Lactobacilli and pleuropulmonary infection.

Serious infections due to lactobacilli have been rarely reported [1, 2]. The most common clinical syndromes are endocarditis and sepsis arising from localized infection. Recently we published the first case of pneumonia caused by Lactobacillus sp [3]. To date only two other cases of pleuropulmonary infection have been published [4]; an empyema and a pneumonia with a concomitant non-related lactobacillaemia. After our first report we have seen two more cases of Lactobacillus empyema. The fJISt case is a patient with a squamous carcinoma of the oesophagus, in whom the insertion of a prosthesis was the origin of a pleuroesophageal fistula that caused an empyema; culture of the pleural exudate yielded Lactobacillus sp and Bacteroides distansonis. The second case is a patient with hepatic cirrhosis who required surgical therapy for oesophageal variceal bleeding. After the surgical procedure a chest film showed a pleural effusion. Thoracentesis evidenced an empyema, and Lactobacillus sp and Pseudomonas aeruginosa were identified in the culture. In this patient the hypothetical pleuroesophageal fistula could not be proven with an oesophagogram. The first case is very similar to the one we published recently [3]; here an oesophageal carcinoma was also the origin of the pleurointestinal fistula. The fistula between the gastrointestinal tract and pleura was responsible for the empyema. Lactobacillus in the two cases was isolated from cultures of pleural fluid. The second case reported is different but a surgical procedure on the gastrointestinal tract was the hypothetical origin of the fistula to the pleural cavity. The case of empyema reported by SHARPE [4] was a 64 year old man who had had a previous operation for a hiatus hernia. A fistula from the stomach to the pleural space through the diaphragm was the origin of the empyema. Considering the four cases of empyema, the one reported by SHARPE and three of ours, it seems that a direct communication through a fistula between the gastrointestinal tract and pleura or lung must exist for the establishment of infection by Lactobacillus sp. Lactobacilli are usually sensitive to penicillin, ampicillin and co-trimoxazole [5, 6] but in two of our cases the strains were tolerant to clindarnycin and co-trimoxazole and the third was tolerant to co-trimoxazole and tetracycline.