Correspondence

Human Streptococcus suis Meningitis in the United States

N Engl J Med 2006; 354:1325March 23, 2006

Article

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

2 References

1. 1

   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.)
   

2. 2

   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
   CrossRef | Web of Science | Medline

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   Tara C. Smith, Abby L. Harper, Rajeshwari Nair, Shylo E. Wardyn, Blake M. Hanson, Dwight D. Ferguson, Anne E. Dressler. (2011) Emerging Swine Zoonoses. Vector-Borne and Zoonotic Diseases 11:9, 1225-1234
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   Lili Song, Hui Zhou, Xuehui Cai, Chunyang Li, Jingnan Liang, Cheng Jin. (2011) NeuA O-acetylesterase activity is specific for CMP-activated O-acetyl sialic acid in Streptococcus suis serotype 2. Biochemical and Biophysical Research Communications 410:2, 212-217
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   VG Papatsiros, D Vourvidis, AA Tzitzis, PS Meichanetsidis, D Stougiou, D Papaioannou. (2011) Streptococcus suis: an important zoonotic pathogen for human prevention aspects. Veterinary World216
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   Hee Jae Huh, Kyoung-Jin Park, Ja-Hyun Jang, Mina Lee, Jang Ho Lee, Yoon Hee Ahn, Cheol-In Kang, Chang-Seok Ki, Nam Yong Lee. (2011) Streptococcus suis Meningitis with Bilateral Sensorineural Hearing Loss. The Korean Journal of Laboratory Medicine 31:3, 205
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   Anding Zhang, Ming Yang, Pan Hu, Jiayan Wu, Bo Chen, Yafeng Hua, Jun Yu, Huanchun Chen, Jingfa Xiao, Meilin Jin. (2011) Comparative genomic analysis of Streptococcus suis reveals significant genomic diversity among different serotypes. BMC Genomics 12:1, 523
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   Marcelo Gottschalk, Jianguo Xu, Cynthia Calzas, Mariela Segura. (2010) Streptococcus suis : a new emerging or an old neglected zoonotic pathogen?. Future Microbiology 5:3, 371-391
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   Youjun Feng, Huimin Zhang, Ying Ma, George F. Gao. (2010) Uncovering newly emerging variants of Streptococcus suis, an important zoonotic agent. Trends in Microbiology 18:3, 124-131
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   Ghyslaine Vanier, Mariela Segura, Marie-Pier Lecours, Daniel Grenier, Marcelo Gottschalk. (2009) Porcine brain microvascular endothelial cell-derived interleukin-8 is first induced and then degraded by Streptococcus suis. Microbial Pathogenesis 46:3, 135-143
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    Mariela Segura. (2009) Streptococcus suis : An Emerging Human Threat. The Journal of Infectious Diseases 199:1, 4-6
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    Wittaya Wangsomboonsiri, Teerasak Luksananun, Shaloem Saksornchai, Kwanjai Ketwong, Somnuek Sungkanuparph. (2008) Streptococcus suis infection and risk factors for mortality. Journal of Infection 57:5, 392-396
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    Marcelo Gottschalk, Mariela Segura, Jiangu Xu. (2007) Streptococcus suis infections in humans: the Chinese experience and the situation in North America. Animal Health Research Reviews 8:01, 29
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16. 16

    Nahuel Fittipaldi, Josée Harel, Benoit D’Amours, Sonia Lacouture, Marylène Kobisch, Marcelo Gottschalk. (2007) Potential use of an unencapsulated and aromatic amino acid-auxotrophic Streptococcus suis mutant as a live attenuated vaccine in swine. Vaccine 25:18, 3524-3535
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17. 17

    Zhao-Rong Lun, Qiao-Ping Wang, Xiao-Guang Chen, An-Xing Li, Xing-Quan Zhu. (2007) Streptococcus suis: an emerging zoonotic pathogen. The Lancet Infectious Diseases 7:3, 201-209
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