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Refer to: Denney D, Bigley RH, Rashad AL, et al: Recurrentpneumonitis due to pseudomonas cepacia-An unexpectedphagocyte dysfunction. West J Med 122:160-164, Feb1975

Recurrent Pneumonitis Dueto Pseudomonas Cepacia-An Unexpected Phagocyte

Dysfunction

DUANE DENNEY, MDROBERT H. BIGLEY, MDABDEL L. RASHAD, MD, PhDWALTER J. MacDONALD, MDMICHAEL J. MILLER, MD

Portland

A PATIENT with necrotizing pneumonitis due toPseudomonas cepacia (EO-I) was described pre-viously.' Two years later at age 21 years, thispatient again had severe pneumonia, and Ps.cepacia was isolated from bronchial washings.

The patient's phagocytes ingested but failed tokill Ps. cepacia and several other organisms. Thephagocyte dysfunction was indistinguishable fromthat found in chronic granulomatous disease ofchildhood (CGD). Most patients with CGD havefrequent infections, have multiple granulomatousabscesses beginning early in life, and have a shortlife span. In the present case, in sharp contrast tothis pattern, the clinical course of the patient hasbeen benign.

Materials and MethodsPhagocyte bactericidal capacity was determined

by a modification of the method of Quie et al.2From the Departments of Medicine, Clinical Pathology and

Pediatrics, University of Oregon Medical School, Portland.Supported in part by grants from USPHS, The Children's

Bureau, and the Medical Research Foundation of Oregon.Submitted, revised, August 9, 1974.Reprint requests to: D. Denney, MD, Department of Psychiatry,

University of Oregon Medical School, 3181 S.W. Sam JacksonPark Road, Portland, OR 97201.

One milliliter of reaction mixture containedphagocytes isolated from heparinized venousblood and bacteria, in quantities noted in Table1, suspended in Hanks' balanced salt solution con-taining 0.1 ml type AB Rh+ serum. After incuba-tion at 37°C (98.6°F) for two hours in a rotatingtumbler, 0.1 ml of reaction mixture was dilutedwith 0.9 ml of distilled water to lyse leukocytes;after culture in pour plates for 12 hours, colonieswere counted. Viable organisms remaining in amixture containing serum, known concentrationsof bacteria, and leukocytes before and after twohours' incubation were counted after lysis of cellswith sterile water.

Phagocyte nitroblue tetrazolium (NBT) reduc-tion was quantitated by the method of Baehner andNathan3 except that instead of fibrinogen for redcell sedimentation, one volume of 6 percent dex-tran in sterile 1 percent phosphate-buffered salinesolution, pH 7.4, was added to ten volumes ofblood.

Leukocyte fractionation and enzyme assayswere assessed by the methods of Holmes et al.4Formate oxidation (H202 production) was meas-ured by the technique of Holmes, Page and Good.5Some enzyme assays and determinations of

NBT reduction were done on blood specimens thathad been drawn six to ten hours earlier and trans-ported at airplane cabin temperatures. Activitiesof control specimens handled in the same fashionwere not different from those of fresh normalblood. Normal control specimens were taken fromadult laboratory and hospital personnel.

Case SummaryBefore age 5 years, the patient had frequent

respiratory infections with high fever. On fouroccasions, brief periods in hospital and penicillintherapy resulted in prompt resolution of fever.He was subsequently healthy until age 19 years,

when pneumonitis due to Ps. cepacia developed.The lungs cleared after several weeks' therapywith chloramphenicol.1 He was then well until 24months later when symptoms of upper respiratoryinfection developed in him and in others in hisfamily. Family members recovered promptly; butthe patient had progressively more severe chills,

160 FEBRUARY 1975 * 122 * 2

CASE REPORTS

fever, cough and pleuritic chest pain. An x-rayfilm of the chest showed a left lower lobe infiltrate.Treatment for one week with penicillin and ceph-loridin brought no improvement and he was trans-ferred to the University of Oregon Medical SchoolHospital.No other family member has had serious or re-

current infections.The patient was acutely ill, with a painful non-

productive cough. He appeared well developedand well nourished, and there was no evidence ofchronic debilitation. Blood pressure was 112/60mm of mercury, pulse 120 per minute and regu-lar, respiratory rate 20 per minute, and tempera-ture 40.6°C (105°F). Mucous membranes ofthe pharynx were dry but not erythematous.Lymph nodes were normal to palpation. The lefthemidiaphragm was elevated. Decreased breathsounds and occasional crepitant and fine inspira-tory rales were heard over the left lower lung. Nofriction rub was heard. Results of examination ofthe heart and peripheral vessels were within nor-mal limits. The liver, spleen and kidneys were notpalpable. No skin lesions were noted. Neurologicalexamination results were normal except for slightobtundation and irritability.The hematocrit was 40 percent and leukocytes

numbered 4,150 per cu mm with 63 percent poly-morphonuclear neutrophils, 14 percent bandforms, 13 percent lymphocytes and 10 percentmonocytes. Thrombocytes were present in normalnumbers. The urine was slightly cloudy with a p11of 5, specific gravity of 1.023 and 3 + albumin.Microscopic examination showed 5 to 10 pus cellsper high-power field and an occasional red cell,but no casts. The blood urea nitrogen was 17 mgper 100 ml and the creatinine clearance was 95 mlper minute. Quantitative urine protein was 100 mgin 24 hours. The serum glutamic oxaloacetic trans-aminase (SGOT) was 162 units (normal, 15 to45), bilirubin 0.7 mg per 100 ml, prothrombin-proconvertin 100 percent of normal, and brom-sulfalein retention 4 percent in 45 minutes.

Skin tests for tuberculosis, histoplasmosis, coc-cidioidomycosis and blastomycosis were negative,but normal cellular immunity was suggested by apositive mumps skin test. Cold agglutinins werepositive in a titer of 1:32. The patient's ability toform humoral antibodies was shown by the pres-ence of low titers of salmonella Groups C and E,brucella, and Weil-Felix antibodies. Serum IgGwas 2,000 (normal, 800 to 1,800), IgA 560 (nor-mal 90 to 450), IgM 90 (normal 60 to 250), and

group pB1C complement 570 mg per 100 ml (nor-mal 80 to 140).An x-ray film of the chest on admission showed

an infiltrate in the postero-lateral segments of theleft lower lobe. The films were strikingly similar tothose taken two years before (Figure 1).

Sputum, nasopharyngeal and blood culturesgrew no pathogenic organisms. At bronchoscopy,segmental bronchi of the left lower lobe were ob-served to be inflamed and edematous, and pusobtained from this area grew Ps. cepacia. Bothin its cultural and biochemical characteristics itwas similar to the organism isoiated from the pa-tient's sputum in 1967. Results of in vitro anti-microbial disc susceptibility tests were identical inboth isolates. They were sensitive to chlorampheni-col and kanamycin, intermediately sensitive totetracycline and resistant to ampicillin, cephalo-thin, streptomycin, polymyxin and penicillin. ThePs. cepacia isolated in 1969 was also found to beresistant to gentamicin.

In view of the patient's critical condition andprevious response, he was given cloramphenicol,12 grams a day. Within 36 hours, the temperaturehad returned to normal. Over the ensuing tendays, chest findings and x-ray showed pronouncedimprovement. The SGOT and urine abnormalitiesdisappeared. Chloramphenicol was decreased to6 grams a day on the third day, and to 2 grams aday on the seventh day. This dose was maintainedfor 24 days, although serum inhibitory activity(SIA) determinations showed no inhibition ofgrowth in undiluted serum. On the basis of discsensitivity tests, kanamycin was given for ten days(day 22 to 32) but was discontinued because ade-quate SIA could not be obtained.We considered use of carbenicillin, a drug

known to be active against Pseudomonas orga-nisms. The minimum inhibitory concentration(MIC) determined by the broth dilution methodwas found to be 6.2 jug per ml and disc diffusiontests showed a zone of 28 mm around a 100 tLGmcarbenicillin disc. Since adequately high serumlevels can easily be achieved with carbenicillin,6the patient received 6 grams a day intravenouslyfrom day 32 through discharge on day 39.

The patient left the hospital without symptomsand without physical findings of residual lung dis-ease. An x-ray film of the chest showed no ab-normality except for scarring and elevation of theleft diaphragm as shown in Figure 1.

In follow-up by the patient's family physicianto the present time no new findings or subsequent

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CASE REPORTS

AU1jGUST 22 SEPTEMBER 14

OCTOBER 13 NOVEMBER 14

Figure 1.-Admission and discharge chest x-ray films showing similar left lower lobe infiltrates which cleared ineach case after chloramphenicol therapy.

162 FEBRUARY 1975 * 122 * 2

1967-

_.....

1969-

.i

k

7

CASE REPORTS

- .032 (2) .158 (2) 03 4 9 .249

Chart 1.-Family pedigree and nitroblue tetrazolium re-duction tests. Patient indicated by arrow. Figures repre-sent net change in optical density X515/2.5X10" phago-cytes, with number of determinations in parenthesis.Normal controls (N=34) averaged 0.206, range 0.153-0.425. -/ /-= divorce.

serious illness of any kind has been observed. Thepatient appears to have fully recovered.

Additional StudiesQuantitative NBT reduction (Chart 1) by the

patient's leukocytes was decidedly low on hospitalday 38, and was unchanged three months later.Values in his mother were intermediate, and thoseof his maternal grandmother and of a half-sisterwere near but below the lowest normal valuesobserved in our laboratory.

Bactericidal studies (Table 1) showed that thepatient's leukocytes failed to kill Ps. cepacia, Ps.aeruginosa, E. coli and S. aureus.

Phagocytosing H202 production, measured asformate oxidation, was subnormal (Table 2). Pa-tient phagocytes, incubated with latex alone for15 minutes, engulfed 5 to 20 particles per cell,showing that phagocytosis was normal. Activitiesof glutathione peroxidase, glutathione reductase,glucose-6-phosphate dehydrogenase and 6-phos-phogluconate dehydrogenase in the patient's leu-kocytes were normal.

Review of biopsy material from the lung ob-tained during the patient's first admission showednecrotizing granulomas (Figure 1 ). No pigmentedhistiocytes were found.

After the patient was discharged from thehospital, a second strain of Ps. cepacia highly re-sistant to carbenicillin was identified in the originalculture.

DiscussionIt was difficult to decide on the right therapy for

this patient. His condition did respond to massivedoses of chloramphenicol without serious side

TABLE 1.-Comparison of Leukocyte Bacterial Capacityin Patient and a Normal Control

120 MinutesZero Time

Organism Control Subject Cells Control Cells

S. aureus* ......... 6.3 6.2 (98) 3.5 (55)Ps. aeruginosa* .. 3.35 3.3 (98) 1.1 (33)E. coli* . 6.05 5.8 (96) 2.35 (39)Ps. cepacia (EO-I)t . 1.4 0.9 (64) 0.05 (3)

Results expressed as numbers of viable bacteria X 106/ml ofincubation mixture before (zero time) and after (120 min) incu-bation. The zero time mixture contained no phagocytes. Figuresin parentheses represent percent of zero time control bacteria sur-viving at 120 minutes.

*1.OX106 phagocytes in 1 ml incubation mixture.t2.0X10" phagocytes in 1 ml incubation mixture.

TABLE 2.-Phagocyte 14C-Formate Oxidation

Subject Cells Control Cells

Number of Determinations .... 2 12Resting .................... 0.26* 0.46±0.16tPhagocytosing ............... 0.36t 1.19±0.28

*Nanomoles C02/107 phagocytes/40 mmtMean ± S.D.tp <.005

effects. However, the severity of illness and thehigh likelihood that the patient was still infectedand susceptible to reactivation of life-threateningdisease led some consultants to recommend lobec-tomy on the infected lung. We elected not to dothis because of the likelihood that there was bothupper and lower lobe involvement that would re-quire pneumonectomy which could be carriedout at a time when he was clinically well. Further-more, we were hesitant to cross pleural barriers ina patient who had clinically recovered from acuteinfection.

Therapeutic concentration of kanamycin couldnot be achieved, making it an unsatisfactory back-up drug should he once again become ill. Carbeni-cillin appeared promising on the basis of discsensitivity studies, but SIA was not determined.Even with an adequate serum inhibitory level, thedrug may not penetrate into diseased lung andgranulomas. Unfortunately, Pseudomonas strainsmay rapidly become resistant to carbenicillintherapy.7 Furthermore, we were able to separatea resistant mutant in his original culture, suggest-ing that, even with adequate tissue levels, survivalof organisms remained a possibility. Two recentreports8 9 demonstrated that combinations includ-ing trimethoprim (TMP) and sulfamethoxazole areactive against Ps. cepacia. TMP-sulfamethoxazolewas used for treatment of Ps. cepacia endocarditisand in one case9 it was successful in sterilizing thepatient's blood and aortic valve.

In the present case, the unusual infections seem

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CASE REPORTS

clearly related to the patient's leukocyte dysfunc-tion. His mild clinical course sets him apart fromother patients with CGD. CGD is characterized clini-cally by severe recurrent infections with bacteriawhich are often of low virulence, widespread sup-purative granulomas containing lipid-laden macro-phages, and sex-linked inheritance. Clinical varia-tions among patients with CGD have beennoted.'0-'4 Only one patient, Case 8 of Thompsonand Soothill, approaches our patient in paucityof infections." That patient, an 11-year-old boy,had chronic skin sepsis during his first year, agroin abscess at age three years and pneumoniatwice at age ten years. Of five patients living toages 13 to 20 years, all had abdominal visceralabscesses in addition to many other infections."'-14

CGD phagocytes have subnormal post-phagocyticincrements in H202 production5 and NBT reduc-tion.3 They do not efficiently kill staphylococciand certain Gram-negative bacilli, organismswhich produce no net H202.15 In these respects,our patient's phagocytes are quantitatively as ab-normal as other CGD phagocytes. However, thesedeterminations do not directly measure the activityof the undefined abnormal gene product(s) re-sponsible for CGD. Leukocyte glutathione peroxi-date deficiency4"16 (which is clinically differentfrom CGD only in its autosomal recessive inheri-tance) and profound G-6PD deficiency are twoof possibly several enzyme deficiencies whichmake up the CGD syndrome.

Variation in clinical and laboratory manifesta-tions of genetically determined disorders is deter-mined by differences in kinds of mutation and inmodifying factors, including environment. Thecauses of clinical variation among patients withCGD and glutathione peroxidase deficiency are notyet established, but extreme variation obviouslyoccurs. Our patient's relatively infrequent severeinfections may be due to a less than disastrousmutation. This case suggests that leukocyte dys-function should be considered in any patient, re-gardless of age, who has unusual infections.

SummaryRecurrent pneumonitis due to Pseudomonas

cepacia (EO-I) developed in a previously healthypatient. Phagocyte bactericidal, peroxide-generat-ing and nitroblue tetrazolium-reducing capacitieswere decreased. A relatively benign history and thegood health of the patient at age 22 years set thiscase apart from other cases of chronic granuloma-tous disease.

AddendumShortly after this manuscript was submitted, the

patient was readmitted to the University of OregonHealth Sciences Center with a recurrence of severeleft lower lobe pneumonitis. The history, physicaland radiological findings were remarkably similarto those in the previous two episodes. Mild phago-cyte dysfunction was again demonstrated. Nopathogen could be isolated from sputum, bronchialwashings, blood cultures or material from needleaspiration of the lung. In the face of a rapidlydeteriorating course, his physicians institutedchemotherapy consisting of cephalothin, genta-mycin and carbencillin. Within 36 hours the pa-tient's temperature returned to normal and thepneumonitis resolved rapidly over the ensuing fivedays. The patient has returned to Alaska and iscurrently asymptomatic.

ACKNOWLEDGMENTS: J. W. Mortenson, MD, Ketchi-kan, Alaska, the patient's family physician, made manycontributions to this study. The Charles Pfizer Com-pany (Dr. A. Knirsch) supplied carbenicillin gratis.

REFERENCES1. Daily RH, Benner EJ: Necrotizing pneumonitis due to the

Pseudomonad "Eugonic Oxidizer-Group I." N Engl J Med 279:361-362, 1968

2. Quie PG, White JG, Holmes RA: In vitro bactericidal ca-pacity of human polymorphonuclear leukocytes-Diminished ac-tivity in chronic granulomatous disease of childhood. J Clin Inv46:668-679, 1967

3. Baehner FL, Nathan DG: Quantitative nitroblue tetrazoliumtest in chronic granulomatous disease. N Engl J Med 278:971-976,1968

4. Holmes B, Park BH, Malawista SE, et al: Chronic granu-lomatous disease in females-Deficiency of leukocyte glutathioneperoxidase. N Engl J Med 283:217-221, 1970

5. Holmes B, Page AR, Good RA: Studies of the metabolicactivity of leukocytes from patients with a genetic abnormalityof phagocyte function. J Clin Inv 46:1422-1432, 1967

6. Acred P, Brown DM, Knudsen ET, et al: New synthetic peni-cillin active against Pseudomonas pyocyanea. Nature (London)215:25-30, 1967

7. Meyers BR, Sabbaj J, Weinstein L: Bacteriological, pharma-cological and clinical studies of carbenicillin. Arch Intern Med125:282-286, 1970

8. Hamilton J, Burch W, Grimmet G, et al: Successful treat-ment of Pseudomonas cepacia endocarditis with trimethoprim-sulfamethoxazole. Antimicrob Agents Chemoth 4:551-554, 1973

9. Neu HC, Garvey GJ, Beach PB: Successful treatment ofPseudomonas cepacia endocarditis in a heroin addict with tri-methoprim-sulfamethoxazole. J Infect Dis 128 (Suppl):S768-S770,1973

10. Douglas SD, Davis WC, Fudenberg HH: Granulocytopathies:Pleomorphism of neutrophil dysfunction. Am J Med 46:901-909,1969

11. Thompson EF, Soothill JF: Chronic granulomatous disease-Quantitative clinicopathologic relationships. Arch Dis Child45:24-32, 1970

12. Davis WC, Douglas SD, Fudenberg HH: A selective neu-trophil dysfunction syndrome-Impaired killing of staphylococci.Ann Intern Med 69:1237-1243, 1968

13. Mattison RA, Gooch WM, Guezlow KWL, et al: Chronicgranulomatous disease of childhood in a 17-year-old boy. J Ped76:890-894, 1970

14. Mandell GL, Hook EW: Leukocyte function in chronicgranulomatous disease of childhood. Am J Med 47:473-486, 1969

15. Mandell GL, Hook EW: Leukocyte bactericidal activity inchronic granulomatous disease-Correlation of bacterial hydrogenperoxide production and susceptibility to intracellular killing. JBact 100:531-532, 1969

16. Quie PG, Kaplan EL, Page AR, et al: Defective polymorpho-nuclear-leukocyte function and chronic granulomatous disease intwo female children. N Engl J Med 278:976-980, 1968

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