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Home , Shigella sonnei, Shigellosis

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Vicki Stambos, Address for correspondence: Vicki Stambos, pnea and a cough producing purulent Jean-Paul Chaine, Heath Kelly, Victorian Infectious Diseases Reference sputum. He had traveled to India and Mariana Sablan, Laboratory, Locked Bag 815, Carlton South had visited urban and rural areas over and Michaela Riddell 3053, Melbourne, Victoria, Australia; email: a 15-day period. He returned home 7 Author affi liations: Victorian Infectious Dis- [email protected] days before hospital admission. Dur- eases Reference Laboratory, Melbourne, ing his travel, the patient reported epi- Victoria, Australia (V. Stambos, H. Kelly, M. sodes of vomiting and moderate diar- Riddell); and Department of Public Health, rhea without . These signs were Saipan, Commonwealth of the Northern resolved 4 days before his return to Mariana Islands (J.-P. Chaine, M. Sablan) Italy. Initial examination showed he had a temperature of 37°C and an oxy- DOI: 10.3201/eid1511.081267 Caused gen saturation of 88% in room air. Ar- References terial blood gas levels were pH 7.42, by sonnei partial pressure of oxygen in arterial 1. Centers for Disease Control and Preven- in Man Returned blood 42 mm Hg, and partial pressure tion. CDC immigration requirements: of carbon dioxide 35 mm Hg. Because technical instructions for , from India 2007 [cited 2008 Aug 12]. Available of his progressive respiratory failure, from http://www.cdc.gov/ncidod/dq/pdf/ To the Editor: is a he was transferred to the intensive ti_vacc.pdf cause of infectious frequent- care unit. Relevant laboratory tests 2. Central Statistics Division. Annual statis- were performed, and abnormal values tical yearbook 2002. Saipan (Common- ly occurring in developing countries wealth of the Northern Mariana Islands); yet usually associated with in of erythrocyte sedimentation rate 85 Department of Commerce; 2002. travelers from regions where Shigella mm/h, C-reactive protein 105 mg/L, 3. Ratnam S, Gadag V, West R, Burris J, infections are endemic. Shigella spp. hemoglobin 10.2 g/dL, and neutro- Oates E, Stead F, et al. Comparison of philia were found. commercial enzyme immunoassay kits are usually spread directly from per- with plaque reduction neutralization test son to person by the fecal–oral route A chest radiograph showed dif- for detection of measles virus antibody. J or indirectly by fecal contamination of fuse pneumonia with infi ltrates. A Clin Microbiol. 1995;33:811–5. food or water with ingestion of computed tomography scan of the tho- 4. World Health Organization. Immuniza- rax showed nodular lesions and cavity tion profi le—Philippines 2007 [cited 2009 contaminated food or water (1). Aside Mar 19]. Available from http://www.who. from clinical intestinal manifestations, formations. No neurologic or abdomi- int//globalsummary/immuniza- shigellosis causes a wide variety of ex- nal abnormalities were found, and tion/countryprofi leresult.cfm?C=’phl’ traintestinal signs, such as bacteremia peristalsis was within normal limits. 5. World Health Organization. Immuniza- Sputum and bronchial alveolar tion profi le – China 2007 [cited 2009 Mar or neurologic manifestations (2). 19]. Available from http://www.who.int/ Pneumonia is an atypical but po- lavage (BAL) smears showed gram- vaccines/globalsummary// tential of shigellosis. In negative microorganisms. countryprofi leresult.cfm?C=’chn’ developing countries, was suspected because the man had 6. Zandotti C, Jeantet D, Lambert F, Waku- traveled to a known melioidosis-en- Kouomou D, Wild F, Freymuth F, et al. and S. fl exneri infections were report- Re-emergence of measles among young ed to cause acute pneumonia in mal- demic area. In view of this informa- adults in Marseilles, France. Eur J Epi- nourished infants and, in these cases, tion, blood, sputum, and BAL samples demiol. 2004;19:891–3. DOI: 10.1023/ were associated with severe prognosis were collected, and the patient was B:EJEP.0000040453.13914.48 immediately given empirical antimi- 7. Cutts FT, Robertson SE, Diaz-Ortega JL, and a death rate of 14% (3). Samuel R. Control of rubella and congeni- We describe a case of severe crobial drug therapy with / tal rubella syndrome (CRS) in develop- pneumonia caused by S. sonnei that clavulanic acid, plus meropenem and ing countries, Part 1: Burden of disease developed in a man from Italy who norfl oxacin. Given the absence of gas- from CRS. Bull World Health Organ. trointestinal symptoms and because 1997;75:55–68. had traveled to India. This is an atypi- 8. Filia A, Curtale F, Kreidl P, Morosetti G, cal case of shigellosis occurring in an shigellosis was not suspected, stool Nicoletti L, Perrelli F, et al. Cluster of immunocompetent person, generally samples were not obtained. Specimens measles cases in the Roma/Sinti popula- healthy and without any underlying were sent to the Istituto Superiore di tion, Italy, June–September 2006. Euro Sanità, Infectious Diseases Depart- Surveill. 2006;11:E061012 2. severe predisposing condition. 9. Danovaro-Holliday MC, LeBaron CW, A 69-year-old white man was ad- ment for bacteriologic examination. Allensworth C, Raymond R, Borden TG, mitted to the emergency unit of the Blood cultures were negative; gram- Murray AB, et al. A large rubella outbreak Presidio Ospedaliero, Department of negative rods were recovered from the with spread from the workplace to the sputum and BAL smears. The micro- community. JAMA. 2000;284:2733–9. Infectious Diseases, Treviso, Italy, on DOI: 10.1001/jama.284.21.2733 February 24, 2008, with severe dys- organisms were identifi ed as S. sonnei

1874 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009 LETTERS by the API 20E strip (bioMerieux Ital- reported as secondary manifestations This work was supported by the Ital- ia, Florence, Italy). The agglu- of dysentery. In particular, bacter- ian Ministry of Research and University, tinated in Shigella group D antiserum emia is reported as a gastrointestinal Rome, Italy, FIRB grant Costruzione di un but failed to agglutinate in Shigella complication in infants in developing laboratorio nazionale per le resistenze agli groups A, B, and C antisera (Becton countries (4) or in immunocompro- antimicrobici. Dickinson Diagnostic Systems Italia, mised adults (5); pneumonia associ- Milan, Italy). To further confi rm bac- ated with S. sonnei is more rare but Fabiola Mancini, terial identifi cation, we amplifi ed the possible and has been described in Antonella Carniato, full length of 16S rRNA nucleotide malnourished children (4,6), in human and Alessandra Ciervo sequence by using the universal prim- immunodefi ciency virus–infected pa- Author affi liations: National Public Health ers for eubacteria, 16S rRNAs (27f 5′- tients (7), and in patients with chronic Institute, Rome, Italy (F. Mancini, A. Ciervo); GAGAGTTTGATCCTGGCTCAG-3′ diseases (8–10). Generally, in these and Presidio Ospedaliero, Treviso, Italy (A. and 1495r 5′-CTACGGCTACCTTG cases, pneumonia is associated with Carniato) TTACGA-3′) and sequenced the bacteremia. PCR product. The sequence obtained This reported case of severe pneu- DOI: 10.3201/eid1511.090126 was compared by using the BLAST monia related to S. sonnei is unusual search tool (www.ncbi.n/m.nib.gov/ in a healthy patient with self-limiting References BLAST), which showed 100% iden- dysentery whose symptoms and clini- tity with the 16S rRNA S. sonnei cal conditions were not suggestive 1. Centers for Disease Control and Preven- tion. Shigella. Annual summary. Atlanta strain AU65 sequence GenBank ac- of bacteremia. Vomiting and aspira- (GA): The Centers; 2002. cession no. EF032687). Antimicrobial tion of mixed mouth fl ora containing 2. Ashkenazi S. Shigella infections in chil- drug susceptibility of the isolate was Shigella spp. could be a possible cause dren: new insights. Semin Pediatr Infect determined for 26 agents by the disk- of pneumonia in this patient. How- Dis. 2004;15:246–52. DOI: 10.1053/j. spid.2004.07.005 diffusion method in Mueller Hinton ever, the hematogenous route cannot 3. Bennish ML. Potentially lethal compli- agar, according to the Clinical and be excluded. A potential explanation cations of shigellosis. Rev Infect Dis. Laboratory Standards Institute. The of the severe illness could be that in 1991;13:S319–24. isolate was susceptible to amikacin healthy elderly people the immune 4. Dutta P, Mitra U, Rasaily R, Bhattacha- rya SK, Bhattacharya MK. Assessing the 30 μg/mL, ceftazidime 30 μg/mL, system functions are less vigorous and cause of pediatric in-patients diarrheal ceftriaxone 30 μg/mL, meropenem thus more susceptible to infections. deaths: an analysis of hospital records. In- 10 μg/mL, sulfi soxazole 0.25 μg/mL, Nevertheless, the acute episode in this dian Pediatr. 1995;32:313–21. sulfonamides 300 μg/mL, and triple patient was effectively treated by a 5. Mandell W, Neu H. Shigella bacteremia in adults. JAMA 1986;255:3116–7. sulfa 23.75/1.25 μg/mL; intermedi- combination of meropenem, norfl oxa- 6. Garanin A. Isolation of Shigella son- ate to cefotaxime 30 μg/mL, gen- cin, and amoxicillin/clavulanic acid, nei from the lung of a child who died of tamicin 10 μg/mL, kanamycin 30 μg/ although the bacterium is resistant to acute dysentery [in Russian]. Pediatriia. mL, and tobramycin 10 μg/mL; and the latter 2 drugs. 1970;49:81–2. 7. Miller RF, Symeonidou C, Shaw PJ. resistant to amoxicillin 25 μg/mL, This case report should be of par- Pneumonia complicating Shigella sonnei amoxicillin/clavulanic acid 20/10 μg/ ticular interest for clinicians because it dysentery in an HIV infected adult male. mL, 10 μg/mL, ampicillin- describes an atypical case of extraint- Int J STD AIDS. 2005;16:763–5. DOI: sulbactam 20 μg/mL, cefoxitin 30 estinal shigellosis and an example of 10.1258/095646205774763243 8. Hawkins C, Taiwo B, Bolon M, Jul- μg/mL, chloramphenicol 30 μg/mL, misdiagnosis of melioidosis. Clini- ka K, Adewole A, Stosor V. Shigella ciprofl oxacin 5 μg/mL, clarithromy- cians should be alert for pneumonia sonnei bacteremia: two adult cases cin 15 μg/mL erythromycin 15 μg/ associated to Shigella spp. or Burk- and a review of the literature. Scand mL, nalidixic acid 30 μg/mL, nor- holderia pseudomallei, specifi cally J Infect Dis. 2007;39:170–3. DOI: 10.1080/00365540600786580 fl oxacin 10 μg/mL, streptomycin 10 in healthy people who have traveled 9. Margolin L, Engelhard D. Bilateral μg/mL, tetracycline 30 μg/mL, and to areas to which these pathogens are pneumonia associated with Shigella trimethoprim 5 μg/mL. endemic. sonnei dysentery. Am J Infect Con- The patient was discharged from trol. 2003;31:445–6. DOI: 10.1067/ mic./2003.69 hospital after 40 days. At follow-up Acknowledgments 10. Raffensperger EC. Combined bacillary and 6 months later, his general health sta- We thank Maria Losardo for techni- amebic ulcerative colitis associated with tus was good, and a chest radiograph cal help. We are also grateful to Giusep- atypical pneumonitis and Shigella-posi- tive sputum. Am J Med. 1956;20:964–7. showed no abnormalities. pina Mandarino for language assistance DOI: 10.1016/0002-9343(56)90263-7 Extraintestinal signs associated and manuscript revision. with S. sonnei infections are generally

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009 1875 LETTERS

Address for correspondence: Alessandra Ciervo, stock cases in the United Kingdom. malaise, eosinophilia, and impaired Department of Infectious, Parasitic and Immune- From January 1, 2008, through Janu- liver function; therefore, distinguish- mediated Diseases, Istituto Superiore di Sanità, ary 31, 2009, 11 human cases were ing between the 2 phases can be diffi - Viale Regina Elena, 299–00161 Rome, Italy; confi rmed by the reference labora- cult. Fifty percent of chronic infection email: [email protected] tory for England and Wales, compared is subclinical (1,2). Compatible radio- with 6 cases during the preceding 10 logic features are capsular enhance- years. The Scottish reference labora- ment with contrast, hypodense nodu- tory detected no human cases during lar areas, and low-density serpiginous the study period. lesions (2). Our analysis comprised 11 Fascioliasis was defi ned as a cases (Table). Two patients were white positive Fasciola immunofl uorescent British, both of whom had recently antibody test with a screening titer traveled to sub-Saharan Africa. Cases Imported Human of 1:32 and either compatible clini- from the preceding 10 years diagnosed Fascioliasis, United cal or radiologic features consistent in our laboratory were all in persons Kingdom with the disease. We obtained clinical with histories of travel to fascioliasis- and radiologic information from the endemic areas. Therefore, these cases To the Editor: We initiated en- referring physician. Clinical features do not provide fi rm evidence of indig- hanced surveillance for human fascio- of both acute and chronic infection enous zoonotic transmission within liasis after a reported increase in live- include fever, upper , England and Wales.

Table. Characteristics of human fascioliasis case-patients during enhanced surveillance, United Kingdom, January 1, 2008–January 31, 2009* Eosinophil Abnormal Case Age, Country Years since Risk Clinical count, liver no. y/sex of origin migration Other travel factor features x109/L) function Hepatic imaging IFAT† 1 45/F Yemen 7 Yemen Khat Abdominal 8.4 Yes Mixed-density 1:128 regularly use pain liver lesion (CT) 2 44/M Somalia 16 Ethiopia Khat Fever, 3.4 Yes Serpiginous 1:64 2007 use abdominal lesion (MRI) pain 3 34/F Ethiopia 3 S. Africa Khat Fever, 11.4 No Heterogeneous 1:128 regularly use abdominal lesion (USS) pain 4 44/F Somalia 7 Somalia Khat Abdominal 8.3 No Heterogeneous 1:128 2004, use pain lesion (USS) Netherlands 5 54/F Somalia 21 (to None Khat Anorexia 8.4 No Low-density 1:32 Netherlands), use lesion (CT) 4 (to UK) 6 43/M Somalia 28 (to India), None Khat Fever 1.0 Yes Heterogeneous 1:128 21 (to UK) use lesion (USS) 7 28/F UK – Uganda – Abdominal 1.84 Yes Hepatomegaly 1:512 2007–2008 pain, with large mixed hepatomegaly cystic and solid lesion (USS) 8 67/M UK – Kenya – Malaise, 0.04 Yes Multiple 1:256 2008, prior abdominal gallstones world travel pain (MRCP) 9 38/M Ethiopia 10 Ethiopia – Abdominal 18.7 Yes Normal (USS, 1:128 2006 pain, fever MRCP) 10 28/M Ethiopia Unknown Unknown – Fever, gram- <0.04 Yes Lesion in 1:64 negative hepatic vein ; new HIV diagnosis 11 47/F Somalia 16 (to Unknown Khat Abdominal 16.8 Yes Low-density 1:256 Yemen), use pain, fever lesion (CT) 6 (to UK) *IFAT, immunofluorescent antibody test; CT, computed tomography; MRI, magnetic resonance imaging; USS, ultrasound scan, MRCP, magnetic resonance cholangiopancreatography. †Titer of IFAT (screening titer 32).

1876 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 11, November 2009