The relevance of the following article is the common claim by accusing physicians that hospital caused infections are induced by the mother. Attorneys and parents are ill-equipped to defend against such claims, unless they know what organisms are considered normally found in feces. Feces can contain almost any kind of organism, yet any organism can not be considered a fecal organism. It is important to establish this fact. 

The New England Journal of Medicine -- December 3, 1998 -- Vol. 339, No. 23
Munchausen's Microbes?

To the Editor:

  Infection induced by a patient is a difficult problem. (1) The diagnosis is often delayed because objective signs are absent. The microbiology laboratory may provide clues to the diagnosis. (2)

A 30-year-old patient, a nurse's aide, was transferred from another hospital with a history of recurrent episodes of septic arthritis of the right ankle. Over a period of 3 years, she had been hospitalized for 168 days and had undergone 15 surgical interventions. A total of 72 wound samples (including biopsy  specimens and tissue fragments obtained during debridement of the ankle) and 110 blood specimens were sent for culture. Apart from "conventional" bacteria such as staphylococci, streptococci, and coliforms, cultures of both wound and blood samples grew unusual nonfermenting, gram-negative rods.

(Table 1). These organisms included Alcaligenes denitrificans subspecies xylosoxidans, A. faecalis, flavobacterium species, Comamonas testosteroni, Sphingomonas paucimobilis, and Stenotrophomonas  maltophilia as identified by a commercial biochemical test panel (API 20 NE, BioMerieux, Marcy-l'Etoile, France).

Blood specimens for culture were obtained during febrile episodes by the hospital phlebotomy team or the medical staff. The bacteremic episodes were recurrent, and 10 of 13 positive blood cultures contained multiple organisms. All the polymicrobial blood cultures were obtained when the patient had an intravenous catheter in place, but none of the catheters that were removed grew bacteria. Unusual nonfermenting bacteria account for only 0.2 percent of all blood-culture isolates in our hospital.

In the context of the patient's manipulation of thermometers and the recurrent malfunctioning of her intravenous catheters, the microbiologic findings suggested self-induced infection. It was strongly suspected that she rinsed her wounds with water from a toilet, which was considered to be the probable source of contamination. When confronted with this suspicion, the patient denied it. Over a three-year follow-up period, however, no further infections occurred.

Nonfermenting bacteria live in soil, water, and sea water. They are ubiquitous in the hospital, where their growth is supported by a humid atmosphere. (3) Isolation of these microorganisms from the blood generally points to an exogenous source of infection, such as a hemodialysis system. (4) These organisms are opportunistic and affect severely immunocompromised patients such as those with neutropenia. (5)

In this case, the isolation of unusual nonfermenting bacteria, in the absence of other likely explanations, suggested deliberate contamination. Self-induced infection should be suspected if a patient without an underlying malignant or immunosuppressive condition has recurrent polymicrobial infections with unusual gram-negative rods.

Nico E.L. Meessen, M.D., Ph.D.
Geert H.I.M. Walenkamp, M.D., Ph.D.z
Jan A. Jacobs, M.D., Ph.D.
University Hospital Maastricht
6202 AZ Maastricht, the Netherlands

References

 1. Reich P, Gottfried LA. Factitious disorders in a teaching hospital. Ann Intern Med 1983;99:240-7.

 2. Wallach J. Laboratory diagnosis of factitious disorders. Arch Intern Med 1994;154:1690-6.

 3. du Moulin G. Minimizing the potential for nosocomial pneumonia: architectural, engineering, and environmental considerations for the intensive care unit. Eur J Clin Microbiol Infect Dis 1989;8:69-74.

4. Reverdy ME, Freney J, Fleurette J, et al. Nosocomial colonization and infection by Achromobacter  xylosoxidans. J Clin Microbiol 1984;19:140-3.

5. Jacobs JA, Stobberingh EE, Schouten HC. Fatal infection due to Alcaligenes xylosoxidans subsp. xylosoxidans in a neutropenic host. Clin Microbiol Newslett 1992;14:182-4.