E R Y S I P E L O T H R I X E N D O C A R D I T I S W I T H P R E V I O U S C U T A N E O U S L E S I O N : R E P O R T O F A C A S E A N D R E V I E W O F T H E L I T E R A T U R E
M a r i o n P . R O C H A ( 1 ) , P a u l o R . S . F O N T O U R A ( 2 ) , S u z a n a N . B . A Z E V E D O (2) & A r m a n d o M . V . F O N T O U R A (2)
S U M M A R Y
This report describes the first documented case of Erysipelothrix rhusiopathiae endocarditis in Latin America. The patient was a 51-years-old male, moderate alcoholic, with a previous history of aortic failure. He was used to fishing and cooking as a hobby and had his left hand wounded by a fish-bone. The disease began with erysipeloid form and developed to septicemia and endocarditis. He was treated with antibiotics and surgery for aortic valve replacement. There are only 46 cases of E . rhusiopathiae endocarditis reported to date. The authors wonder if several other cases might go unreported for lack of microbiological laboratorial diagnosis.
K E Y W O R D S : Erysipelothrix, Endocarditis, Erysipeloid.
C A S E R E P O R T
A 51-years-old white male was admitted to Hospital Mãe de Deus on November 30, spring of 1987, for evaluation of unexplained fever. He was a retired, mild alcoholic, who used to fish and cook as a hobby. On October 12, while cleaning some fish, he had gashed his left hand thumb, developing probable erysipeloid disease that was not detected at the time. Fifteen days later, his right foot showed signs of infection, with an erythematous lesion. His doctor prescribed corticosteroid and erythromicin for 2 days. Articular pain and astenia persisted and about 3 weeks later patient had sudden thoracic pain and a cough with ferruginous sputum. He was admitted to a hospital with a diagnosis of pneumonia and received daily doses of
oxy-tetracycline while in the hospital. He was discharged on the seventh day but, as fever persisted, he went to Hospital Mãe de Deus. He reported feeling articular pain, dyspnea on effort and astenia. Several years earlier he had been told to have a heart murmur. When admitted, he had a fever of 37.6°C. Physical examination showed a well-fed man, with slightly discoloured mucous membranes; sisto-diastolic aortic murmur + + / 6 ; crepitation on the base of the right lung; no hepato or splenomegalies, no haemorrhagic suffusions; blood pressure 110/60 mmHg; bilateral pul-monar infiltration evident on chest X-ray; normal electrocardiogram; white blood cells count 5.000/cu.mm; normal differential count, haematocrit 32% and haemoglobin 10.2 mg/dl; erythrocyte sedimentation rate 112 mm/hr.
(1) B i o c h e m i s t , L a b o r a t ó r i o B i o c l í n i c o Mãe de D e u s . P o r t o A l e g r e , R S , B r a z i l . (2) M e d i c a l D o c t o r , H o s p i t a l M ã e de D e u s . P o r t o A l e g r e , R S , B r a z i l .
Address f o r correspondence: D r . M a r i o n P . R o c h a . Department o f M i c r o b i o l o g y , L a b o r a t ó r i o B i o c l í n i c o Mãe de D e u s . R u a
Three blood cultures were positive for a gram-positive bacilli, 48 hours later identified as Erysipelothrix rhusiopathiae. E c h o -cardiogram with no evidence of vegetation, but showing left ventricular disfunction and aortic failure signs. Patient was treated for subacute bacterial endocarditis. The antibiotic used was penicillin G (18 millions units daily) for 30 days, associated with cefoxitin (6 gr. daily) for 28 days. Haemodinamic conditions deterio-rated, with signs of anemia but no fever. Aortic valve replacement was indicated. Surgery was performed on December 28. A metallic prothesis was implanted. Examination during surgery showed bicuspid aortic valve with vegetation and left coronary leaflet rupture. Right coronary leaflet was also impaired. Patient recovered well and was able to leave the hospital on January 14, 1988, performing his normal activities up to now.
M I C R O B I O L O G I C A L S T U D I E S Three blood cultures were collected and sent to Laboratório Bioclínico Mãe de Deus. After 24 hours, there was a growth of slender, curved and non-spore-forming gram-positive bacilli. Subculture in microaerofilic conditions showed a growth of colonies, 0.3 mm in diameter, non hemolytic in human blood^agar, resembling Streptococcus viridans on plates, and diphteroids, Listeria monocytogenes or
Lactobacillus, on gram-stained smears. The
absence of beta-hemolysis and catalase excluded Listeria. The diphteroids species are catalase-positive, except Corynebacterium haemolyticum, Corynebacterium pyogenes and E group. Characterization of E . rhusiopathiae was obtained by the production of hydrogen sulphide in the butt of a T S I agar. Identifica-tion was later confirmed at the Microbiology Laboratory of the Fundação Oswaldo Cruz, in Rio de Janeiro.
The organism was sensitive to penicillin G , ampicillin, cephalothin, cefoxitin, cefotaxime, lincomycin, erythromycin and tetracycline, but resistent to amikacin, gentamicin, tobramycin, kanamycin, fosfomicin, trimethoprim-sulfa-methoxazole, rifampicin and vancomycin revealed by Kirby-Bauer assay. Minimal inhibi-tory concentration of penicillin G was less than 0.1 mcg/ml.
D I S C U S S I O N
Erysipelothrix endocarditis was first described in animals in 1870. Kock was the first to isolate the organism in 1878 from the blood of m i c e7 1 3
E r y s i p e l o t h r i x rhusiopathiae is an organism that can be found in nature, in various animal species such as sea and fresh-water fish and crabs and in several mammals, such as swine. It can also survive in
the environment1 1. It has been noticed that,
under natural conditions, the organism survives for 12 days in direct sunlight, four months in petrified flesh and nine months in a buried carcass". In 1884 R O S E N B A C H first described the erysipela-like lesions of the human skin cau-sed by Erysipelothrix rhusiopathiae; hence, the skin disease is called erysipeloid of R O S E N
-B A C H2 5 2 7. Contact with contaminated animals
is the usual route of penetration, and therefore occupational contacts and cutaneous infections occur primarily among kitchen and slaughter-house workers, butchers, fishermen, poultry
workers, farmers and veterinarians1 3, generally
affecting hand or arms. Symptoms appear 2 to 7 days after contamination. Usually, violaceous skin lesions are present with an advancing pink border and clearing of skin
previously involved1 3. Absence of suppuration
and pitting distinguishes erysipeloid from other pyogenic cutaneous infections such as
staphylococcal or streptococcal cellulitis1 0 1 3.
The lesion is usually self-limiting, spontaneous recovery occuring generally in one to four
w e e k s4 7 1 0. Fever and articular pain are
common7. Positive cultures are rarely obtained
from material collected from swabs of a local lesion. Biopsies should be taken and cultured in glucose broth followed by subculture on blood
agar plates1 3. Only a few cases have been
studied h i s t o l o g i c a l l y . E . rhusiopathiae organisms are not demonstrable in skin biopsies
by the usual histologic staining techniques2.
The difuse cutaneous form is quite rare and involves progression from the original site of
innoculation2 2. Some cases with no evidence of
skin lesion have been postulated as infection by the oral route due to ingestion of infected
undercooked p o r k9 2 8. Evolution of the disease
to septicemia has been described as
r ar e 3 , 4 , 5 , 1 1 , 1 3 , 2 0 , 2 5 , 2 6 , 2 9 , 3 0 , 3 2 , 3 3 . This low frequency is
emphasized by its absence in 500 cases of hand
observed by G I L C H R I S T1 2 and 115 cases
observed by K I N G1 4. Whenever present,
septicemic infection is frequently associated with endocarditis. Systemic infection may be quite serious, being particularly destructive to
the heart v a l v e s2 5. O n l y 46 cases of
Erysipelothrix endocarditis have been described in medical literature since Gunther observed the first case in 1912. Most of the authors agree as
to the importance of predisposing factors5 such
as previous heart disease, congenital cardiac anomalies, alcoholism, poor nutrition and
diabetes4'5 1 9. Endocarditis can occur without
primary or secundary skin lesions1 3. Cutaneous
erysipeloid was present in only 50% of the
patients with endocarditis1 1. Clinical signs of
Erysipelothrix endocardits are undistinguish-able from those seen in other forms of bacterial endocardits1 9-2 5-3 3. Cerebral manifestations and
meningitis were observed in one c a s e3 0.
Hematuria has been noticed in some previously ieported cases2 0 3 1-3 3. As to gender, prevalence
of Erysipelothrix endocarditis is greater in male than in female patients (a 1:4 ratio). Patients ages range from 10 to 72 years old, predomi-nance being between the ages of 40 to 60 years o l d " . F R E L A N D1 1 mentioned the influence of
climate and seasons, observing that most of the cases occurred in temperate climates and that animal contamination was more frequent between the months of May and July, while human contamination occurred mostly between J u l y and O c t o b e r . Our patient was contaminated in October and developed endocarditis in November, spring months in Brazil, fall in the U S A and Europe. A l l previously reported cases occurred in the U S A or Europe, with four exceptions: 1 in New Zealand, 1 in Australia, 1 in Korea, 1 in Thailand.
All cases reported before 1945 were fatal. Use of hyperimmune serum was then the only
available treatment2 5. T h e discovery of
penicillin changed the history of the disease. From the 39 cases reported after the first documented cure with antibiotic therapy
( L A W E S , 1952)1% 17 died and 22 recovered.
Modern drug therapy prescribes the use of 12 to 24 million units of penicillin daily for four to
six weeks2 5. For penicillin-sensitive individuals,
erythromycin and clindamycin or lincomycin
offer an effective alternative3 1. Most authors
report that E . rhusiopathiae produces
alpha-hemolysis on blood agar. T A N O M S U P3 3 found
a non-hemolytic organism on sheep blood agar,
while N O R M A N N2 3 observed a slight
alpha-hemolysis on human blood agar. Our case was caused by alpha-hemolytic organism on sheep blood agar, non-hemolytic on human blood agar. For a correct identification of E . rhusiopathiae there must be an absence of beta-hemolysis and the presence of hydrogen
sulphide production in T S I agar. N O R M A N N2 3
observed hydrogen sulphide production in SIM medium.
E . rhusiopathiae is often dismissed as a skin contaminant when grown from blood culture'\ While not difficult to obtain through culture, it is not an easily-identifiable
organism6. Many physicians and laboratory
personnel are unfamiliar with it2 5. The increase
in its incidence after 1970 is probably due to the improvement of laboratorial techniques.
A L E X A N D E R1 raised the possibility that
Erysipelothrix septicaemia is essentially an opportunistic i n f e c t i o n . A l t h o u g h
F L I E G E L M A N1 0 finds that man is relatively
immune to it, we have never found any reports in medical literature discussing a case where E . rhusiopathiae had not caused a disease, nor have we heard about the isolation of E . rhusiopathiae in healthy individuals. It is our opinion that many cases might go undetected for lack of a correct microbiologic laboratorial d i a g n o s i s . We do not think that E . rhusiopathiae is difficult to identify. Its identification does not start in laboratory bottles, plates or computers but rather in the mind of the microbiologist.
R E S U M O
Endocardites por Erysipelothrix com Lesão Cutânea Prévia: Relato de um Caso e Revisão
da Literatura
Este relato descreve o primeiro caso docu-mentado de endocardite por E . rhusiopathiae na América Latina. O paciente tinha 51 anos de idade, era alcoólatra moderado, com uma his-tória prévia de insuficiência aórtica. Ele costu-mava pescar e cozinhar como hobby e feriu sua mão esquerda com uma espinha-de-peixe. A doença começou com a forma erisipelóide e evoluiu para septicemia e endocardite. Ele foi tratado com antibióticos e cirurgia para troca da válvula aórtica. Até hoje forma relatados
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