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Intrathoracic Infections Due to Eikenella Corrodens

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Intrathoracic Infections Due to Eikenella Corrodens Thorax: first published as 10.1136/thx.42.9.700 on 1 September 1987. Downloaded from Thorax 1987;42:700-701 Intrathoracic infections due to Eikenella corrodens SHAHROKH JAVAHERI, RICHARD M SMITH, DAVID WILTSE From the Pulmonary Division and Department ofMedicine, Veterans Administration Medical Center, University ofCincinnati College ofMedicine; and the Pulmonary Division, Department ofMedicine, Good Samaritan Hospital, Cincinnati, Ohio, USA Eikenella corrodens, a fastidious facultative anaerobic Gram choscopy showed swelling of the left upper lobe bronchi; all negative bacillus,' is part of the normal human oral flora. specimens were negative for malignant cells. On day 7 a Although it has been implicated as the sole causative agent Gram negative rod was cultured from one of the blood cul- for certain infections, I- its pathogenetic importance ture bottles, and this was identified as E corrodens by mor- remains uncertain. E corrodens has been isolated in respira- phological and biochemical criteria.1 2 The organism was tory tract infections, including pneumonia, abscess, and resistant to clindamycin but sensitive to penicillin. All other empyema, where detailed bacteriological investigations have blood cultures, both aerobic and anaerobic, were negative; been performed, but only in association with other sputum grew normal flora. On day 9 ampicillin was given microbes.2 356 It was recently isolated by transtracheal or and gentamicin and clindamycin were stopped. He then percutaneous aspiration from seven patients with pneu- became afebrile and felt better and his appetite improved. monia or lung abscess,5 but in each case several other Repeated attempts to wean him from intravenous fluid organisms were cultured. The present report shows that E resulted in hypotension. Extensive investigation revealed corrodens can be the sole cause of respiratory tract infection. hypoaldosteronism, for which fludrocortisone was adminis- The organism has an unusual antibiotic sensitivity and the tered. therapeutic importance of this is illustrated by our case his- Amoxycillin was stopped after three months, when the tories. chest radiograph showed that the abscess had resolved. Cultures for acid fast bacilli and fungi were negative. copyright. Case reports CASE 2 CASE 1 A 44 year old white man, with a history of alcoholism and A 52 year old man complained of a flu like syndrome, cough seizures, complained of nausea, anorexia, fever, increasing with purulent green sputum, chills, and fever one week after shortness of breath, and bilateral pleuritic chest pain of two a syncopal episode. The respiratory rate was 28, temperature weeks' duration. He had a history of depression, and had 37°C, and blood pressure 94/80 mmHg. He had extensive been drinking excessively during the past two weeks. http://thorax.bmj.com/ periodontal disease. Cardiopulmonary and abdominal His temperature was 39 5'C, heart rate 140 beats/min, examination showed nothing abnormal. His white blood cell and respiratory rate 44/min. Breath sounds were diminished count was 17-3 x 109/1 with 90% neutrophils. A chest bilaterally and end inspiratory crackles were heard. The clin- radiograph showed a left upper lobe abscess, which was not ical examination otherwise showed nothing abnormal. present on a chest radiograph obtained three weeks pre- The white blood cell count was 25 9 x 109/l with 75% viously. neutrophil leucocytes. The arterial oxygen tension (Pao2) Gram stain ofsputum showed many neutrophil leucocytes was 38 and the carbon dioxide tension (Paco2) 20 mm Hg and occasional Gram positive cocci. After blood had been (5-1 and 2-7 kPa) and pH 7 45 in room air. A chest radio- obtained for microbial cultures, he was treated with intra- graph showed bilateral lower lobe shadowing, a right lower on September 26, 2021 by guest. Protected venous fluid and penicillin (12 million units daily). The next lobe abscess cavity, and a pleural effusion. Gram staining of day he felt better and had an improved appetite. Later in the sputum showed many neutrophil leucocytes with mixed day, however, his blood pressure fell to 64/44 mm Hg when organisms. He was treated with oxygen, phenytoin, penicil- the rate of intravenous fluid administration was reduced. lin, and tobramycin. The hypotension was thought to be due to sepsis, so penicil- Two days later the patient was still febrile. Penicillin treat- lin was stopped and he was treated with more fluid, ment was discontinued and clindamycin was added. On the dopamine, clindamycin (600 mg intravenously every six third day thoracocentesis yielded 20 ml of non-putrid cloudy hours), and gentamicin. fluid with a white cell count of 13-1 x 109/1, 90% being Fever and chills recurred, and he remained febrile with a neutrophils. Sputum culture grew normal flora, and blood temperature up to 38 5°C for the next eight days. Bron- cultures were negative. Bronchoscopy showed that the orifices of the middle and right lower lobe bronchi were ery- narrowed. Address for reprint requests: Dr Shahrokh Javaheri, Pulmonary thematous, oedematous, and Section, 11 IA, Veterans Administration Medical Center, 3200 Vine He remained febrile with a high leucocyte count despite Street, Cincinnati, Ohio 45220, USA. tube thoracostomy. On the 11th day he underwent tho- racotomy. Removal of a large volume of non-putrid pus Accepted July 1986 (1600ml) revealed a large abscess in the right lower lobe 700 Thorax: first published as 10.1136/thx.42.9.700 on 1 September 1987. Downloaded from Intrathoracic infections due to Eikenella corrodens 701 causing collapse of the middle lobe. Lobectomy and decor- Respiratory tract infections due to Eikenella corrodens are tication were performed, and two chest tubes left in situ. not well recognised. Recognition of E corrodens as the cause Postoperatively he continued to have a leucocytosis and of an intrathoracic infection is particularly important since, fever while taking clindamycin. as noted in this report, infections mimic anaerobic infections The empyema fluid was submitted for aerobic and anaer- but have different antibiotic sensitivities. Anaerobic infec- obic cultures and grew E corrodens, sensitive to ampicillin, tions are effectively treated with clindamycin,7 whereas E carbenicillin, cephalothin, chloramphenicol, gentamicin, corrodens is invariably resistant to this antibiotic,8 as shown t bramycin, and tetracycline. Cultures for acid fast bacilli by our case reports. a d fungi were negative. Clindamycin was discontinued and We believe that the incidence of E corrodens pleu- a picillin started. This resulted in clinical recovery with dis- ropulmonary infections has been underestimated. This is a pearance of the fever and leucocytosis. because penicillin, to which E corrodens is sensitive, is com- monly used to treat aspiration pneumonia. E corrodens is CASE 3 characteristically difficult to grow and, as exemplified in this A 72 year old white woman was admitted for investigation report, only one of several cultures may be positive. Con- of a peripheral lung mass on the chest radiograph. She was sequently, the infections were present for some time before a heavy smoker with chronic obstructive lung disease. A the correct aetiological diagnosis was made. A pleuro- limited thoracotomy showed squamous cell carcinoma of pulmonary infection that is clinically presumed to be anaer- the pleura. Five days later, when she developed fever and a obic but fails to respond favourably to clindamycin should productive cough, the chest radiograph showed a pleural alert the clinician to the possibility that E corrodens may be effusion, with shadowing and loss of volume in the left lower the causative agent. lobe. The sputum contained many neutrophils but grew nor- mal flora only and blood cultures remained negative. Yellow fluid drained from the old chest tube site. On Gram staining the fluid contained many leucocytes but no organisms; E corrodens, however, grew on culture. All other aerobic and References -anaerobic cultures were negative. Intravenous penicillin was 1 Jackson FL, Goodman Y. Genus Eikenelia. In: Kreig NR, ed. given. E corrodens was also sensitive to ampicillin, car- Bergey's Manual ofsystematic bacteriology. Vol 1. Baltimore: benicillin, cephalothin, tobramycin, gentamicin, chlo- Williams and Wilkins, 1984:591-7. ramphenicol, and tetracycline. For the next three weeks her 2 Brooks GF, O'Donohue JM, Rissing JP, Soapes K, Smith JW. course was punctuated by episodes of chills and fever. These Eikenella corrodens, a recently recognized pathogen. Medicine copyright. occurred at times when drainage from the pleural space was (Baltimore) 1974;53:325-42. diminished, and it responded to incision and drainage. A 3 Dorff GJ, Jackson LI, Rytel MW. Infections with Eikenella cor- fluid E corrodens and rodens. Ann Intern Med 1974;80:305-9. second culture of the pleural grew 4 Geraci JE, Hermans PE, Washington JA II. Eikenella corrodens Haemophilus parainfluenzae. She was discharged from hospi- endocarditis. Mayo Clin Proc 1974;49:950-3. tal while continuing treatment with an oral cephalosporin. 5 Goldstein EJC, Kirby BA, Finegold SM. Isolation of Eikenella corrodens from pulmonary infections. Am Rev Respir Dis Discussion 1979;119:55-8. http://thorax.bmj.com/ 6 Bottone EJ, Kittick J Jr, Schneierson SS. Isolation of bacillus We report three patients who presented with thoracic infec- HB-1 from human clinical sources. Am J Clin Pathol tion due to E corrodens. Two had a primary lung abscess, 1973;59:560-6. and the with car- 7 Levison ME, Mangura CT, Lorber B, et al. Clindamycin com- one in association with empyema; third, pared with penicillin for treatment of anaerobic lung abscess. cinoma of the lung, presented with postoperative pneumonia Ann Intern Med 1983;98:466-71. and empyema. Two had E corrodens bacteraemia. This 8 Robinson JVA, James AL. In vitro susceptibility of Bacteroides report strongly suggests that E corrodens was the sole cause corrodens and Eikenelia corrodens to ten chemotherapeutic of infection in these patients. agents. Antimicrob Agents Chemother 1974;6:543-6. on September 26, 2021 by guest. Protected.
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