LETTERS

8. Aranaz A, Liebana E, Gomez-Mampaso E, Table. Results of deletion typing for Mycobacterium tuberculosis and M. bovis in goats, Nigeria* Galan JC, Cousins D, Ortega A, et al. My- cobacterium tuberculosis subsp. Caprae Region of difference M. tuberculosis M. bovis subsp. Nov.: a taxonomic study of a new RD1 + + member of the Mycobacterium tuberculo- RD4 + – sis complex isolated from goats in Spain. RD9 + – Int J Syst Bacteriol. 1999;49:1263–73. RD12 + – 9. Crawshaw T, Daniel R, Clifton-Hadley R, *+, present; –, absent. Clark J, Evans H, Rolfe S, et al. Tuber- culosis in goats caused by Mycobacterium with advanced TB may occur, given Author affi liations: University of Ibadan, bovis. Vet Rec. 2008;163:127. the endemic nature of TB in humans Ibadan, Nigeria (S.I. Cadmus, H. K. Adeso- 10. World Health Organization. Global tuber- culosis control: surveillance, planning, kan); University of Pretoria, Onderstepoort, in Nigeria (10). TB cases caused by fi nancing. Geneva: The Organization; EAI strains have been found in hu- Pretoria, South Africa (A.O. Jenkins); and 2008. p. 1–304 [cited 2008 Dec 14]. Avail- mans in southwestern Nigeria (4; S.I. National Institute for Public Health and the able from http://www.stoptb.org/events/ Cadmus et al., unpub. data), a fi nding Environment, Bilthoven, the Netherlands world_tb_day/2008/assets/documents/ WHO_2008_global_TB_report.pdf.) that supports zoonotic transmission of (D. van Soolingen) this organism from humans to goats. DOI: 10.3201/eid1512.090319 Address for correspondence: Simeon I. Cadmus, However, different lineages of M. tu- Department of Veterinary Public Health and berculosis may vary in host range, and Preventive Medicine, Faculty of Veterinary EAI genotype strains may be adapted References Medicine, University of Ibadan, Ibadan, Nigeria; to human and animal hosts. Converse- email: [email protected] ly, human-to-animal transmission of 1. Ojo SA. A survey of pathological condi- M. tuberculosis has been reported in tions in slaughtered goats at Zaria slaugh- Nigeria relative to infection in cattle ter houses. Small ruminant research and (3,4). Thus, confi rmation of TB in development in Africa. Proceedings of the Third Biennial Conference of the Af- goats supports the possibility of risk rican Small Ruminant Research Network– for TB transmission between humans UICC. Kampala, Uganda. 1994 Dec and animals in Nigeria. 5–9 [cited 2009 Feb 7]. Available from This study should be interpreted http://www.fao.org/documents/pub_dett. asp?pub_id=18823&iang=en suis in the context of its limitations. Be- 2. Cadmus SI, Atsanda NN, Oni SO, Akang , Hawaii cause the sources of the animals were EE. Bovine tuberculosis in one cattle herd unknown, we could not determine in Ibadan in Nigeria. Veterinárni Medici- To the Editor: Streptococcus whether the organisms were imported na. 2004;49:406–12. suis is a swine and zoonotic 3. Cadmus S, Palmer S, Okker M, Dale J, from a neighboring country (3). In ad- Gover K, Smith N, et al. Molecular analy- agent responsible for septicemia and dition, we lacked information on the sis of human and bovine tubercle meningitis (1). S. suis is in emergence breed and condition of the animals. from a local setting in Nigeria. J Clin Mi- in some Asian countries. Indeed, this However, we have identifi ed M. tu- crobiol. 2006;44:29–34. DOI: 10.1128/ pathogen has been described as the JCM.44.1.29-34.2006 berculosis and TB in goats in Nigeria. 4. Cadmus SI. Molecular characterization of most and second-most common cause Additional studies of other slaughter- human and bovine tubercle bacilli in Iba- of adult meningitis in Vietnam and houses in Nigeria are needed to con- dan, Nigeria [dissertation]. Ibadan (Nige- Thailand, respectively (2,3). Moreover, fi rm our results. ria): University of Ibadan; 2007. during an outbreak in People’s Repub- 5. Idrisu A, Schnurrenberger P. Public health signifi cance of bovine tuberculosis in four lic of China in 2005, 39 of 215 patients Acknowledgments northern states of Nigeria: a mycobacte- died from S. suis diseases (4). On the We thank the students at the abbatoir riologic study. Nigerian Journal of Medi- other hand, only 2 human S. suis cases cine. 1977;7:384–7. have been reported in the United States for assistance during meat inspection. 6. Warren RM, Gey van Pittius NC, Barnard M, Hesseling A, Engelke E, de Kock M, (5,6). Here, we describe a fi rst case of This study was supported by the Mac- et al. Differentiation of Mycobacterium human S. suis meningitis in Hawaii. Arthur Foundation/University of Ibadan, tuberculosis complex by PCR amplifi ca- The patient, a 34-year-old Ton- Nigeria. tion of genomic regions of difference. Int gan male with no medical history who J Tuberc Lung Dis. 2006;10:818–22. 7. Kamerbeek J, Schouls L, Kolk A, van worked as a coconut tree trimmer, Simeon I. Cadmus, Agterveld M, van Soolingen D, Kuijper was singing in his church choir when Hezekiah K. Adesokan, S, et al. Simultaneous detection and strain he developed an acute-onset, global Akinbowale O. Jenkins, differentiation of Mycobacterium tuber- headache and emesis. Upon hospital culosis for diagnosis and epidemiology. J and Dick van Soolingen Clin Microbiol. 1997;35:907–14. admission, he described a week of

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 12, December 2009 2067 LETTERS antecedent nonspecifi c symptoms for about swine contact. He described and mild-to-moderate bilateral hear- which he had taken nonsteroidal anti- slaughtering by hand several noncom- ing loss. He was readmitted; a repeat infl ammatory drugs without relief. mercially raised over the preced- lumbar puncture showed resolving On examination, he was afe- ing several weeks for a church-related CSF pleocytosis, and an MRI showed brile, tired-appearing but alert, and luau. The patient did not recall any that his prior radiographic fi ndings had with stable vital signs. He presented clear incident of mucosal exposure normalized. The symptoms, attributed mild meningismus and photophobia; to blood or secretions. The exact to residual meningeal/cerebral edema, no rash was observed. Blood tests route of S. suis infection for humans resolved quickly after the reintroduc- showed 27,600 leukocytes/μL with is not known. However, most cases tion of steroids. Audiometric testing 65% neutrophils; 168,000 platelets/ have been linked to accidental inocu- suggested mild sensorineural hearing μL; hemoglobin 17.3 g/dL; and crea- lation through skin injuries (1). The loss in the right ear. The patient com- tinine 1.4 mg/dL. A computed tomog- patient did not wear gloves, masks, or pleted the remainder of his intravenous raphy scan of the head was read as any other protective equipment dur- ceftriaxone course and was discharged showing substantial motion artifact ing the prolonged process of butcher- on a 2-week course of amoxicillin and and a possible cerebral mass. Nuclear ing the pigs, and his exposure to pig oral steroids. magnetic resonance imaging (MRI) blood, skin, and internal organs was He was again admitted 2 days of the head showed no mass, but T2- extensive. He sustained multiple small after completing treatment, with dis- weighted images (postgadolinium) cuts on his hands during butchering. abling dizziness. On exam he showed suggested both increased grey/white No other church members who par- new torsional nystagmus, more pro- matter contrast consistent with dif- ticipated in preparing pigs for the luau nounced with left lateral gaze, consis- fuse cortical edema, and vascular became ill. tent with a right peripheral vestibul- congestion/infl ammation of the sulci. The patient was treated with cef- opathy. An MRI of the head was again Cerebrospinal fl uid (CSF) ob- triaxone and a 4-day course of dex- normal. Oral dexamethasone promptly tained from a lumbar puncture had amathasone. His headache and menin- resolved his vestibulopathy, and the 2,770 leukocytes/μL with 94% neu- gismus improved progressively, and he patient was discharged on a slow ste- trophils; glucose 30 mg/dL; and pro- was discharged after 6 days to complete roid taper. After a month, dexametha- tein 230 mg/L. A Gram stain of the a 2-week course of intravenous ceftri- sone was discontinued. The patient CSF showed numerous gram-positive axone. However, 1 day after discharge, has been asymptomatic since, and his cocci, mostly in pairs and short chains the patient complained of headaches hearing loss has resolved fully. (Figure). Empiric intravenous therapy with dexamethasone, vancomycin, and ceftriaxone was administered for possible pneumococcal meningitis. Blood cultures grew a Strepto- coccus species, later identifi ed by 16S rRNA gene sequencing as being S. suis, sensitive to , vanco- mycin, and ceftriaxone. The isolate was assigned to serotype 2 by the coagglutination test (7) and shown by Western blot to produce suilysin, extracellular protein factor and mu- ramidase-released protein, which are virulence markers often associated with highly virulent strains of Eur- asian, but not North American, origin (1,8). A strain of this phenotype was responsible for a previous US S. suis meningitis case, but the patient had been infected in the Philippines (5; unpub. data). Figure. Gram-positive cocci, mostly in pairs and short chains, found in cerebrospinal fl uid Upon identifi cation of the S. suis from a 34-year-old man with Streptococcus suis meningitis. The sample was not centrifuged isolate, the patient was questioned before staining. Original magnifi cation ×1,000.

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The role of steroids in treating 3. Suankratay C, Intalapaporn P, Nun- Chorioamnionitis patients with S. suis infection remains thapisud P, Arunyingmongkol K, Wilde H. Streptococcus suis meningitis in Thai- and Neonatal unclear, although this case illustrates land. Southeast Asian J Trop Med Public that the infl ammation associated with Health. 2004;35:868–76. from this infection can be profound and 4. Yu H, Jing H, Chen Z, Zheng H, Zhu X, Community- can require prolonged steroid therapy. Wang H, et al. Human Streptococcus suis outbreak, Sichuan, China. Emerg Infect associated MRSA Since at least 2 cases of relapse have Dis. 2006;12:914–20. been reported after 2 and 4 weeks 5. Lee GT, Chiu CY, Haller BL, Denn PM, To the Editor: Chorioamnionitis of treatment (1), prolonged therapy Hall CS, Gerberding JL. Streptococcus is a common cause of maternal and should be considered for infections suis meningitis, United States. Emerg In- fect Dis. 2008;14:183–5. DOI: 10.3201/ neonatal illness and death (1), but cho- caused by this pathogen. Hearing loss eid1401.070930 rioamnionitis attributed to Staphylo- from S. suis meningitis occurs fre- 6. Willenburg KS, Sentochnik DE, Za- coccus aureus, including methicillin- quently and can be irreversible (1). doks RN. Human Streptococcus suis resistant S. aureus (MRSA), is reported Hawaii’s swine industry is character- meningitis in the United States. N Engl J Med. 2006;354:1325. DOI: 10.1056/ infrequently (2–5). In the context of ized by small herds and a high degree NEJMc053089 the rising incidence of community- of concentration (9). This case of 7. Higgins R, Gottschalk M. An update on associated MRSA (CA-MRSA) infec- human S. suis meningitis in Hawaii Streptococcus suis identifi cation. J Vet Di- tions (6), we report an apparent case of emphasizes the need for these data agn Invest. 1990;2:249–52. 8. Vecht U, Wisselink HJ, Jellema ML, Smith CA-MRSA chorioamnionitis. to be generated and made available. HE. Identifi cation of two proteins associ- The patient, a 31-year-old woman Indeed, this bacterium is increasingly ated with virulence of Streptococcus suis with polycystic ovary syndrome and recognized as a signifi cant zoonotic type 2. Infect Immun. 1991;59:3156–62. hypothyroidism, had 1 prior preg- agent in Asia; although it remains a 9. Sharma K, Leung PS, Zaleski H. Econom- ic analysis of size and feed type of swine nancy but no viable offspring. After a relatively rare cause of human infec- production in Hawaii. Swine Health and clomiphene-assisted conception, rou- tion elsewhere, persons in close oc- Production. 1997;5:103–10. tine ultrasound at 21 weeks’ gestation cupational contact with pigs or pork identifi ed a shortened cervix (5 mm). products are at higher risk than others Address for correspondence: Nahuel The patient declined amniocentesis (1). Increasing awareness of this dis- Fittipaldi, Universite de Montreal–GREMIP for cerclage and was treated with pel- ease is expected to help counter hu- 3200, rue Sicotte CP5000, St-Hyacinthe, Quebec, vic rest and vaginal progesterone. Five man S. suis infections. Canada; email: n.fi [email protected] days later, she arrived at the emergency department with foul-smelling vaginal Nahuel Fittipaldi, Tarquin Collis, discharge. At this time, the patient was Bryscen Prothero, afebrile and hemodynamically stable, and Marcelo Gottschalk Letters had no abdominal pain, and had a leu- Author affi liations: Université de Montréal, Letters commenting on recent articles kocyte count of 9.5 × 103 cells/mm3. St-Hyacinthe, Quebec, Canada (N. Fitti- as well as letters reporting cases, out- Premature rupture of membranes paldi, M. Gottschalk); and Kaiser Moanalua breaks, or original research are wel- was diagnosed, and the patient was Hospital, Honolulu, Hawaii, USA (T. Collis, come. Letters commenting on articles admitted and administered intrave- B. Prothero) should contain no more than 300 nous ampicillin and azithromycin. DOI: 10.3201/eid1512.090825 words and 5 references; they are more Nine days into treatment, at 23 weeks’ likely to be published if submitted gestation, 210 hours after membrane References rupture, a 415-g live-born girl was within 4 weeks of the original article’s delivered spontaneously in footling 1. Gottschalk M, Segura M, Xu J. Strep- publication. Letters reporting cases, breech with Apgar scores of 1 (1 min) tococcus suis infections in humans: outbreaks, or original research should the Chinese experience and the situ- and 5 (5 min). During admission, the ation in North America. Anim Health contain no more than 800 words mother was never febrile and did not Res Rev. 2007;8:29–45. DOI: 10.1017/ and 10 references. They may have 1 complain of abdominal tenderness or S1466252307001247 chills. The highest leukocyte count 2. Mai NT, Hoa NT, Nga TV, Linh LD, Figure or Table and should not be di- was 12.4 × 103 cells/mm3. The mother Chau TT, Sinh DX, et al. Streptococ- vided into sections. All letters should cus suis meningitis in adults in Vietnam. was discharged the day after deliv- Clin Infect Dis. 2008;46:659–67. DOI: contain material not previously pub- ery without further complications. At 10.1086/527385 lished and include a word count. 6-week follow-up, she remained well, with no signs of infection.

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