Beruflich Dokumente
Kultur Dokumente
ABSTRACT
Throat swabs from 61 patients, aged 1832 years, with non-streptococcal tonsillitis (NST) and 92
healthy controls were examined for the presence of Fusobacterium necrophorum DNA using a novel
TaqMan-based real-time quantitative PCR assay for F. necrophorum subspecies. The assay was based
on the gyrB subunit gene, and detected F. necrophorum DNA in 48% of patients with NST and in
21% of controls (p <0.001). F. necrophorum subsp. funduliforme was the only subspecies found in both
patients and controls. The load of F. necrophorum DNA on swabs from patients with NST was
significantly higher than that on swabs from controls (p <0.001). Furthermore, patients with recurrent
NST had a significantly higher load of F. necrophorum DNA compared to patients with acute NST
(p 0.04). In addition, 26 patients with tonsillitis and group C streptococci (GCS) had a significantly
higher load of F. necrophorum DNA compared to the NST group (p <0.001). It was concluded that
F. necrophorum subsp. funduliforme is present in small numbers as part of the normal human throat
flora, and that F. necrophorum in large quantities may cause tonsillitis, especially recurrent tonsillitis.
In addition, the study suggests that the concomitant presence of GCS may aggravate F. necrophorum
tonsillitis.
Keywords Commensal throat flora, Fusobacterium necrophorum, group C streptococci, Lemierres syndrome, real-
time PCR, tonsillitis
Original Submission: 6 October 2006; Revised Submission: 4 January 2007; Accepted: 25 January 2007
Clin Microbiol Infect 2007; 13: 695701
(a) DISCUSSION
108
n = 92 n = 61 n = 26 30 The results of this study confirmed that F. necro-
107
phorum subsp. funduliforme is part of the normal
106 flora of the human tonsils. Previous studies have
35
105
failed to detect F. necrophorum DNA from the
CFU/swab
CT
103 not detect F. necrophorum in healthy controls, but
45
found F. necrophorum in 10% of patients with a
2
10 sore throat. Aas et al. [6] did not detect F. necro-
50
101 phorum on tonsils from five individuals aged 23
55 years by sequencing 16S rRNA genes from the
100 55
total sample DNA. It was therefore surprising to
detect F. necrophorum DNA on swabs from healthy
Healthy controls NST GCS
individuals in the present study. However, the
(b) 108 findings seem to be reliable, as both real-time PCR
assays yielded consistent results, and sequencing
n = 43 n = 18
107 30 of amplicons from both the control and patient
groups showed homology with F. necrophorum
106
35 subsp. funduliforme sequences. F. necrophorum
105 probably resides in small numbers, mainly in the
CFU/swab
104
40 crypts of the tonsil in healthy humans, but is
present on the surface of inflamed tonsils in higher
CT
isolated F. necrophorum more frequently from required. In the meantime, it is suggested that all
patients with persistent sore throat than from patients with signs of bacterial tonsillitis be
patients with acute tonsillitis. examined for F. necrophorum.
F. necrophorum is a commensal pathogen
known to cause peritonsillar abscesses as well as
ACKNOWLEDGEMENTS
Lemierres syndrome, and it therefore seems
plausible that F. necrophorum can also cause We would like to thank H. Nielsen for laboratory assistance,
tonsillitis. The trigger for F. necrophorum to J. S. Lindholt for statistical advice and N. Nrskov-Lauritsen
for critical review of the manusript. Genomic DNA of 23
cause tonsillitis, or lead to the development of strains of F. necrophorum subsp. necrophorum was kindly
peritonsillar abscess or Lemierres syndrome, provided by I. Davies (VLA, Shrewsbury, UK) and K. Perry
is unknown, but genetic precursors may be (VLA, Winchester, UK). Sequencing of bacterial DNA was
involved [20]. Further studies are required to performed by D. Melsvik (Department of Haematology,
Aarhus University Hospital, Aarhus, Denmark). The study
reveal the mechanisms involved in the transition was approved by the Danish Scientific Ethical Committee
from a local F. necrophorum infection of the tonsils (VN 2005 33).
to Lemierres syndrome.
F. necrophorum rarely penetrates intact mucosal
surfaces. Therefore, interaction with viruses and REFERENCES
other bacteria has been suggested as a precursor 1. Lemierre A. On certain septicaemias due to anaerobic
for F. necrophorum infection [21,22]. EpsteinBarr organisms. Lancet 1936; i: 701703.
2. Aliyu SH, Marriott RK, Curran MD et al. Real-time PCR
virus has been suspected to be a predisposing
investigation into the importance of Fusobacterium necro-
factor for F. necrophorum infection, especially phorum as a cause of acute pharyngitis in general practice.
Lemierres syndrome [23,24]. EpsteinBarr virus J Med Microbiol 2004; 53: 10291035.
is thought to induce immunosuppression, with a 3. Batty A, Wren MW. Prevalence of Fusobacterium necro-
transient decrease in T-cell-mediated immunity phorum and other upper respiratory tract pathogens
isolated from throat swabs. Br J Biomed Sci 2005; 62: 66
that may predispose to bacterial infection. In the 70.
present study, three of four cases of acute mono- 4. Jousimies-Somer H, Savolainen S, Makitie A, Ylikoski J.
nucleosis were PCR-positive for F. necrophorum. Bacteriologic findings in peritonsillar abscesses in young
There may be a connection between F. necrophorum adults. Clin Infect Dis 1993; 16: 292298.
5. Batty A, Wren MW, Gal M. Fusobacterium necrophorum as
infection and acute mononucleosis, but a study
the cause of recurrent sore throat: comparison of isolates
with sufficient samples has yet to be conducted. from persistent sore throat syndrome and Lemierres
An association was found between F. necropho- disease. J Infect 2004; 51: 299305.
rum subsp. funduliforme and GCS in patients with 6. Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defi-
tonsillitis. Such an association was not found ning the normal bacterial flora of the oral cavity. J Clin
Microbiol 2005; 43: 57215732.
between F. necrophorum and other Lancefield 7. Hagelskjaer Kristensen L, Prag J. Human necrobacillosis,
groups of streptococci. However, the sample sizes with emphasis on Lemierres syndrome. Clin Infect Dis
for other groups of streptococcal tonsillitis were 2000; 31: 524532.
small, and results regarding GAS may be biased 8. Nagaraja TG, Narayanan SK, Stewart GC, Chengappa
MM. Fusobacterium necrophorum infections in animals:
because of the frequent use of GAS diagnostic kits
pathogenesis and pathogenic mechanisms. Anaerobe 2005;
by general practitioners. To our knowledge, the 11: 239246.
present study is the first to suggest a pathogenic 9. Jin J, Xu D, Narongwanichgarn W, Goto Y, Haga T, Shinjo
connection between F. necrophorum and GCS, T. Characterization of the 16S)23S rRNA intergenic spacer
although a few examples of co-infections with regions among strains of the Fusobacterium necrophorum
cluster. J Vet Med Sci 2002; 64: 273276.
F. necrophorum and GCS have been reported 10. Narayanan S, Nagaraja TG, Okwumabua O, Staats J,
previously [25,26]. Blossom et al. [27] recently Chengappa MM, Oberst RD. Ribotyping to compare
reported a classic case of Lemierres syndrome Fusobacterium necrophorum isolates from bovine liver
caused by GCS alone. Although F. necrophorum abscesses, ruminal walls, and ruminal contents. Appl
Environ Microbiol 1997; 63: 46714678.
was not detected, it might have been overlooked
11. Narongwanichgarn W, Kawaguchi E, Misawa N, Goto Y,
because of the delayed growth of F. necrophorum Haga T, Shinjo T. Differentiation of Fusobacterium necro-
compared to GCS in blood cultures. The present phorum subspecies from bovine pathological lesions by
data suggest a synergic relationship between RAPD-PCR. Vet Microbiol 2001; 82: 383388.
F. necrophorum subsp. funduliforme and GCS in 12. Narongwanichgarn W, Misawa N, Jin JH et al. Specific
detection and differentiation of two subspecies of
tonsillitis, but further research on this topic is
Fusobacterium necrophorum by PCR. Vet Microbiol 2003; 91: 21. Smith GR, Thornton EA. Pathogenicity of Fusobacterium
183195. necrophorum strains from man and animals. Epidemiol Infect
13. Hoffman S, Jousimies-Somer H, Svenstrup HF et al., eds. 1993; 110: 499506.
Anaerobic bacteriology manual, 6th edn. Belmont: Star Pub- 22. Tan ZL, Nagaraja TG, Chengappa MM. Fusobacterium
lishing Co., 2002. necrophorum infections: virulence factors, pathogenic
14. Murray PR, Baron EJ, Jorgensen JH, Pfaller MA, Yolken mechanism and control measures. Vet Res Commun 1996;
RH, eds. Manual of clinical microbiology, 8th edn. Wash- 20: 113140.
ington, DC: ASM Press, 2003. 23. Brook I. The association of anaerobic bacteria with infec-
15. Jin J, Haga T, Shinjo T, Goto Y. Phylogenetic analysis of tious mononucleosis. Anaerobe 2005; 11: 308311.
Fusobacterium necrophorum, Fusobacterium varium and 24. Dagan R, Powell KR. Postanginal sepsis following infec-
Fusobacterium nucleatum based on gyrB gene sequences. tious-mononucleosis. Arch Intern Med 1987; 147: 15811583.
J Vet Med Sci 2004; 66: 12431245. 25. Hagelskjaer LH, Prag J, Malczynski J, Kristensen JH.
16. Benson DA, Karsch-Mizrachi I, Lipman DJ, Ostell J, Incidence and clinical epidemiology of necrobacillosis,
Wheeler DL. GenBank. Nucleic Acids Res 2006; 34: 1620. including Lemierres syndrome, in Denmark 19901995.
17. Hall TA. BioEdit: a user-friendly biological sequence Eur J Clin Microbiol Infect Dis 1998; 17: 561565.
alignment editor and analysis program for Windows 26. Sinave CP, Hardy GJ, Fardy PW. The Lemierre syn-
95 98 NT. Nucleic Acids Symp Ser 1999; 41: 9598. dromesuppurative thrombophlebitis of the internal
18. Altschul SF, Gish W, Miller W, Myers EW, Lipman DJ. Basic jugular vein secondary to oropharyngeal infection.
local alignment search tool. J Mol Biol 1990; 215: 403410. Medicine 1989; 68: 8594.
19. Brazier JS. Fusobacterium necrophorum infections in man. 27. Blossom DB, Shah MD, Armitage KB. Lemierre syndrome
Rev Med Microbiol 2002; 13: 141149. caused by group C streptococus. Infect Dis Clin Pract 2005;
20. Constantin JM, Mira JP, Guerin R et al. Lemierres syn- 13: 324326.
drome and genetic polymorphisms: a case report. BMC
Infect Dis 2006; 6: 115.