HUMAN INFECTION WITH PASTEURELLA
PSEUDOTUBERCULOSIS RODENTIUM OF
PFEIFFER
R E P O B T OF CASE*
EMMA S. MOSS AND JOHN D. BATTLE, JR.
From the Departments of Pathology and Baderiology of the School of Medicine of
Louisiana State University and Charity Hospital of Louisiana at New Orléans
T h e genus Pasteurella contains a number of species of t h e
hemorrhagic septicemia group of organisms which are infectious
for animais, particularly rodents (Bergey 1 ). T o this genus belong
three species which are also infectious for m a n and which are the
etiologic agents responsible for plague, tularemia and pseudotuberculosis. Thèse three species, P. pestis, P. tularensis, a n d
P. pseudotuberculosis rodentium (Pfeiffer) hâve certain striking
similarities. Ail three are gram-negative, pleomorphic bacilli.
Ail three, although primarily infectious for rodents, are also
infectious for m a n . Ail three produce lésions of t h e "infectious
granuloma" type, especially in the liver, spleen and lymph nodes
of the infected animal or t h e infected h u m a n subject.
The differentiation between plague, tularemia and pseudotuberculosis has occasioned considérable difficulty. McCoy 2 ,
who identified tularemia in 1911, considered it a "plague-like
disease of rodents," a n d as late as 1927 Poppe (cited b y Topping
et al. 3 ) suggested t h a t it might be a h u m a n form of pseudotuberculosis. I n the light of subséquent investigations 4 - 5 it became
clear t h a t thèse three infections are caused by species of microorganisms which are distinct b u t which are still sufficiently related to each other t o warrant their inclusion in the genus Pasteurella. Topley and Wilson 6 , however, regard P. tularensis as
belonging t o t h e genus Brucella.
* Read before The Nineteenth Annual Convention of The American Society
of Clinical Pathologists, New York, June 7-9, 1940.
677
678
EMMA 8. MOSS AND JOHN D. BATTLE, JR.
Eberth 4 applied the terni pseudotuberculosis to a rare, tuberculosis-like disease in rabbits and guinea pigs which he described
for the first time in 1885. T h e first studies on Bacillus pseudotuberculosis were made b y Malassez and Vignal (cited b y Topping
et al. 3 ) in 1883, b u t it was not until several years later t h a t
Pfeiffer (cited b y Reimann and Rose 4 ) isolated and described the
organism. Only one of the four strains which Reimann 6 obtained for study from t h e Pribram collection was P. pseudotuberculosis rodentium {Pfeiffer), which suggests t h a t several strains of
organisms isolated from various animais hâve been designated
b y this name.
Occasional reports in this country a n d numerous articles in
the foreign literature point to this organism as the cause of spontaneous épidémies among guinea pigs. N o a t t e m p t has been
made to review the literature of the subject in this contribution,
b u t attention is called to the extensive lists of références attached t o the récent articles b y Reimann 5 , Reimann and Rose 4 ,
a n d W a t t s , Topping and Lillie 3 .
So far as can be determined, only five authentic cases of human
infection with P. pseudotuberculosis rodentium (Pfeiffer) seem to
hâve been recorded in the literature to this time 3 . Lorey, (1911),
isolated the organism from the blood stream antemortem and
from the liver and spleen postmortem. Saisawa, (1931), obtained it from the blood stream antemortem. Roman, (1916),
a n d Neugebauer, (1933), both cultured it from t h e liver and the
spleen postmortem. T h e strain studied b y W a t t s , Topping and
Lillie 3 , who collected t h e cases previously listed, was isolated
from the blood stream antemortem and t h e liver postmortem.
T h e case herewith reported is thus the sixth to be p u t on
record. I t occurred in a colored maie who was a native résident
of Louisiana, and is the second case to be reported from the
United States. T h e first (Watts, Topping and Lillie3) occurred
in a white maie in Seattle, Washington.
T h e causative organism in our case was isolated on two occasions a n t e m o r t e m from t h e blood stream, a n d from the blood
stream, spleen and abdominal lymph node postmortem.
INFECTION WITH P. PSEUDOTTJBERCULOSIS RODENTIUM
679
CASE REPORT
P. V. (T39-59530), a maie mulatto, 34, was admitted to Charity Hospital of
Louisiana at New Orléans December 14, 1939. He died February 4, 1940 (53
days later), and postmortem examination was performed two hours after death.
Clinical history. Illness began December 1, 1939, two weeks before admission with a "head cold," which two days later developed into a "chest cold,"
accompanied by pain in the right lumbar région and cough productive of a
moderate amount of sputum. The following day (December 3) he had a dull
frontal headache, mild chilly sensations, and a température élévation to 101°F.
The fever, accompanied by night sweats and chills at two to three day intervais,
continued until he entered the hospital. Constipation, not relieved by purgation, was marked from the onset of illness. Borborygmus was prominent and
associated with an increase in the severity of the lumbar pain. The urine was
scanty and highly colored.
The patient had had the usual diseases of childhood. Ever since an appendectomy in 1927 he suffered from mild constipation and indigestion. He had
had a tonsillectomy in 1928 and gonorrheal urethritis in 1931. The family and
marital history were irrelevant.
The patient worked in a coffee factory as a roaster and sampler. He stated
that he had eaten cooked rabbit three weeks before admission, but otherwise
had had no contact with rabbits. There was no history of rat or tick bites.
Physical examination. A well developed, moderately well nourished mulatto,
café-au-lait in color, 5 feet 11 inches tall and weighing 140 pounds. Température 104°F., puise rate 90 and respirations 14 per minute. The blood pressure
was 138/86. The patient, although in considérable pain and apparently critically ill, was well oriented, intelligent and coopérative.
There was moderate hyperemia of the forehead and malar eminences. The
respiration was of normal depth. The second heart sounds were increased,
particularly Pj and M2. The lungs evidenced moderately increased voice
sounds on the right and slightly increased voice sounds on the left side, with an
increase in the bronchial élément over the right upper lobe in the interscapular
région.
The abdomen was slightly distended and moderately tympanitic. Borborygmi were heard but were not exaggerated.
The patellar réflexes were active bilaterally. The Kernig sign was positive
bilaterally and was more marked on the right. The neck was not stiff, but passiveflexionproduced pain in the lower lumbar région. There was a small area
of tenderness over the right lumbar région 3 cm. from the third and fourth
lumbar spines. The physical examination was otherwise négative. Proctoscopic examination December 24 showed reddened bowel at the junction of the
rectum and sphincter.
Laboratory studies. Urinalyses on the day of admission and on three subse-
680
EMMA S. MOSS AND JOHN D. BATTUS, JE.
quent occasions were essentially négative. Albuminose (Bence-Jones) was not
présent when tested for on two occasions.
Blood examination December 14 revealed 4,800,000 red blood cells with 75
per cent hemoglobin (Sahli), and 11,000 white blood cells per eu. mm., 64 per
cent were neutrophiles, and 36 per cent lymphocytes. No malarial parasites
were found. December 26, 31,000 white cells per eu. mm. were found, with 72
per cent neutrophiles and 28 per cent lymphocytes. A shift to the left was
noted. December 31 there were 34,450 white blood cells per eu. mm.; 78 per
cent were neutrophiles, 20 per cent lymphocytes and 2 per cent monocytes.
Examination January 3 revealed 3,200,000 red blood cells and 23,250 white
blood cells per eu. mm., with 66 per cent neutrophiles, 24 per cent lymphocytes,
and 10 per cent monocytes.
Studies by the Division of Hematology January 9 were reported as follows:
Total red blood cells 4.02 millions per eu. mm.; hemoglobin 84 per cent, 12.7
gms. (Sahli); hematocrit 33 (Wintrobe); mean corpuscular volume 82 eu. microns; mean corpuscular hemoglobin 30 micromicrograms; total white blood
cells 15,200; premyelocytes 1; myelocytes 6; metamyelocytes 29; neutrophiles
(mature) 46; eosinophils 1; lymphocytes 15; monocytes 2. The granulocytic
séries showed immaturity and a definite shift to the left. The granulocytes
showed toxic granulations. Sternal puncture revealed no striking changes in
the sternal bone marrow. The hematologist reported the blood picture to be
suggestive of a leukemoid reaction to some infectious intoxication.
The Kline and Kolmer tests December 15 were négative. January 16 the
blood urea nitrogen was 18.2 mg. per cent and the uric acid 5.6 mg. per cent.
Stool culture December 19 was négative for non-lactose fermenting organisms
of the Eberthella, Salmonella and Shigella groups, and stool examination
December 26 was négative for parasites, cysts and ova.
The cerebrospinal fluid January 3 was clear and under no increased pressure.
Pandy's test for protein content was négative and the cell count was less than
10 cells per eu. mm. The Kline and Kolmer tests were négative.
The tuberculin test was négative January 20 and the Frei test was négative
two days later.
Blood agglutination tests December 27 and January 17 were négative for
typhoid, paratyphoid, typhus, undulant fever and tularemia.
Two guinea pigs inoculated intraperitoneally January 17 with the patient's
urine were living and well when they were sacrificed 19 days later, and no lésions
were found on postmortem examination.
Blood cultures made December 15 and January 3 were reported finally négative January 3 and January 16 respectively. Cultures made January 5 and
January 17 were positive for gram négative pleomorphic bacilli, type undetermined, January 10 and January 20 respectively.
Biopsy of a lymph node secured from the left inguinal région January 16
showed chronic lymphadenitis.
Roentgenologic studies. The chest December 15 showed considérable increase
INFECTION WITH P. PSETJDOTTJBERCTTLOSIS RODENTIUM
681
in lung markings, especially at the right base, and decreased expansion of the
left lung. There was no évidence of pneumonia. A second examination December 19 showed clear lung fields, and an old fracture of the seventh rib on the left.
Examination January 9 showed increased lung markings on both sides. There
was no évidence of parenchymal involvement, no abnormal élévation of the
diaphragm and no diminution of the angles on either side.
Examination of the lumbar and dorsal spine December 19 was négative.
A flat film of the abdomen December 28 showed both psoas muscles well visualized and no definite évidence of a perinephritic abscess. Intravenous pyelography December 29 showed both rénal pelves and calices well filled in the first
view. A double pelvis was seen on the right side. Both rénal shadows were
seen indistinctly, and both psoas muscle shadows were well seen.
Gastrointestinal examination with an opaque médium January 3 "showed a
large duodenal cap with redundancy of the first portion of the duodénum. Examination of the rectum and large bowel with a barium enema January 25 showed
no constant filling defect or obstruction.
Clinical course. The température remained septic after the patient's admission to the hospital (fig. 1) and a leukocytosis was constantly présent. The
abdominal distention and lumbar pain also continued. Four weeks after
admission, the liver, heretofore not palpable, was felt 4 cm. below the right
costal margin. A 10-day course of emetin hydrochloride was instituted, without
effect, and therapeutic tests with quinine did not alter the course of the septic
fever. Mepharsen (0.03 mg.) was also used, by the intravenous route.
In addition to the therapy already mentioned, the patient was treated symptomatically for pain, headache, constipation, hyperpyrexia and progressive
weakness. He had a high vitamin and high calorie diet. Sulfanilamide was
given in 5 gr. doses three times a day from December 29, 1939, to January 11,
1940. Transfusions of citrated blood (500 ce. each) were given January 4,
January 7, January 17, January 24, January 29 and February 1.
When the patient died February 4, 53 days after his admission to the hospital,
the diagnosis had still not been established. During the period of hospitalization the following diagnoses were considered and discarded: typhoid fever,
tularemia, malaria, spinal epidural and perinephritic abscess, amebic abscess of
the liver, abdominal Hodgkin's disease, lymphosarcoma, relapsing fever, and rat
bite fever and other spirochetal infections. Exploratory laparotomy was discussed shortly before the patient's death, but was not considered feasible because
of his very poor condition.
Autopsy
The body was that of a well developed, poorly nourished mulatto maie,
measuring 182 cm. in length and weighing 120 pounds. No enlargement of the
external lymph nodes was noted. The following are the significant fmdings:
Peritoneal cavity. The membranes were smooth and glistening. The cavity
contained approximately 1,000 ce. of clear, straw-colored fluid. Several of the
682
EMMA S. MOSS AND JOHN D. BATTLE, JR.
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FIG. 1. TEMPÉRATURE, PULSE AND RESPIRATOBY RATE FOR ONE WEEK OF
INFECTION WITH PASTEURELLA PSEUDOTUBERCULOSIS RODENTIUM
(PFEIFFER)
The reaction during the entire course of the illness was similar
INFECTION WITH P. PSEUDOTTJBERCULOSIS RODENTIUM
683
lymph nodes surrounding the head of the pancréas were enlarged. The largest
measured 2.5 cm. in diameter and presented a pale, yellowish gray surface.
On section numerous small, yellow, well circumscribed, necrotic patches were
seen. The mesenteric lymph nodes were unchanged. The leaves of the diaphragm were at their usual levels.
Pleural cavities. Each cavity contained approximately 300 ce. of clear,
straw-colored fluid. The membranes were smooth and glistening.
Lungs. The right lung weighed 410 gms. and the left 335 gms. There were
no areas of consolidation. Both bases were soggy and bright red in color, and a
FIG. 2. SPLEEN AND LYMPH NODE FBOM CASE OP HUMAN INFECTION WITH
PASTEURELLA PSEUDOTTJBERCULOSIS BODENTIUM (PFEIFFER)
large amount of frothy, blood-tinged fluid could be expressed from the eut
surfaces.
Spleen. The spleen weighed 130 gms. (fig. 2). Pale, yellowish-gray nodules
could be seen through the thin capsule. On eut section, thèse nodules replaced
the splenic tissue and appeared irregular, moderately firm, and necrotic. The
remainder of the splenic pulp was brownish-red and the trabeculae were not
prominent.
hiver. The liver weighed 1,660 gms. The edges were somewhat blunt.
The periportal markings were prominent. No macroscopic areas of necrosis
were présent. The gallbladder and biliary tract showed nothing of note.
684
EMMA S. MOSS AND JOHN D. BATTLE, JR.
Kidneys. The right kidney weighed 245 gms. and the left 300 gms. They
were pale and somewhat soft in consistency. The capsules stripped with ease
and the underlying surfaces were smooth and gray. On the surface were a
number of pinpoint yellowish-gray lésions surrounded by a zone of redness.
Similar lésions were clearly seen on the eut surface, which otherwise showed
nothing of note. The kidney pelves, ureters and urinary bladder were not
abnormal.
Examination of other organs, including the brain, showed nothing
remarkable.
Bactériologie findings. A postmortem blood culture was positive for a gramnegative, pleomorphic bacillus. The same organism was recovered on several
occasions from white mice and guinea pigs injected with macerated spleen and
lymph node. The organism was identified as Pasteurella pseudotuberculosis
rodentium (Pfeiffer).
Histopathology
Heart. Several rather large accumulations of lymphocytes were présent in
the pericardial fat. The muscle fibers were somewhat atrophie, but no areas
of necrosis were présent.
Lungs. A few bronchioles with their adjoining alveolar sacs were filled
with an exudate of polymorphonuclear leukocytes. No abscess areas were
présent.
Spleen (fig. 3). The Malpighian corpuscles were for the most part smaller
than normal and definitely reduced in number. None showed germinal centers.
Some of the normal-sized corpuscles and many of those which were reduced
were surrounded by a rather wide zone of reticular cells and fibroblasts, and in
some instances only a small collection of lymphocytes remained around the
central artery. Numerous areas of necrosis were présent throughout the pulp.
They varied considerably in size and shape, but in gênerai their borders were
quite irregular because of peripheral fmger-like extensions of the process. The
central portions of the lésions were composed either of a mixture of polymorphonuclear leukocytes, macrophages and scattered nuclear fragments, or of pinkstaining necrotic cellular débris in which the outlines of cells were still recognizable. Peripheral to the necrotic central areas was a rather wide zone of
polymorphonuclear leukocytes, macrophages and lymphocytes surrounded by a
narrow zone of connective tissue and reticular cells. Numerous large colonies
of organisms composed of cocco-bacillary forms were located at the junction of
the area of necrosis and the cellular reaction at the periphery. The pulp which
was not involved by necrosis showed prominent venous sinus walls because of
fibrosis and reticular cell hyperplasia; very few lymphocytes were noted in
them. The lining cells were hyperplastic and enlarged. There was considérable
phagocytosis by thèse cells of hemotoidin burrs, hemosiderin pigment, red
blood cells, lymphocytes, polymorphonuclear leukocytes, cells of their own type,
and unidentifiable cellular débris. Many of the arteries other than the central
INFECTION WITH P. PSEUDOTUBERCTJLOSIS RODENTIUM
685
arteries showed mild to marked infiltration of the média by macrophages,
lymphocytes and an occasional polymorphonuclear leukocyte.
hiver. The normal liver architecture was well preserved. The liver cells
showed a mild degree of parenchymatous and fatty degeneration in addition
to a moderate increase in lipochrome pigment. The Kupffer cells were large
and many showed phagocytosis of hemosiderin pigment, red blood cells and
lymphocytes. One small area of focal necrosis was infiltrated by polymorphonuclear leukocytes. No colonies of organisms were observed either in this
area or elsewhere in the liver.
Pancréas. The acinar and islet cells appeared normal. Small foci of lymphocytes and macrophages were présent in the interlobular connective tissue and,
to a less extent, in the intralobular tissues.
Suprarenal glands. The chief findings were an occasional small cortical
ecchymosis, fibrinous thrombi in a number of the veins, and a few small accumulations of lymphocytes, most of which were in the medulla.
Kidneys (fig. 4). The glomeruli and blood vessels appeared normal. Almost
ail the tubules were dilated. Hyaline droplet as well as parenchymatous
degeneration and fatty metamorphosis were the important changes in the
tubular epithelium, particularly that of the convoluted tubules. Many of the
686
EMMA S. MOSS AND JOHN D. BATTLE, JR.
largest cells were desquamated. Two small areas of necrosis consisted of a
central area of polymorphonuclear leukocytes and a peripheral zone of macrophages and lymphocytes. A récent cortical bland infarct was noted.
FIG. 4. PASTEURELLA PSEUDOTUBERCULOSIS RODENTIUM (PPEIFFER).
HUMAN
KlDNEY. COAGULATIVE AND LIQUEFACTION NECROSIS SHOWING
COLONIES OF ORGANISMS AT THE PERIPHERY.
(X
105)
Prostate. Moderate hyperplasia without inflammatory reaction was présent.
Lymph nodes. Lymph nodes from the hilus of the lungs showed marked
reticulo-endothelial cell hyperplasia and phagocytosis of red blood cells by
INFECTION WITH P. PSEUDOTTJBERCULOSIS RODENTIUM
687
macrophages. No necrosis was présent. Some abdominal lymph nodes,
particularly those obtained from the upper abdomen, showed necrotic lésions
similar to those observed in the spleen, except that in a few instances liquéfaction
necrosis was more prominent than the proliferative feature. Colonies of organisms were numerous in ail lésions. Ail of the lymph nodes showed reticuloendothelial cell hyperplasia and phagocytosis of degenerated cells and of
hemosiderin pigment.
Fat tissue. The fat tissue everywhere showed marked atrophy and reversai
to the embryonic type.
Bacteriology
The cultural and biologie characteristics of our strain of P. pseudotuberculosis
rodentium (Pfeiffer), as well as its behavior on animal inoculation, are in agreement with the findings of other investigators.
The gênerai characteristics of the microorganisms isolated from the blood
stream of the patient before and after death, from animais inoculated with human
spleen and lymph node, and from animais inoculated with pure culture of the
bacteria. were identical and constant.
The biological and cultural characteristics of the New Orléans strain of
Pasteurella pseudotuberculosis rodentium (Pfeiffer) are as follows :
It takes simple stains readily, is gram négative and non-acid fast.
Vacuolization, bipolar staining, and other irregularities of staining are
marked, especially in old culture.
The organism is a pleomorphic cocco-bacillus. Coccoid forms predominate
in young cultures, bacillary forms in older cultures (fig. 5).
The organism grows well on ordinary culture média. Growth appears in
24-48 hours.
It is easily recovered from the blood stream of man or of animais.
It has no motility at 37°C. or 20°C.
Appearance of growth on solid culture média:
1. Plain agar. Small, discrète, opalescent, slightly convex colonies with
smooth, entire edges.
2. Brom-thymol-Mue agar. Small, smooth, moist, blue, opalescent, slightly
convex colonies with smooth, entire edges.
3. Loeffler's blood' sérum média. Discrète, pinpoint, moist, slightly convex
colonies, glistening in reflected light. No liquéfaction of the médium occurs.
4. Dorsett's egg média. Moist, glistening, discrète, pinhead colonies, with
smooth edges, slightly convex, but flatter than on Loeffler's médium or plain
agar. There is no change in the médium.
5. Rabbit blood-infusion-agar. Gray, pinhead, moist, convex, round colonies
with entire edges which appear lighter by transmitted light. Beta-hemolysis
is présent.
6. Rabbit blood-dextrose (0.5 per cent) beef extract-agar. Colonies appear as
on rabbit blood-infusion-agar, but smaller. Methemoglobin is formed.
688
EMMA S. MOSS AND JOHN D. BATTLE, JE.
1
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FIG. 5. PASTEURELLA PSEUDOTUBERCULOSIS RODENTIUM (PFEIFFER). SMEAR
OF GROWTH FROM PLAIN AGAR (48 HOURS) STAINED WITH DILUTE
FUCHSIN SHOWING COCCO-BACILLARY FORMS. (X 1656)
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FIG. 'i. I'A-TIOUEELLA PSEUDOTUBERCULOSIS RODENTIUM (PFEIFFER). SMEAR
OF GROWTH ON 3 PER CENT SODIUM CHLORIDE AGAR STAINED WITH
DILUTE FUCHSIN SHOWING EXTRÊME PLEOMORPHISM. (X 1656)
INFECTION WITH P. PSEUDOTTJBERCULOSIS RODENTIUM
689
7. Human blood-infusion-agar. Pinhead, slightly mucoid colonies. There
is no hemolysis présent and methemoglobin is not formed.
8. Sait agar (3.0 per cent NaCl). Growth is scant, granular, white and dry.
Smears show marked pleomorphism. The organisms appear as long rods,
filamentous forms, short, plump rods, large coccoid and globular forms, vacuolated forms, and long rods with swollen, globular ends (fig. 6).
9. Gelatin. No liquéfaction occurs.
10. Citrate agar. This médium does not support growth.
Appearance of growth in liquid média:
1. Broth. Moderate turbidity with heavy granular sédiment. The organisms on smear show a tendency to form short chains.
2. Peptone water. The appearance is similar to the appearance in broth, but
the growth is less profuse.
Biochemical reactions:
1. In litmus milk the reaction is alkaline after four or five days.
2. Hydrogen sulphide is formed.
3. Indol is not formed.
4. Nitrates are reduced to nitrites.
5. Urea is split, and a small amount of ammonia is formed.
Fermentation reactions :
1. Dextrose, arabinose, salicin, adonitol, d-mannose, galactose, xylose,
rhamnose and glycérine are fermented with the production of acid but no gas.
2. Dulcitol, raffinose, sorbitol, inositol, inulin, lactose, maltose and mannite
are not changed.
3. Sucrose is fermented with the production of acid in the first two or three
days, but the médium consistently reverts to an alkaline reaction within a week.
Attempts to demonstrate motility in the New Orléans strain at 37°C. or 20°C.
were not successful. Our observations are thus at variance with those of some
investigators, who hâve reported motility under thèse circumstances and hâve
suggested that this finding furnishes sufficient évidence to differentiate
P. pseudoluberculosis rodentium (Pfeiffer) from P. pestis. McCoy2 considers
that the use of litmus milk offers a more certain means of differentiating the two
organisms, especially when facilities for study are limited. He writes:
"The action of P. pseudotuberculosis rodentium (Pfeiffer) on litmus milk is
especially convenient in distinguishing the organism from P. pestis. As is well
known, thèse organisms hâve many points of similarity, but a différence in their
actions on litmus milk appears to be constant. The plague organism is likely
to leave the culture médium unchanged, or to render it slightly acid; the pseudotuberculosis rodentium organism may give a very slight initial acidity but after
three or four days to a week a distinctly alkaline reaction develops."
Our findings confirmed this observation.
When the New Orléans organism was cultured on rabbit blood-infusion-agar,
beta hemolysis was produced, and when it was grown on rabbit blood-dextroseextract-agar, methemoglobin was formed. Other observers report that their
2/22/40 Subcutane- Macerated human spleen 12 hrs.
ous, left 18 days in refrigerator at
40°F.
groin
2/1S/40 Subcutane- 0.5 ce. of saline suspension 6 days
ous, left from plain agar slant of
organisms from antemorgroin
tem human blood culture
2/18/40 Subcutane- 0.15 ce. same suspension as 42 dayst Blood néga- 3/30/40. Sacrificed. 10 ce. Lymph nodes of left groin redull gray peritoneal exudate. placed by caseous necrotic
tive
ous, left
#4
Liver showed several gray tissue with many polygroin
white lésions (1-3 mm.). morphonuclear leukocytes.
Spleen small,no gross lésions. Liver shows numerous areas
Mass of yellow caseous focal necrosis. Spleen, kidlymph nodes in left groin neys, adrenals and tesets
normal
(2 cm.)
Guinea
pig 3
Guinea
pig 4
Guinea
pig 5
Blood posi- 2/22/40. Sacrificed. Mass of Local mass shows abscesses,
yellow necrotic tissue at site necrosis and hemorrhage.
tive
of inoculation. Diffuse, yel- Liver and spleen show nulowish lésions in liver. merous areas of necrosis.
Many pale yellowish areas Kidneys axe not remarkable
in spleen
Autopsy delayed. Postmortem changes présent
Blood posi- 2/27/40. Sacrificed. Indurated hemorrhagic mass in
tive
left groin. Lymph nodes
right groin enlarged and firm.
Liver enlarged with diffuse
yellow mottling. Spleen
normal in size with many
pale grayish areas
Macerated pancreatic human 7 days
lymph node 16 days in
refrigerator at 40°F.
2/20/40 Subcutaneous, left
groin
Microscopic
2/22/40. Died. Postmortem Diffuse hemorrhages of liver
6 hours after death. Hemor- and spleen. No nécroses
rhagic induration of left inguinal nodes. Liver enlarged
with many yellow mottled
areas- Spleen négative
Gross
Guinea
pig 2
CULTURE
Macerated pancreatic human 50 hrs.
lymph node 16 days in
refrigerator at 40°F.
TIME
ELAPSED
2/20/40 Subcutaneous, left
groin
F INOCU- SOURCE OF MATERIAL
DATE SITELAO
TION
POSTMORTEM EXAMINATION*
Guinea
pigl
ANIMAL
NUMBER
TABLE 1
Results of animal inoculation
«H
P
o
a
3
Z
O
ow
w
>
Ê
O
Ci
3/13/40
3/ 4/40
3/ 4/40
3/ 4/40
2/22/40
Macerated human spleen
22 hrs.
3 days
Peritoneal
0.25 ce. saline suspension 2 days
from plain agar slant of
organism of # 2 (5 générations on artificial médium)
Subcutane- 0.5 ce. same suspension as 3 days
ous, left
#7
groin
Subcutane- 0.3 ce. same suspension as
ous, left
#7
groin
Subcutane- 0.75 ce. of saline suspension 24 hrs.
ous, left from plain agar slant of
groin
organism isolated from
blood of #2 (3 générations
on artificial médium)
Peritoneal
Multiple focal nécroses in liver.
Extensive necrosis and hemorrhage in spleen. Colonies
of microorganisms présent
Peritoneal
exudate
positive
3/15/40. Died. Diffuse dirty
gray exudate in peritoneum.
Liver and spleen normal in
size. No gross lésions
H3
W
W
cl
O
O
•d
m
H
cl
O
O
3
No areas of focal necrosis in
O
liver and spleen. No colonies of organisms. Diffuse
o
fibrinopurulent exudate on
z
capsule
Blood posi- 3/7/40. Sacrificed. Hemor- Multiple focal nécroses in liver
tive
rhagic induration. Right and spleen
inguinal nodes pale gray,
firm and enlarged. Liver
shows diffuse yellowish mottled lésions
3/7/40. Died. Postmortem f
hrs. later. Hemorrhagic in
duration at site of inoculation. Liver enlarged with
yellowish mottled lésions.
Spleen enlarged with fine
yellowish lésions
Blood posi- 3/5/40. Sacrificed. No lésions Liver and spleen négative
in liver, spleen or local site
tive
Blood posi- 2/23/40. Hemorrhagic fibrin-Fibrinopurulent exudate over
ous exudate in peritoneal liver and spleen. No areas
tive
cavity especially about liver of focal necrosis
and spleen. Liver normal.
Spleen enlarged. No gross
lésions
*JA11 animais sacrificed were very sick or actually moribund at the time.
f3/21/40 small, firm mass of lymph nodes in left groin. 3/28/40 pig sick and emaciated.
Guinea
pig 10
Guinea
pig 9
Guinea
pig 8
Guinea
pig 7
Guinea
pig 6
2.5 ce. saline suspension of 30 hrs.
24-hr. plain agar culture
from antemortem human
blood culture
5/24/40 Intraperitoneal
5/24/40 Subcutane- Subcultured on artificîal 3 days
ous, left média since 2/4/40. No
groin
previous animal passage
Guinea
pig 12
Guinea
pig 13
Gross
Microscopic
3/16/40. Died. Diffusethick Fibrinous, slightly purulent
gray peritoneal exudate. exudate on peritoneal surLiver and spleen normal in faces. Liver and spleen
size. No gross lésions noted show no areas of focal necrosis
Blood posi- 5/27/40. Sacrificed. Enlarged Numerous areas of focal necroand necrotic liver, diffusely sis in liver and spleen. No
tive
studded with yellowishfoci. colonies of organisms seen
Spleen normal
Peritoneal 5/25/40. Sacrificed. Thin
Small amount fibrinopurulent
turbid peritoneal exudate. exudate on peritoneum.
exudate
and blood Peritoneum injected. Liver Liver shows areas of early
studded with small yellow- focal necrosis
positive
ish foci. Spleen négative
CULTURE
POSTMORTEM EXAMWATION*
Mouse 1
2/20/40 Intraperitoneal
Macerated spleen
12 hrs.
Peritoneal
exudate
positive
2/20/40- Died. Slight hemor- Hemorrhagic fibrinous peritoneal exudate. No areas of
rhagic exudate
focal necrosis in liver and
spleen
Rabbit 2 3/ 4/40 Subcutaneous, 2 ce saline suspension of 59 days§ Blood néga- 5/3/40. Sacrificed. Encap- Négative
sulated mass in left groin
tive
plain agar slant of organism
left groin
(3.5 x 3 x 1.5 cm.) composed
from blood of guinea pig
of thick yellow caseous mate#2 (3 générations on artirial. No gross lésions in
ficîal médium)
liver and spleen
Rabbit 1 2/18/40 Intradermal 0.5 ce. of saline suspension 75 daysl Blood néga- 5/3/40. Sacrificed. Négative Négative
tive
findings
in right ab- from 24-hr. plain agar slant
dominal wall of organism from blood of
guinea pig * 4
0.75 ce. same suspension as 3 days
#10
TIME
ELAPSED
3/13/40 Peritoneal
OF INOCU- SOURCE OF MATERIAL
DATE SITELA
TION
Guinea
pig 11
ANIMAL
NUMBER
TABLE 1--Concluded
e-i
M
X
3
O
2!
t)
g
O
50
00
>
05
2/20/40 Intraperitoneal
0.25 ce. saline suspension 13 hrs.
from plain agar slant of
organisms from antemortem human blood culture
Peritoneal
exudate
positive
% 3/1/40 small local lésion at site of inoculation.
§ 3/28/40 nodes in left groin enlarged.
** Eats never appeared sick, or developed noticeable local lésions.
White rats 2/20/40 Subcutane- 0.5 ce. saline suspension from 72 days**
ous, left plain agar slant of organ(2) adult
groin
isms from antemortem
human blood culture.
Pathogenic for guinea pig
# 4 and mouse # 2
Mouse 2
Hemorrhagicfibrinousperitoneal exudate. No areas of
focal necrosis in liver and
spleen
5/3/40. Sacrificed. No gross Négative
pathologie changes
2/20/40. Died. Slight hemorrhagic exudate over peritoneum. No intrinsic change
in liver, spleen and lungs
ai
d
M
2!
H
o
«
ci
f
o
m
tu
O
03
ci
O
O
•3
cl
w
H3
2!
o
I—I
a
694
EMMA 8. MOSS AND JOHN D. BATTLE, JR.
type strains of P. pseudotuberculosis do not cause hemolysis when grown on
human blood média, and this was also true of our strain.
Like other observers, we found that the pseudotuberculosis organism becomes
markedly pleomorphic when grown on 3 per cent NaCl agar, and that this
characteristic feature can be used to distinguish it from other groups of pleomorphic gram négative, non-motile bacilli which are not changed by this
médium.
The New Orléans strain of P. pseudotuberculosis rodentium (Pfeiffer) consistently produced acid during the first few days of growth in sucrose, but pro-
FIG. 7. PASTEUEELLA PSEUDOTUBERCULOSIS RODENTIUM (PFEIFFER). GUINEA
PIG SPLEEN SHOWING MASSIVE COAGULATIVE NECROSIS WITH COLONIES
OF ORGANISMS. ( X 105)
duced an alkaline reaction of the médium within a week. The action of this
organism on sucrose is variously reported by other observers as producing no
change or only slight acidity.
Summary of animal inoculations {table 1)
1. The New Orléans strain of pseudotuberculosis rodentium (Pfeiffer) was
highly pathogenic for guinea pigs, regardless of the source from which it was
obtained. Within 12 hours to seven days after subcutaneous or intraperitoneal
INFECTION WITH P. PSEUDOTTJBERCULOSIS RODENTIUM
695
inoculation ail the animais either had died or were sacrificed because they were
moribund.
2. The organism could be isolated from the blood stream or peritoneal exudate
of the animais dying of the infection.
FlG. 8. LlVER FROM GUINEA PlG INOCULATED WITH PASTEURELLA
PSEUDOTUBERCULOSIS RODENTIUM (PFEIFFER)
3. Characteristic lésions were produced in spleen, liver and régional lymph
nodes of the animais which did not immediately succumb to the infection but
lived for varying periods of time after the inoculation.
4. The lésions of the liver and spleen of guinea pigs dying within Ave to seven
days after inoculation resembled, both grossly and microscopically, those seen
at autopsy in the human subject (figs. 7, 8, and 9).
696
EMMA S. MOSS AND JOHN D. BATTLE, JR.
5. Pathogenicity for rabbits was not marked, and only local lésions were
produced in the régional lymph nodes on subcutaneous inoculation and in the
skin on intradermal inoculation. According to Meyer and his associâtes7,
guinea pig strains of P. pseudotuberculosis rodentium (Pfeiffer) rarely produce
generalized lésions in rabbits, and only local infiltrations and nécroses are
noted on subcutaneous injection.
6. White rats were apparently not susceptible to the infection, no gross or
microscopic lésions being produced by subcutaneous inoculation.
7. White mice were highly susceptible to intraperitoneal infection with the
freshly isolated organism or with macerated tissue removed postmortem from
FIG. 9. PASTEURELLA PSEUDOTUBERCULOSIS RODENTIUM (PFEIPFER). GUINEA
PIG LIVER SHOWING EARLY LÉSION OP FOCAL NECROSIS. NO COLONIES
OP ORGANISMS PRÉSENT. ( X 105)
the human subject. They succumbed to the infection within 12 hours, and a
hemorrhagic, nbrinous peritoneal exudate was présent, from which the organism
could be isolated. The liver and spleen showed no gross or microscopic lésions.
8. Subculture on artificial média up to the time of writing (123 days) has not
reduced the pathogenicity of the organism for guinea pigs.
Agglutination reactions
Diagnostic antiserum of B. melitensis, P. tularensis, and S. dysenteriae
(Flexner) failed to show agglutination by either macroscopic or microscopic
INFECTION WITH P. PSEUDOTUBERCULOSIS RODENTIUM
697
methods with any of the cultures of P. pseudotuberculosis used as antigen. The
blood sérum of four rabbits and one guinea pig which had been inoculated with
living P. pseudotubercidosis rodentium showed no agglutination of B. melitensis
or P. tularensis antigens, and agglutination with the homologous antigen was
only as high as 1:80.
P. pestis and P. pseudotuberculosis rodentium antisera suitable for diagnostic
purposes were unobtainable from outside sources.
DISCUSSION
I t was particularly important t o differentiate P. pseudotuberculosis rodentium (Pfeiffer) from P. pestis, as well as from P. tularensis, because épidémies of h u m a n plague hâve occurred in
New Orléans as late as 1920-1921 8 , a n d in rodents as late as
1924 9 , and because tularemia appears in t h e city sporadically
throughout the year. At the time the case reported in this paper
was under observation, a number of unusually severe cases of
tularemia, several of which were fatal, were also under observation in t h e hospital.
A history of contact with rabbits can be obtained in the majority of cases of tularemia, b u t in t h e case of pseudotuberculosis
infection herewith recorded t h e only such contact which could
be established was t h a t t h e patient had eaten cooked rabbit
three weeks prior t o t h e onset of his illness. T h e significance of
this fact is at présent not clear. Cats are known t o harbor in
their throats a strain of Pasteurella saprophytic for t h e animal
b u t highly pathogenic for m a n and other animais 10 , and in
Wisconsin Hansmann 1 1 has recently isolated an organism of this
genus from a cat bite. I n a single case of P.
pseudotuberculosis
rodentium (Pfeiffer) infection 4 a history of contact with cats was
elicited, although t h e n a t u r e of t h e contact was n o t stated. N o
such history was elicited in our case.
T h e P. pseudotuberculosis rodentium remains viable in tissue for
variable periods of time when kept in cold storage. T h e organism was pathogenic for white mice and guinea pigs when t h e y were
inoculated intraperitoneally or subcutaneously with h u m a n spleen
and lymph node which h a d been kept at 40°C. for 16-18 days.
The organism was recovered from the peritoneal exudate of the
heart blood of the animais which succumbed to t h e infection.
698
EMMA 8. M08S AND JOHN D. BATTLE, JR.
T h e lésions produced in t h e liver, spleen a n d lymph nodes b y
P. pseudotuberculosis rodentium (Pfeiffer) show colonies of organisms which are visible in t h e necrotic tissue after hematoxylin
and eosin staining. This is in striking contrast t o t h e lésions of
tularemia, in which such colonies are n o t visible, although
Foshay 1 2 has devised a spécial staining method b y which P.
tularensis can be demonstrated in tissue.
T h e ease with which P. pseudotuberculosis rodentium (Pfeiffer)
can be isolated from t h e blood stream a n t e m o r t e m a n d from both
h u m a n a n d animal tissues, as well as t h e facility with which it can
be cultivated in ordinary culture média, would seem t o preclude
t h e possibility of confusing this organism with P. tularensis.
McCoy's 2 suggestion, previously cited, t h a t t h e reaction on
litmus milk be employed for this purpose, would seem t o obviate
any difficulty in differentiating t h e pseudotuberculosis organism
from P. peslis.
STJMMARY
There is p u t on record herewith what is apparently the sixth
case of h u m a n infection b y P. pseudotuberculosis
rodentium
(Pfeiffer) t o be added t o t h e médical literature. I t was observed
at Charity Hospital of Louisiana a t New Orléans during the
winter of 1939-1940, in a maie m u l a t t o 34 years of âge. T h e
clinical history, postmortem fmdings a n d animal studies are
recorded in détail, a n d various points of interest a n d significance
are discussed.
REFERENCES
(5) REIMANN, H. A.: Further studies
(1) BEBGEY, D. H.: Manual of Deon P. pseudotuberculosis. Am.
terminative Bacteriology. 5th
J. Hyg., 16: 206-214, 1932.
édition, Williams & Wilkins
Company, Baltimore, 1939.
(6) TOPLEY, W. W. C , AND WlLSON,
(2) MCCOY, G. W.: Personal comG. S.: The Principles of Bacmunication.
teriology and Immunology.
(3) TOPPING, N. H., WATTS, C. E.,
William Wood & Company,
New York, 1929.
AND LILLIB, R. D.: A case of
(7) MEYER, K. F. IN JORDAN, E. O.,
human infection with P. pseudoAND FALK, I. S.: Newer Knowltuberculosis rodentium. Pub.
edge of Bacteriology and ImHealth Rep., 63: 1340-1352,
munology. University of Chi1938.
cago Press, Chicago, 1929.
(4) REIMANN, H. A., AND ROSE, W. J. :
(8) Annual Report of the Surgeon
The similarity of pseudo-tuGeneral of the Public Health
berculosis
and tularemia.
Service of the U. S., page 101,
Arch. of Path., 11:684-588,1931.
1921.
INFECTION WITH P. PSETJDOTUBERCTJLOSIS RODENTITJM 699
(9) Annual Report of the Surgeon
General of the Public Health
Service of the U. S., page 82,
1925.
(10) Abstract in J. A. V. M. A.: New
points in the pathology of cat
bites, 46: 412, 1940.
(11) HANSMANN, G. H.: Personal communication.
(12) FOSHAT, L.: New
Method
for
staining Bacterium tularense
in tissue sections. J. Lab.
and Clin Med., 17: 193-195,
1931.