Ir J Med Sci (2009) 178:541–542 DOI 10.1007/s11845-009-0396-3
CASE REPORT
A fatal case of Pasteurella multocida epiglottitis K. O’Connell Æ J. Fennell Æ J. Callaghan Æ B. Rowaiye Æ M. Cormican
Received: 3 March 2009 / Accepted: 29 June 2009 / Published online: 7 August 2009 Ó Royal Academy of Medicine in Ireland 2009
Abstract Introduction Pasteurella multocida, a Gram-negative bacillus, is rarely associated with acute respiratory infections. Aim To describe a case of fatal P. multocida epiglottitis. Results A 52-year-old gentleman developed a sore throat and died suddenly within an hour of seeing his general practitioner. Post-mortem findings were consistent with death due to laryngeal obstruction associated with epiglottitis and laryngopharyngitis. A swab taken from the epiglottis for culture was positive for P. multocida. Conclusion Physicians should be aware of the potential for acute deterioration in adults with acute epiglottitis. Keywords
Fatal Pasteurella multocida Epiglottitis
Background Pasteurella multocida is a Gram-negative bacillus present in the nasopharynx of many species of domestic and wild animals. Human infection usually follows animal bites or droplet transmission from animals. Typical manifestations are skin or soft-tissue infection at the site of a cat or dog bite. P. multocida
K. O’Connell (&) J. Fennell Department of Medical Microbiology, Galway University Hospital, Galway, Ireland e-mail:
[email protected]
is very rarely associated with acute respiratory infections. We report a case of fatal P. multocida acute epiglottitis.
Case report In May 2006, a 52-year old man developed a sore throat. He lived in a rural area with his brother. On examination, his general practitioner (GP) noted a mildly erythematous and swollen pharynx and low-grade temperature. There was no dyspnoea, stridor, or other respiratory symptoms. He prescribed amoxicillin. The patient died suddenly within an hour of seeing the GP. At post mortem examination, the findings included massive edema and acute suppurative inflammation of the epiglottis and larynx extending widely into adjacent muscle. Tardieu spots were present in the lungs (subpleural spots of ecchymosis seen after death by suffocation). There was also marked congestion and edema within the lungs. Blood collected at the post mortem revealed a neutrophil count of 15.8, with a normal eosinophil count. Penicillin-specific IgE was not detected and serum tryptase was normal. The findings were consistent with death due to laryngeal obstruction with associated epiglottitis and laryngopharyngitis. A swab from the epiglottis was taken for culture and was positive for P. multocida. The identity of the organism was confirmed by Vitek 1 GNI card. The patient kept ten cats including one that slept on the bed of the deceased. Nasal and pharyngeal swabs collected by a veterinarian from this cat were negative for P. multocida.
J. Callaghan B. Rowaiye Department of Histopathology, Galway University Hospital, Galway, Ireland
Discussion
M. Cormican Department of Bacteriology, National University of Ireland Galway, Galway, Ireland
Pasteurella multocida is a small, Gram-negative, non-motile, non-spore-forming coccobacillus. Pasteur characterized
123
542
bacteria belonging to the genus in 1880, 2 years after they were isolated from birds with cholera. It is capsulate in culture at the optimal growth temperature of 37°C and exhibits bipolar staining. The organism grows readily on blood agar and is carried in the nasopharyngeal region of many species of both domestic and wild animals. Infection in humans results usually from animal contact with a domestic cat or dog however, several cases with no known animal exposure have been described. The most common manifestation of infection with P. multocida is soft-tissue infection following animal bites and scratches. P. multocida can also be isolated from the respiratory tract. This is most often seen in patients with underlying pulmonary disease and may result in pneumonia, empyema and lung abscess. Other sites of infection, including bone and joint, central nervous system, endocarditis and intra-abdominal infections have also been reported. P. multocida is a very rare cause of acute epiglottitis. Acute epiglottitis is a cellulitis of the epiglottis and adjacent structures with risk of acute respiratory obstruction. There has been a decline in the incidence of epiglottitis in children since the introduction of a vaccine for Haemophilus influenza b vaccine, which is the most common etiological agent. The incidence of epiglottitis in adults, however, has increased steadily. The mortality rate is also higher in adults than in children and this is thought to be related to delay in diagnosis and inappropriate treatment [1]. Adult patients with epiglottitis usually present with sore throat and odynophagia. Acute epiglottitis can only be diagnosed reliably by fiberoptic laryngoscopy [2]. Haemophilus influenza type b is the etiological agent in the majority of cases; however, other bacterial causes include Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus and Gram-negative organisms. The treatment of epiglottitis consists of administration of appropriate antibiotics and management of the airway. Some authors advocate aggressive management of the
123
airway with early intubation, whereas others promote a more conservative approach [2]. This case illustrates the potential for acute deterioration in adults with acute epiglottitis. The first reported case of acute epiglottitis caused by P. multocida was in 1977 [3]. Since this time, there have been six further case reports [4–9]. In all cases, the patient responded to treatment with a combination of a b-lactam antibiotic with or without steroids. To our knowledge, this is the first fatal case report of P. multocida epiglottitis. The presumed source of infection was cats; however, the pathogen was not isolated from the only cat available for testing.
References 1. MayoSmith MF, Hirsch PJ, Wodzinski SF et al (1986) Acute epiglottitis in adults: an 8-year experience in the state of Rhode Island. N Engl J Med 314:1133–1139 2. Wick F, Ballmer P, Haller A (2002) Acute epiglottitis in adults. Swiss Med Wkly 132:541–547 3. Johnson RH, Rumans LW (1977) Unusual infections caused by Pasteurella multocida. JAMA 237:146–147. doi:10.1001/jama. 237.2.146 4. Rydberg J, White P (1993) Pasteurella multocida as a cause of acute epiglottitis. Lancet 341:381. doi:10.1016/0140-6736(93) 90193-K 5. Leung R, Jassal J (1994) Pasteurella epiglottitis. Aust N Z J Med 24:218 6. Jenkins WA (1997) Pasteurella multocida as a cause of acute adult epiglottitis. Am J Emerg Med 15:323. doi:10.1016/S0735-6757 (97)90028-0 7. Wine N, Lim Y, Fierer J (1997) Pasteurella multocida epiglottitis. Arch Otolaryngol Head Neck Surg 123:759–761 8. Glickman M, Klein RS (1997) Acute epiglottitis due to Pasteurella multocida in an adult without animal exposure. Emerg Infect Dis 3:408–409 9. Prakash V, Yun H (2008) Pasteurella multocida epiglottitis and bacteremia in a patient with chronic lymphocytic leukemia: case report and review of the literature. Infectious Diseases in Clinical Practice. Lippincott Williams & Wilkins, September
