Human Streptococcus suis Meningitis in the United States
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《新英格兰医药杂志》
To the Editor: Streptococcus suis commonly causes meningitis in swine. Human infection is infrequent and is typically manifested as meningitis, frequently followed by permanent sensorineural hearing loss. Most cases have occurred in Southeast Asia. A recent outbreak in China resulted in substantial morbidity and mortality. The World Health Organization reports that nearly all those affected were farmers or butchers who had been either killing sick pigs or handling their meat. Transmission may occur through breaks in the skin.1 We report a case of human S. suis infection in the United States.
A 59-year-old, previously healthy male farmer presented with a sudden onset of fever and confusion. On physical examination, he was minimally responsive with meningismus, a temperature of 39.2°C, blood pressure of 115/63 mm Hg, a pulse of 135 beats per minute, and a respiratory rate of 22 breaths per minute. The white-cell count was 12,800 per cubic millimeter with 73 percent neutrophils and 12 percent bands. A lumbar puncture yielded the following: cloudy fluid with 3520 white cells per cubic millimeter (100 percent neutrophils); glucose less than 1 mg per deciliter; and total protein 368 mg per deciliter; a Gram's staining showed gram-positive diplococci. Ceftriaxone (2 g) and vancomycin (1 g every 12 hours) with dexamethasone (0.15 mg per kilogram of body weight every 6 hours) were given intravenously. His condition deteriorated and he required intubation. Cultures of blood and cerebrospinal fluid obtained at presentation grew S. suis. On the basis of results of susceptibility testing, his antibiotic therapy was modified to intravenous ampicillin (2 g every four hours). On hospital day 4, the patient was extubated; he was verbally responsive and able to follow commands. The next day, he reported low back pain. Magnetic resonance imaging revealed diskitis and osteomyelitis of L3 and L4. S. suis has been associated with spondylitis.2 The patient was discharged to his home without symptoms and neurologically intact after a 13-day hospital stay, with instructions to complete 6 weeks total of intravenous ampicillin followed by 6 weeks of oral clindamycin (450 mg, three times daily) for presumed osteomyelitis. At the completion of the antibiotic therapy, the patient appeared well and said he no longer had back pain. His hearing, although not formally tested, remained grossly normal.
An investigation to identify the source of S. suis revealed that several months before admission, the patient had acquired piglets from a local farm where a littermate subsequently died of illness consistent with meningitis. The patient's piglets remained healthy and were routinely slaughtered before indications for S. suis testing were evident. Endemic S. suis was found on the farm of origin. This case should heighten awareness of the potential for occupational exposure and human infection with S. suis.
Kara S. Willenburg, M.D.
Deborah E. Sentochnik, M.D.
Mary Imogene Bassett Hospital
Cooperstown, NY 13326
kara.willenburg@bassett.org
Ruth N. Zadoks, D.V.M., Ph.D.
Cornell University College of Veterinary Medicine
Ithaca, NY 14850
References
World Health Organization Regional Office for the Western Pacific. Outbreak associated with Streptococcus suis in pigs in China: update. 2005. (Accessed March 6, 2006, at http://www.wpro.who.int/media_centre/news/news_20050816.htm.)
Marie J, Morvan H, Berthelot-Herault F, et al. Antimicrobial susceptibility of Streptococcus suis isolated from swine in France and from humans in different countries between 1996 and 2000. J Antimicrob Chemother 2002;50:201-209.
A 59-year-old, previously healthy male farmer presented with a sudden onset of fever and confusion. On physical examination, he was minimally responsive with meningismus, a temperature of 39.2°C, blood pressure of 115/63 mm Hg, a pulse of 135 beats per minute, and a respiratory rate of 22 breaths per minute. The white-cell count was 12,800 per cubic millimeter with 73 percent neutrophils and 12 percent bands. A lumbar puncture yielded the following: cloudy fluid with 3520 white cells per cubic millimeter (100 percent neutrophils); glucose less than 1 mg per deciliter; and total protein 368 mg per deciliter; a Gram's staining showed gram-positive diplococci. Ceftriaxone (2 g) and vancomycin (1 g every 12 hours) with dexamethasone (0.15 mg per kilogram of body weight every 6 hours) were given intravenously. His condition deteriorated and he required intubation. Cultures of blood and cerebrospinal fluid obtained at presentation grew S. suis. On the basis of results of susceptibility testing, his antibiotic therapy was modified to intravenous ampicillin (2 g every four hours). On hospital day 4, the patient was extubated; he was verbally responsive and able to follow commands. The next day, he reported low back pain. Magnetic resonance imaging revealed diskitis and osteomyelitis of L3 and L4. S. suis has been associated with spondylitis.2 The patient was discharged to his home without symptoms and neurologically intact after a 13-day hospital stay, with instructions to complete 6 weeks total of intravenous ampicillin followed by 6 weeks of oral clindamycin (450 mg, three times daily) for presumed osteomyelitis. At the completion of the antibiotic therapy, the patient appeared well and said he no longer had back pain. His hearing, although not formally tested, remained grossly normal.
An investigation to identify the source of S. suis revealed that several months before admission, the patient had acquired piglets from a local farm where a littermate subsequently died of illness consistent with meningitis. The patient's piglets remained healthy and were routinely slaughtered before indications for S. suis testing were evident. Endemic S. suis was found on the farm of origin. This case should heighten awareness of the potential for occupational exposure and human infection with S. suis.
Kara S. Willenburg, M.D.
Deborah E. Sentochnik, M.D.
Mary Imogene Bassett Hospital
Cooperstown, NY 13326
kara.willenburg@bassett.org
Ruth N. Zadoks, D.V.M., Ph.D.
Cornell University College of Veterinary Medicine
Ithaca, NY 14850
References
World Health Organization Regional Office for the Western Pacific. Outbreak associated with Streptococcus suis in pigs in China: update. 2005. (Accessed March 6, 2006, at http://www.wpro.who.int/media_centre/news/news_20050816.htm.)
Marie J, Morvan H, Berthelot-Herault F, et al. Antimicrobial susceptibility of Streptococcus suis isolated from swine in France and from humans in different countries between 1996 and 2000. J Antimicrob Chemother 2002;50:201-209.