Bircher, Andreas J.

Burnens, André P.

Haefeli, Walter E.

Ott, Rudolf

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CID 1995;20 (March)	 Correspondence	 723Hair Loss Following Typhoid Fever: A ForgottenPhenomenonSIR—Typhoid fever is currently a rare disease in Switzerland, asonly 45 cases were reported in 1992. Effective treatments fortyphoid fever have become available in the last few decades, andlife-threatening salmonellal infections are now rare. Beforetreatment was available, reversible effluvium was a well-recog-nized clinical finding during the final stages of typhoid fever[ 1-4]. In contrast, hair loss has not been reported since the in-troduction of antimicrobial agents; not only has it not been re-ported in large clinical trials of typhoid fever [5, 6], but it is noteven mentioned in modern textbooks on infectious diseases [7].We recently studied a small epidemic outbreak of Salmonellatyphi infections in which all patients experienced symptomaticalopecia, a finding that indicates that this symptom may still beassociated with typhoid fever.An 83-year-old female, the index patient, was admitted to thehospital because of critical impairment of consciousness on day11 of a high fever. Cultures of blood and stool specimens yieldedS. typhi, and, after receiving antibiotic treatment with ciproflox-acin for 14 days, she recovered without any sequelae. Stool speci-mens were immediately obtained from all 15 persons who livedin the index patient's household or who were employed at thenursery where the patient worked, and these 15 persons weregiven therapy with oral ciprofloxacin (250 or 500 mg b.i.d.). Atthe time the stool specimens were collected, three of these 15individuals already had had nonspecific symptoms of infection(e.g., cough, diarrhea, chills, and fever [temperature of 41°C]for 4-10 days); culture of these specimens yielded S. typhi.The probable source of the infection was a 24-year-old maleemployee from the Middle East who was employed in the nurs-ery where the patient worked; this employee had had typhoidfever a few months before the index patient became ill and hadnot complied with the prescribed antibiotic therapy. S. typhiisolates from two patients (as well as isolates from the sourcepatient's stool specimens) were available for epidemiologic typ-ing; isolates from all three patients shared lysotype A and Pstlribopattern E [8], indicating that all patients were infected bythe same source.The general conditions of all three patients improved withindays of receiving therapy, but 2-4 weeks (mean ± SD, 3.6 ± 0.8weeks) after initiation of ciprofloxacin (i.e., 2.5-8 weeks afterthe onset of symptoms) all patients spontaneously reported dif-fuse loss of scalp hair (they attributed this loss to the antibacte-rial therapy). The source patient had also noted effluvium. All11 uninfected individuals who were receiving ciprofloxacinwere contacted, and none reported hair loss. Within 9-16weeks, a complete reversal of effluvium was noted for the threepreviously healthy younger patients (24-46 years old), and apartial reversal was noted for the two elderly patients (81 and 83Reprints or correspondence: Dr. Walter E. Haefeli, Division of ClinicalPharmacology, Department of Internal Medicine, University Hospital(Kantonsspital), Petersgraben 4, CH-4031 Basel, Switzerland.Clinical Infectious Diseases 1995;20:723-4© 1995 by The University of Chicago. All rights reserved.1058-4838/95/2003-0048$02.00years old) who received long-term maintenance therapy withenalapril and reserpine, respectively, because of mild hyperten-sion. Chronic carriage of S. typhi was excluded in all cases onthe basis of the (negative) results of follow-up stool cultures;these results were obtained several weeks after all the patientscompleted antibiotic therapy.Earlier this century, alopecia was a well-known phenomenonthat occurred as a consequence of highly febrile bacterial andviral infections [2-4]. During the 1918 influenza epidemic, inparticular, dramatic but reversible effluvium was noted in manycases 1-2.5 months following infection [2, 3]. Effluvium hasalso been reported to occur as a consequence of bacterial infec-tions such as pneumonia, scarlet fever, and typhoid fever. Aspostfebrile effluvium usually occurs in patients with fever (tern-perature of >39°C) [3], the availability of effective antipyreticand antibiotic treatment may have decreased its incidence. Thismay explain why we could not find a report of typhoid feverassociated with alopecia after extensively searching the worldliterature with use of on-line media (MEDLINE, Pharmline,IOWA Drug Information, Toxline, EMBASE, PARA, andHealth Periodicals).In our cases, an infectious etiology of effluvium is supportedby several facts: (1) Despite the widespread use of ciprofloxacin,there are no reports relating alopecia to this drug and the manu-facturer was aware only of five reports in which effluvium oc-curred during ciprofloxacin therapy and in which the causal re-lationship between this therapy and effluvium was notconfirmed; (2) None of the 11 healthy individuals who receivedciprofloxacin had symptomatic effluvium; and (3) The facts thatall patients had a prolonged course of disease and developed ahigh fever before therapy was initiated may have favored themanifestation of effluvium.We describe a troubling but reversible symptom of febrilesalmonellal infections that has been forgotten. The findings ofour cases may therefore be valuable for patients who experienceeffluvium following typhoid fever and for physicians who treatpatients worried about hair loss.Walter E. Haefeli, Rudolf Ott, Andreas J. Bircher, andAndre P. BurnensDepartment of Internal Medicine, Division of Clinical Pharmacology, andDepartment of Dermatology, University Hospital, Basel; general practice,Bid-Benken; and Swiss Reference Laboratory pr Foodborne Diseases,Bern, SwitzerlandReferences1. Kligman AM. Pathologic dynamics of human hair loss. Arch Dermatol1961;84:175-98.2. Richter R. Die Haare. In: Jadassohn J, ed. Handbuch der Haut- undGeschlechtskrankheiten. Erganzungswerk. Vol I, Part 3. Berlin:Springer-Verlag, 1963:472.3. Darier J. Precis de dermatologie. 4th ed. Paris: Masson, 1928:543.4. Galwesky E. Erkrankungen der Haare und des Haarbodens. In: Jadas-sohn J, ed. Handbuch der Haut- und Geschlechtskrankheiten. Vol.13. Berlin: Springer-Verlag, 1932:221.5. Stuart BM, Pullen RL. Typhoid: clinical analysis of three hundred andsixty cases. Arch Intern Med 1946;78:629-61.724	 Correspondence	 CID 1995;20 (March)6. Saphra I, Winter JW. Clinical manifestations of salmonellosis in man: anevaluation of 7779 human infections identified at the New York Sal-monella Center. N Engl J Med 1957;256:1128-34.7. Hook EW. Salmonella species (including typhoid fever). In: MandellGL, Douglas RG Jr, Bennett JE, eds. Principles and practice of in-fectious diseases. 3rd ed. New York: Churchill Livingstone,1990:1700-16.8. Altwegg M, Hickman-Brenner FW, Farmer JJ III. Ribosomal RNA generestriction patterns provide increased sensitivity for typing Salmonellatyphi strains. J Infect Dis 1989;160:145-9.Lactobacillus acidophilus Endocarditis After anAppendectomySIR-Lactobacillus endocarditis is a rare infection usually ob-served only in patients with preexisting structural heart diseasewho have recently undergone dental work [1, 2]. We report anunusual case of native-valve endocarditis due to Lactobacillusacidophilus, with the digestive tract as the probable portal ofentry.A 28-year-old woman was hospitalized in early October 1993following an 11-week history of fever (temperature, 38.5°-39°C), night sweats, and fatigue, and a 7-kg weight loss.Seven days before the onset of symptoms, the patient hadundergone a celioscopic appendectomy. Postoperative follow-up revealed a previously undetected heart murmur. Transtho-racic echocardiograms showed prolapse of the anterior cusp ofthe mitral valve with no vegetation. One month before admis-sion to the hospital, the patient had complained of severe pain inthe left hypochondrium and was given trimethoprim-sulfameth-oxazole and pefloxacin for 6 days. She had cramps in her rightcalf 48 hours before admission. The patient reported that shehad no history of valvular heart disease, had not had recentdental work, and did not use intravenous drugs. She did nothave an intrauterine contraceptive device.On admission to the hospital, physical examination revealed apansystolic murmur in the mitral area, a temperature of 39°C,splenomegaly, and a tender right calf with moderate edema.Results of laboratory tests were as follows: erythrocyte sedi-mentation rate, 60 mm/h; white blood cell count, 12,600/AL(78% neutrophils); and circulating immune complexes, 5.6 Ag/mL (detected by latex agglutination test). Lupus anticoagulantwas not detected.Transesophageal echocardiograms revealed a large vegetation(6 X 10 mm) on the anterior leaflet of the mitral valve thatextended into the left ventricle, and a moderate regurgitation.Abdominal echograms showed heterogeneous splenomegaly,suggesting multiple splenic infarcts. A deep venous thrombosisof the right posterior tibial vein was detected by Doppler ultraso-nography. No abnormalities were seen on chest, dental, andsinus roentgenograms. Cultures of urine were sterile.After 12 cultures of blood were set up, empirical intravenoustherapy combining penicillin G, tobramycin, and heparin wasstarted. Fever still persisted 72 hours later, at which time theReprints or correspondence: Dr. Didier Bessis, Service de Medecine In-terne A, HOpital Saint-Eloi, 2, av Bertin-Sans, 34295 Montpellier Cedex 5,France.Clinical Infectious Diseases 1995;20:724-5© 1995 by The University of Chicago. All rights reserved.1058-4838/95/2003-0049$02.00patient developed 10 Osler's nodes in the palmar and plantarareas and multiple asymptomatic maculopapules on the anteriorsurface of the lower left limb, predominantly around a homo-lateral effusion in the knee joint that was too small to be aspi-rated. All blood cultures were positive for organisms within 2-5days (bioMerieux Vital System; bioMerieux, Marcy l'Etoile,France); L. acidophilus was identified (Bacterial IdentificationLaboratory, Institut Pasteur, Paris). The strain was susceptibleto amoxicillin, ticarcillin, piperacillin, erythromycin, clindamy-cin, rifampin, and vancomycin, and it was resistant to cefoxitin,gentamicin, tetracycline, trimethoprim-sulfamethoxazole, andmetronidazole.The patient was treated intravenously with a combination ofvancomycin and rifampin, and she was apyretic within 48 hours;cutaneous and articular manifestations disappeared within 4days. The patient then complained of severe pain in the leftinguinal fold extending to the anterior thigh. Doppler ultrasono-grams showed a partial occlusion of the superficial femoral ar-tery, which was revascularized by Fogarty embolectomy. Painpersisted around the left inguinal scar 14 days after surgery, soarteriography was performed; it revealed a saccular aneurysm(3.5 cm in diameter) at the base of the left femoral artery bifur-cation. The patient's pain diminished after arterial resection andgrafting.After 6 weeks of intravenous antibiotic therapy, a 15-daycourse of oral amoxicillin was prescribed. Follow-up cultures ofblood taken during antibiotic therapy and after it was discontin-ued were negative. The vegetation was no longer visible on trans-thoracic echocardiograms after 8 weeks of antibiotic therapy.The patient was discharged at that time. No recurrence was ob-served at a follow-up visit 3 months later.Endocarditis due to Lactobacillus species is rare. Griffiths etal. [2] found only 41 cases reported in the English-languageliterature since 1938. Lactobacillus species are gram-positive,nonsporulated, anaerobic bacteria that normally reside in thehuman oral cavity, gastrointestinal tract, and female genitaltract. In our patient, recent colon surgery seemed to be the onlyplausible portal of entry. Indeed, lactobacillus bacteremias origi-nating from the intestinal tract have been described, particularlyin patients who have recently undergone endoscopy [3, 4]. Tothe best of our knowledge, this is the first report of the develop-ment of lactobacillus endocarditis after celioscopic appendec-tomy. This case suggests that patients with mitral valve prolapsewho undergo appendectomy are at risk for developing endocar-ditis [5, 6].Didier Bessis, Alain Le Quellec, Albert Sotto, Colette Perez,and Albert-Jean CiuranaService de Medecine Interne A, HOpital Saint-Eloi, Montpellier; Service deMedecine Interne B, 115pital Caremeau, Nimes; and Laboratoire deBacteriologie, HOpital Arnaud de Villeneuve, Montpellier, France

Hair Loss Following Typhoid Fever: A Forgotten Phenomenon

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