AMERICAN JOURNAL OP CLINICAL PATHOLOGY
Vol. 33, No. 1, January, I960, pp. 43-47
Printed in U.S.A.
DISSEMINATED VISCERAL BOTRYOMYCOSIS
REPORT OF A FATAL CASE PROBABLY CAUSED BY
Pseudomonas aeruginosa
DONALD J. WINSLOW, LT. COL., MC, USA, AND STUART A. CHAMBLIN, CAPT., MC, USA
Armed Forces Institute of Pathology, Washington, D. C.
REPORT OF A CASE
An 80-year-old man was admitted to
Letterman Army Hospital because of
urinary retention, secondary to prostatic
hyperplasia, and transurethral prostatectomy was performed. Approximately 3
months later, the patient was again hospitalized for pneumonia that involved the
lower lobe of the left lung and the middle
lobe of the right lung. Treatment with
penicillin and streptomycin caused conspicuous improvement, but the patient was
Received, June 19, 1959; revision received,
August 5; accepted for publication September 2.
Colonel Winslow is Pathologist, Armed Forces
Institute of Pathology, Washington, D. C. Captain Chamblin is Pathologist, Letterman Army
Hospital, San Francisco, California.
* This term is used to indicate the presence of
epithelioid cells, with or without multinucleated
giant cells, in the wall of an inflammatory lesion.
f Structures simulating those found in actinomycosis or mycetoma, but differing from them by
containing bacteria rather than branching filamentous fungi or broad hyphae of the higher fungi.
43
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rehospitalized 2 months later because of
progressive loss of appetite, impaired memory, general debilitation, and chronic cough.
At the time of final admission, the blood
pressure was 100/80, pulse rate 96 per min.,
and temperature 97.8 F. The patient seemed
to be chronically ill, and his respiration was
of Cheyne-Stokes character. There was 3 +
pitting edema of the ankles, but the heart
seemed normal on physical examination.
Laboratory studies revealed that the
patient's urine contained numerous white
blood cells and innumerable, small, motile
bacteria. Similar findings had been previously noted in a preoperative urine specimen, but no culture was reported. His white
blood cell count on this final admission was
22,900 per cu. mm., with 94 per cent neutrophils. A chest film revealed diffuse pneumonitis of both lungs. The blood urea nitrogen was 21 mg. per 100 ml.
The patient was treated with terramycin
and later erythromycin, but he became
cyanotic and lethargic. His temperature rose
to 100 F., respirations to 30 per min., and
his blood pressure decreased to 88/40. He
died 9 days after his final admission and 5
months following the date of his prostatectomy.
At autopsy, the left pleural cavity contained approximately 500 ml. of a greenbrown fluid, and the trachea and bronchi
were filled with green-yellow foamy fluid.
The lungs contained numerous small, firm
nodules (Fig. 1), which, on section, seemed
to be grey-yellow and measured approximately 2 to 3 mm. in diameter. The left
kidney was enlarged (250 Gm.), and was
surrounded by an abscess that was continuous with a large, yellow abscess involving
the lower pole of the kidney. Small satellite
abscesses were present in the parenchyma
(Fig. 2). The right kidney, ureters, and
bladder were grossly normal, but the pros-
Human botryomycosis is usually a localized staphylococcal infection of the integument, characterized by the presence of more
or less granulomatous* suppurative foci,
containing fungus-like "grains" or granules,!
within which the microorganisms may be
observed microscopically by means of
special bacterial stains.14 There have been
rare reports in the literature, however, in
which the disease, in humans, has involved
the viscera. 3,6 ' u - 1 2 , u In the disseminated
visceral form of botryomycosis, the cause
has on occasion been ascribed to Actinobacillus,3 Proteus,14 and Pseudomonas.14
The probable incrimination of Pseudomonas
has previously been mentioned only briefly.
Because of the rarity of this type of case, a
more detailed report was thought to be
desirable.
WINSLOW AND CHAMBLIN
'
*
*
*
«
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Vol. S3
•
tatic remnant contained numerous firm,
yellow nodules. In the right lateral lobe of
the prostate gland, there was an abscess
filled with green-yellow pus.
Postmortem cultures of the heart's blood,
right lung, left lung, and left kidney all
yielded growth of a microorganism identified
as Pseudomonas aeruginosa. This microorganism was thought to be a contaminant,
and was not further studied; unfortunately,
the cultures were discarded by the laboratory technician.
Microscopically, the prostate gland, left
kidney, and both lungs were similarly involved by numerous discrete abscesses that
contained granules (Fig. 3). These consisted
of irregular particles which, with hematoxylin and eosin, were stained eosinophilically,
peripherally, and partially basophilically
centrally. Special stains for fungi, such as
the Gomori methenamine-silver method and
the Gridley stain, failed to reveal either the
branching filaments of the Actinomycetaceae
or the broad hyphae of higher fungi. The
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,L SS'-A ( u PP er )- A portion of lung containing multiple botryomycotic lesions.
(AFIP Neg. No. 58-9261-1).
FIG. 2 (lower). A portion of kidney with some of the satellite botryomycotic
lesions. (AFIP Neg. No. 58-9261-2).
Jan. 1960
DISSEMINATED VISCERAL
BOTRYOMYCOSIS
45
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FIG. 3 •iippcri. Scciion nf lung, illiMr.-ning :i iliM-ivu1 1»itryomycotic lesion with
granules in tne center. (AFIP Neg. No. 59-4395). Hematoxylin and eosin. X 165.
FIG. 4 (lower). A granule in the lung, with bacilli in the central portion. (AFIP
Neg. No. 59-4444). Giemsa. X 1410.
46
W I N S L O W AND
Brown and Brenn and Goodpasture-MacCallum Gram stains, however, both revealed
myriads of Gram-negative, rod-shaped particles in the central portions of the granules.
These particles measured approximately
0.5 M in diameter and 1 to 2 n in length. In
Giemsa-stained sections, their structure
was more clearly delineated and most consistent with that of bacilli (Fig. 4).
DISCUSSION
It seems of considerable interest that the
kidneys and lungs were involved in the
present instance and also in Case 1 of the
article on botryomycosis by one of us
(D. J. W.).14 In the latter instance, the
patient, a 60-year-old Negro man, had a
severe, persistent, and refractory urinary
tract infection caused by a Proteus microorganism. At autopsy, the kidneys and lungs
contained numerous botryomycotic abscesses from which a Proteus microorganism
was isolated.
It may be of significance that the patient
described in the present report had motile
bacilli and numerous white blood cells in his
urine, before and also after the transurethral
prostatectomy. Unfortunately, there is no
report of any urine culture. Nevertheless,
the clinical history, the sites of involvement,
the type of microorganism, and the morphology of the lesions certainly are suggestive
that the portal of entry was the genito-
urinary tract, with dissemination to the
lungs by way of the blood stream.
The natural or acquired resistance to
various antibiotics and the dissociative
behavior of such Gram-negative bacilli as
Pseudomonas aeruginosa and Proteus has
been demonstrated. 1 ' 2 ' 4 ' 6 " 9 ' 18 The ability
of Pseudomonas to cause botryomycotic
lesions is perhaps somewhat surprising in
view of the usual pathologic picture that has
been associated with this microorganism13
in the past. In this respect, however, it must
be recalled that Magrou10 was able to produce experimental botryomycosis with
staphylococci by means of using a minimal
dose with which to infect rabbits. He was of
the opinion that the development of botryomycotic granules depended upon a delicate
balance between the virulence of the microorganisms and the resistance of the host.
Now, in the present era of antibiotics, this
natural balance can be modified by artificial means. 1 ' 8i 13 As a consequence, it may
be possible for certain bacteria to produce
botryomycotic types of lesions even though
they would not ordinarily do so.
SUMMARY
This paper deals with the findings in a
fatal case of disseminated visceral botryomycosis, probably caused by Pseudomonas
aeruginosa. To the authors' knowledge, this
is the first reported instance of botryomycosis thought to be caused by Pseudomonas. There are some similarities to a
previously published case of disseminated
visceral botryomycosis presumed to be
caused by a Proteus microorganism. In both
instances, it seems likely that the portal of
entry was the genitourinary tract, and that
dissemination to the lungs occurred by way
of the blood stream.
The suggestion is offered that the etiology
of botryomycotic types of lesions may
possibly be influenced by the artificial
modification of the balance between virulence of the microorganism and host resistance, as an effect of therapy with antibiotics.
SUMMARIO I N
INTERLINGUA
Es presentate le constatationes in un caso
mortal de disseminate botryomycosis vis-
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On the basis of the microscopic findings,
we think that the case reported here is
another example of disseminated visceral
botryomycosis. The absence of branching
filaments or broad hyphae in any of the
numerous granules, stained by various methods and examined microscopically, would
seem to rule out the possibility of actinomycosis or some other fungous disease. On
the other hand, the presence of Gram-negative bacilli in the granules and the growth of
Pseudomonas aeruginosa in cultures of heart's
blood, lung, and left kidney support the presumptive diagnosis of disseminated Pseudomonas infection. We have not found in the
literature any reports of disseminated visceral botryomycosis caused by Pseudomonas
organisms.
Vol. 33
CHAMBLIN
Jan. 1960
DISSEMINATED VISCERAL
REFERENCES
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ceral, probabilemente causate per Pseudomonas aeruginosa. Secundo le informationes
del autores, isto es le prime reportate caso
de botryomycosis supponitemente causate
per pseudomonas. Es noteta certe similaritates con un previemente publicate caso de
disseminate botrymycosis visceral, supponitemente causate per un organismo
proteus. In ambe iste casos il pare probabile
que le porta de accesso esseva le vias genitourinari e que le dissemination in le pulmones
occurreva via le circulation del sanguine.
Es formulate le notion que le etiologia de
lesiones del typo botryomycotic es possibilemente influentiate per modificationes artificial del balancia inter le virulentia del
microorganismo e le resistentia del hospite,
i.e., modificationes effectuate per therapias
a antibioticos.
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BOTRYOMYCOSIS