Venous-arterial extracorporeal membrane oxygenation for psittacosis pneumonia complicated with cardiogenic shock: case report and literature review

INTRODUCTION

Dilated cardiomyopathy (DCM) is characterized by the enlargement of the left ventricle or biventricular, accompanied by myocardial systolic dysfunction. Chlamydia psittacosis (CP) is a zoonotic pathogen, which can cause severe pneumonia, respiratory failure, and acute organ dysfunction. The deterioration of DCM caused by CP infection is extremely rare, and few cases of successful management were reported.

CASE PRESENTATION

We reported a 67-year-old male patient with DCM and chronic heart failure. Who was admitted to ICU with severe pneumonia, acute hypoxemic respiratory failure, acute decompensated heart failure, arrhythmia, and cardiogenic shock. Mechanical ventilation (MV) and venous-arterial extracorporeal membrane oxygenation (VA-ECMO) were established for respiratory and circulatory support. Broncho alveolar lavage fluid(BALF)was collected for culture and metagenomics next-generation sequencing (mNGS) test. Repeated mNGS tests indicated the high possibility of CP pneumonia, thereafter, moxifloxacin and doxycycline were prescribed. After targeted antibiotics and organ support treatment, pneumonia, respiratory and circulatory failure were gradually resolved, patient was successfully weaned from MV and VA-ECMO. Finally, the patient was recovered and discharged alive.

CONCLUSIONS

Severe respiratory and circulatory failure caused by CP infection in DCM patients is a rare life-threatening clinical condition. Early accurate diagnosis, targeted antibiotic therapy, coupled with extracorporeal life support posed positive impact on the patient's disease course and outcome.

Chlamydia psittaci Pneumonia in a patient with motor neuron disease: a case report

BACKGROUND

Motor neuron disease (MND) is a fatal neurodegenerative disorder that leads to progressive loss of motor neurons. Chlamydia psittaci (C. psittaci) is a rare etiology of community-acquired pneumonia characterized primarily by respiratory distress. We reported a case of C. psittaci pneumonia complicated with motor neuron disease (MND).

CASE PRESENTATION

A 74-year-old male was referred to the Shaoxing Second Hospital at January, 2022 complaining of fever and fatigue for 2 days. The patient was diagnosed of MND with flail arm syndrome 1 year ago. The metagenomic next-generation sequencing (mNGS) of sputum obtained through bedside fiberoptic bronchoscopy showed C. psittaci infection. Then doxycycline was administrated and bedside fiberoptic bronchoscopy was performed to assist with sputum excretion. Computed Tomography (CT) and fiberoptic bronchoscopy revealed a significant decrease in sputum production. On day 24 after admission, the patient was discharged with slight dyspnea, limited exercise tolerance. One month later after discharge, the patient reported normal respiratory function, and chest CT showed significant absorption of sputum.

CONCLUSIONS

The mNGS combined with bedside fiberoptic bronchoscopy could timely detect C. psittaci infection. Bedside fiberoptic bronchoscopy along with antibiotic therapy may be effective for C. psittaci treatment.

Chlamydia psittaci -Induced Reactive Infectious Mucocutaneous Eruption With Ocular Involvement

INTRODUCTION

This report highlights a postinfectious mucocutaneous inflammatory response involving the ocular surface and adnexa after Chlamydophila psittaci exposure.

CASE DESCRIPTION

A 35-year-old man presented after a prodrome of upper respiratory symptoms with rash and mucocutaneous blistering involving the ocular and oral mucosa, causing pseudomembranous conjunctivitis and corneal epithelial defects. Extensive inflammatory and infectious workup suggested recent C. psittaci infection. The patient was treated with doxycycline and supportive therapy, whereas the ocular surface was treated with lubrication and prophylactic antibiotics. In follow-up, he has retained excellent visual acuity but required scleral contact lenses to control ocular surface symptoms because of fibrotic changes of the marginal conjunctiva.

DISCUSSION

Such blistering inflammation has most commonly been described after pediatric respiratory infections because of Mycoplasma pneumoniae with additional instances related to Chlamydia pneumoniae , Epstein-Barr virus, influenza B, and other stimuli . To the best of our knowledge, this is the first reported case of C. psittaci- induced reactive infectious mucocutaneous eruption (RIME). RIME is a rare parainfectious inflammatory condition with sequelae frequently involving the periocular mucosa. Although systemic and nonocular adverse outcomes in this condition tend to be self-limited, the impact on the ocular surface may be severe, and the consequences to vision may be ongoing, especially if not treated aggressively at the outset.

Psittacosis caused severe community-acquired pneumonia accompanied by acute hypoxic respiratory failure: a multicenter retrospective cohort study from China

INTRODUCTION

Psittacosis can cause severe community-acquired pneumonia (CAP). The clinical manifestations of psittacosis range from subclinical to fulminant psittacosis with multi-organ failure. It is essential to summarize the clinical characteristic of patients with severe psittacosis accompanied by acute hypoxic respiratory failure (AHRF).

METHODS

This retrospective study included patients with severe psittacosis caused CAP accompanied by AHRF from 19 tertiary hospitals of China. We recorded the clinical data, antimicrobial therapy, respiratory support, complications, and outcomes. Chlamydia psittaci was detected on the basis of metagenomic next-generation sequencing performed on bronchoalveolar lavage fluid samples. Patient outcomes were compared between the treatment methods.

RESULTS

This study included 45 patients with severe CAP and AHRF caused by psittacosis from April 2018 to May 2021. The highest incidence of these infections was between September and April. There was a history of poultry contact in 64.4% of the patients. The median PaO2/FiO2 of the patients was 119.8 (interquartile range, 73.2 to 183.6) mmHg. Four of 45 patients (8.9%) died in the ICU, and the median ICU duration was 12 days (interquartile range, 8 to 21) days. There were no significant differences between patients treated with fluoroquinolone initially and continued after the diagnosis, fluoroquinolone initially followed by tetracycline, and fluoroquinolone combined with tetracycline.

CONCLUSION

Psittacosis caused severe CAP seems not rare, especially in the patients with the history of exposure to poultry or birds. Empirical treatment that covers atypical pathogens may benefit such patients, which fluoroquinolones might be considered as an alternative.

[Psittacosis Pneumonia with Pleural Effusion:Report of Three Cases and Literature Review]

It was generally believed that psittacosis pneumonia (pneumonia caused by Chlamydia psittaci) was rarely combined with pleural effusion and the characteristics of pleural effusion were rarely reported in the domestic literature.Herein,we reported three cases of pleural effusion due to psittacosis pneumonia,with elevated level of adenosine deaminase and lymphocyte-predominant exudative pleural effusion.Further,we reviewed the psittacosis pneumonia reports with complete clinical and lung imaging data.The imaging manifestations included pulmonary consolidation and common occurrence of a small amount of pleural effusion.The patients of psittacosis pneumonia combined with pleural effusion had severe symptoms,obvious hypoxia,and increased risk of invasive ventilation.

Multi-organ failure with necrotic skin lesions due to infection with Chlamydia psittaci

Presented is a patient with dyspnea and painful ulcers finally resulting in multi-organ failure. A detailed history resulted in positive PCR testing for Chlamydia psittaci. We emphasize the importance of a definitive history in establishing the correct diagnosis. When clinicians observe dyspnea with multi-organ failure, they should be aware of psittacosis.

Metagenomic next-generation sequencing in the diagnosis of severe pneumonias caused by Chlamydia psittaci

PURPOSE

Chlamydia psittaci infection in humans can lead to serious clinical manifestations, including severe pneumonia, adult respiratory distress syndrome, and, rarely, death. Implementation of metagenomic next-generation sequencing (mNGS) gives a promising new tool for diagnosis. The clinical spectrum of severe psittacosis pneumonia is described to provide physicians with a better understanding and to highlight the rarity and severity of severe psittacosis pneumonia.

METHODS

Nine cases of severe psittacosis pneumonia were diagnosed using mNGS. Retrospective analysis of the data on disease progression, new diagnosis tool, treatments, and outcomes, and the findings were summarised.

RESULTS

Frequent symptoms included chills and remittent fever (100%), cough and hypodynamia (100%), and headache and myalgia (77.8%). All patients were severe psittacosis pneumonia developed respiratory failure, accompanied by sepsis in 6/9 patients. mNGS takes 48-72 h to provide the results, and help to identify diagnosis of psittacosis. Laboratory data showed normal or slightly increased leucocytes, neutrophils, and procalcitonin but high C-reactive protein levels. Computed tomography revealed air-space consolidation and ground-glass opacity, which began in the upper lobe of one lung, and spread to both lungs, along with miliary, nodular, or consolidated shadows. One patient died because of secondary infection with Klebsiella pneumoniae, while the other eight patients experienced complete recoveries.

CONCLUSIONS

The use of mNGS can improve accuracy and reduce the delay in diagnosis of psittacosis. Severe psittacosis pneumonia responds well to the timely use of appropriate antibiotics.

Case report: Possible psittacosis in a military family member-clinical and public health management issues in military settings

Chlamydia psittaci infection among humans (psittacosis) and pet birds (avian chlamydiosis), also known as parrot disease, parrot fever, and ornithosis, is a zoonotic bacterial disease. Humans most often become infected by inhaling the organism when urine, respiratory secretions, or dried feces of infected birds are dispersed in the air as very fine droplets or dust particles. C. psittaci infection of humans can cause influenza-like symptoms, such as fever of abrupt onset, pronounced headache, and dry cough, and can lead to severe pneumonia and non-respiratory health problems. Infection can also be asymptomatic. There is no vaccine for this infection. The disease is treatable with a tetracycline antibiotic, usually doxycycline, or a second-line therapy such as erythromycin or azithromycin. With appropriate treatment, the infection is rarely fatal. This report describes a case of severe, community-acquired pneumonia possibly due to C. psittaci in a resident of Colorado and examines significant clinical and epidemiological characteristics of psittacosis that affect confirming the diagnosis and managing the risks of exposure to psittacine (parrot-type) birds.

Hepatitis in a Family Infected by Chlamydia Psittaci

Hepatic involvement is considered a rare complication of psittacosis. Occurrence of icteric hepatitis as the cardinal manifestation of the disease has been rarely reported. We describe two members of a family infected by psittacosis, in whom icteric hepatitis was the prominent expression of the disease.

The diagnosis of psittacosis was confirmed by isolation of the pathogen and by detection of serum antibodies to Chlamydia species. No serological evidence for acute TWAR infection was found. Chlamydia psittaci was also isolated from the family's parrot.

Psittacosis: Rare Respiratory Problem in Children

Psittacosis is a rare disease particularly in children with usual presentation of respiratory and constitutional symptoms. The cases may remain undiagnosed or diagnosis may be delayed because of lack of awareness among the paediatricians and physicians. Early diagnosis is very important as this is potentially curable and preventable disease. An interesting case of psittacosis is being reported here, which has been treated successfully with azithromycin.

Clinicopathologic characteristics and treatment of marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

Extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT lymphoma) accounts for 7% to 8% of newly diagnosed lymphomas. Because of its association with infectious causes, such as Helicobacter pylori (HP) or Chlamydophila psittaci (CP), and autoimmune diseases, it has become the paradigm of an antigen-driven malignancy. MALT lymphoma usually displays an indolent course, and watch-and-wait strategies are justified initially in a certain percentage of patients. In patients with gastric MALT lymphoma or ocular adnexal MALT lymphoma, antibiotic therapy against HP or CP, respectively, is the first-line management of choice, resulting in lymphoma response rates from 75% to 80% after HP eradication and from 33% to 65% after antibiotic therapy for CP. In patients who have localized disease that is refractory to antibiotics, radiation is widely applied in various centers with excellent local control, whereas systemic therapies are increasingly being applied, at least in Europe, because of the potentially systemic nature of the disease. Therefore, the objective of this review is to briefly summarize the clinicopathologic characteristics of this distinct type of lymphoma along with current data on management strategies.

Infection, disease, and transmission dynamics in calves after experimental and natural challenge with a Bovine Chlamydia psittaci isolate

Chlamydia (C.) psittaci is the causative agent of psittacosis, a zoonotic disease in birds and man. In addition, C. psittaci has been repeatedly found in domestic animals and is, at least in calves, also able to induce respiratory disease. Knowledge about transmission routes in cattle herds is still deficient, and nothing is known about differences in host response after either experimental or natural exposure to C. psittaci. Therefore, our recently developed respiratory infection model was exploited to evaluate (i) the presence of the pathogen in blood, excretions and air, (ii) the possibility of transmission and (iii) clinical symptoms, acute phase and immune response until 5 weeks after exposure. In this prospective study, intrabronchial inoculation of 10⁸ inclusion-forming units of C. psittaci (n = 21 calves) led to reproducible acute respiratory illness (of approximately one week), accompanied by a systemic inflammatory reaction with an innate immune response dominated by neutrophils. Excretion and/or exhalation of the pathogen was sufficient to transmit the infection to naïve sentinel calves (n = 3) co-housed with the infected animals. Sentinel calves developed mild to subclinical infections only. Notably, excretion of the pathogen, predominantly via feces, occurred more frequently in animals naturally exposed to C. psittaci (i.e. sentinels) as compared to experimentally-inoculated calves. The humoral immune response was generally weak, and did not emerge regularly following experimental infection; however, it was largely absent after naturally acquired infection.

A bovine model of respiratory Chlamydia psittaci infection: challenge dose titration

This study aimed to establish and evaluate a bovine respiratory model of experimentally induced acute C. psittaci infection. Calves are natural hosts and pathogenesis may resemble the situation in humans. Intrabronchial inoculation of C. psittaci strain DC15 was performed in calves aged 2–3 months via bronchoscope at four different challenge doses from 10⁶ to 10⁹ inclusion-forming units (ifu) per animal. Control groups received either UV-inactivated C. psittaci or cell culture medium. While 10⁶ ifu/calf resulted in a mild respiratory infection only, the doses of 10⁷ and 10⁸ induced fever, tachypnea, dry cough, and tachycardia that became apparent 2–3 days post inoculation (dpi) and lasted for about one week. In calves exposed to 10⁹ ifu C. psittaci, the respiratory disease was accompanied by severe systemic illness (apathy, tremor, markedly reduced appetite). At the time point of most pronounced clinical signs (3 dpi) the extent of lung lesions was below 10% of pulmonary tissue in calves inoculated with 10⁶ and 10⁷ ifu, about 15% in calves inoculated with 10⁸ and more than 30% in calves inoculated with 10⁹ ifu C. psittaci. Beside clinical signs and pathologic lesions, the bacterial load of lung tissue and markers of pulmonary inflammation (i.e., cell counts, concentration of proteins and eicosanoids in broncho-alveolar lavage fluid) were positively associated with ifu of viable C. psittaci. While any effect of endotoxin has been ruled out, all effects could be attributed to infection by the replicating bacteria. In conclusion, the calf represents a suitable model of respiratory chlamydial infection. Dose titration revealed that both clinically latent and clinically manifest infection can be reproduced experimentally by either 10⁶ or 10⁸ ifu/calf of C. psittaci DC15 while doses above 10⁸ ifu C. psittaci cannot be recommended for further studies for ethical reasons. This defined model of different clinical expressions of chlamydial infection allows studying host-pathogen interactions.

Chlamydophila psittaci subclinical infection in chronic polyarthritis

OBJECTIVES

Recent evidence indicates that Chlamydophila psittaci (Cp) may establish chronic infections, which may promote autoimmunity and/or B cell lymphoproliferation.

METHODS

The presence of a subclinical Cp infection was investigated in 293 patients with chronic inflammatory polyarthritis, including 175 patients with rheumatoid factor (RF)-positive and/or anti-CCP-positive rheumatoid arthritis (RA) and 118 with seronegative polyarthritis (46 RF-negative/anti-CCP-negative RA, 36 psoriatic arthritis and 36 undifferentiated spondyloarthritis). One hundred and eighty-five healthy controls were also investigated. The presence of Cp infection was assessed in peripheral blood mononuclear cells using several PCR protocols targeting different regions of the Cp genome (16S-23S spacer rRNA, OMP-A, and Gro-EL). The DNA of other Chlamydia species (C. Pneumoniae and C. Trachomatis) was also investigated. Amplicons were sequenced to confirm the specificity of PCR products.

RESULTS

The presence of a subclinical chronic Cp infection was observed in a significantly higher percentage of patients with chronic polyarthritis (38/293; 13%) compared to healthy controls (1/185, 0.5%; OR=27.4, 95%CI:3.73-201.6, p<0.0001). Furthermore, the prevalence of Cp was higher in seronegative polyarthritis (23/118; 19.5%) than in seropositive RA patients (15/175; 7.4%; OR=2.58, 95%CI: 1.28-5.19, p=0.0078). The highest prevalence of Cp infection was found in RF/anti-CCP double-negative RA patients (13/46, 28.3%), followed by patients with psoriatic arthritis (6/36; 16.7%). No differences in age, sex, disease duration and undergoing therapies were noticed between Cp-positive and Cp-negative patients; nor between seropositive and seronegative patients.

CONCLUSIONS

Cp may be an infectious trigger possibly involved in the pathogenesis of a fraction of inflammatory polyarthritis, particularly in seronegative patients.

Psittacosis infection and tracheobronchomalacia in a patient undergoing thyroidectomy

A 34-year-old woman with papillary thyroid carcinoma underwent total thyroidectomy with central and lateral lymphadenectomy. Immediate airway compromise required re-intubation immediately after surgery. Marked tracheal and bronchial collapse of greater than 50% of the lumen indicated tracheobronchomalacia. Subsequent attempts at extubation failed over the next week. The patient soon developed evidence of a lower respiratory tract infection. Empirical treatment with penicillins was unsuccessful. A clinical suspicion of chlamydia infection prompted initiation of macrolide treatment followed by resolution of both the patient's respiratory infection and tracheobronchomalacia. Serology returned positive for Chlamydophila psittaci infection. It later transpired that the patient had symptoms of an upper respiratory tract infection just prior to surgery. This case demonstrates an interesting and unreported cause of tracheobronchomalacia as well as providing a good lesson on the importance of preoperative screening for infection.

Chlamydophila psittaci infections in The Netherlands

Psittacosis, caused by Chlamydophila psittaci, is a well described but sporadically occurring clinical entity, which mainly presents as community-acquired pneumonia. Diagnosis used to be relatively difficult. However, new molecular techniques, such as real-time polymerase chain reaction, increased detection of cases. Furthermore, genotyping of the ompA gene can be used as a tool to trace the possible source of an outbreak or to link a specific bird to a particular patient.

Low prevalence ofChlamydia psittaciin ocular adnexal lymphomas from Cuban patients

Most ocular adnexal lymphomas (OAL) are extranodal marginal zone B-cell lymphomas (EMZL) of mucosa-associated lymphoid tissue (MALT)-type. Chronic antigen stimulation has been suggested to have a pathogenetic role in EMZL and Chlamydia psittaci chronic infection has been recently associated with the development of OAL in a series of patients from Italy. To assess this association, an evaluation of the presence of C. psittaci was made in a different OAL population. DNA samples were obtained from formalin-fixed, paraffin-embedded sections samples of 26 patients with OAL, 20 non-OAL and 20 benign ocular lesions, diagnosed and treated between 1998 and 2003 at National Institute of Oncology in Havana, Cuba. All samples were histologically reviewed by an expert pathologist. Fluorescence in situ hybrization (FISH) analysis of translocations involving MALT1 was performed. The presence of bacterial DNA was assessed with a multiplex touchdown enzyme time release polymerase chain reaction. DNA sequencing was performed to confirm suspicious bands. Seventy-three percent of the OAL cases were EMZL and 81% were in stage IE. FISH analysis was performed in 13 OAL cases and none of them evidenced MALT1 translocations. DNA of C. psittaci was detected in 11% of the 46 lymphomas: two orbital EMZL and three non-OAL. All 20 benign ocular lesions were negative for C. psittaci. The low prevalence of C. psittaci in OAL suggests geographical differences in the etiology of this entity. International studies are needed to clarify the role of C. psittaci in OALs.

Meta-analyses of the association between Chlamydia psittaci and ocular adnexal lymphoma and the response of ocular adnexal lymphoma to antibiotics

BACKGROUND

There are conflicting reports regarding the association between Chlamydia psittaci (Cps) and ocular adnexal lymphoma (OAL) and the efficacy of antibiotics for OAL. In the current study, the authors attempted to clarify the association between Cps and OAL and the efficacy of antibiotics for OAL.

METHODS

Two meta-analyses were conducted. One focused on the association between Cps and OAL across geographic regions and among different studies. The other was a meta-analysis of the response of OAL to antibiotic treatment.

RESULTS

The authors identified 11 studies of Cps prevalence that included 458 cases of OAL from 10 different countries. Four studies regarding the efficacy of oral antibiotics to treat OAL were found. One hundred four of the 458 OAL specimens (23%) and 87 of the 346 mucosa-associated lymphoid tissue (MALT) lymphoma specimens (25%) were found to be positive for Cps. Ninety-four of the 104 Cps-positive OAL specimens (90%) came from 3 of the 11 studies. There was wide variation noted between geographic regions and even between studies from the same geographic region with regard to the rate of Cps positivity. The 4 studies concerning the efficacy of antibiotics for OAL were from Italy, Austria, Taiwan, and the U.S. and included 42 patients. Twenty patients (48%) achieved some response (complete response in 8 patients, partial response in 8 patients, and minimal response in 4 patients). Twenty patients also had stable disease, and 2 patients progressed during antibiotic therapy. Objective documentation of response (radiographs or clinical slit-lamp photographs) was available for only 3 of the 42 patients. Seven additional patients developed disease recurrence after their initial response or stable disease after antibiotic therapy; 6 of these cases of disease recurrence occurred during the first 12 months of follow-up.

CONCLUSIONS

The findings of the current study suggest a striking variability in the association between Cps and OAL across geographic regions and even between studies from the same geographic regions. The overall rate of Cps positivity in our meta-analysis (23%) was much lower than that reported in the original report. The current study findings also suggest that antibiotics have variable efficacy against OAL. Future prospective trials with standard objective response criteria and a longer follow-up period would be necessary to evaluate the role of antibiotics in the treatment of OAL further.

Chlamydia psittaci infection and clinicopathologic analysis of ocular adnexal lymphomas in Korea

Ocular adnexal lymphoma (OAL) is a mostly extranodal marginal zone lymphoma (EMZL). Recent findings have suggested an association between Chlamydia psittaci (Cp) infection and OAL. We sought to confirm this issue and to analyze the clinicopathologic characteristics of OAL in Korea. Between 1993 and 2004, 33 OAL cases were identified at the Asan Medical Center, Seoul, Korea. DNA was extracted from paraffin-embedded tissues, and touchdown enzyme time release polymerase chain reaction was performed to identify three Chlamydia species (Cp, C. tracomatis, and C. pneumoniae). The same procedures were also performed in 21 samples from patients with non-neoplastic ocular adnexal disease (NNOAD). All OAL cases were EMZL. Cp DNA was detected in 26/33 (79%) OAL samples compared with 5/21 (23%) NNOAD samples (P < 0.001). With a median follow-up of 38.5 months (range: 1-105 months), the 5-year progression-free survival (PFS) and overall survival (OS) rates of OAL patients were 72% and 93%, respectively. Clinicopathologic characteristics, recurrence rate, PFS, and OS were not associated with Cp infection. Our study demonstrates an association between OAL and Cp infection in Korea, suggesting that Cp plays a role as a causative antigen in Korean OAL patients.

[A case of psittacosis with wandering infiltrates developing to acute respiratory distress syndrome]

A 52-year-old woman visited a local hospital with a high fever, non-productive cough and general fatigue. Her chest X-ray showed infiltrate in the right middle lung field. Computed tomography scans revealed ground-glass opacity and surrounding ring-shaped air-space consolidation, the "reversed halo sign". Cefpirom was administered, but her symptoms persisted and the infiltrate migrated to the left upper lobe. As cryptogenic organizing pneumonia was suspected, she was then treated with intravenously pulsed methylprednisolone followed by prednisolone. Despite these therapies, acute respiratory failure occurred and she was therefore transferred to our hospital. On admission, severe hypoxemia and diffuse bilateral infiltrates on chest images suggested acute respiratory distress syndrome. As we obtained information that a parakeet had recently died at her home, minocycline was administered, resulting in prompt improvement of the symptoms, respiratory insufficiency and pulmonary infiltrates. Finally, elevated antibody titers against Chlamydophila psittasi confirmed a diagnosis of Psittacosis. Sequential chest computed tomography scans in this case indicate that absorption of marginal air-space consolidation with extended central ground glass attenuation in concordance with a new infiltrate on another lung field appeared to create wandering infiltrate. Wandering infiltrate on chest X-ray in psittacosis may be a sign of disease progression.

Bacteria-Eradicating Therapy With Doxycycline in Ocular Adnexal MALT Lymphoma: A Multicenter Prospective Trial

BACKGROUND

An association between ocular adnexal MALT lymphoma (OAL) and Chlamydia psittaci (Cp) infection has been proposed, and recent reports suggest that doxycycline treatment causes tumor regression in patients with Cp-related OAL. The effectiveness of doxycycline treatment in Cp-negative OAL has not been tested.

METHODS

In a prospective trial, 27 OAL patients (15 newly diagnosed and 12 having experienced relapse) were given a 3-week course of doxycycline therapy. Objective lymphoma response was assessed by computerized tomography scans or magnetic resonance imaging at 1, 3, and 6 months after the conclusion of therapy and every 6 months during follow-up. Cp infection in patients was determined by touchdown enzyme time-release polymerase chain reaction (TETR-PCR). Statistical tests were two-sided.

RESULTS

Eleven patients were Cp DNA-positive and 16 were Cp DNA negative. Doxycycline was well tolerated. At a median follow-up of 14 months, lymphoma regression was complete in six patients, and a partial response (> or = 50% reduction of all measurable lesions) was observed in seven patients (overall response rate [complete and partial responses] = 48%). Lymphoma regression was observed in both Cp DNA-positive patients (seven of 11 experienced regression) and Cp DNA-negative patients (six of 16 experienced regression) (64% versus 38%; P = .25, Fisher's exact test). The three patients with regional lymphadenopathies and three of the five patients with bilateral disease achieved objective response. In relapsed patients, response was observed both in previously irradiated and nonirradiated patients. The 2-year failure-free survival rate among the doxycycline-treated patients was 66% (95% confidence interval = 54 to 78), and 20 of the 27 patients were progression free.

CONCLUSIONS

Doxycycline is a fast, safe, and active therapy for Cp DNA-positive OAL that was effective even in patients with multiple failures involving previously irradiated areas or regional lymphadenopathies. The responses observed in PCR-negative OAL may suggest a need for development of more sensitive methods for Cp detection and investigation of the potential role of other doxycycline-sensitive bacteria.

Rapidly Increasing Incidence of Ocular Non-Hodgkin Lymphoma

A recent report suggesting that ocular adnexal non-Hodgkin lymphoma (NHL) may be related to Chlamydia psittaci infection underscores the need for reliable epidemiologic data for this malignancy. We examined population-based incidence data from the Surveillance, Epidemiology, and End Results (SEER) Program. During 1992-2001 in the 12 SEER areas, ocular (i.e., eye and adnexa) NHL rates per 100,000 person-years for both sexes were highest among Asians/Pacific Islanders, lower in whites, and lower still in blacks. Incidence increased with advancing age and showed little difference by sex, in contrast to other (extranodal and nodal) NHLs, which occurred predominantly in males. From 1975-2001, there was a rapid and steady increase in incidence of ocular NHL, with annual increases of 6.2% and 6.5% among white males and females, respectively, with no evidence of peaking. By contrast, other NHLs showed evidence of peaking in recent years. The distinctive patterns of ocular NHL call for further studies to identify risk factors and mechanisms, including the potential role of C. psittaci or other infections.

An unusual cause of sepsis during pregnancy: recognizing infection with chlamydophila abortus

BACKGROUND

Chlamydophila abortus (formerly Chlamydia psittaci serovar 1) is a rare but severe cause of gestational septicemia, with particular problems in diagnosis and clinical management.

CASE

A 32-year-old woman in her fourth pregnancy (16th week of gestation) presented with progressive septicemia after extensive contact with abortive material from her goat flock. Treatment with levofloxacin could not prevent abortion. Multiorgan failure requiring catecholamines and artificial ventilation developed in the patient. After the agent was identified by polymerase chain reaction from acute-phase serum, macrolides were administered and yielded clinical improvement. The patient fully recovered. There were no sequelae in the subsequent 6 months.

CONCLUSION

Cp abortus must be considered in gestational septicemia after contact with ruminants. Polymerase chain reaction from acute-phase serum is a quick and easy way to establish the diagnosis. Macrolide antibiotics are still the treatment of choice.

Chlamydia psittaci is variably associated with ocular adnexal MALT lymphoma in different geographical regions

Infectious agents play a critical role in MALT lymphoma development. Studies from Italy showed Chlamydia psittaci infection in 87% of ocular adnexal MALT lymphomas and complete or partial regression of the lymphoma after C. psittaci eradication in four of nine cases. However, C. psittaci was not demonstrated in ocular adnexal MALT lymphomas from the USA. This study was thus designed to investigate further the role of C. psittaci, and other infectious agents commonly associated with chronic eye disease, in the development of ocular adnexal MALT lymphoma. The presence of C. psittaci, C. trachomatis, C. pneumoniae, herpes simplex virus 1 and 2 (HSV1, HSV2), and adenovirus 8 and 19 (ADV8, ADV19) was assessed separately by polymerase chain reaction in 142 ocular adnexal MALT lymphomas, 53 non-marginal zone lymphomas, and 51 ocular adnexal biopsies without a lymphoproliferative disorder (LPD), from six geographical regions. C. psittaci was detected at similar low frequencies in non-LPD and non-marginal zone lymphoma groups from different geographical regions (0-14%). Overall, the prevalence of C. psittaci was significantly higher in MALT lymphomas (22%) than in non-LPD (10%, p=0.042) and non-marginal zone lymphoma cases (9%, p=0.033). However, the prevalence of C. psittaci infection in MALT lymphoma showed marked variation among the six geographical regions examined, being most frequent in Germany (47%), followed by the East Coast of the USA (35%) and the Netherlands (29%), but relatively low in Italy (13%), the UK (12%), and Southern China (11%). No significant differences in the detection of C. pneumoniae, C. trachomatis, HSV1, HSV2, ADV8, and ADV19 were found between lymphomas and controls from different geographical regions. In conclusion, our results show that C. psittaci, but not C. pneumoniae, C. trachomatis, HSV1, HSV2, ADV8 or ADV19, is associated with ocular adnexal MALT lymphoma and that this association is variable in different geographical areas.

Pathogenic interactions between Chlamydophila psittaci and avian pneumovirus infections in turkeys

Both Chlamydophila psittaci and avian pneumovirus (APV) are highly prevalent in Belgian turkeys and might contribute to the respiratory disease complex observed in turkeys. Initial outbreaks of chlamydiosis occur mostly at the age of 4-8 weeks, often accompanied by an APV infection in APV non-vaccinated farms. Regardless APV vaccination, breakthroughs of APV infection from 8 weeks on do occur, a period when also a second C. psittaci infection appears. Therefore, this study examined the pathogenicity of an APV superinfection in C. psittaci predisposed turkeys. Turkeys were infected with C. psittaci, APV or with C. psittaci followed by APV. Simulating the impact of an APV infection during the acute phase or latent phase of a C. psittaci infection, turkeys have been infected with APV at 1 and 5 weeks post C. psittaci infection, respectively. APV infection during the acute phase of a C. psittaci infection aggravates the severity of clinical signs, macroscopic lesions, pharyngeal APV excretion and histological tracheae lesions. In contrast, no clear interaction could be established after APV infection in latently C. psittaci infected specific pathogen-free (SPF) turkeys. This study clearly demonstrates the exacerbating role of APV during acute C. psittaci infection, which can play an important role in the respiratory disease complex of turkeys.

Key role of Chlamydophila psittaci on Belgian turkey farms in association with other respiratory pathogens

Two hundred turkey sera from eight Belgian and two French farms were tested for the presence of antibodies against avian pneumovirus (APV), Ornithobacterium rhinotracheale (ORT), Mycoplasma gallisepticum, Mycoplasma meleagridis and Chlamydophila psittaci. At slaughter, C. psittaci, APV and ORT antibodies were detected in 94, 34 and 6.5% of the turkeys, respectively. No antibodies against M. gallisepticum or M. meleagridis were present. Additionally, turkeys on three Belgian farms were examined from production onset until slaughter using both serology and antigen or gene detection. All farms experienced two C. psittaci infection waves, at 3-6 and 8-12 weeks of age. Each first infection wave was closely followed by an ORT infection starting at the age of 6-8 weeks, which was still detectable when the second C. psittaci infection waves started. Animals on farm A were not vaccinated against APV leading to an APV subtype B outbreak accompanying the first C. psittaci infection wave. Despite subtype A APV vaccination on farms B and C, the second C. psittaci infection waves were accompanied (farm B) or followed (farm C) by a subtype B APV infection. On all farms respiratory signs always appeared together with a proven C. psittaci, APV and/or ORT infection. This study suggests an association between C. psittaci, APV and ORT, and indicates the multi-factorial aetiology of respiratory infections in commercial turkeys. All three pathogens should be considered when developing prevention strategies for respiratory disease.

Regression of ocular adnexal lymphoma after Chlamydia psittaci-eradicating antibiotic therapy

PURPOSE

Some infectious agents contributing to lymphomagenesis have been considered targets for new therapeutic strategies. Chlamydia psittaci DNA has been detected in 80% of ocular adnexal lymphomas. The present pilot study was carried out to assess whether C psittaci-eradicating antibiotic therapy is associated with tumor regression in ocular adnexal lymphomas.

PATIENTS AND METHODS

Nine patients with C psittaci-positive marginal-zone B-cell lymphoma of the ocular adnexa at diagnosis or relapse were treated with doxycycline 100 mg, bid orally, for 3 weeks. The presence of C psittaci DNA in peripheral-blood mononuclear cells (PBMCs) was also assessed before and after treatment in seven patients. Objective lymphoma regression was assessed 1, 3, and 6 months after therapy conclusion and every 6 months during follow-up.

RESULTS

All patients completed antibiotic therapy with excellent tolerability. At 1 month from doxycycline assumption, chlamydial DNA was no longer detectable in PBMCs of all four positive patients. Objective response was complete in two patients, partial response (> 50%) was observed in two patients, and minimal response (< 50%) was observed in three patients. Duration of response in the seven responders was 12+, 29+, 31+, 8+, 7+, 2+, and 1+ months, respectively.

CONCLUSION

C psittaci-eradicating antibiotic therapy with doxycycline is followed by objective response in patients with ocular adnexal lymphoma, even after multiple relapses of the disease. A confirmatory, large, phase II trial is warranted to confirm whether this fast, cheap, and well-tolerated therapy could replace other more aggressive strategies as first-line treatment against ocular adnexal lymphomas.

A comparative ultrastructural and molecular biological study on Chlamydia psittaci infection in alpha-1 antitrypsin deficiency and non-alpha-1 antitrypsin deficiency emphysema versus lung tissue of patients with hamartochondroma

BACKGROUND

Chlamydiales are familiar causes of acute and chronic infections in humans and animals. Human pulmonary emphysema is a component of chronic obstructive pulmonary disease (COPD) and a condition in which chronic inflammation manifested as bronchiolitis and intra-alveolar accumulation of macrophages is common. It is generally presumed to be of infectious origin. Previous investigations based on serology and immunohistochemistry indicated Chlamydophila pneumoniae infection in cases of COPD. Furthermore, immunofluorescence with genus-specific antibodies and electron microscopy suggested involvement of chlamydial infection in most cases of pulmonary emphysema, but these findings could not be verified by PCR. Therefore, we examined the possibility of other chlamydial species being present in these patients.

METHODS

Tissue samples from patients having undergone lung volume reduction surgery for advanced alpha-1 antitrypsin deficiency (AATD, n = 6) or non-alpha-1 antitrypsin deficiency emphysema (n = 34) or wedge resection for hamartochondroma (n = 14) were examined by transmission electron microscopy and PCR.

RESULTS

In all cases of AATD and 79.4% of non-AATD, persistent chlamydial infection was detected by ultrastructural examination. Intra-alveolar accumulation of macrophages and acute as well as chronic bronchiolitis were seen in all positive cases. The presence of Chlamydia psittaci was demonstrated by PCR in lung tissue of 66.7% AATD vs. 29.0% non-AATD emphysema patients. Partial DNA sequencing of four positive samples confirmed the identity of the agent as Chlamydophila psittaci. In contrast, Chlamydophila pneumoniae was detected only in one AATD patient. Lung tissue of the control group of non-smokers with hamartochondroma was completely negative for chlamydial bodies by TEM or chlamydial DNA by PCR.

CONCLUSIONS

These data indicate a role of Chlamydophila psittaci in pulmonary emphysema by linking this chronic inflammatory process to a chronic infectious condition. This raises interesting questions on pathogenesis and source of infection.

A woman with a lobar infiltrate due to psittacosis detected by polymerase chain reaction

This report presents a case of community-acquired pneumonia due to Chlamydia psittaci presenting with a lobar infiltrate and diagnosed by a newly developed ompA gene-based polymerase chain reaction (PCR). This gene encodes a specific C. psittaci major outer membrane protein. This kind of PCR could reduce antibiotic consumption and expedite outbreak management.

Presence of Chlamydophila psittaci DNA in the central nervous system of a patient with status epilepticus

This study reports an extraordinarily severe and prolonged course of neuroornithosis with generalized status epilepticus as an initial symptom. Direct invasion of the central nervous system by Chlamydophila psittaci was confirmed by the demonstration of specific DNA in the patient's cerebrospinal fluid. The patient recovered slowly under administration of doxycycline.

[Abortion in cattle caused by Chlamydia psittaci]

A case of bovine abortion was for the first time in Switzerland diagnosed by immunohistochemistry PCR (16S rRNA, ompA) and gene sequence analysis to be caused by Chlamydia psittaci. A possible occurence of further cases has to be investigated. Based on the existence of several methods with very different sensitivity and specificity to diagnose chlamydia it is suggested that at least two verified diagnostic tools should be used to diagnose an involvement of chlamydia in bovine abortion.

[Abortion in small ruminants in Switzerland: investigations during two lambing seasons (1996-1998) with special regard to chlamydial abortions]

Abortion cases of 144 goats und 86 sheep were investigated etiologically during 2 lambing seasons (1996/1997, 1997/1998). Macroscopic inspection of fetus and placenta was completed by histopathology and bacteriological isolation of agents. In addition, immunohistologically the following antigens were labeled in formalin-fixed and paraffin-embedded tissue sections: Toxoplasma gondii, Neospora caninum, Chlamydophila abortus (formerly Chlamydia psittaci serovar 1) and Border Disease Virus. From farms with abortions caused by Chlamydophila abortus specific data were recorded. In 75% of abortion cases in sheep and in 59% of cases in goats an etiologic diagnosis could be substantiated. Chlamydophila abortus is the most commonly involved agent in the etiology of caprine and ovine abortion (sheep 39%, goats 23%), followed by Toxoplasma gondii (sheep 19%, goats 15%) and Coxiella burnetti (sheep 1%, goats 10%). All other agents are of minor importance. An infectious cause of abortion based on histopathologic findings without isolation of agents was observed in sheep (10%) and goats (21%). Malformation occurred in sheep (2%) and goats (3%) and lesions suggestive for Vitamin E/Selenium deficiency were seen in goats only (2%).

[Abortion in humans caused by Chlamydophila abortus (Chlamydia psittaci serovar 1)]

On a farm housing cattle and goats an abortion storm occurred affecting 50% of the goats during the lambing season 2000/2001. In one of three investigated caprine abortions Chlamydophila abortus could be identified as etiology. During this time a pregnant woman (pregnancy week 19/20) had contact with aborting goats. She developed a severe generalized infection and aborted. The placenta contained Chlamydophila abortus shown by immunohistochemistry and PCR. Aim of the present case report is to alert veterinarians about the potential zoonotic risk of ovine/caprine abortions.

[Severe multiorgan psittacosis in a 10-year-old boy]

Psittacosis is rare among children and severe cases appear exceptional. We describe a child with psittacosis and multiorgan involvement.

CASE REPORT

T., a ten-year-old boy, was admitted for a prolonged fever associated with meningism. Laboratory tests showed an important inflammatory response, mild renal failure and coagulation disorders. On admission, the chest X-Ray and the cerebrospinal fluid were normal. He rapidly developed shock, acute abdomen, oxygenodependency, pneumonia and bilateral pleural effusion. No improvement was observed after 48 hours of cefotaxime therapy. History revealed the presence of two parrots at home. Treatment by intravenous clarithromycin was therefore initiated. Serology for Chlamydia psittaci was strongly positive. All symptoms disappeared a few days later.

CONCLUSION

The case reported was particular for two reasons: severe disease with multi-organ involvement and young age of the patient. We emphasize the need to search for a history of contact with birds in any case of unexplained pneumonia.

[A case of fulminant psittacosis with rhabdomyolysis]

We encountered a case of psittacosis accompanied with rhabdomyolysis in a 66-year-old woman admitted to our hospital because of myalgia, fever, diarrhea, and disorientation. A chest CT scan showed air-space consolidation and ground-glass attenuation in the left lung. Laboratory findings showed elevation of CPK, myoglobin, and aldolase, consistent with rhabdomyolysis. She recovered after administration of intravenous erythromycin and steroid pulse therapy. Psittacosis was diagnosed from the history of exposure to pigeons and from elevation of the IgG titer for Chlamydia psittaci. Rhabdomyolysis is associated with some kinds of viral or bacterial infections. But few case reports have been found in the case of psittacosis. The mechanism whereby rhabdomyolysis complicates psittacosis is unknown. We suggest that psittacosis should be added to the list for differential diagnosis, when rhabdomyolysis develops in a patient with pneumonia.

Familial cases of psittacosis: possible person-to-person transmission

A 29-year-old woman with primary myelofibrosis developed severe pneumonia, and 20 days later her 31-year-old sister also contracted pneumonia. The first patient had been in contact with parakeets but the second patient had not been in contact with any birds. Psittacosis was diagnosed in both cases by microplate immunofluorescence antibody technique. Person-to-person transmission between the sisters was suspected to have taken place.

Association between Chlamydia psittaci seropositivity and abortion in Italian dairy cows

Although the seroprevalence of Chlamydia psittaci is widespread in Italian dairy herds, its role in inducing genital disorders has not been elucidated. We therefore set up a case-control study to compare seroprevalence to C. psittaci in an aborted-cow population and in a randomly selected control group in the province of Parma (the Po Valley of northern Italy). The true seroprevalence (45%) in aborted cows was significantly higher than that in the control group (24%) (adjusted odds ratio=2.53).

A possible association between Chlamydiae psittacci infection and temporal arteritis

Some arguments are in favor of the role of Chlamydia in the pathogenesis of atherosclerosis and some vasculitis. Illustrating this possible relation, we report the case of a patient developing consecutively a Chlamydia psittacci infection and a temporal arteritis. A 73-year-old woman, with no significant medical history, was hospitalized for constitutional symptoms. Three weeks before, she had described fever and sore throat of two days' duration. Since that time, she had remained exhausted and developed a mild intermittent claudication of the jaws. Clinical examination was poor. A biological inflammatory syndrome was noticed. Chest X-ray revealed bilateral interstitial opacities. The titer of anti-C. psittaci antibodies was significant (positive 1g G at 1/2048). Soon after initiation of doxycycline, a temporal arteritis biopsy was performed, due to the persistence of clinical symptoms and high inflammatory syndrome, conclusive for the diagnosis of temporal arteritis. Corticotherapy was added to antibiotic therapy, resulting in the decrease of inflammatory syndrome and an improvement in the general status of the patient. X-ray opacities decreased in three weeks. Serological control after three months showed a decrease of the titer of anti-C. psittacci antibodies to 1/256, confirming the initial diagnosis of Chlamydia pneumopathy. Our observation could provide one more argument for the role of bacteria-like Chlamydia in the pathogenesis of vascular diseases. Prospective seroepidemiological and molecular biology studies could allow us to clarify the association between Chlamydia infections and inflammatory vasculitis-like temporal arteritis.

Detection of chlamydial antibody by fetal serology--an aid to the diagnosis of ovine abortion

Two serological tests (indirect immunofluorescence and enzyme-linked immunosorbent assay) were developed for the detection of fetal antibody to Chlamydia psittaci. Fetal blood and thoracic fluid from 126 field cases of suspected ovine chlamydial abortion were examined using both tests. Placenta and fetal tissues (lung, liver, and kidney) from the same animals were also examined by the following conventional diagnostic methods: isolation in McCoy cells, detection of chlamydial lipopolysaccharide (LPS), modified Ziehl-Nielsen staining, and direct fluorescent antibody staining of chlamydia in frozen cryostat sections. Seventy cases were positive by fetal serology, and of these, 68 were also positive by isolation and/or LPS detection. The remaining 56 cases had negative fetal serology, and of these, 39 were positive by isolation and/or LPS detection. Results indicate that fetal serology, although less sensitive than either isolation in McCoy cells or detection of chlamydial LPS antigen, may be of particular use when placenta is not available.

ARDS in fulminant ornithosis and treatment with extracorporeal lung assist

We report a 47-year-old male patient with fulminant ornithosis who developed severe respiratory failure leading to acute respiratory distress syndrome (ARDS) complicated by gastrointestinal, neurological and renal symptoms. ARDS was successfully treated by extracorporeal lung assist. As leukocytosis is typically absent in ornithosis, C-reactive protein, interleukin 6 and procalcitonin were used as infection parameters in order to monitor clinical development. The English-language literature on severe cases of ornithosis requiring respiratory support over the past 30 years is reviewed.

Selenium and vitamin E effect on antibody production of sheep vaccinated against enzootic abortion (Chlamydia psittaci)

The effect of selenium (Se) and vitamin E (vit E) on antibody production of sheep vaccinated against Chlamydia psittaci (ovis) was investigated. Thirty-two sheep, one year old, seronegative to Chlamydia infection, vaccinated against enterotoxemia and dewormed were used. Injectable sodium selenite (0.1 mg/kg b.w.) was given twice to animals of the first group (gSe), with a three week interval. The sheep of the second group (gE) received 1 g vit E each orally, six times at weekly intervals. The animals of the third group (gSeE) were given Se and vit E in doses and routes of administration as in gSe and gE. The animals of the fourth group served as controls (gC) and injected normal saline. The first vaccination was made at the time that the second Se injection was given. Revaccination was made two weeks later. The experiment lasted 29 weeks. The results indicated that Se alone led to a significant increase of Chlamydia antibody response (P < 0.05), but not when it was given in combination with vit E. Animals that received vit E (gE) had much lower titres, just above of those of the controls.

Role of polymorphonuclear neutrophils in a murine model of Chlamydia psittaci-induced abortion

To assess the role of polymorphonuclear neutrophils (PMNs) in Chlamydia psittaci infection in a pregnant mouse model, pregnant and nonpregnant Swiss OF1 mice were depleted of PMNs by treatment with the RB6-8C5 monoclonal antibody before intraperitoneal infection with C. psittaci serotype 1. Nondepleted mice served as infection controls. Depleted mice aborted earlier and had a much higher mortality rate than nondepleted mice. Bacteriological analysis showed that the number of chlamydiae isolated from the spleens of depleted mice at 5 and 7 days postinfection was 100 times greater than that isolated from nondepleted mice. Histopathological analysis of the placentas of depleted mice showed widespread necrosis of the uteroplacental units, with weak immunoreaction to chlamydial antigen, while the placentas of nondepleted mice showed substantial neutrophil infiltration but no large areas of necrosis, with moderate to strong immunoreaction to chlamydial antigen. The livers of depleted mice showed numerous chlamydial inclusions in the hepatocytes, delayed microgranuloma formation, and in the pregnant animals extensive coagulative periportal necrosis. The livers of nondepleted mice displayed multiple small foci of PMNs and mononuclear cells with microgranuloma formation. Among this group of mice, the pregnant animals always had more hepatic damage than nonpregnant animals. Our results suggest that PMNs play an essential role in the response to C. psittaci primary infection, preventing the uncontrolled multiplication of chlamydiae in the liver and spleen.

[A very serious course of psittacosis in pregnancy]

A 33-year-old pregnant woman was admitted because of atypical pneumonia. She developed adult respiratory distress syndrome complicated by premature birth and perinatal mortality. The diagnosis 'psittacosis' was established on clinical grounds and confirmed serologically (complement fixation test). She was treated with doxycycline 200 mg i.v. daily for 3 weeks and was discharged in good condition after three months. Indirect case history revealed infected birds from the neighbours as the likely source of infection. Psittacosis is caused by Chlamydia psittaci and is acquired after inhalation of dry secreta or excreta from infected animals. Retrospective direct questioning often reveals contact with birds. Diagnostic delay can be considerable. Doxycycline is contraindicated in pregnant women, but erythromycine can be prescribed. Pregnant women should be advised to avoid contact with infected birds as they run an increased risk of a severe disease course.

Rhizomucor pusillus mucormycosis combined with chlamydiosis in an African grey parrot (Psittacus erithacus erithacus)

This paper describes a case of mucormycosis combined with chlamydiosis in an African grey parrot (Psittacus erithacus erithacus). The clinical signs included diarrhoea, an unsteady gait and a twisted neck. Smears of the spleen, liver and contents of the cloaca stained strongly positive for Chlamydia species. Histologically, hyphae typical of Zygomycetes were observed invading through the walls of blood vessels of the spleen. Rhizomucor pusillus was isolated as a pure culture from the intestines, lungs and liver.