laboratory Standards Institute guidelines.6
In the case of S. pneumoniae, an isolate was considered
susceptible to TMP-SMX if the Kirby-Bauer test showed an inhibi-
tion zone of ⱖ19 mm in diameter, intermediate if the zone of
inhibition was between 16 and 18 mm and resistant if the zone of
inhibition was ⱕ15 mm. For H. influenzae, an isolate was consid-
ered susceptible if a zone of inhibition of ⱖ16 mm was observed,
intermediate for those isolates with a zone of inhibition between 11
and 15 mm and resistant strains if a zone of inhibition of ⱕ10 mm
was present.
For the historic cohort (period 1992–1997) an S. pneumoniae
or H. influenzae isolate was considered susceptible if the minimum
inhibitory concentration (MIC) was ⱕ0.5/9.5, intermediate if the
MIC was between 1/19 and 2/38 and resistant if the MIC was ⱖ4/76.
The original OM protocols were approved by an Independent
Review Board, and an informed consent was obtained from the
parents of each study participant before enrollment.
The statistical package Epi-Info (version 6.0) was used to
calculate statistical values. P ⬍ 0.05 was considered significant.
840
RESULTS
The distribution of MEF study pathogens obtained from AOM
patients (31 isolates) was 20 S. pneumoniae and 11 H. influenzae. The
distribution of MEF study pathogens obtained from ROM, FOM or
AOM at risk patients was 40 S. pneumoniae and 34 H. influenzae
isolates.
Table 1 shows the overall activity of TMP-SMX against the
studied MEF pathogens and the susceptibility distribution among
MEF pathogens isolated during 1992–1997 compared with those of
2002–2003.
The comparative susceptibility rates between pathogens ob-
tained from AOM patients versus pathogens obtained from ROM
and/or FOM or AOM at risk patients were: S. pneumoniae 42% versus
58% were susceptible isolates, respectively (P ⫽ 0.76), 0% versus 3%
were intermediate isolates, respectively (P ⫽ 1.0) and 58% versus 39%
were resistant isolates, respectively (P ⫽ 0.49); and for H. influenzae
91% versus 59% were susceptible isolates, respectively (P ⫽ 0.45), 0%
versus 6% were intermediate isolates, respectively (P ⫽ 1.0) and 9%
versus 34% were resistant isolates, respectively (P ⫽ 0.42).
DISCUSSION
For many years, TMP-SMX was recommended as an alter-
native in the treatment of pediatric patients with OM.2– 4,7 In Costa
Rica, TMP-SMX is commonly used for the treatment of respiratory,
gastrointestinal and uncomplicated urinary tract infections. On the
basis of the initial susceptibility pattern, observed during 1992–
1997, on isolates obtained from the MEF of Costa Rican children,
we recommended at that time the use of TMP-SMX as an alternative
agent for the treatment of OM in Costa Rica.2 However, this report
shows a statistically significant increase in the number of resistant
S. pneumoniae and H. influenzae strains among MEF isolates in
2002–2003. This percentage of TMP-SMX resistance correlates well
with recent reports from our group showing the same resistance
pattern among nasopharyngeal and oropharyngeal isolates obtained
also from Costa Rican patients with OM.8
Although we do not have the information regarding the
number of yearly prescriptions of TMP-SMX, we believe that this
phenomenon of increased resistance is most likely a result of
frequent use for many decades rather than of a sudden increase
recently in the number of TMP-SMX prescriptions.
Previous clinical trials on the efficacy of TMP-SMX in OM
demonstrated good clinical efficacy rates in patients with S. pneu-
moniae and H. influenzae OM.3,4,7 However, a more recent study
suggested that TMP-SMX treatment was equivalent to placebo in
the treatment of AOM in children.9
TABLE 1. Trimethoprim-Sulfamethoxazole
Susceptibility Distribution Among Middle Ear Fluid
Streptococcus pneumoniae and Haemophilus influenzae
Isolates Obtained from Costa Rican Children with Otitis
Media
1992–1997 2002–2003 P
S. pneumoniae 46 isolates 60 isolates
Susceptible 42 (91.3)* 29 (53) 0.03
Intermediate 4 (8.7) 1 (2) 0.17
Resistant 0 (0) 25 (45) 0.00008
H. influenzae 26 isolates 45 isolates
Susceptible 22 (84.6) 29 (67) 0.46
Intermediate 3 (11.5) 2 (5)1 0.29
Resistant 1 (3.8) 12 (28) 0.04
*Numbers in parentheses, percent.
© 2005 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
Based on the microbiologic information presented in this
analysis, it is evident that common MEF pathogens have recently
developed resistance against TMP-SMX in Costa Rican children;
and caution is recommended regarding the use of this antibiotic in
Costa Rican children with OM.
REFERENCES
1. American Academy of Pediatrics, American Academy of Family Physi-
cians, Subcommittee on Management of Acute Otitis Media. Diagnosis
and management of acute otitis media. Pediatrics. 2004;113:1451–1465.
2. Arguedas A, Loaiza C, Perez A, et al. Microbiology of acute otitis media
in Costa Rican children. Pediatr Infect Dis J. 1998;17:680 – 684.
3. Schwartz RH, Rodriguez WJ, Khan WN, et al. Trimethoprim-sulfa-
methoxazole in the treatment of otitis media caused by ampicillin-resistant
strains of Haemophilus influenzae. Rev Infect Dis. 1982;4:514 –516.
4. Blumer JL, Bertino JS Jr, Husak MP. Comparison of cefaclor and
trimethoprim-sulfamethoxazole in the treatment of acute otitis media.
Pediatr Infect Dis. 1984;3:25–29.
5. Arguedas A, Dagan R, Soley C, et al. Microbiology of otitis media in
Costa Rican children, 1999 through 2001. Pediatr Infect Dis J. 2003;22:
1063–1068.
6. Clinical and Laboratory Standards Institute. Twelfth Informational Sup-
plement. Clinical and Laboratory Standards Institute document. M100-
S12 (ISBN 1-56238-454-6). Wayne, PA: Clinical and Laboratory Stan-
dards Institute; 2002.
7. Barnett ED, Teele DW, Klein JO, Cabral HJ, Kharasch SJ. Comparison of
ceftriaxone and trimethoprim-sulfamethoxazole for acute otitis media.
Greater Boston Otitis Media Study Group. Pediatrics. 1997;99:23–28.
8. Arguedas A, Soley C, Sierra H et al. In vitro activity of trimethoprim-
sulfamethoxazole (TMP-SMX) against middle ear fluid (MEF), nasopha-
ryngeal (NP) and oropharyngeal (OP) pathogens obtained from Costa
Rican children (CR) with otitis media (OM). In: 44th Interscience
Conference on Antimicrobial Agents and Chemotherapy, October 30 –
November 2, 2004, Washington, DC. Washington, DC: American Society
for Microbiology; 2004. Abstract G-280/221.
9. Leiberman A, Leivobitz E, Piglansky L, et al. Bacteriologic and clinical
efficacy of trimethoprim-sulfamethoxazole for treatment of acute otitis
media. Pediatr Infect Dis J. 2001;20:260 –264.
COMMUNITY-ACQUIRED METHICILLIN-RESISTANT
STAPHYLOCOCCUS AUREUS OUTBREAK IN A LOCAL
HIGH SCHOOL FOOTBALL TEAM
UNSUCCESSFUL INTERVENTIONS
Jeffrey A. Rihn, MD,* Klara Posfay-Barbe, MD,†
Christopher D. Harner, MD,* Andy Macurak, Atc,储
Adrianne Farley, RN,§ Kathy Greenawalt, BS,‡
and Marian G. Michaels, MD†
Abstract: A retrospective review of an outbreak of community-
acquired methicillin-resistant Staphylococcus aureus soft tissue in-
fections in a high school football team was conducted. Thirteen
players had 20 infections. Available community-acquired methicil-
lin-resistant S. aureus isolates showed identical antibiotic suscepti-
bility and field inversion gel electrophoresis analysis band patterns.
Nasal cultures and mupirocin were ineffective at predicting and
controlling infection, respectively. Infections treated with ␤-lactam
antibiotics were at risk for recurrence.
Accepted for publication March 16, 2005.
From the *Departments of Orthopaedic Surgery and †Pediatrics, University
of Pittsburgh School of Medicine; the ‡Department of Pathology and
§Infection Control, Children’s Hospital of Pittsburgh; and the 㛳Depart-
ment of Athletic Training, University of Pittsburgh Medical Center,
Pittsburgh, PA
E-mail marian.michaels@chp.edu. Reprints not available.
DOI: 10.1097/01.inf.0000177287.11971.d4
© 2005 Lippincott Williams & Wilkins
CA-MRSA in a Football Team
M ethicillin-resistant Staphylococcus aureus (MRSA) is well-
recognized as a significant pathogen in health care settings.
More recently, MRSA skin and soft tissue infections have been
identified as an emerging community problem.1–3 Participants of
contact sports are at risk for outbreaks of skin and soft tissue
infection, including viruses, fungi and bacteria. Reports of commu-
nity-acquired MRSA (CA-MRSA) outbreaks among athletic teams
have been infrequent; accordingly knowledge of associated risk
factors and appropriate interventions is limited.1,4 – 6 This report
describes a large outbreak of CA-MRSA skin and soft tissue infec-
tions in a high school football team along with efforts made to treat
and curtail the infections.
MATERIALS AND METHODS
An outbreak was suspected during week 4 of a football season
when abscesses occurred in 4 team players, 3 of which cultured
CA-MRSA. Accordingly serial intervention strategies were imple-
mented to define, diagnose, treat and control the outbreak. Approval
was obtained from the Children’s Hospital of Pittsburgh Institutional
Review Board to perform a retrospective review of the outbreak.
Cases were defined as follows: (1) a proven case was a clinically
diagnosed cellulitis/abscess plus a positive culture for MRSA; (2) a
suspected case was clinically diagnosed cellulitis/abscess during the
football season in the absence of a culture; and (3) colonization was
a positive nasal culture for MRSA without clinical findings.
Proven and suspected cases of CA-MRSA were reviewed for
potential exposures, hygiene behavior, timing of infection, treat-
ment, hospitalization and response to treatment. Characteristics (ie,
grade, position, frequency of showering, use of antibacterial soap,
sharing of towels and equipment and potential exposures to MRSA)
of infected and uninfected players were compared with identify risk
factors. These data were obtained by surveys distributed to all
players. Descriptive statistics were determined with SPSS 12.0
software (Chicago, IL). Odds ratios (OR) with 95% confidence
intervals (95% CI) were calculated to identify risk factors for
infection.
Cultures. Results of wound and nasal cultures performed throughout
the season were recorded. All available isolates were tested for
antibiotic susceptibility and were then frozen at ⫺70°C for field
inversion gel electrophoresis analysis (FIGE). Standard antimicro-
bial susceptibility testing was performed using Microscan Walk-
away 96 (Dade Behring, Deerfield, IL) PosCombo 20 panels.
S. aureus isolates that were sensitive to clindamycin but resistant to
erythromycin were further tested by double disk diffusion to detect
inducible resistance to clindamycin.
FIGE. Available isolates were thawed and suspended in buffer at a
turbidity of 1.5–1.8 McFarland standard. DNA from each isolate
was lysed and extracted into agarose plugs by standard procedures.
Each plug was digested with a SmaI restriction enzyme and run on
a 1% agarose gel. Multidirectional electric pulses were applied to the
gel for 40 hours, allowing the DNA bands to separate according to
weight and electric charge. The gel was visualized with ethidium
bromide and photographed under UV light. Restriction patterns of
individual isolates were compared according to the definitions of
Tenover et al.7
Interventions. Education regarding hygiene behavior (eg, routine
hand washing, not sharing towels and equipment, prompt attention
to skin lesions) was provided to the entire team and reiterated
throughout the season. Each player was fully inspected for infectious
lesions by the athletic trainers on a weekly basis. Players with an
active infection were referred to their physician for wound culture
and treatment and were restricted from practice and games until
treatment was initiated. Skin lesions were fully covered during all
contacts. Nasal cultures were performed on all 102 players and staff
841
Rihn et al The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
members to identify carriers of MRSA. Cultures were obtained from
the anterior nare using a sterile Dacron swab and plated on blood
and chocolate agar plates. S. aureus were screened for MRSA with
the use of oxacillin screening agar (BD Biosciences, Cockeysville,
MD) with susceptibility testing performed as noted above. Mupiro-
cin nasal ointment (2%) was initially prescribed for the players who
had positive nasal cultures for MRSA and subsequently to the entire
team. Administration of mupirocin was not supervised. All players
were questioned regarding their use of mupirocin and, if noncom-
pliant, the specific reason(s) for noncompliance.
RESULTS
The football team included 90 players, (9th–12th grade), and
12 staff members. The football season extended from August 17
through December 11, 2003. Thirteen players had 20 episodes of
infection caused by CA-MRSA (11 proven, 9 suspected). No staff
members developed infection. Infections were characterized as an
abscess/cellulitis located on the arm/elbow/forearm (n ⫽ 11), knee/
leg (n ⫽ 5), face (n ⫽ 3), neck (n ⫽ 1) and abdomen (n ⫽ 1). One
player had 2 separate lesions concurrently. Recurrent infection
occurred in 6 players 关2 episodes (N ⫽ 5) and 3 episodes (N ⫽ 1)兴.
Eighteen of 21 lesions required incision and drainage. Six of 13
infected players reported the use of mupirocin nasal ointment before
developing lesions. When infected and uninfected players were
compared, risk factors for developing an infection included playing
a lineman position (OR 4.0, 95% CI 1.02–15.7) and having junior
class status (OR 3.53, 95% CI 1.05–11.9). No other variables,
including sharing of equipment and towels, hygiene practices or
exposures to health care facilities, were identified as risk factors.
Only 1 player had a coinfected family member or significant other.
Five of the 13 players had sites of infection that were cultured
and treated with antibiotics guided by culture during their initial
episode of infection. Seven of 8 who were not initially cultured were
treated empirically with cephalexin or amoxicillin/clavulanate; 1
was treated with clindamycin based on the physician’s suspicion for
CA-MRSA. In total, 8 of 20 infectious episodes were treated with
drainage and empiric ␤-lactam antibiotics. Seven of 8 of these
infections had an initial satisfactory response. However, they were
33 times more likely (OR 33.0, 95% CI 2.5– 443.6) to develop a
recurrent infection than were those treated with antibiotics guided by
culture. Four players required hospitalization for intravenous anti-
biotics with an average length of hospitalization of 4 days (range,
3–5 days). Of these 4 patients, 3 were hospitalized for severe soft
tissue involvement, and 1 was hospitalized for failure to respond to
␤-lactams.
Three of 102 (2.9%) nare cultures were positive for MRSA,
and 32 of 102 (31.4%) were positive for MSSA. Of the players who
developed CA-MRSA, 8 had negative surveillance nasal cultures, 3
had nasal cultures that were positive for MSSA and 2 had nasal
cultures that were positive for MRSA. All 3 players treated with
mupirocin for nasal carriage of MRSA reported using the ointment
as directed; 2 subsequently developed episodes of proven MRSA
infection. After prescriptions were given to the entire team,
35 of 90 (38.9%) stated that they used mupirocin nasal ointment as
prescribed.
Antibiotic susceptibilities performed on isolates of
CA-MRSA from the nasal cultures and/or the wounds of 11 players.
Identical susceptibility patterns were found, including susceptibility
to trimethoprim-sulfamethoxazole and to clindamycin (confirmed by
double disk diffusion). Two nasal cultures and 4 wound cultures
were available for FIGE testing and showed identical band patterns.
842
DISCUSSION
Although traditionally viewed as a hospital pathogen, MRSA
has emerged as a community problem most commonly manifested
as skin and soft tissue infection.1–3 Limited outbreaks of CA-MRSA
skin and soft tissue infections have been reported in athletic
teams.1,4 – 6 The outbreak reported here involved 13 players with
20 episodes of infection and is the largest reported outbreak of
CA-MRSA to date in an athletic team. Although MRSA isolates
from all players were not available, the identical antibiotic capabil-
ities in 11 isolates and FIGE band patterns on 6 isolates suggest that
this outbreak was caused by a single strain of MRSA.
Similar to other reports, the majority of infections occurred on
the extremities, areas of the body most susceptible to skin injury.1,8,9
Playing a lineman position carried a 4-fold greater likelihood of
infection, suggesting that the repetitive, close contact inherent to this
position predisposes to infection with CA-MRSA. Position played
was also found to be a risk factor by Stacey et al,6 who reported on
an outbreak of CA-MRSA infection in a rugby football team. All 5
affected members were forward players, a position in rugby that is
associated with prolonged, close physical contact.
Nasal cultures were performed in an attempt to characterize
the extent of MRSA colonization and to target carriers for treatment
with mupirocin nasal ointment. Only 3 of 102 team members,
however, were identified as carriers of MRSA. This low prevalence
of colonization was similar to results reported by Stacey et al,6 who
found only 1 of 5 infected rugby players to have MRSA on nasal
culture. Based on these findings, surveillance cultures cannot be
endorsed as a means of determining the risk for CA-MRSA infection
at a single time point.
Mupirocin nasal ointment (2%) was used in an attempt to
control the outbreak. Only 36% of players reported using the
mupirocin nasal ointment as directed. Reasons for noncompliance
included cost, inability or unwillingness to fill the prescription and
the discomfort associated with administration of the ointment. Fur-
thermore players who were compliant did not use the ointment
simultaneously. Subsequent cases of CA-MRSA infection afater this
intervention suggest that this strategy is ineffective in controlling
such outbreaks. It is possible that mupirocin would be more effective
if used by all players simultaneously in conjunction with systemic
antibiotics and isolation of those with active infection. This would
require (1) that the ointment be provided to the players to eliminate
the need to fill the prescription and (2) that administration of the
ointment be overseen by a staff member.
Eight episodes reported in this outbreak were treated with
drainage and empiric cephalexin or amoxicillin/clavulanate. Seven
of these lesions healed. Lee et al10 prospectively followed 69
children with culture-proved CA-MRSA infection and reported
adequate healing response to incision and drainage whether or not
effective antibiotics were administered. They concluded that inci-
sion and drainage were sufficient treatment of CA-MRSA skin and
soft tissue infection. Our study shows that although abscesses treated
with drainage and ineffective antibiotics tended to heal, there was a
significantly higher recurrence rate than in those treated with anti-
biotics guided by culture. Accordingly an important rationale for
performance of cultures and prescription of effective antibiotics is
the prevention of recurrent infections.
ACKNOWLEDGMENTS
We greatly appreciate the critical review of the manuscript
by Dr Ellen Wald, and the contributions to the study design made by
Dr Sylvia Choi.
© 2005 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
REFERENCES
1. Centers for Disease Control and Prevention. Methicillin-resistant Staph-
ylococcus aureus infections among competitive sports participants: Col-
orado, Indiana, Pennsylvania, and Los Angeles County, 2000 –2003.
MMWR. 2003;52:793–795.
2. Centers for Disease Control and Prevention. Public Health dispatch:
outbreaks of community-associated methicillin-resistant Staphylococcus
aureus skin infections: Los Angeles County, California, 2002–2003.
MMWR. 2003;52:88.
3. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired
methicillin-resistant Staphylococcus aureus in children with no identi-
fied predisposing risk. JAMA. 1998;279:593–598.
4. Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillin-
resistant Staphylococcus aureus among professional football players.
N Engl J Med. 2005;352:468 – 475.
5. Lindenmayer JM, Schoenfeld S, O’Grady R, Carney JK. Methicillin-
resistant Staphylococcus aureus in a high school wrestling team and the
surrounding community. Arch Intern Med. 1998;158:895– 899.
6. Stacey AR, Endersby KE, Chan PC, Marples RR. An outbreak of
methicillin resistant Staphylococcus aureus infection in a rugby football
team. Br J Sports Med. 1998;32:153–154.
7. Tenover FC, Arbeit RD, Goering RV, et al. Interpreting chromosomal
DNA restriction patterns produced by pulsed-field gel electrophoresis:
criteria for bacterial strain typing. J Clin Microbiol. 1995;33:2233–2239.
8. Bartlett PC, Martin RJ, Cahill BR. Furunculosis in a high school football
team. Am J Sports Med. 1982;10:371–374.
9. Sosin DM, Gunn RA, Ford WL, Skaggs JW. An outbreak of furun-
culosis among high school athletes. Am J Sports Med. 1989;17:828 –
832.
10. Lee MC, Rios AM, Aten MF, et al. Management and outcome of
children with skin and soft tissue abscesses caused by community-
acquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis
J. 2004;23:123–127.
STROKE IN TWO CHILDREN WITH MYCOPLASMA
PNEUMONIAE INFECTION
A CAUSAL OR CASUAL RELATIONSHIP?
Salvatore Leonardi, MD, Piero Pavone, MD,
Novella Rotolo, MD, and Mario La Rosa, MD
Abstract: We report on 2 children who had a stroke biologically
related to Mycoplasma pneumoniae infection. Invasion of the central
nervous system and an immune mechanism represent 2 pathogenesis
pathways. Prompt macrolide therapy does not prevent stroke, but
immediate and aggressive immunosuppressive treatment seems to
help recovery.
Key Words: stroke, Mycoplasma pneumoniae, childhood
Accepted for publication March 3, 2005.
From the Paediatric Department, University of Catania, Catania, Italy
Address for reprints: Salvatore Leonardi, MD, Pediatric Department, Uni-
versity of Catania, Via S. Sofia 78-95125, Catania, Italy. Fax 39-095-
222532; E-mail leonardi@unict.it.
DOI: 10.1097/01.inf.0000177284.88356.56
E xtrapulmonary manifestations of Mycoplasma pneumoniae infec-
tion include disorders of the central and peripheral nervous
systems.1 They occur not less than 3 days after onset of respiratory
disease (parainfectious type) and up to 2–3 weeks after the end of
the respiratory disease (postinfectious type) with clinical manifes-
tations such as meningoencephalitis, acute disseminated encephalo-
myelopathy, transverse myelitis, seizures and peripheral nervous
system involvement.1–5
To date, stroke has been attributed to M. pneumoniae infec-
tion in only 4 children.6 –9
© 2005 Lippincott Williams & Wilkins
Stroke and Mycoplasma pneumoniae
We describe 2 children who had a stroke biologically related
to M. pneumoniae infection.
CASE REPORTS
Case 1. A 6-year-old boy was admitted to the Department of
Pediatrics for evaluation and treatment of respiratory distress. He
had no underlying cardiac abnormalities and no previous history of
frequent infections. Family history was negative for vascular dis-
eases or coagulation disorders.
Three days earlier, he had developed fever, cough, tachypnea
and wheezing. These symptoms progressed despite 2 days of anti-
biotic therapy with a cephalosporin. At the time of admission he had
a temperature of 37.5°C and a respiratory rate of 45/min. Expiratory
wheezes from both lungs and rhonchi and rales in both lower lobes
were present. Chest radiograph revealed interstitial infiltration in
both lungs. Complete blood count was 7900 white cells/ mm3 with
70% segmented neutrophils. Normal values were recorded for he-
matocrit, platelet count, glucose, creatinine, plasma urea and liver
enzymes.
Rapid viral diagnostic tests for influenza, parainfluenza and
respiratory syncytial viruses were negative.
Cold agglutinins were positive. Serum M. pneumoniae anti-
bodies tested by a microparticle agglutination assay were 1/160
(cutoff for positive result, 1/64).
He received oral erythromycin, and fever disappeared and
respiratory symptoms improved in 2 days. On the third day, because
of an acute headache, somnolence and rapidly increasing lethargy
and dyspnea, the patient was taken to the Intensive Care Unit. He
had 3 generalized seizures treated with diazepam intravenously. An
electroencephalogram showed diffuse slow wave activity. His neu-
rologic status deteriorated rapidly as did his respiratory status.
Arterial blood gas revealed pH 7.45, PCO2 30.1 mm Hg and PO2
60 mm Hg.
An electrocardiogram showed sinus tachycardia and normal
ventricular repolarization. Heart ultrasound examination was nor-
mal. Computed tomography showed a low density lesion in the right
caudate and internal capsule, representing an area of cerebral infarc-
tion. Axial T2-weighted spin echo scans at the level of the thalami
showed a large and acute ischemic lesion involving the left middle
cerebral artery area, partially including the lenticular and caudate
nuclei, with predominantly gray matter vasogenic edema. The isch-
emic lesion at the level of the left thalamus was considered related
to the diffuse brain edema and transtentorial herniation of the
temporal lobe, with ipsilateral compression. Magnetic resonance
angiography revealed in significant flow signal intensity on the left
middle cerebral artery.
Coagulation studies showed normal prothrombin time, partial
thromboplastin time, fibrinogen, fibrin D-dimer, protein S, protein
C, factor V and anti-thrombin III. Anticardiolipin antibodies, an-
tiphospholipin antibodies, anticytoplasmic antibodies, antinuclear
antibodies and anti-DNA were absent.
Serum samples screened for antibodies to herpes simplex
virus types 1 and 2, measles, cytomegalovirus, influenza virus,
mumps, Chlamydia spp. and Borrelia burgdorferi were negative.
Serum M. pneumoniae antibodies were increased at 1/1280. A
serum immunoblot assay revealed positive IgA (100), IgM (640) and
IgG (200) responses against M. pneumoniae.
Cerebrospinal fluid (CSF) leukocyte count (2 ⫻ 106 cells/L),
glucose (60 g/L), protein (25 g/L) and CSF-serum albumin (4.8;
normal range: 2.0 –7.4) were normal. No bacterial or viral antigen
was found in the CSF. Immunoglobulin-matched immunoblot as-
says showed specific IgA (10), IgG (40) and IgM (160) against
M. pneumoniae in the CSF.
843
Leonardi et al The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
Because of worsening neurologic disease, we performed a
second lumbar puncture 3 days later which showed a 5-fold increase
of specific IgM (800) and a 2-fold of specific IgG (80) M. pneu-
moniae antibodies in CSF. Serum samples showed also an increase
of specific IgM (3200) and IgG (800) M. pneumoniae antibodies.
Therapy with antibiotics (ceftriaxone iv and erythromycin iv),
diuretics and dexamethasone was given, but the patient died 1 week
later.
Case 2. A 5-year-old girl was admitted to the Department of
Pediatric because of sudden hypotonia and foot drop gait.
She had had febrile upper respiratory tract infection ⬃2
weeks before admission. Weight, height and head circumference
were normal for age. Neither cardiac abnormalities nor signs of
cranial nerves involvement were present. Neurologic examination
revealed foot drop gait with an extra rotation of the lower right limb.
Tendon reflexes showed a right lower limb hyporeflexia with
reduced muscle tone. The Romberg sign was absent. Magnetic
resonance imaging of the lumbosacral region and funduscopic
examination were normal. Chest radiograph was normal. The elec-
troencephalogram was characterized by diffuse slow waves. Axial
3-dimensional time of flight magnetic resonance angiography
showed absence of flow signal intensity at the level of the left
middle cerebral artery, whereas the right middle cerebral artery flow
was normal. Coronal T2-weighted fluid-attenuated inversion recov-
ery scans at the level of the frontal and parietal lobes showed a large
high signal intensity lesion mainly involving the watershed areas of
the left hemisphere. Subtle signal changes were depicted at the level
of corresponding cortical layer. Mild left ventricle dilatation sec-
ondary to atrophic changes was present.
Coagulation studies showed normal prothrombin time, par-
tial thromboplastin time, fibrinogen, fibrin D-dimer, protein S,
protein C, factor V and anti-thrombin III. Anticardiolipin anti-
bodies, antiphospholipin antibodies, anticytoplasmic antibodies,
antinuclear antibodies and anti-DNA were absent. Complete
blood count showed 8900 white blood cells/mm3 with 75%
segmented neutrophils.
Normal values were recorded for hematocrit, platelet count,
glucose, sodium, potassium, creatinine, plasma urea, creatine kinase
and pancreas and liver enzymes. Serum and urinary amino acids,
serum ammonia and blood lactic acid were also normal.
Rapid viral diagnostic tests for hepatitis viruses, human im-
munodeficiency virus, influenza, parainfluenza and respiratory syn-
cytial virus were negative. Cold agglutinins were positive. M.
pneumoniae antibodies by the agglutination assay was elevated
(1/160). A serum immunoblot assay revealed positive IgM (80) and
IgG (800) against M. pneumoniae.
Lumbar puncture showed a normal CSF leukocyte count (2 ⫻
106 cells/L) and glucose. Total protein content (0.43 g/L; reference
value, ⬍0.40 G/L) and CSF-serum albumin ratio (7.6; normal range,
2.0 –7.4) were slightly increased.
No bacterial or viral antigen was found in the CSF but
immunoglobulin-matched immunoblot showed IgG antibody (160)
to M. pneumoniae.
The patient was treated with intravenous erythromycin,
prednisolone and immunoglobulins. A CSF sample obtained 2
weeks after starting therapy showed a ⬎4-fold decrease of IgG
M. pneumoniae antibodies (40). A ⬎10-fold drop of serum IgG
(80) M. pneumoniae antibodies and a disappearance of IgM M.
pneumoniae antibodies was found 30 days later coincident with
improvement of neurologic symptoms. The patient’s symptoms
and magnetic resonance imaging abnormalities had disappeared 6
months later.
844
DISCUSSION
Stroke related to M. pneumoniae infection still remains doubt-
ful, and to date it has been reported in only 4 children. Parker et al6
reported an 8-year-old girl with a cerebral infarction and pneumonia
who developed an acute hemiparesis associated with clinical and
serologic evidence of M. pneumoniae infection. Fu et al7 reported a
5-year-old girl who had a stroke with middle cerebral artery occlu-
sion. 10 days after M. pneumoniae infection. Ovetchkine et al8
reported an 8-year-old boy with acute stroke in whose cerebral
angiography showed a pattern suggestive of vasculitis associated to
a recent M. pneumoniae infection. Antachopoulos et al9 reported a
case of a child with posterior cerebral artery occlusion and hemipa-
resis associated with M. pneumoniae infection. In all cases but the
last, vascular occlusion occurred in the anterior brain circulation.
Different mechanisms have been proposed to explain stroke
associated with M. pneumoniae infection. Direct damage of central
nervous system with detection of M. pneumoniae DNA in the CSF
already has been described.3,10 It occurs generally not less than 3
days after onset of respiratory disease (parainfectious type).
In our first case, we found the presence of increasing values
of IgA, IgM and IgG M. pneumoniae antibodies in serum and CSF
samples, but the pathogenesis is uncertain because M. pneumoniae
was not isolated by PCR or culture.
Alternatively an immune mechanism can be considered if
CSF is M. pneumoniae-free and stroke starts 2-3 weeks after
respiratory disease subside (postinfectious type).11
We suggest that this mechanism could have had a key role in
second case because elevated IgG M. pneumoniae antibodies were
found in CSF even though pneumonia was not present. When we
initiated immunosuppressive treatment, IgG antibodies in serum and
CSF decreased, and the patient improved.
There are very limited data showing a major effect by immu-
nosuppressive therapy, but in our second case we observed a
favorable outcome by aggressive therapy with steroids and high
dosage immunoglobulins.
ACKNOWLEDGEMENTS
We thank Nicolò Bonanno for his technical assistance.
REFERENCES
1. Koskiniemi M. CNS manifestations associated with Mycoplasma pneu-
moniae infections: summary of cases at the University of Helsinki and
review. Clin Infect Dis. 1993;17(suppl 1):S52–S57.
2. Decaux G, Szyper M, Ectors M, Cornil A, Francken L. Central nervous
system complication of Mycoplasma pneumoniae. J Neurol Neurosurg
Psychiatry. 1980;43:883– 887.
3. Bencina D, Dovc P, Mueller-Premru M, et al. Intrathecal synthesis of
specific antibodies in patients with invasion of the central nervous
system by Mycoplasma pneumoniae. Eur J Clin Microbiol Infect Dis.
2000;19:521–530.
4. Pfausler B, Enegelhardt K, Kampfl A, Spiss H, Taferner E,
Schmutzzhard E. Post-infectious central and peripheral nervous system
disease complicating Mycoplasma pneumoniae infection: report of three
cases and review of the literature. Eur J Neurol. 2002;9:93–96.
5. Sotgiu S, Pugliatti M, Rosati G, Deiana GA, Sechi GP. Neurological
disorders associated with Mycoplasma pneumoniae infection. Eur J Neu-
rol. 2003;10:165–168.
6. Parker P, Puck J, Fernandez L. Cerebral infarction associated with
Mycoplasma pneumoniae infection. Pediatrics. 1981;67:373–375.
7. Fu M, Wong KS, Lam WW, Wong GW. Middle cerebral artery occlu-
sion after recent Mycoplasma pneumoniae infection. J Neurol Sci.
1998;157:113–15.
8. Ovetchkine P, Brugieres P, Seradj A, Reinert P, Cohen R. An 8-y-old
boy with acute stroke and radiological signs of cerebral vasculitis after
recent Mycoplasma pneumoniae infection. Scand J Infect Dis. 2002;34:
307–309.
© 2005 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
9. Antachopoulos C, Liakopoulou T, Palamidou F, Papathanassiou D,
Youroukos S. Posterior cerebral artery occlusion associated with Myco-
plasma pneumoniae infection. J Child Neurol. 2002;17:55–757.
10. Padovan CS, Pfister HW, Bense S, Fingerle V, Abele-Horn M. Detection
of Mycoplasma pneumoniae DNA in cerebrospinal fluid of a patient with
M. pneumoniae infection-“associated” stroke. Clin Infect Dis. 2001;33:
E119 –E121.
11. Clyde WA. Mycoplasma diseases. In: Sheld WM, Whitley RJ, Durack
DT, eds. Infection of the Central Nervous System. 2nd ed. Philadelphia,
PA: Lippincott-Raven Publisher; 1997:603– 612.
NAIL DISCOLORATION INDUCED BY DOXYCYCLINE
Mustafa Akcam, MD,* Reha Artan, MD,*
Fusun Zeynep Akcam, MD,† and Aygen Yilmaz, MD*
Abstract: All tetracyclines are deposited in calcifying areas of the
bones and teeth and may cause discoloration. Although hyperpig-
mentation of the skin, teeth and nails have been reported and well
documented due to other tetracycline intake, it has been rarely
reported that discolored nails induced by doxycycline in pediatric
patients. Here we report an 11-year-old-boy with nail discoloration
caused by doxycycline intake.
Key Words: nail, discoloration, doxycycline
Accepted for publication March 10, 2005.
From the *Division of Pediatric Gastroenterology, Hepatology and Nutrition,
Department of Pediatrics, Medical School, Akdeniz University, Antalya,
Turkey; and †Department of Clinic Bacteriology and Infectious Dis-
ease, Medical School, Süleyman Demirel University, Isparta, Turkey
Supported by Akdeniz University Research Foundation.
Reprints not available.
E-mail makcam88@hotmail.com.
DOI: 10.1097/01.inf.0000177283.71692.56
T etracyclines, among the first of the antibiotics to become avail-
able 55 years ago, remain widely used. Doxycycline is a tetra-
cycline-derived antibiotic that may be used in the treatment of
common infections in children and adults. On the basis of pharma-
cokinetic considerations, doxycycline is the preferred agent among
the tetracycline congeners.1,2 This group of antibiotics has the
ability to chelate calcium ions and to be incorporated into teeth,
cartilage and bone.3,4 Photosensitivity can occur, particularly in
sunny climates, and consists of greater skin sensitivity to the effects
of the sun. These drugs have an affinity for calcified tissues and are
deposited and persist in osteogenetic regions of normal bone. The
affinity for mineralizing tissue is the result of binding to calcium to
form a tetracycline-calcium orthophosphate complex.4 Minocycline
hydrochloride, a semisynthetic derivative of tetracycline often used
for the treatment of acne, has been shown to cause pigmentation of
a variety of tissues including skin, thyroid gland, nails, sclera, teeth,
conjunctiva, tongue and bone.5–10 Skin and tooth discolorations
induced by doxycycline are the reported side effects of doxycy-
cline.11,12 We found only 2 reports that described painful nail
discoloration induced by doxycycline in pediatric patients.13,14 Here
we report a patient with painless brown discoloration of the nails
caused by doxycycline intake.
CASE REPORT
An 11-year-old boy was referred to our hospital in May 2004
for the evaluation of nail discoloration. The history revealed that, in
April 2004, the patient had brucellosis that was treated with doxy-
cycline 200 mg on the first day and 100 mg daily thereafter,
combined with gentamicin for 10 days. Doxycycline therapy was
stopped because he developed photosensitivity. Trimethoprim-sul-
© 2005 Lippincott Williams & Wilkins
Nail Discoloration and Doxycycline
FIGURE 1. Brown discoloration of the fingernails (a), espe-
cially in the thumbs (b).
famethoxazole was given instead. The symptoms of brucellosis
resolved, but brown discoloration of the nails developed after 15
days of doxycycline intake. He had no symptoms related to the nails.
Physical examination revealed painless brown discoloration of the
fingernails (Fig. 1). The oral cavity and teeth had no changes in
color. The laboratory findings revealed normal hematologic and
biochemical results. Echocardiographic findings were normal. The
nail discoloration disappeared in ⬃1 month.
DISCUSSION
All tetracyclines are deposited in calcifying areas of the bones
and teeth and may cause discoloration.3 Skin hyperpigmentation is
a well-recognized side effect of minocycline but has been docu-
mented in only 1 report for doxycycline. It results from deposition
of pigment in the basal keratinocytes and pigment-laden histiocytes
in the dermis and subcutaneous fat.11 Taken together, the histomor-
phologic and ultrastructural changes induced by doxycycline shared
several features with cutaneous hyperpigmentation caused by mino-
cycline. A study showed a direct deposition of doxycycline, prob-
ably chelated with iron and/or calcium, within the lesional skin.11
Based on the present case and the reviewed literature, only suprap-
harmacologic doses of doxycycline are sufficient to cause such
pigment changes.
Two pediatric patients who previously reported discoloration
of the nails induced by doxycycline presented with painful discol-
oration.13,14 In contrast, our patient had no symptom accompanying
the discoloration.
Doxycycline was given in the conventional treatment dose
for 10 days in our patient. Nevertheless he developed discolora-
tion of the nails. This is the first report of painless brown
discoloration of the nails induced by doxycycline. When the
doxycycline was discontinued, the normal color of the nails was
restored in 1 month.
REFERENCES
1. Smilack JD. The tetracyclines. Mayo Clin Proc. 1999;74:727–729.
2. Schuster A, Schwachman H. The tetracyclines: applied pharmacology.
Pediatr Clin North Am. 1956;3:295–303.
3. van der Bijl P, Pitigoi-Aron G. Tetracyclines and calcified tissues. Ann
Dent. 1995;54:69 –72.
4. Dhen A, Piret N, Fortunati D. Tetracyclines, doxycycline and calcified
tissues. 1976;9:42– 46.
5. Eisenberg E. Anomalies of the teeth with stains and discolorations.
J Prev Dent. 1975;2:7–20.
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Trapp et al The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
6. Cale AE, Freedman PD, Lumerman H. Pigmentation of the jawbones
and teeth secondary to minocyclines hydrochloride therapy. J Periodon-
tol. 1988;59:112–114.
7. Gordon G, Sparano BM, Iatropoulos MJ. Hyperpigmentation of the skin
associated with minocycline therapy. Arch Dermatol. 1985;121:618–623.
8. Patterson JW, Wilson B, Wick MR, et al. Hyperpigmented scar due to
minocycline therapy. Skin. 2004;74:293–298.
9. Angeloni VL, Salasche SJ, Ortiz R. Nail, skin, and scleral pigmentation
induced by minocycline. Cutis. 1987;40:229 –233.
10. Wolfe ID, Reichmister J. Minocycline hyperpigmentation: skin, tooth,
nail, and bone involvement. Cutis. 1984;33:457– 458.
11. Bohm M, Schmidt PF, Lodding B, et al. Cutaneous hyperpigmentation
induced by doxycycline: histochemical and ultrastructural examination,
laser microprobe mass analysis, and cathodoluminescence. Am J Der-
matopathol. 2002;24:345–350.
12. Lochary ME, Lockhart PB, Williams WT Jr. Doxycycline and stain-
ing of permanent teeth. Pediatr Infect Dis J. 1998;17:429 –
431.
13. Coffin SE, Puck J. Painful discoloration of the fingernails in a 15-year-
old boy. Pediatr Infect Dis J. 1993;12:702–703; 706.
14. Yong CK, Prendiville J, Peacock DL, Wong LT, Davidson AG. An
unusual presentation of doxycycline-induced photosensitivity. Pediat-
rics. 2000;106:E13.
SEPTIC ARTHRITIS SECONDARY TO
FUSOBACTERIUM NECROPHORUM IN A 4-YEAR-OLD
GIRL: CASE REPORT AND REVIEW OF THE LITERATURE
Christine M. Trapp, MS,† Junichi Tamai, MD,‡
and Mark R. Schleiss, MD*
Abstract: We report an unusual case of septic arthritis in a 4-year-
old child caused by Fusobacterium necrophorum. In spite of ag-
gressive parenteral antibiotic therapy with ampicillin-sulbactam af-
ter surgical drainage, disease recurred, requiring additional
arthrotomies. The infection was eventually eradicated with paren-
teral meropenem and clindamycin, and additional surgical drainage.
Key Words: fusobacterium necrophorum, Lemierre syndrome,
septic arthritis, pediatric anaerobic infection
Accepted for publication April 7, 2005.
From the *Division of Infectious Diseases, Department of Pediatrics, Uni-
versity of Minnesota School of Medicine, Minneapolis, MN; the †Uni-
versity of Connecticut School of Medicine Farmington, CT; and the
‡Department of Orthopedic Surgery, University of Cincinnati School of
Medicine and Children’s Hospital Medical Center, Cincinnati, OH
E-mail schleiss@umn.edu. Reprints not available.
DOI: 10.1097/01.inf.0000178295.48885.fa
O steomyelitis and septic arthritis are uncommonly caused by
anaerobic organisms. We report a case of septic arthritis in a
4-year-old girl caused by the anaerobe Fusobacterium necrophorum.
CASE REPORT
A 4-year-old previously healthy girl was admitted in October
2004 to Cincinnati Children’s Hospital (Cincinnati, OH) because of
right knee pain, limp and fever. The only significant history reported
had been a routine dental examination ⬃1 month before admission.
The patient’s teeth were in good repair, and reportedly no extrac-
tions, fillings or other dental manipulation were required.
At the time of admission, the patient had low grade fever
(38.5°C). Physical examination was remarkable for swelling of the
right knee. The remainder of the physical examination was normal.
Laboratory evaluation included a complete blood count that showed
a total of 5600 white blood cells/mm3 (63% segmented neutrophils,
25% lymphocytes, 9% monocytes, 1% eosinophils and 2% ba-
sophils), a hemoglobin of 10.4 g/dl, a hematocrit of 28.7% and a
846
platelet count of 359,000 platelets/mm3. C-reactive protein was 3.4
mg/dL, and the erythrocyte sedimentation rate was 65 mm/h.
Needle aspiration of the right knee revealed cloudy yellow
synovial fluid with a total white blood cell count of 89,900 white
blood cells/mm3 (89% segmented neutrophils, 7% lymphocytes
and 4% monocytes) and a red blood cell count of 20 erythrocytes/
mm3. A Gram-stained smear of the synovial fluid revealed
leukocytes but no organisms. The patient underwent an arthrot-
omy on the day of admission. Aerobic and anaerobic cultures of
the synovial fluid were obtained, and the anaerobic culture was
positive for F. necrophorum. A blood culture obtained before the
initiation of antibiotics was negative. Ampicillin-sulbactam therapy
was given. After ⬃1 week of hospitalization, the patient was
discharged home, with a recommendation to complete a 21-day
course of parenteral antibiotic therapy, with periodic monitoring of
the erythrocyte sedimentation rate and C-reactive protein.
Although the patient remained afebrile at home, the swelling
and pain in the right knee did not resolve, and her inflammatory
markers remained elevated. Approximately 1 month after the first
admission, as the patient was nearing completion of a 21-day course
of ampicillin-sulbactam, fever returned, and increased swelling was
noted in the knee. Laboratory evaluation revealed a total white blood
cell count of 4900/mm3 (67% segmented neutrophils, 23% lympho-
cytes, 9% monocytes and 1% eosinophils), a hemoglobin of 8.7
g/dL, a hematocrit of 25.0% and a platelet count of 397,000/mm3.
The C-reactive protein and sedimentation rate increased signifi-
cantly (10.6 mg/dL and ⬎140 mm/h, respectively. The patient
underwent 2 additional arthrotomies during this admission, sepa-
rated by a period of 2 days. Gram stain of the knee fluid again
revealed many leukocytes but no organisms. Knee fluid culture,
collected during the first arthrotomy on the day on readmission,
again grew out F. necrophorum. Ampicillin-sulbactam was discon-
tinued, and meropenem and clindamycin therapy were commenced.
A subsequent knee fluid culture obtained at the time of the second
arthrotomy during this admission remained negative. A series of
daily blood cultures remained negative. There was no radiographic
evidence of osteomyleitis. A computed tomography scan of the
abdomen, chest and pelvis was performed to rule out an occult focus
of infection, which could have caused reseeding of the right knee
joint, and these examinations were negative.
By the date of discharge, the patient was afebrile and had no
pain in the right knee. The orthopedic service placed the patient in
an above-the-knee cast before discharge. The patient was discharged
on iv clindamycin and meropenem to complete a 6-week course.
Acute phase reactants gradually normalized, and antibiotics were
discontinued. After completion of this course of antibiotics, the
patient did well, with normal ambulation and a good functional
outcome.
DISCUSSION
F. necrophorum is a Gram-negative obligate anaerobe that is
present as part of the normal flora of the oral cavity, gastrointestinal
tract and female genital tract.1,2 The clinical manifestations of
disease caused by this organism range from uncomplicated pharyn-
gitis to Lemierre syndrome, an aggressive oropharyngeal infection
in which pharyngitis precedes symptomatic bacteremia, typically in
association with suppurative thrombophlebitis of the jugular venous
system. This bacteremia often leads to metastatic septic emboli,
especially involving the lungs and joints. In the preantibiotic era,
Lemierre syndrome had a mortality rate as high as 90%. Although
this rate has been reduced to ⬍20% in the modern era, mortality
remains substantial, and patients with Lemierre syndrome are typi-
cally critically ill, requiring intensive care and prolonged antibiotic
therapy.
© 2005 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 24, Number 9, September 2005
TABLE 1. Previously Reported Cases of Fusobacterium necrophorum Septic Arthritis
Joint Age (yr) Sex Source
Knee 8 M Dental abscess
Knee 14 F Lemierre syndrome
Hip 9 M Tonsillectomy
Ankle, knee 13 M Lemierre syndrome
Ankle 21 M Pharyngitis
Hip 8 M Lemierre syndrome
Sternoclavicular joint 26 M Upper respiratory
infection
Knee 24 M Lemierre syndrome,
pneumonia
Shoulder, hip, knee 12 M Lemierre syndrome
In addition to Lemierre syndrome, F. necrophorum can cause
orbital abscess, mastoiditis, and brain abscess.3–5 Septic arthritis
caused by F. necrophorum was a common metastatic manifestation
of Lemierre syndrome in the preantibiotic era, but this has become
uncommon in recent years. Review of the medical literature pub-
lished since 1980 identified 9 cases of septic arthritis caused by
F. necrophorum (Table 1).6 –14 This entity has been observed in
adults and older children (age range, 8 –26 years). The knee (n ⫽ 5)
and the hip (n ⫽ 3) are the most commonly reported involved joints.
Most cases have occurred in the context of Lemierre syndrome.
Most cases of F. necrophorum-associated septic arthritis, with or
without Lemierre syndrome, have been described in male patients
(Table 1). Only a few cases have been noted in patients without
Lemierre syndrome. One case was related to bacteremic seeding of
the knee joint after a dental abscess, and another case occurred after
a tonsillectomy.6,7 Seeding of the sternoclavicular joint was de-
scribed in a 26-year-old man occurring after symptoms of an upper
respiratory infection8 and in the ankle of a 21-year-old man who
had pharyngitis without frank Lemierre syndrome.9 Most patients
(Table 1) in this review were noted to have been treated with
␤-lactam antibiotics (typically penicillin) or metronidazole. One
patient with F. necrophorum septic arthritis and Lemierre syndrome
died, in spite of having been treated with a 10-day course of oral
ampicillin.10
The case we report is unique for several reasons. First the age
of the patient we describe (4 years) is significantly younger than
those of the youngest patients previously reported. Second, in
contrast to previous reports, we did not identify any predisposing
factor to explain the isolation of F. necrophorum from her knee
joint. Our patient did not have an antecedent pharyngitis, nor did she
have Lemierre syndrome. She had not undergone any previous
surgical or dental procedures, although she had undergone a routine
dental examination a few weeks before her episode of septic arthri-
tis. We postulate that she was asymptomatically colonized with
F. necrophorum, and even the minimal trauma associated with a
dental examination allowed a transient bacteremia to ensue, with
resultant seeding of the knee joint. A notable feature of her illness
was the persistence of her fever and knee pain after surgical drainage
and 3 weeks of intravenous ampicillin-sulbactam. Only after a
second hospitalization and 2 additional arthrotomies did she
defervesce. A change in antibiotic therapy from ampicillin-sulbac-
tam to meropenem and clindamycin also coincided with clinical
improvement, although surgical drainage was likely the more im-
portant reason for her improved status. ␤-Lactamase production by
F. necrophorum was noted in ⬎20% of isolates in 1 review.15 This
patient’s isolate was not tested for ␤-lactamase production. Al-
though the use of ampicillin-sulbactam in this patient would have
© 2005 Lippincott Williams & Wilkins
F. necrophorum Septic Arthritis
Therapy Reference
Flucloxacillin, ampicillin, metronidazole Sonsale et al.,9 2004
Penicillin, cefotaxime, metronidazole Liu and Argent,14 2002
Amoxicillin, clindamycin, penicillin Beldman et al.,6 1997
Penicillin Stahlman et al.,11 1997
Ceftriaxone, penicillin, imipenem, Gerst and Primrose,9 1997
metronidazole
Ampicillin, patient succumbed Goyal et al.,10 1995
Cloxacillin, clindamycin, ciprofloxacin, Lau and Shuckett,8 1993
metronidazole
Penicillin, metronidazole Gibb et al.,12 1990
Penicillin, chloramphenicol Vogel and Boyer,13 1980
been predicted to be therapeutic even in the face of ␤-lactamase
production, inadequate penetration of the sulbactam moiety into the
synovial fluid may have possibly rendered this agent relatively
ineffective. The response to meropenem and clindamycin suggested
that these may be more useful agents in the treatment of F. necro-
phorum joint infections.
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3. Han XY, Weinberg JS, Prabhu SS, et al. Fusobacterial brain abscess: a
review of five cases and an analysis of possible pathogenesis. J Neuro-
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4. Morrison A, Weir I, Silber T. Otogenic Fusobacterium meningitis,
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585–587.
6. Beldman TF, Teunisse HA, Schouten TJ. Septic arthritis of the hip by
Fusobacterium necrophorum after tonsillectomy: a form of Lemierre
syndrome? Eur J Pediatr. 1997;156:856 – 857.
7. Sonsale PD, Philipson MR, Bowskill J. Septic arthritis of the knee
due to Fusobacterium necrophorum. J Clin Microbiol. 2004;42:
3369 –3370.
8. Lau ES, Shuckett R. Fusobacterium septic arthritis of the sternoclavic-
ular joint. J Rheumatol. 1993;20:1979 –1981.
9. Gerst C, Primrose JM. Septic arthritis of the ankle from Fusobacterium
necrophorum. Acad Emerg Med. 1997;4:1172–1173.
10. Goyal M, Sharma R, Jain Y, Gupta A, Berry M. Unusual radiological
manifestations of Lemierre’s syndrome: a case report. Pediatr Radiol.
1995;25(suppl 1):S105–S106.
11. Stahlman GC, DeBoer DK, Green NE. Fusobacterium osteomyelitis and
pyarthrosis: a classic case of Lemierre’s syndrome. J Pediatr Orthop.
1996;16:529 –532.
12. Gibb PA, Donell ST, Dowd GS. Near-fatal necrobacillosis presenting
as septic arthritis of the knee: a case report. J Bone Joint Surg Am.
1990;72:1250 –1253.
13. Vogel LC, Boyer KM. Metastatic complications of Fusobacterium
necrophorum sepsis. Two cases of Lemierre’s postanginal septicemia.
Am J Dis Child. 1980;134:356 –358.
14. Liu AC, Argent JD. Necrobacillosis: a resurgence? Clin Radiol. 2002;
57:332–338.
15. Appelbaum PC, Spangler SK, Jacobs MR. ␤-Lactamase production
and susceptibilities to amoxicillin, amoxicillin-clavulanate, ticarcil-
lin, ticarcillin-clavulanate, cefoxitin, imipenem, and metronidazole of
320 non-Bacteroides fragilis Bacteroides isolates and 129 fusobac-
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847