CASE REPORT

Bacteremia due to cinaedi in two patients with human virus infection

ANDREW E SIMOR, MD, FRCPC, JAMES L BRUNTON, MD, FRCPC

AE SIMOR, JL BRUNTON. Bacteremia due to Helicobactercinaedi in two patients with human immuno­ deficiency virus infection . Can J Infect Dis 1992;3(3):139-141. Heli.cobacterci.naedi. (formerly Campylo­ bacterci.naedi.) has been associated with enteric disease in homosexual men. The authors report 1:\vo cases of H ci.naedi. bacteremia occurring in patients with human immunodeficiency virus (HIV) infection. These cases illustrate that H c i.naedi. may act as an opportunistic in patients with HN infection or the acquired immune deficiency syndrome.

Key Words: Helicobacter cinaedi bacteremi.a. HIV irifection

Bacteriemies dues a Helicobacter cinaedi chez deux patients porteurs du virus de l' immunodeficience humaine RESUME: Heli.cobacter ci.naedi. (anciennement ci.naedi) est associe aux maladies enteriques chez !es hommes homosexuels . Les auteurs rapportent deux cas de bacteriemies a H ci.naedi. chez des patients porteurs du virus de l'immunodeficience humaine (VlH) . Ces cas illustrent le fait que H ci.naedi. pourrait agir a titre d'agent pathogene opportuniste chez les patients porteurs du VIH ou atteints du syndrome d'immunodepression acquise.

AMPYLOBACTER SPECIES ARE FREQUENTLY ISOLATED Campylobacter cinaedi and Campylobacter fennelliae) C from homosexual men and have been recovered (4). have recently been associated with enteric disease from patients with the acquired immune deficiency in homosexual men (5,6). syndrome (AJDS) (1-3). Most patients have symptoms of The authors report two cases of bacteremia due to H enterocolitis, although occasionally systemic illness cinaedi occurring in patients with human immuno­ with bacteremia has also been reported. The majority of deficiency virus (HIV) infection. These cases provide these infections have been due to either Campylobacter further information regarding tl1e spectrum of illness jejuni or Campylobacter fetus subspecies fetus. 1\vo associated with this organism and serve to illustrate newly recognized and related bacterial species, H elico­ that H cinaedi may act as an opportunistic pathogen in bacter cinaedi and Helicobacter fennelliae (formerly patients with HIV infection.

Departments of Medi.cine and Microbiology. Mount Sinai Hospital: and the University of Toronto, Toronto. Ontario Correspondence and reprints: Dr AE Simor. Department of Microbiology. Mount Sinai Hospital. 600 University Avenue. Toronto. Ontario MSG 1X5. Telephone (416) 586-4695 Received for publication February 27. 1991 . Accepted April 30. 1991

CAN J INFECT DIS VOL 3 No 3 MAY/ JUNE 1992 139 SIMOR AND BRUNTON

CASE PRESENTATIONS 10 days, and there has been no recurrence of symptoms Case 1: A 38-year-old homosexual male ,vi.th AJDS was after four months of fo llow-up. admitted to hospital in June 1990 for investigation of Isolation of H cinaedi from the present two patients fever, cough and dyspnea. The patient had first been occurred approximately one month apart. The patients found to be HN antibody positive in 1988 when he were not sexual partners and had no other known developed Kaposi's sarcoma and Pneumocystis carinii common contacts. Neitl1er of them had a significant . Subsequently, he developed pulmonary in­ history of animal contact or travel. Their isolates were volvement with Kaposi's sarcoma and was started on identified as H cinaedi-like organisms by accepted witl1 adriamycin. bleomycin and vinblas­ criteria (4 ,5); the identities were confirmed by the Na­ tine. Other medications were zidovudine, acyclovir and tional Laboratory for Ente1ic Patl1ogens (Laboratory ketoconazole. Ten days prior to admission the patient Centre for Disease Control, Ottawa, Ontario). developed fever, chills, increasing cough and shortness of breath. He also had mild diarrhea but no abdominal pain. DISCUSSION On examination, the patient was cachectic, febrile, There are now several Campylobacter and Helicobac­ tachycardic and dyspneic. Blood and stool cultures ter species known to be associated with human disease. obtained on admission yielded no significant growtl1. Cjejuni and Campylobacter coli are important causes of No opportunistic pulmonary infections were identified infectious diarrhea, whereas Cfetus subspeciesjetus is and the respiratory failure was attributed to progressive recognized as a cause of bacteremia and in pulmonary Kaposi's sarcoma. A colonoscopy revealed debilitated or irnmunocompromised hosts. Helicobacter edematous mucosa involving the transverse colon. His­ pylori has been associated with chronic active gastritis topathological examination of a colonic biopsy revealed (7) . although patients with AJDS appear to have lower cytomegalovirus inclusions identified by in situ DNA than e:x.'})ected rates of infection with this organism (8). hybridization. Treatment with ganciclovir was started The name H cinaedi has been proposed to denote a new and continued for three weeks. The diarrhea resolved, species within the genus Helicobacter based on pheno­ but the patient remained febrile. Repeat blood cultures. typic characteristics, biochemical tests and DNA hom­ obtained two months following admission to hospital, ology studies (4). The organisms are fastidious and slow yielded H cinaedi after five days of incubation. During growing, typically requiring several days of incubation treatment with eryfuromycin the patient became in a microaerophilic environment for growtl1 to be afebrile and was subsequently discharged from hospi­ detected. The source and natural reservoir of H cinaedi tal. Three months later, the patient died of respiratory are not known. although the organism has been re­ failure; there was no evidence of recurrent bacteremia. covered from the feces of healthy hamsters (9) . Whether Cas e 2: A 35-year-old homosexual male presented to colonized hamsters serve as a reservoir for human H the emergency department in July 1990 with a one day cinaedi infection has not been determined. The or­ history of fever. chills, myalgias and arthralgias. In tl1e ganism appears to be transmitted sexually within male previous two weeks. the patient had also noted mild homosexual populations, and had initially been iso­ diarrhea and a cough productive of scanty amounts of lated only from homosexual or bisexual men; no iso­ sputum. The patient had first been found to be HN lates were recovered from 150 heterosexual men or antibody positive in 1987. In the fo llowing year, he was women san1pled by Quinn and co-workers (1). More hospitalized with bacteremic pneumococcal pneu­ recently, however, Vandamme et al (10) reported tl1e monia. The patient had had oral candidiasis for several isolation of H cinaedi from two female adults and three years, but no other opportunistic infections had been children. identified. Medications included zidovudine, acyclovir The spectrum of illness associated with H cinaedi and ketoconazole. infection includes asymptomatic gastrointestinal car­ On examination in the emergency department. the riage, proctitis, enterocolitis and bacteremia (1). The patient was afebrile and did not appear to be acutely ill. present report adds to the seven previously reported There was oropharyngeal candidiasis, but no other cases of H cinaedi bacteremia (10-13). Six cases (in ­ focus of infection was apparent. Cardiopulmonary and cluding the two reported here) have occurred in abdominal examinations were normal. A chest x-ray homosexual or bisexual men, four of whom were known was also normal. Blood and urine specimens were to be infected witl1 HN. The other two male patients obtained for culture and the patient was discharged presented with H cinaedi bacteremia prior to tl1e home from the emergency department with no specific availability of HN serological testing (1) . Interestingly. treatment. He continued to complain of intermittent they both had concurrent pulmonary tuberculosis. fever, myalgias and diarrhea. Empiric treatment with suggesting that tl1ey may also have had HN infection. ciprofloxacin was started and the patient became H cinaedi bacteremia occurring in two adult women and afebrile with resolution of the diarrhea 48 h later. After one child were reported by Vandamme et al (10). but no five days of incubation. the blood cultures grew H other clinical information is provided. All six of the cinaedi. Treatment with ciprofloxacin was continued for patients for whom clinical data are available presented

140 C AN J INFECT DIS V OL 3 No 3 MAY/JUNE 1992 Bacteremia due to H cinaedi in HIV infection

with a nonspecific febrile illness; only two patients had with persistent and severe C j ejuni infection had abnor­ preceding gastrointestinal symptoms. In each of the mally low campylobacter-specific antibody responses reports, blood cultures were processed using the Bactec compared to otl1erwise healthy volunteers. and specific system (Johnston Laboratories, Maryland). The blood humoral in1munity was found to be important in cultures were incubated for two to six days before preventing can1pylobacter bacteremia (2). Changes in bacterial growth was detected. Patients were treated mucosa! secretory antibody production have also been with a variety of antimicrobial agents, including eryth­ noted in HIV-infected patients. Kotler et al (15) found a romycin, tetracycline, chloramphenicol, ciprofloxacin, reduction in the number of IgA-containing plasma cells gentamicin and antituberculous drugs. All of the patients in the intestinal lanuna propria of patients with AJDS. survived their episode of bacteremia and there were no Not surprisingly, changes in mucosa! cell-mediated im­ reported relapses, although one HIV-infected patient munity have also been reported. Rodgers and co­ subsequently had bacteremia due to Hfennelliae (13). workers (16) have documented abnormalities in the Susceptibility testing of H cinaedi to a variety of distribution of T-lymphocyte subsets in the intestinal antimicrobial agents suggests that isolates are general­ mucosa of AJDS patients. The number of CD4 helper-in­ ly susceptible to ampicillin, tetracycline, chloran1pheni­ ducer T cells in the lanuna propria was found to be col, anunoglycosides and quinolones, although 28% of reduced, paralleling the depletion of circulating lym­ 43 isolates were found to be resistant to 8 µg/mL phocytes. These defects have been related to direct erythromycin (14). Susceptibility testing for these slow­ infection of intestinal mucosa! cells by HIV. Combined growing organisms has not been standardized, and local and systemic defects in cell-mediated and optimal therapy for H cinaedi infection has not been humoral in1munity may render the HIV-infected patient determined. However, based on in vitro susceptibility susceptible to enteric infections that subsequently be­ test results, appropriate therapy for bacteremic infec­ come bacteremic or chronic and relapsing. tions may include tetracycline, ciprofloxacin or an In summary, H cinaedi is a recently recognized . enteric pathogen that may cause proctocolitis or bac­ In HIV-infected patients, bacterial enteric teremia . Most cases have been reported in homosexual such as salmonella, campylobacter and slugella may men , and the organism is believed to be transmitted cause chronic relapsing and/or bacteremic infection. sexually in these patients. Bacteremic illness is more Both humoral and cell-mediated immunity may be im­ likely to occur in patients with HIV infection, possibly portant in host defence against infection due to bac­ because of intestinal mucosa! and systemic defects in terial enteropathogens. Sera from HIV-infected subjects humoral and cell-mediated in1munity.

REFERE NCES 9. Gebhart CJ. Fennell CL, Murtaugh MP, Stan1m WE. 1. Quinn TC. Goodell SE, Fennell C, et al. Infections with Campylobactercinaedi is normal intestinal Dora in and campylobacter-like organisms hamsters. J Clin Microbial 1989:27:1692-4. in homosexual men. Ann Intern Med 1984:101:187-92. 10. Vandan1me P. Falsen E. Pot B. Kersters K. De LeyJ. 2. Perlman OM. Ampel NM, Schifman RB, et al. Persistent Iden tifi cation of Campylobacter cinaedi isolated from Campylobacter jejuni infections in patients infected with blood and feces of children and adult females. J Clin human immunodeficiency virus (HIV) . Ann Intern Med Mi crobiol 1990;28: 1016-20. 1988: 108:540-6. 11. Pasternal, J. Bolivar R, Hopfer RL. et al. Bacteremia 3. Vittecoq D. Boucot I, Bary M, Berche JF. Campylobacter caused by campylobacter-like organisms in two male and AIDS. Program and Abstracts. 30th Interscience homosei(uals. Ann Intern Med 1984:101:339-4 1. Conference on Antimicrobial Agents and Chemoth erapy, 12. Cimolai N. Gill MJ, Jones A, et al. ·campylobacter cinaedi" 1990:272. (Abst 1114) bacteremia: Case report and laboratory findings. J Clin 4. Vandamme P. Falsen E , Rossau R, et al. Revision of Microbial l 987;25:942-3. campylobacter, helicobacter, and wolinella ta'Conomy: 13. Ng VL, Hadley WK, Fennell CL. Flores BM, Stamm WE. Emendation of generic description and proposal of Successive bacteremias with ·campylobacter cinaedi" and Arcobacter gen nov. Int J Syst Bacte1iol 1991 :41:88- 103. ·campylobacter jennelliae· in a bisexu a l male. J Clin 5. Totten PA. Fennell CL, Tenover FC, et al. Campylobacter Microbial 1987;25:2008-9. cinaedi (sp nov) and Campylobacterfennelliae (sp nov). 14. Flores BM. Fennell CL, Holmes KK. Stamm WE. In vitro Two new Campylobacter species associated with enteric s u sceptibilities of campylobacter-like organisms to twenty disease in homosexual men. J Infect Dis 1985: 15 1: 13 1-9. antimicrobial agents. Antimicrob Agents Chemother 6. Grayson ML. Tee W. Dwyer B. associated 1985:28: 188-91. with Campylobacter cinaedi. MedJ Aust 1989: 150:214-5. 15. Kotler DP. Scholes JV, Tierney AR. Intestinal plasma cell 7. Blaser MJ. and the pathogenesis of alterations in acquired immunodeficiency syndrome. gastroduodenal . J Infect Dis Dig Dis Sci 1987:32: 129-38. 1990: 161 :626-33. 16. Rodgers VD. Fassett R, Kagnoff MF. Abnorm alities in 8. Francis ND. Logan RPH. Walker MM , et a l. intestinal mucosa! T cells in homosexual populations Campylobacter pylori in the upper including those with the lyrnphadenopathy syndrome and of patients with HIV-1 infection. J Clin Pathol acquired immunodefici ency syndrome. Gastroenterology 1990:43:60-2. 1986:90:552-8.

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