Proteus mirabilis infection - NCBI

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Gangrenous changes of the skin have not been de- ... that is, there was no loss of hair, and the skin was not ... The next day we excised the three affected ...
Blackened toes caused by Proteus mirabilis infection S. KRAJDEN,* MD, FRCP[C] M. DEITEL,t MD, FRCS[C] M. FUKSA,t D SC The next day we excised the three vascular surgeon performed Doppler A cutaneous infection by Proteus mirabilis may cause acute cellulitis with or affected toenails along with the proxi- studies of blood flow in the feet and legs. without gas formation, as well as macu- mal matrix. No specimens for culture The blood flow was normal. She was lar, papular or ecthymatous lesions in- were obtained at this time. A week later treated with cloxacillin, 500 mg intravedistinguishable from those caused by the drainage was still considerable, and nously every 6 hours, for 5 days and Pseudomonas aeruginosa.' Gangrenous conservative treatment, including warm then discharged from hospital. Cultures changes of the skin have not been de- soaks of the patient's feet, was institut- of the discharge from the toes had scribed in association with P. mirabilis ed. After 2 weeks the inflammation was yielded a heavy growth of P. mirabilis infection. We present a patient with an more marked, and pus continued to sensitive to cefazolin, ampicillin, genindolent P. mirabilis infection of her drain. The black discoloration of the tamicin, ticarcillin and tobramycin. No toes, of which the outstanding feature digits had persisted. In addition to eleva- anaerobes could be isolated. Two weeks after the woman's diswas black discoloration of the affected tion of the legs and warm soaks, penicildigits. This feature must be added to the lin V, 300 mg orally every 6 hours for 8 charge from hospital her toes were still black, inflamed and discharging pus spectrum of disease caused by this orga- days, was now prescribed. Six weeks after the nails had been (Fig. 1). P. mirabilis was again cultured nism. removed the same three toes were in- from the pus but anaerobes were not Case report flamed and giving off a yellow dis- isolated. Realizing that the P. mirabilis A 50-year-old American Indian was ,charge. Little healing had occurred, and might be the cause of the pseudoganreferred by her family physician for the the discoloration had spread proximally; grene, we prescribed ampicillin, 500 mg management of ingrown toenails. Eight the blackened portions seemed to have orally every 6 hours for 10 days. After 2 weeks earlier the large toes on both feet become progressively devitalized. She weeks there was no more purulent drainand the left second toe had become was admitted to hospital for more inten- age, the edema and erythema had subinfected. Five weeks after that a black sive therapy, including sodium hypo- sided, and cultures of specimens from discoloration of the infected toes had chlorite (Hygeol) compresses, regular the toes were negative for P. mirabilis. warm-water soaks, leg elevation and Roentgenograms of the toes did not become evident. The patient was afebrile and without parenteral antibiotic therapy. She was reveal any metallic deposits in the soft lymphangitis, inguinal adenopathy or afebrile, her peripheral leukocyte count tissues. Two months later the inflammation of any other cdnstitutional symptoms or was 11.4 X 109/l with a normal differensigns. The infected toenails were de- tial, and her fasting blood glucose level the toes had resolved and the black formed, elevated, rolled and digging into was 119 mg/dl (6.6 mmol/l). Since the discoloration had almost entirely disapthe skin, with pus oozing from under- toes were black and seemingly necrotic a peared (Fig. 2). A further 2 months neath them. The skin bordering the nails was black, and the surrounding areas were tender, erythematous and edematous. The patient denied a history of . diabetes mellitus in herself or other ~ .J~ family members. Her feet never felt cold, and she experienced no intermittent claudication. We found no trophic changes of ischemia on her feet or toes; that is, there was no loss of hair, and the FG. _1T bc iP , I Protemsmirabilis skin was not smooth and shiny. The dorsalis pedis and posterior tibial arteri- FIG. 1-Tws blackened by Proteus mirabilis infection. al pulses were excellent. We made a diagnosis of infected ingrown toenails with early gangrene related to digging and pressure.

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From St. Joseph's Health Centre, Toronto, and the University of Toronto *Director of medical microbiology, St. Joseph's Health Centre, and assistant professor of medicine and medical microbiology, University of Toronto tStaff surgeon, St. Joseph's Health Centre, and associate professor of surgery, University of Toronto .Assistant director of medical microbiology, St. Joseph's Health Centre Reprint requests to: Dr. S. Krajden, Department of medical microbiology, St. Joseph's Health Centre, 30 The Queensway, Toronto, Ont. M6R I B5

FIG. 2-Two months after ampicillin treatment the discoloration has almost disappeared.

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later the colour of her toes was normal. Discussion P. mirabilis was the agent responsible for both the infection and the black discoloration of our patient's toes. The strain we isolated was typical in its biochemical reactions2 and did not differ from the strains commonly isolated at our hospital. Hydrogen sulfide is a metabolic byproduct of P. mirabilis,2 and it is possible for this gas to react with trace metals in the skin. Iron, lead and copper are normally found in minute concentrations in the skin and nails,3 and the sulfides of these metals are black.4 Excessive quantities of these elements may have resulted in the discoloration of the infected tissues in our patient, but

roentgenograms of the toes showed no metallic deposits. No tissue analyses were undertaken, and the woman was lost to follow-up. Reaction of hydrogen sulfide with trace metals may well have caused blackening of the fingernails in a case reported a decade ago.5 In both that patient and our own the black discoloration of the digits cleared only after administration of an appropriate antimicrobial agent. We suggest that when the appearance of an infected digit suggests gangrenous cellulitis, chronic infection with P. mirabilis should be considered in the differential diagnosis. We thank Drs. Mladen Seidl for referring the patient, Douglas Wooster for the Doppler studies and Robert Bannatyne for reviewing

the manuscript, Ms. J. Widla for the bacterial identification and sensitivity studies and Messrs. L.J. Rudnicki and RI. Harris for the photography.

References I. WEINBERG AN, SwARTZ MN: Gram-negative coccal and bacillary infections. In FITZPATRICK TB, EISEN AZ, WOLFF K, FREEDBERG IM, AUSTEN KF (eds): Dermatology in General Medicine, 2nd ed, McGraw, New York, 1979: 1445-1459 2. MARTIN WJ, WASHINGTON JA II: Enterobacteriaceac. In LENNETrE EH, BALows A, HAUSLER Wi JR. TRU-

ANT JP (eds): Manual of Clinical Microbiology, 3rd ed, American Society for Microbiology, Washington, 19g0: 195-219 3. GOLDBLUM RW, DERBY 5, LERNER AB: The metal content of skin, nails and hair. J Invest Dermatol 1953; 20: 13-IS 4. HOGNESs TR, JOHNSON WC: Qualitative Analysis and Chemical Equilibrium, 4th ed, HR&W, New York, 1954 5. ZUEHIKE RL, TAYLOR WB: Black nails with Proteus mirahilis. Arch Dermasol 1970; 102: 154-155

Problems in diagnosis of bilateral obstruction of bronchi by foreign bodies KWAN-LEUNG CHAN, MD CHARLES J. CRUISE, MD

Foreign body aspiration is a well recognized problem in children;"3 most cases occur in the first 3 years of life,2'4'5 and a variety of objects, organic and inorganic, have been found in the tracheobronchial tree.4'5 However, aspiration by adults of foreign bodies besides food is not widely recognized, even though adults account for about one tenth of all cases of foreign body aspiration.2 Paroxysmal coughing, choking and wheezing are often associated with foreign body aspiration; however, up to two thirds of the patients do not have such a history.6 During the acute episode the patient may cough up the foreign body, but even if it is not dislodged the symptoms often subside. The patient may remain asymptomatic for a long time, then have a chronic productive cough, recurrent pneumonia, bronchiectasis or a lung abscess.4'7 Most foreign bodies can readily be removed by bronchoscopy; less than 10% necessitate thoracotomy.26 It is therefore very important to cDnsider this diagnosis so as to prevent long-term complications. The following case report underscores From the department of medicine, National Defence Medical Centre, Ottawa, and the University of Ottawa Reprint requests to: Dr. Kwan-Leung Chan, Department of medicine, Ottawa Civic Hospital, Ottawa, Ont. K Y 4E9

the importance of considering foreign turn production again increased and he body aspiration in patients with chronic began to experience dyspnea at rest. He obstructive lung disease whose pulmo- was therefore admitted to hospital. nary function suddenly and unexpectedThe roentgenographic appearance of ly deteriorates. the chest was unchanged. The patient was producing tenacious green sputum Case report from which Pseudomonas aeruginosa A 52-year-old man with a 40 pack- was cultured. A fever developed, his year smoking history and symptoms of sputum became rust-coloured, and that chronic asthmatic bronchitis for 10 day a chest roentgenogram showed an years noted an increase in sputum pro- infiltrate at the posterobasal segment of duction and a decrease in exercise toler- the right lung's lower lobe. He respondance: he would get short of breath after ed well to carbenicillin and gentamicin walking about 30 m and was unable to given intravenously. perform his normal work duties. Despite medical treatment his symptoms worsened, and he was admitted to hospital for investigation. He had diffuse rhonchi a.i minimal chest movement. Chest roentgenography did not demonstrate any infiltrate or foreign body (Fig. 1). Because an obstructive endobronchial neoplasm was suspected his airways were examined twice with a fibreoptic bronchoscope. The first examination was inadequate because of excessive mucus. The second revealed polypoid lesions at the carina that prevented further passage of the bronchoscope. Biopsy of the lesions showed squamous metaplasia. His symptoms subsided, and he was Fig 1 Chest roentgenogranu of patient with discharged taking bronchodilators and chronic asthmatic bronchitis, showing no infil ampicillin. At home, however, his spu- trate or foreign body

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