ffournal of Hospital Infection (1985) 6, 3 2 3 - 3 2 5

S H O R T R E P O R T

B r a n h a m e l l a o a t a r r h a l i s e e l l u l i t i s a r o u n d a e e r e b r o - s p i n a l f l u i d s h u n t : c a s e r e p o r t

B r u c e A. K a u f m a n a n d M a t t J. L i k a v e c *

Divis ion o f N e u r o s u r g e r y , Case W e s t e r n Rese rve Un ive r s i t y , U n i v e r s i t y Hosp i t a l s of Cleve land , 2074 A b i n g t o n Road , Cleve land , Oh io 44106, U S A *Divis ion o f N e u r o s u r g e r y , Case W e s t e r n Reserve Un ive r s i t y , C leve land M e t r o p o l i t a n Gene ra l Hospi ta l , 3395 S c r a n t o n Road , Cleve land , Oh io

44109, U S A

Accepted for publication 5 February 1985

Summary: A cel lu l i t i s s u r r o u n d i n g a c e r e b r o s p i n a l f lu id s h u n t c a u s e d b y Branhamella catarrhalis is d e s c r i b e d . T h i s is t he f i rs t r e p o r t e d case o f a ce l lu l i t i s c a u s e d b y t h i s b a c t e r i u m .

I n t r o d u c t i o n

.Branhamella catarrhalis, fo rmer ly Neisseria catarrhalis, has been cons ide red a c o m m e n s a k o f the u p p e r r e sp i r a to ry t rac t tha t is pa thogen ic on occas ion (Feigin , San Joaqu in 86 M i d d e l k a m p , 1969; D o e r n , Mi l le r 86 W i n n , 1981; S r in ivasan et al., 1981; Edi tor ia l , 1982). T h e o r g a n i s m has been p rev ious ly r epor t ed to be respons ib le for m i n o r u p p e r r e sp i r a to ry t rac t infect ions, or m o r e ser ious infec t ions in i m m u n o c o m p r o m i z e d pat ients . W e repor t the first k n o w n case o f celluli t is caused by this o r g a n i s m in a hea l thy pat ient .

Case h i s tory

T h e pa t i en t was a 4 - y e a r - o l d wh i t e girl w i th a craniofacia l abnorma l i t y . She deve loped obs t ruc t ive h y d r o c e p h a l u s r e q u i r i n g ven t r i cu lope r i tonea l s h u n t - ing at age 5 m o n t h s . N o s u b s e q u e n t s h u n t revisions were r equ i red .

She u n d e r w e n t several craniofacia l r epa i r opera t ions p r io r to this ad- miss ion . A t age 3½ years , she suf fered a r e sp i r a to ry a r res t a f ter he r t r a c h e o s t o m y inadve r t en t ly d is lodged. A spon t a ne ous l y reso lv ing p n e u m o - m e d i a s t i n u m was no ted .

She p r e s e n t e d at 4 yea r s of age w i t h a fever , and h a d an area of i n d u r a t i o n Address correspondence to: Bruce A. Kaufman M.D. , Division of Neurosurgery, Cleveland Metropol i - tan General Hospitial, 3395 Scranton Road, Cleveland, Ohio 44109 USA. (2162459-4384)

0195-6701/85/030323 + 03 $03.00/0 ~) | 985 The Hospital Infection Society

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324 B. A. K a u f m a n a n d M. J. Likave©

and tenderness above her right breast overlying her shunt tract and approximately 4 cm from the .healed tracheostomy site. Over several days the area enlarged to 7 cm × 10 cm. The patient defervesced on treatment with oral dicloxacillin. During removal of the shunt caseous material extruded from the region of induration and Bran. catarrhalis was cultured from it. The infection quickly cleared with parenteral nafcillin and the shunt was later replaced without difficulty.

D i s c u s s i o n

Infections of cerebrospinal fluid shunts separate into two groups: 'acute' infections occurring within several months of implantation, and 'delayed' infections appearing later. Approximately 60-+80% of shunt infections are acute. Since staphylococcal species are responsible for 60-70% of these infections (Shurtleff, Christie & Fultz, i971; Schoenbaum, Gardner & Shillito, 1975; George, Leibrock & Epstein, 1979), peri-operative introduc- tion of the infecting organism has been suggested as the source for the majority of these infections (Schoenbaum et al., 1975).

The delayed shunt infections noted by George et al. (1979) showed no significant difference from acute infections in either the type of organism isolated, or in the species of staphylococcus found. Schoenbaum et al. (1975), however, postulate that a bacteraemia in the presence of the shunt could lead to seeding and infection, but they 'note no statistical confirmation of this.

Staphylococcus epidermidis occurs about twice as often as Staph. aureus. Enterobacteriaceal are isolated in approximately 15°~, streptococcal species in approximately 9%, and a variety of organisms (including diphtheroids, anaerobes, Mycobacteriurn tuberculosis, Haemophilus influenzae and Can- dida) in approximately 10% of shunt infections (Shurtleff et al., 1971; Schoenbaum et al., 1975; George et al., 1979).

Branhamella catarrhalis is a Gram-negative coccus that is ubiquitous to the upper respiratory tract. Generally considered a harmless commensal, it has been associated with upper respiratory infection and has been reported as a primary pathogen in lower respiratory tract infections in immunocom- promised patients (Srinivasan" et al . , 1981; Editorial, 1982). The organism has been isolated as the cause of several fulminar/t infections; meningit'~s in at least 34 cases, and endocarditis in four (Doern et al., 1981). Many other infections have been attributed to Bran. catarrh'alis (I~erbert & Ruskin, 1981), bu t there is n o repOrt of the organism causing cellulitis. The aetiology o f the infection in our patient is not clear; the absence of ihamunologic deficiency, operative manipulation of the shunt and the nature of the infecting oxganism all mitigate against a primary shunt+ infection. H o w e v ~ , the patient had a long history of upper respiratory tract difficul- ties with several opera t ions that could have resulted in a haematologic spread of'the organism. But is it more likely that infection resulted by direct

B. catarrhalls cellulitis 325

extension of the organism from the tracheostomy site, perhaps introduced at the time of the respiratory arrest and resuscitation months earlier.

References

Doern, G. V., Miller, M. J. & Winn, R. E. (1981). Branhamella (Neisseria) eatarrhalis systemic disease in humans: case reports and review of the literature. Archives of Internal Medicine 141, 1690-I 692.

Editorial (1982). Branhamella catarrhalis: Pathogen or Opportunist? Lancet i, 1056. Feigin, R., San Joaquin, V. & Middelkamp, J. N. (1969). Purpura Fulminas associated with

Neisseria catarrhalis septicemia and meningitis. Pediatrics 44, 120-123. George, R., Leibrock, L. & Epstein, M. (1979). Long term analysis of eerebrospinal fluid

shunt infections: A 25 year experience, ffournal of Neurosurgery 51, 804-811. Herbert, D. A. & Ruskin, J. (1981). Are the "Non-Pathogenic" Neisseria pathogenic?

American ffournal of Clinical pathology 75, 739-743. Scheonbaum, S. C., Gardner, P. & Shillito, J. (1975). Infections of cerebrospinal fluid

shunts: epidemiology, clinical manifestations, and therapy. ~ournal of Infectious Disease 131, 543-552.

Shurtleff, D. B., Christie, D. & Fultz, E. L. (1971). Ventriculostomy associated infection: A 12 year study. Journal of Neurosurgery 35, 686-694.

Srinivasan, G., Raft, M., Templeton, W. C., Givens, S., Graves, R. C. & Melo, J. C. (1981). BranhameUa catarrhalis pneumonia: Report of two cases and review of the literature. American Review of Respiratory Disease 123, 553-555.