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Zoonotic Chlamydia Caviae Presenting As Community-Acquired Pneumonia

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Zoonotic Chlamydia Caviae Presenting As Community-Acquired Pneumonia The new england journal of medicine Correspondence Zoonotic Chlamydia caviae Presenting as Community-Acquired Pneumonia To the Editor: Chlamydia caviae is a member of national surveillance system for psittacosis, in the family of gram-negative intracellular bacteria which samples identified as positive in a poly- Chlamydiaceae. Bacteria of this family cause a merase-chain-reaction assay are genotyped by broad spectrum of diseases in animals and hu- sequencing a part of the gene that encodes the mans and are currently subdivided into a single outer membrane protein A, ompA5 (details are genus and 11 species.1 Among these species, provided in Sections S2 and S3 in the Supple- C. psittaci and C. abortus are known for their zoo- mentary Appendix). In one patient, chlamydia notic potential, causing psittacosis and abortion, seroconversion was detected by means of com- respectively, in humans.2,3 In contrast, only one plement fixation, which revealed an increase in case of mild conjunctivitis has previously been the antibody titer by a factor of 4 (see Section S3 documented in association with C. caviae.4 in the Supplementary Appendix for details). No We describe three unrelated cases of infec- other causes of community-acquired pneumonia tion in otherwise healthy adults in their early were found (see Section S4 in the Supplementary 30s who had respiratory failure caused by severe Appendix). Although different antibiotic regimens community-acquired pneumonia (see chest radio- were used to treat the patients, in accordance graphs in Section S1 of the Supplementary Ap- with local protocols (Table 1), all three patients pendix, available with the full text of this letter recovered after being treated with doxycycline. at NEJM.org) after exposure to ill guinea pigs One of the guinea pigs owned by Patient 2 (Table 1). The three cases, which appeared over showed signs of respiratory illness before com- a period of approximately 3 years, occurred in munity-acquired pneumonia developed in the persons from different families, at different hos- patient. C. caviae was isolated from a conjunctival pitals, and in different geographic areas. Two pa- swab. To confirm transmission between this tients were treated with mechanical ventilation guinea pig and its keeper, we performed a tandem in the intensive care unit for several days. repeat analysis and sequenced the ompA coding Chlamydia DNA was detected in specimens region in a sample of the patient’s bronchoalveo- obtained from the respiratory tract, serum, or lar lavage fluid (GenBank accession numbers, both in all three patients, and the species was KY777669 and KY777670), the guinea pig isolate identified as C. caviae by means of the Dutch (GenBank numbers, KY777661 and KY777662), and several samples from other C. caviae strains this week’s letters (GenBank numbers, KY777663–KY777668). The sequences of ompA and the single variable- 992 Zoonotic Chlamydia caviae Presenting number tandem-repeat (VNTR) region that were as Community-Acquired Pneumonia identified (from among 27 potential VNTRs) were identical in the bronchoalveolar lavage 994 Early, Goal-Directed Therapy for Septic Shock fluid from the patient and her guinea pig and — A Patient-Level Meta-Analysis different from the C. caviae reference strain GPIC 996 Buprenorphine for the Neonatal Abstinence (GenBank accession number, AE015925; details Syndrome are provided in Sections S5 through S10 in the Supplementary Appendix). This finding is in line n engl j med 377;10 nejm.org September 7, 2017 The New England Journal of Medicine Downloaded from nejm.org at ZIEKENHUIS BERNHOVEN on September 6, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved. Table 1. Patient Data and Findings.* Characteristics Patient 1 Patient 2 Patient 3 Before hospitalization Appearance of symptoms February 2013 September 2014 September 2015 Age (yr) 32 31 34 Sex Male Female Female Medical history Unremarkable Traumatic epidural hematoma (in 1991), post- Fibromyalgia traumatic stress disorder, and obesity Clinical signs Fever, malaise, coughing, headache, myalgia Fever, coughing, shortness of breath, myalgia Fever, headache, drowsiness, nausea, vomiting, abdominal pain n engljmed Treatment No response to amoxicillin–clavulanic acid plus No response to amoxicillin–clavulanic acid plus No treatment NSAIDs, prescribed by general practitioner NSAIDs, prescribed by general practitioner Diagnosis Pneumonia and severe respiratory insufficiency; Pneumonia and severe respiratory insufficiency; Pneumonia; hospitalization needed hospitalization needed hospitalization needed 377;10 During hospitalization Correspondence Clinical situation ICU admission, mechanical ventilation ICU admission, mechanical ventilation Admission to general ward nejm.org Laboratory findings C-reactive protein (mg/liter) 485 379 212 Reference range at local hospital ≤8 ≤8 ≤5 3 September 7,2017 White-cell count (per mm ) 13,300 3600 NA Reference range at local hospital 4000–10,000 4000–10,000 Sodium (mmol/liter) 131 NA NA Reference range at local hospital 135–145 NA Alkaline phosphatase (U/liter) NA 294 171 Reference range at local hospital 33–98 0–120 Alanine aminotransferase (IU/liter) NA NA 43 Reference range at local hospital <35 γ-Glutamyltransferase (U/liter) NA 111 NA Reference range at local hospital <38 Lactate dehydrogenase (U/liter) NA 420 NA Reference range at local hospital <247 Diagnostic measures Radiography and examination of bronchoalveolar- Radiography and examination of bronchoalveolar- Radiography and sputum smear followed lavage fluid followed by positive PCR assay for lavage fluid followed by positive PCR assay for by positive PCR assay for C. psittaci; Chlamydia psittaci; further typing revealed C. caviae C. psittaci; further typing revealed C. caviae further typing revealed C. caviae Treatment Ceftriaxone plus ciprofloxacin, followed by ceftri- Penicillin plus ciprofloxacin, followed by doxy- Amoxicillin plus ciprofloxacin, followed axone plus doxycycline, followed by meropen- cycline plus ciprofloxacin by doxycycline em plus doxycycline Additional anamnesis 2 Guinea pigs at home that had respiratory symp- 25 Guinea pigs at home that had respiratory Guinea pigs with conjunctivitis and rhinitis toms before development of patient’s commu- symptoms before development of patient’s and a dyspnoeic, indolent wild rabbit at nity-acquired pneumonia community-acquired pneumonia workplace (a veterinary clinic) * ICU denotes intensive care unit, NA not Theavailable, New EnglandNSAIDs Journalnonsteroidal of Medicine antiinflammatory drugs, and PCR polymerase chain reaction. Downloaded from nejm.org at ZIEKENHUIS BERNHOVEN on September 6, 2017. For personal use only. No other uses without permission. Copyright © 2017 Massachusetts Medical Society. All rights reserved. The new england journal of medicine with a C. caviae transmission event, although the Mauro De Rosa, M.D. molecular features described (see Sections S8 Dutch Food and Health Authority (NVWA) through S10 in the Supplementary Appendix) Utrecht, the Netherlands were not unique but were shared with two Ger- Hendrik I.J. Roest, D.V.M., Ph.D. man C. caviae strains. Wageningen Bioveterinary Research Altogether, the data imply that the transmission Lelystad, the Netherlands of C. caviae from guinea pig to human in these Daisy Vanrompay, Ph.D. cases resulted in severe community-acquired pneu- Ghent University monia. Both veterinarians and physicians should Ghent, Belgium be aware of the zoonotic potential of C. caviae. Edou R. Heddema, M.D., Ph.D. Although the extent to which C. caviae actually Zuyderland Medical Center contributes to community-acquired pneumonia is Sittard-Geleen, the Netherlands unclear, awareness may help to clarify this issue. Peter Schneeberger, M.D., Ph.D. Mirjam H.A. Hermans, Ph.D. Bart P. Ramakers, M.D., Ph.D. Jeroen Bosch Hospital Bernhoven Den Bosch, the Netherlands Uden, the Netherlands Drs. Ramakers and Heijne contributed equally to this letter. Marloes Heijne, D.V.M. Supported by a grant from the Dutch Ministry of Health, Wel- Wageningen Bioveterinary Research fare, and Sport through the National Institute for Public Health Lelystad, the Netherlands and the Environment, Bilthoven, the Netherlands (3910014586). [email protected] Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. Natascha Lie, M.D. Zuyderland Medical Center 1. Sachse K, Bavoil PM, Kaltenboeck B, et al. Emendation of the Heerlen, the Netherlands family Chlamydiaceae: proposal of a single genus, Chlamydia, to include all currently recognized species. Syst Appl Microbiol 2015; Thuy-Nga Le, M.D. 38: 99-103. 2. Pospischil A, Thoma R, Hilbe M, Grest P, Zimmermann D, Gelderse Vallei Hospital Gebbers JO. Abortion in humans caused by Chlamydophila Ede, the Netherlands abortus (Chlamydia psittaci serovar 1). Schweiz Arch Tierheilkd Monique van Vliet, M.D. 2002; 144: 463-6. (In German.) 3. Beeckman DS, Vanrompay DC. Zoonotic Chlamydophila Zuyderland Medical Center psittaci infections from a clinical perspective. Clin Microbiol Heerlen, the Netherlands Infect 2009; 15: 11-7. Vivian P.J. Claessen, M.D. 4. Lutz-Wohlgroth L, Becker A, Brugnera E, et al. Chlamydiales in guinea-pigs and their zoonotic potential. J Vet Med A Physiol Municipal Health Service South Limburg Pathol Clin Med 2006; 53: 185-93. Geleen, the Netherlands 5. Heddema ER, van Hannen EJ, Bongaerts M, et al. Typing of Chlamydia psittaci to monitor epidemiology
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