LETTERS

Patrick J. Kelly,* Natalie Meads,* Enterohemorrhagic phenotypically confirmed cytotoxici- Anita Theobald,* ty of these isolates, with most of them Pierre-Edouard Fournier,† Escherichia coli being seroneutralized by rabbit antis- and Didier Raoult† O157, Kinshasa era against Shiga toxin (3). Thus, all *Massey University, Palmerston North, E. coli isolates responded to the defi- New Zealand; and †Faculté de Médecine, To the Editor: During the rainy nition of enterohemorrhagic E. coli. Marseille, France season, from April to September ≤ Before 2003, sporadic infections 2003, 463 children 15 years of age or outbreaks caused by enterohemor- References (median 10 months) with severe rhagic E. coli were not reported as a diarrhea were admitted to the 1. Rolain JM, Franc M, Davoust B, Raoult D. cause of bloody diarrhea in the Molecular detection of Bartonella quin- Pediatric Hospital of Kalembelembe Democratic Republic of Congo. A tana, B. koehlerae, B. henselae, B. clar- in Kinshasa, the capital of the case-control study could not be per- ridgeiae, Rickettsia felis, and Wolbachia Democratic Republic of Congo. The formed because of political unrest in pipientis in cat fleas, France. Emerg Infect population of the outbreak area was Dis 2003;9:338–42. Kinshasa. Although reported out- 2. Roux V, Raoult D. Inter- and intraspecies approximately one million. breaks of E. coli O157 in sub-Saharan identification of Bartonella (Rochalimaea) Several children with bloody Africa have been few to date, avail- species. J Clin Microbiol 1995;33:1573–9. diarrhea without fever were treated. able information indicates that the 3. Fournier PE, Roux V, Raoult D. They came from six districts of Phylogenetic analysis of spotted fever pathogen has wide geographic distri- group rickettsiae by study of the outer sur- Kinshasa (Bumbu, Selembao, bution. E. coli O157–related diarrhea face protein rOmpA. Int J Syst Bacteriol Makala, Kimbanseke, Masina, and outbreaks that occurred before 2003 1998;48:839–49. Ndjili). Abdominal cramps, nausea, have been reported in South Africa, 4. Schriefer ME, Sacci JB Jr., Dumler JS, vomiting, and dehydration were Bullen MG, Azad AF. Identification of a Swaziland (4), and Malawi (5) in novel rickettsial infection in a patient diag- uncommon. The duration of illness 1992; Central African Republic (6) nosed with murine typhus. J Clin Microbiol ranged from 5 days to 2 weeks. and Kenya (7) in 1996; Cameroon in 1994;32:949–54. Available antiparasitic drugs, 1998 (8); and Nigeria (9) and Ivory 5. Richter J, Fournier PE, Petridou J, trimethoprim-sulfamethoxazole, and Haussinger D, Raoult D. Rickettsia felis Coast (10) in 2000. In the Central infection acquired in Europe and docu- ampicillin showed no effect against African Republic and in Zémio, a mented by polymerase chain reaction. the illness. Fifty-six infants died small village located on the Emerg Infect Dis 2002;8:207–8. between June and July. Symptoms of Democratic Republic of Congo bor- 6. Raoult D, La Scola B, Enea M, Fournier hemolytic uremic syndrome deve- PE, Roux V, Fenollar F, et al. A flea-associ- der, outbreaks of bloody diarrhea in ated Rickettsia pathogenic for humans. loped in most of them. 1996 were attributed to E. coli O157 Emerg Infect Dis 2001;7:73–81. Stool samples from 32 patients from molecular test results (6). 7. Joseph AK, Wood CW, Robson JM, Paul were screened for parasites, Since 2001, an increasing number SL, Morris AJ. Bartonella henselae bac- enteropathogenic bacteria, rotavirus, teremia in domestic cats from Auckland. N of cases of acute bloody diarrhea have Z Vet J 1997;45:185–7. and adenovirus. Three samples were been reported in Kinshasa between 8. Dai S, Best S, St John M. Bartonella hense- positive for rotavirus. In contrast, all June and August. During this 2003 lae neuroretinitis in cat scratch disease. N Z stool cultures were positive for outbreak, an investigation could not Med J 2001;114:360–1. Escherichia coli which always grew 9. Gillespie TN, Washabau RJ, Goldschmidt be conducted; possible routes of MH, Cullen JM, Rogala AR, Breitschwerdt as pure cultures on purple bromocre- transmission would include person- EB. Detection of Bartonella henselae and sol agar, a nonselective medium con- to-person contact related to lack of Bartonella clarridgeiae DNA in hepatic taining lactose. The E. coli isolates hygiene, and contaminated food and specimens from two dogs with hepatic dis- appeared sorbitol negative when test- ease. J Am Vet Med Assoc 2003;222:47–51. water. 10. Chomel BB, Carlos ET, Kasten RW, ed on MacConkey sorbitol; they were In 1996 in the Central African Yamamoto K, Chang CC, Carlos RS, et al. agglutinated by O157 and H7 antisera Republic and in 1998 in Cameroon, Bartonella henselae and Bartonella clar- (Difco Laboratories, Detroit, MI) and the major contributing factors of the ridgeiae infection in domestic cats from the lacked expression of β-glucuronidase. Philippines. Am J Trop Med Hyg E. coli O157 outbreak were consump- 1999;60:593–7. All E. coli isolates were sent to the tion of smoked zebu meat and con- Pasteur Institute in Bangui, Central taminated drinking water. Studies of Address for correspondence: Patrick Kelly, African Republic, for further charac- E. coli O157 carriage rates among Institute of Veterinary, Animal and Biomedical terization. Polymerase chain reaction livestock, food, and environment in Sciences, Massey University, Private Bag 11 allowed detection of Shiga-like toxin this central African area might be use- 222, Palmerston North, New Zealand; fax: 64- slt-1 and slt-2 genes (1,2) in isolates ful in assessing the potential for future 6- 350-5616; email: [email protected] from all patients. The Vero cell assay outbreaks.

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Hemolytic uremic syndrome occurs 7. Sang WK, Saidi SM, Yamamoto H, Ezaki stated that 2 days after the therapy, a in approximately 8% of children and T, Iida T, Yoh M, et al. Haemorrhagic colitis fever developed; it persisted for sev- due to Escherichia coli O157:H7 in Kenya. an unknown proportion of adults J Trop Pediatr 1996;42:118–9. eral days, along with redness at the infected with E. coli O157 and can be 8. Germani Y, Cunin P, Tedjouka E, Ncharre inoculation sites, which gradually fatal without hemodialysis. The high C, Morvan J, Martin P. Enterohaemorrhagic developed into nodules. death rate of infants during this out- Escherichia coli in Ngoïla (Cameroon) dur- Standard staining of a biopsied ing an outbreak of bloody diarrhoea. Lancet break was linked to the lack of treat- 1998;352:625–6. specimen from the lesion site was ment (mainly hemodialysis) at the 9. Olorunshola ID, Smith SI, Cker AO. negative for bacteria, fungi, and beginning of the epidemic. Prevalence of EHEC O157:H7 in patients mycobacteria. A histopathologic Obviously, more work is needed to with diarrhoea in Lagos, Nigeria. APMIS examination of a biopsy specimen 2000;108:761–3. better define the incidence and epi- 10. Dadie A, Karou T, Adom N, Kette A, Dosso showed an unspecific granulomatous demiology of E. coli–associated diar- M. Isolation of enteric pathogenic agents in infiltrate. Culture for common bacte- rhea in the Democratic Republic of Côte d’Ivoire: Escherichia coli O157:H7 ria and fungi was negative, but culture Congo so that optimal recommenda- and enteroaggregative E. coli. Bull Soc of a sterile nodule aspirate on tions for preventing and managing ill- Pathol Exot 2000;93:95–6. Lowenstein-Jensen medium was posi- ness can be developed. tive for acid-fast bacteria after 5 Address for correspondence: Yves Germani, weeks. By using restriction endonu- Institut Pasteur, Unité Pathogénie Microbienne Louis Koyange,* Gaelle Ollivier,† clease analysis of the 65-kDa heat Moléculaire and Réseau International des Jean-Jacques Muyembe,* shock protein gene (1), we found that Instituts Pasteur, 25–28 rue du Dr Roux, 75724, Benoit Kebela,‡ Malika Gouali,§ the isolate showed a pattern compati- Paris Cédex 15, France; fax: 00 33 1 45 68 89 and Yves Germani¶ ble with Mycobacterium simiae. 52; email: [email protected] *Institut National de la Recherche Identification was subsequently con- Biomédicale, Kinshasa Gombe, Democratic firmed by high performance liquid Republic of Congo; †Ambassade de France, Kinshasa Gombe, Democratic chromatography of mycolic acids at Republic of Congo; ‡Ministère de la Santé, the Centers for Disease Control and Kinshasa Gombe, Democratic Republic of Prevention, Atlanta, Georgia. The iso- Congo; §Institut Pasteur de Bangui, Bangui, Iatrogenic late was tested for drug susceptibility Central African Republic; and ¶Institut against a panel of drugs and found to Pasteur, Paris, France Mycobacterium be resistant to most drugs tested simiae Skin (streptomycin, isoniazid, rifampin, References Infection in an ethambutol, ethionamide, rifabutin, 1. Pollard DR, Jonhson WM, Lior H, Tyser Immunocompetent ciprofloxacin, kanamycin, capre- SD, Rozee R. Rapid and specific detection omycin, p-aminosalicylic acid, of verotoxin genes in Escherichia coli by Patient the polymerase chain reaction. J Clin ofloxacin, and amikacin) and suscep- Microbiol 1990; 28:540–5. To the Editor: We report a case of tible to clarithromycin at an MIC of 1 2. Tyler SD, Jonhson WM, Lior H, Rozee R. a 36-year-old woman who sought µg/mL. Treatment with clar- Identification of verotoxin type 2 variant B treatment for 45 firm and erythema- ithromycin was started, and the gran- subunit genes in Escherichia coli by the polymerase chain reaction and restriction tous nodular lesions on her face and ulomas slowly cleared after 9 months fragment length polymorphism analysis. J neck. A physical examination showed of treatment. Clin Microbiol 1991;29:1339–43. no other abnormalities. Results of a To our knowledge, this is the first 3. Germani Y, Bégaud E, Desperrier JM. chest x-ray and routine laboratory reported case of an iatrogenic skin Easy-to-perform modified Elek test to iden- tify Shiga-like toxin–producing diar- tests were normal. The patient tested infection caused by M. simiae in an rhoeogenic Escherichia coli. Res Microbiol negative for hepatitis B and HIV. immunocompetent person. M. simiae 1994;145:333–40. Three weeks before she sought treat- is a species of nontuberculous 4. Isaäcson M, Canter PH, Effler P, Arntzen L, ment, the patient reported receiving mycobacterium commonly found in Bomans P, Heenan R. Haemorrhagic colitis epidemic in Africa. Lancet 1993;341:961. multiple intradermal microinjections nature, but its role as a pathogen has 5. Paquet C, Perea W, Grimont P, Collin M, in her face and neck for cosmetic pur- been controversial. The slow-grow- Guillod M. Aetiology of haemorrhagic coli- poses (mesotherapy) with an unli- ing, photochromogenic mycobacteri- tis epidemic in Africa. Lancet 1993; censed product consisting of a solu- um has been isolated from both sur- 342:175. 6. Germani Y, Soro B, Vohito M, Morel O, tion of glycosaminoglycans. The face and tap water and has been asso- Morvan J. Enterohaemorrhagic Escherichia injections had been administered by ciated with a nosocomial pseudo-out- coli in Central African Republic. Lancet an unlicensed practitioner in a non- break suspected to have originated 1997;349:1670. medical office setting. The patient from a contaminated hospital water

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