JOURNAL OF CLINICAL , Aug. 1983, p. 436-437 Vol. 18, No. 2 0095-1137/83/080436-02$02.OO/O Copyright ) 1983, American Society for Microbiology

Septicemia Due to a Maltose-Positive, Glucose-Negative Strain of Group C meningitidis

CHATRCHAI WATANAKUNAKORNl.2* AND RICHARD B. THOMSON, JR.23 Infectious Disease Section, St. Elizabeth Hospital Medical Center, Youngstown, Ohio 445011*; Section of Clinical Microbiology, Akron City Hospital, Akron, Ohio 443093; and Northeastern Ohio Universities College ofMedicine, Rootstown, Ohio 442722 Received 15 November 1982/Accepted 29 April 1983

A glucose-negative, maltose-positive strain of group C was isolated from the blood of a 63-year-old man. Interestingly, maltose degrada- tion was detected by radiometric methods but not by growth methods.

Neisseria meningitidis is an aerobic, gram- 4 days, the penicillin G therapy was changed to negative coccus which produces catalase and oral 500 mg of penicillin orally every 6 h. The cytochrome-oxidase, does not produce DNase, patient did well and was discharged on hospital and generally produces acid from glucose and day 12. maltose (1, 6). Meningococci cause a variety of The gram-negative diplococcus was identified infections, including meningitis and meningo- as Neisseria meningitidis group C by usual labo- coccemia. We describe here a 63-year-old man ratory methods (6). The characteristics of this with meningococcemia caused by a group C N. isolate are listed in Table 1. Initial testing oc- meningitidis which did not degrade glucose or curred after approximately 3 subcultures on maltose by growth methods but did degrade blood agar, and repeat testing was done after maltose by a radiometric nongrowth method. approximately 10 subcultures on blood and The isolate agglutinated in group C meningococ- chocolate agars. Smooth, moist colonies typical cal antisera. of meningococci were repeatedly tested with A 63-year-old man presented to the hospital both cystine-Trypticase agar (two separate lots; with the chief complaints of vomiting and chills BBL Microbiology Systems, Cockeysville, Md.) followed by fever. He denied cough or chest and radiometric methods with consistent results. pain. On examination, he had a temperature of The identification and biochemical characteris- 40.5°C, a blood pressure of 144/70 mmHg, a tics were confirmed by the Section of Clinical pulse of 110/min, and a respiration rate of Microbiology, Mayo Clinic, Rochester, Minn. 26/min. His neck was supple. There were rales The isolate was susceptible to ampicillin, peni- over the lower half of both lung fields and a cillin, tetracycline, cephalothin, chlorampheni- grade 1/6 systolic ejection murmur at the left col, and erythromycin; intermediately resistant sternal border and apex. There was marked to nafcillin; and resistant to clindamycin and ankle edema. He also had mild diabetes mellitus. vancomycin by standard disk diffusion suscepti- Results of pertinent laboratory tests included a bility tests (7). hemoglobin level of 13.8 g/dl; hematocrit 40.7%; This aberrant group C N. meningitidis strain erythrocyte count of 5.11 x 106/mm3; leukocyte could easily have been misidentified. We initial- count of 6,800/mm3, with 88% neutrophils, 1% ly thought it was Branhamella catarrhalis be- stab forms, 10% lymphocytes, and 1% mono- cause of the negative carbohydrate degradation cytes; and an erythrocyte sedimentation rate of tests (growth method). Our experience suggests 35 mm/h. Two blood cultures were obtained. that the DNase test should be used to differenti- The patient was given 500 mg of erythromycin ate B. catarrhalis from Neisseria spp., and me- intravenously every 6 h. The next day he was ningococcal antisera is necessary to definitively much better, being afebrile by afternoon, and identify biochemically aberrant strains. remained so throughout his hospital course. On Instances of biochemically unusual meningo- hospital day 3, the laboratory reported that cocci have been reported. Lactose-fermenting gram-negative diplococci were growing in both group B (5), maltose-negative (4), and glucose- of the blood cultures. Erythromycin was discon- negative (3) N. meningitidis isolates have been tinued, and therapy with 4 x 106 U of penicillin described. More recently, clinical isolates of G intravenously every 4 h was started. A lumbar maltose-negative group Y (2) and glucose-nega- puncture showed normal cerebrospinal fluid tive group B (8) meningococci have been report- findings. There was no growth on culture. After ed. Our isolate is unique in that it is only the 436 VOL. 18, 1983 NOTES 437 TABLE 1. Characteristics of Neisseria meningitidis Kingsbury (4), in reviewing sulfadiazine-re- isolated from blood of a patient sistant, maltose-negative N. meningitidis, dis- Test Reaction cussed the enzymology of maltose utilization by this species. Once in the cell, maltose is split by Gram stain...... Gram-negative maltose phosphorylase, and the resulting prod- diplococci ucts, glucose-i-phosphate and free glucose, are Oxidase ...... + further degraded in the same manner as added glucose. This finding suggests that our aberrant Growth strain was unable to transport glucose into the Chocolate agar ...... + cell but could transport small amounts of malt- Blood agar...... + ose. Thayer-Martin agar ...... + In conclusion, biochemically atypical menin- . gococci are encountered in clinical laboratories 220C ...... Poor With 5% CO2 ...... + and are capable of causing disease, as illustrated Without CO2 ...... + in our example of a 63-year-old man with sepsis. Identification requires careful interpretation of Carbohydrate degradation carbohydrate utilization tests, inclusion of a Growth methoda DNase test to differentiate B. catarrhalis, and Glucose . use of grouping antisera to definitively identify Maltose . N. meningitidis. Sucrose . Nongrowth methodb Glucose . We thank Rebecca A. Burgoon, Akron City Hospital, for Maltose ...... + technical help. Sucrose . ONPGC ...... LITERATURE CITED Nitrate reduction ...... 1. Buchanan, R. E., and N. E. Gibbons (ed.). 1974. Bergey's manual of determinative bacteriology, 8th ed. The Williams DNase ...... & Wilkins Co., Baltimore. 2. Granato, P. A., R. Howard, B. Wilkhison, and J. Laser. ,-Lactamase (nitrocefin) ...... 1980. Meningitis caused by maltose-negative variant of Neisseria meningitidis. J. Clin. Microbiol. 11:270-273. 3. Jyssum, K., and S. Jyssum. 1968. of variants with ...... C Groupingd Group increased mutability from Neisseria meningitidis. Acta a Growth method used, cystine-Trypticase agar Pathol. Microbiol. Scand. 74:93-100. 4. Kingsbury, D. T. 1967. Relationship between sulfadiazine (BBL Microbiology Systems). resistance and the failure to ferment maltose in Neisseria b Nongrowth method used, radiometric (Bactec meningitidis. J. Bacteriol. 94:557-561. model 460; Johnston Laboratories, Inc., Cockeyes- 5. Mitchell, M. S., D. L. Rhoden, and E. 0. King. 1965. ville, Md.). Lactose-fermenting organisms resembling Neisseria men- c ONPG, o-Nitrophenyl-(3-D-galactopyranoside. ingitidis. J. Bacteriol. 90:560. dN. meningitidis antisera, Difco Laboratories, De- 6. Morello, J. A., and M. Bohnhoff. 1980. Neisseria and troit, Mich. Branhamella, p. 111-130. In E. H. Lennette, A. Balows, W. J. Hausler, Jr., and J. P. Truant (ed.), Manual of clinical microbiology, 3rd ed. American Society for Micro- biology, Washington, D.C. second glucose-negative clinical isolate reported 7. National Commitee for Clinical Laboratory Standards. and has the additional property of being maltose 1979. Approved standard M2-A2. Performance standards negative by growth methods and maltose posi- for antimicrobic disc susceptibility tests, 2nd ed. National tive by radiometric nongrowth methods. The Committee for Clinical Laboratory Standards, Villanova, Pa. radiometric procedure is stated to be more sensi- 8. Uyeda, C. T., M. M. Maruyama, and M. S. Hakes. 1980. tive than the cystine-Trypticase agar technique Aberrant strain of group B Neisseria meningitidis. J. Clin. (6). Our report supports this conclusion. Microbiol. 12:286-287.