LETTERS

Identifi cation of In late October 2009, a 66-year- Gram staining of tissue samples old woman was admitted to Hôpital did not show any bacteria, and con- Legionella feeleii Nord, Marseille, France, for a papular ventional cultures incubated under Cellulitis lesion complicated by cellulitis and aerobic and anaerobic conditions did an abscess, centered on her right leg not lead to growth after 3 weeks of in- To the Editor: In general, reports (Figure). The patient’s history noted cubation. Je ne sais pas (or “I don’t of extrapulmonary Legionella spp. in- that she had been bitten by an insect know [what I’m growing]” [10]) shell fections are scarce. For example, L. or spider (suspected to be a spider) on vial culture protocol was done on a micdadei infection was found with the October 9. The next day, the patient skin biopsy sample of the lesion. Cul- following manifestations: a mass on had a fever of 39°C, and a papular le- turing was performed by the centrifu- the left side of the neck and low-grade sion appeared around the bite. Four gation shell vial technique with 3.7 mL fever in a healthy 9-year-old girl (1); days later, the fever had persisted, and human embryonic lung fi broblast cell multiple liver and lung abscesses in a she was given amoxicillin-clavulanate monolayers (Sterilin, Felthan, UK) in- 7-year-old girl with acute lymphoblas- and local wound care. Two days later, oculated with the skin biopsy sample tic leukemia who had undergone allo- the lesion became necrotic, and levo- previously triturated in cell culture geneic cord blood transplantation (2); fl oxacin was added to the medication medium. Small extra- and intracellu- and a cerebral abscess in a patient with regimen. At day 10 after the bite, cel- lar bacilli were observed directly in- legionellosis (3). lulitis with a central abscess appeared side the shell vial by using Gimenez L. feeleii was fi rst described in on her leg. The patient was transferred and Gram staining. DNA extraction, 1984 as the causative agent of a Pon- to Hôpital Nord. At admission, she had partial 16S rRNA gene amplifi cation tiac fever outbreak (4). L. feeleii was leukocytosis (16.9 × 109 cells/L) with and sequencing, and mip and rpoB responsible, according to a recent re- neutropenia (0.51 × 109 cells/L), slight gene amplifi cation and sequencing view, for only 10 reported cases of anemia (104 g/dL), and infl amma- were done on shell vial supernatant. infections, all of which were pneumo- tory syndrome (C-reactive protein 72 Partial sequence of 16S rRNA identi- nia, only 1 complicated by endocardi- mg/L, erythrocyte sedimentation rate fi ed a Legionella sp. Subsequently, L. tis (5). Unlike lung abscesses, cutane- 150 mm after 1 h); she was also still feeleii was identifi ed with 100% and ous lesions caused by Legionella spp. febrile (38°C). She had a history of 96.5% sequence similarity for mip and are uncommon. Recurrent soft tissue chronic lymphocytic leukemia. A cuta- rpoB genes, respectively. The biopsy abscesses of the jaw, wrist, and arm neous biopsy sample showed infl amed sample was unfrozen and then injected caused by L. cincinnatiensis were de- and necrotic tissue, which suggested onto Legionella spp.–buffered char- scribed in a 73-year-old woman with squamous cell evocating carcinoma. coal yeast extract agar as the superna- nephrotic syndrome and idiopathic immunoglobulin gammopathy (6). L. micdadei has been found in a cutane- ous abscess of the leg of a 62-year-old immunosuppressed woman, and it was responsible for necrotizing cellulitis that resulted in amputation of the left arm of a recipient of a cadaveric renal transplant (7). L. pneumophila with mixed fl ora was identifi ed in a peri- rectal abscess (8) and in skin samples from a patient with lymphoma and cel- lulitis associated with pneumonia (9). The infrequency of reporting Legio- nella spp. cutaneous infections may be explained in part by the fact that Legionella spp. agar is not routinely a part of media inoculated for cases of cutaneous abscess. Here we report the identifi cation of L. feeleii in a cutane- ous infection through the use of a shell Figure. Cellulitis with a central abscess present at time of patient’s admission to hospital, vial culture protocol. Marseille, France, 2010. A color version of this fi gure is available online (www.cdc.gov/EID/ content/17/1/145-F.htm).

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 1, January 2011 145 LETTERS tant of the shell vial. No growth was 3. Andersen BB, Sogaard I. Legionnaires’ Sparganosis, Henan obtained from the biopsy sample, but disease and brain abscess. Neurology. 1987;37:333–4. Province, Central L. feelii was identifi ed similarly from 4. Herwaldt LA, Gorman GW, McGrath colonies growing on buffered charcoal T, Toma S, Brake B, Hightower AW. China yeast extract agar plates injected with A new Legionella species, Legionella shell vial supernatant. The patient’s ne- feeleii species nova, causes Pontiac fever To the Editor: Sparganosis is in an automobile plant. Ann Intern Med. crotic tissues were surgically excised; a parasitic zoonosis caused by inva- 1984;100:333–8. sion of the spargana, the plerocercoid a vacuum-assisted closure system was 5. Lee J, Caplivski D, Wu M, Huprikar S. used. Reexamination of the tissue bi- Pneumonia due to Legionella feeleii: larvae of various diphyllobothroid opsy samples ruled out the diagnosis case report and review of the literature. tapeworms belonging to the genus Transpl Infect Dis. 2009;11:337–40. DOI: of carcinoma. Spirometra (1). Although human spar- 10.1111/j.1399-3062.2009.00390.x ganosis is cosmopolitan, it is most Finally, despite the fact that the 6. Gubler JGH, Schorr M, Gaia V, Zbinden R, shell vial technique requires special- Altwegg M. Recurrent soft tissue abscess- frequently found in eastern and south- ized equipment and trained person- es caused by Legionella cincinnatiensis. J eastern Asia (2). During 1927–2009 Clin Microbiol. 2001;39:4568–70. DOI: nel, this method was performed in a in the People’s Republic of China, 10.1128/JCM.39.12.4568-4570.2001 >1,000 cases in humans in 27 provinc- reference center to improve the accu- 7. Kilborn JA, Manz LA, O’Brien M, Doug- racy of a microbiologic diagnosis and, lass MC, Horst HM, Kupin W, et al. es were reported; most cases were in consequently, the care of the patient in Necrotizing cellulitis caused by Legion- southern China, where human infec- ella micdadei. Am J Med. 1992;92:104–6. uncommon situations (10). This im- tions were mainly acquired by eating DOI: 10.1016/0002-9343(92)90024-6 raw or insuffi ciently cooked meat of provement in diagnosis and care was 8. Arnow PM, Boyko EJ, Friedman EL. Peri- also noted in an unusual L. pneumophi- rectal abscess caused by Legionella pneu- frogs and snakes or by placing frog or la infection described by our team (2). mophila and mixed anaerobic bacteria. snake fl esh on open wounds for treat- Ann Intern Med. 1983;98:184–5. In our laboratory, we have been ment of skin ulcers or on eyes to treat 9. Waldor MK, Wilson B, Swartz M. Cel- infl ammation (3,4). performing the je ne sais pas protocol lulitis caused by Legionella pneumophila. almost routinely since 1996 (10). Cell Clin Infect Dis. 1993;16:51–3. Sparganosis is rarely seen in cen- cultures provide supplemental tools to 10. Gouriet F, Fenollar F, Patrice JY, Drancourt tral and northern China. Before 2006, M, Raoult D. Use of shell-vial cell culture elucidate the cause of microbial dis- only 3 imported cases from southern assay for isolation of bacteria from clini- China had been reported in Henan eases when results of PCR and classi- cal specimens: 13 years of experience. J cal agar procedures are negative. Fur- Clin Microbiol. 2005;43:4993–5002. DOI: Province in central China (5). How- thermore, this procedure provides a 10.1128/JCM.43.10.4993-5002.2005 ever, since 2006 in Henan Province, means for the isolation of a wide range 20 autochthonous cases caused by in- Address for correspondence: Bernard La Scola, of intracellular bacteria, even when gestion of live tadpoles have emerged. URMITE, CNRS UMR 6236, IFR 48, Faculté little biopsy material is available. To assess the risk for human infection de Médecine, Université de la Méditerranée, 27 with sparganosis in this province and Severine Loridant, blvd Jean Moulin, 13385 Marseille CEDEX 05, to strengthen public safety awareness, Jean-Christophe Lagier, France; email: [email protected] we investigated spargana infection in and Bernard La Scola the animal hosts of Spirometra tape- Author affi liations: Université de la Méditer- worms. ranée, Marseille, France (S. Loridant, J.-C. During July 2007–July 2010, wild Lagier, B. LaScola); and Hôpital Nord, Mar- frogs and frog tadpoles were collected seille (J.-C. Lagier) from the cities of Shangqiu, Zhou- kou, and Luohe in Henan Province. DOI: 10.3201/eid1701.101346 Necropsies identifi ed plerocercoids in 11.93% (163/1,366) of tadpoles References and in 26.58% (172/647) of frogs. By 1. Qin X, Abe PM, Weissman SJ, Manning frog species, plerocercoids were found SC. Extrapulmonary Legionella micdadei in 31.09% (111/357) of Rana lim- infection in a previously healthy child. Pe- mocharis and 26.29% (61/232) of R. diatr Infect Dis J. 2002;21:1174–6. DOI: nigromaculata frogs, each signifi cant- 10.1097/00006454-200212000-00022 2. La Scola B, Michel G, Raoult D. Isola- ly (p<0.05) more numerous in these tion of Legionella pneumophila by cen- species than in R. temporaria frogs trifugation of shell vial cell cultures from (0/58). In addition, 177 wild frogs sold multiple liver and lung abscesses. J Clin at markets in Luohe were also exam- Microbiol. 1999;37:785–7.

146 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 1, January 2011