A microbiological study of Papillon-Lefèvre syndrome in two patients
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J Clin Pathol 2001;54:371–376 371
A microbiological study of Papillon-Lefèvre
syndrome in two patients
K L Robertson, D B Drucker, J James, A S Blinkhorn, S Hamlet, P S Bird
Abstract pockets form leading to increased tooth mobil-
Aim—To analyse the microflora of subgin- ity.6 Usually, both deciduous teeth7 and perma-
gival plaque from patients with Papillon- nent teeth6 are lost prematurely.
Lefèvre syndrome (PLS), which is a very PLS is a systemic disease with immune
rare disease characterised by palmar- system defects,8 which might result in the pro-
plantar hyperkeratosis with precocious liferation of certain periodontopathogens.
periodontal destruction. Microbiological studies of the oral microflora
Methods—Bacterial isolates were identi- of patients with PLS have shown that the pre-
fied using a combination of commercial dominant organisms in the periodontal sites
identification kits, traditional laboratory are Gram negative anaerobic rods,9 including
tests, and gas liquid chromatography. Porphyromonas gingivalis, Prevotella intermedia,
Some isolates were also subjected to Prevotella loescheii, Bacteroides gracilis,10 and
partial 16S rDNA sequencing. Plaque Fusobacterium nucleatum.10 11 Eikenella corro-
samples were also assayed for the pres- dens, capnocytophaga,11 veillonella, anaerobic
ence of Porphyromonas gingivalis, Prevo- streptococci,12 and spirochaetes have also been
tella intermedia, and Actinobacillus reported.13 14 Although the presence of cultivat-
actinomycetemcomitans in a quantitative able Actinobacillus actinomycetemcomitans and
enzyme linked immunosorbent assay raised serum antibody titres to A actinomyc-
(ELISA) using monoclonal antibodies. etemcomitans have been found,10 12 13 15 16 this is
Results—The culture results showed that not always the case.11 17
most isolates were capnophilic and facul- The aims of our study were to identify the
tatively anaerobic species—mainly Cap- subgingival plaque microflora of two patients
nocytophaga spp and Streptococcus spp. with PLS and to assess the amounts of the
The latter included S constellatus, S ora- periodontopathic bacteria, A actinomycetem-
lis, and S sanguis. Other facultative bac- comitans, P gingivalis, and P intermedia using a
teria belonged to the genera gemella, quantitative enzyme linked immunosorbent
kingella, leuconostoc, and stomatococcus. assay (ELISA).
The aerobic bacteria isolated were species
of neisseria and bacillus. Anaerobic spe-
cies included Prevotella intermedia, Methods
PLAQUE SAMPLES
P melaninogenica, and P nigrescens, as
well as Peptostreptococcus spp. ELISA Two patients with PLS attended the University
detected P gingivalis in one patient in all of Manchester Dental Hospital. Patient 1 had
sites sampled, whereas A actinomycetem- only six teeth remaining and subgingival
comitans was detected in only one site plaque samples were taken from each tooth. A
from the other patient. Prevotella inter- further five subgingival plaque samples were
media was present in low numbers. also collected from the molars and canine teeth
Conclusions—Patients with PLS have a of patient 2. All samples were collected with a
very complex subgingival flora including curette and (1) placed into reduced transport
recognised periodontal pathogens. How- fluid for rapid transportation to Manchester
Oral Microbiology ever, no particular periodontopathogen is Royal Infirmary for initial bacterial cultivation;
Laboratory, University
invariably associated with PLS. (2) resuspended in phosphate buVered saline
of Manchester Dental (PBS) containing 0.01% thiomersal, frozen,
(J Clin Pathol 2001;54:371–376)
School, Higher and sent to the University of Queensland, St
Cambridge Street, Keywords: Papillon-Lefèvre syndrome;
Manchester M15 6FH,
Lucia, Australia for analysis with specific
periodontopathogens monoclonal antibodies by means of ELISA.
UK
K L Robertson
J James Papillon-Lefèvre syndrome (PLS) was first ENZYME LINKED IMMUNOSORBENT ASSAY
A S Blinkhorn described in 1924 by Papillon and Lefevre.1 It Plaque samples were thawed, six to eight 1 mm
D B Drucker
is a rare autosomal recessive disease,2 with an glass beads added to each vial, and the bacteria
University of incidence of 1–4 cases/million people,3 and dispersed by vortexing and then sonicated for
Queensland School of with consanguinity between parents seen in five seconds. Samples were diluted in an equal
Dentistry, Brisbane one third of cases.4 The disease is characterised volume of 0.1 M carbonate buVer pH 9.6. A
Qld 4072, Australia by palmar-plantar hyperkeratosis, a thickening 100 µl volume of each sample was pipetted into
S Hamlet of the skin on the palms of the hands and the triplicate wells of a 96 well Maxisorp microtitre
P S Bird
soles of the feet.5 In addition, precocious perio- plate (Nunc, Roskilde, Denmark). A known
Correspondence to: dontal destruction of both the deciduous and concentration of bacterial cells of either
Dr Drucker permanent teeth is seen.6 The gingiva become A actinomycetemcomitans Y4, P gingivalis FDC-
David.Drucker@man.ac.uk red and inflamed and may be ulcerated5 and a 381, or P intermedia ATCC 25611 (ranging
Accepted for publication form of rapid, severe periodontitis occurs.4 from 9 to 150 × 104 cells/ml) in carbonate
20 November 2000 Alveolar bone is resorbed and deep periodontal buVer were assayed on each plate with the
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372 Robertson, Drucker, James, et al
plaque samples. Microtitre plates were incu- use of schemes in the Wadsworth anaerobic bac-
bated overnight at 4°C and washed three times teriology manual and Virginia Polytechnic Insti-
with PBS/Tween 20 (0.05%; PBS-T). Non- tute anaerobe laboratory manual.18 19 Bacterial
specific binding was blocked with PBS-T con- culture supernatants from Gram positive bac-
taining 1% fetal calf serum (Commonwealth teria were analysed for the presence of
Serum Laboratory, Melbourne, Australia) and non-volatile acids.18 For gas chromatographic
the plates were incubated for one hour at room analysis of end products, established methods
temperature (RT). After washing (×3) with were followed,18 except that supernatant fluid
PBS-T, diluted horseradish peroxidase labelled from 48 hour gas liquid chromatography
monoclonal antibodies specific to either A ac- (GLC) broth (Lab M) cultures was used. Sam-
tinomycetemcomitans, P gingivalis, or P interme- ples (2 µl) were analysed on a column of 6%
dia were added to all the coated wells and incu- Carbowax 20M TPA on Chromosorb W
bated for two hours at RT. After further AWDMCS (Phase Separations, Queensferry,
washing (×3) with PBS-T, colour development UK), whether ether extracts of volatile end
was achieved by adding 150 µl of 2.5 mM products or chloroform extracts of methylated
ó-tolidine (Kodak Eastman, Rochester, New non-volatile acids. The injector and detector
York, USA) in 100 mM phosphate citrate temperatures of the chromatograph (AI, Cam-
buVer (pH 3.5) containing 0.025 mM EDTA bridge, UK) were both 150°C. The initial tem-
and activated by 3% H2O2. The colour perature of the column was 65°C, which was
development was stopped after 10 minutes by held for 30 seconds before being increased lin-
the addition of 50 µl of 1 M HCl. The plates early to 115°C over two minutes, and held for
were read in a Bio-Rad microplate reader six minutes and 20 seconds. The equilibration
model 3550 (Bio-Rad Laboratories, Hercules, time between samples was three minutes.
California, USA) at 450 nm and 655 nm. When satisfactory identification could not be
achieved, the partial sequence of the 16S rRNA
DETECTION OF SPIROCHAETES gene was determined and compared with
Smears were prepared from the plaque sam- library data for known organisms.
ples, air dried, and stained with a modified
Gram stain, where the counter stain was 20%
DNA EXTRACTION: GRAM NEGATIVE BACTERIA
carbol fuchsin, applied for five minutes. Slides
Bacterial isolates were grown to purity on FAA.
were viewed under a Zeiss (Jena, Germany),
Isolated colonies were subcultured into fastidi-
Axioplan light microscope at ×1000 magnifica-
ous anaerobe broth and DNA was extracted
tion.
from a 72 hour culture. Briefly, 5 ml of each
bacterial culture was centrifuged at 3000 ×g for
CULTIVATION OF PLAQUE SAMPLES
10 minutes and the cells resuspended in
Plaque samples were plated on to Columbia
sucrose/Tris/EDTA (STE). Lysozyme (Sigma,
blood agar plates supplemented with 5% defi-
Poole, Dorset, UK) was added to give a final
brinated horse blood (Oxoid, Basingstoke,
concentration of 2 mg/ml and incubated at
UK) and fastidious anaerobe agar (FAA; Lab
37°C for 30 minutes. Proteinase K (0.3 mg/ml)
M, Bury, UK) plates supplemented with 5%
and sodium dodecyl sulphate (SDS; 1% final
defibrinated horse blood (Oxoid). Columbia
concentration) were added and incubated at
agar plates were incubated in an aerobic
55°C for one hour, to induce cell lysis. An
atmosphere for three days at 37°C. The latter
equal volume of phenol/chloroform/isoamyl
were incubated in a Compact M anaerobic
alcohol (25/24/1, vol/vol/vol) was added to each
cabinet (Don Whitley Scientific, Shipley, UK)
suspension and vortexed. After centrifugation
in an atmosphere of 10% hydrogen, 10%
at 16 000 ×g for 10 minutes, 24 µl 5 M NaCl
carbon dioxide, and 80% nitrogen for three to
and 600 µl propan-2-ol were added. Gentle
five days at 37°C. Selected isolated colonies
mixing and incubation at 0°C for 10 minutes
were subcultured.
were followed by centrifugation at 16 000 ×g
for 10 minutes. The pellet was resuspended in
IDENTIFICATION OF ISOLATES
water and one volume of ammonium acetate
Plaque contains many species; thus, we se-
was added (final concentration of 2.5 M). The
lected the predominant organisms for further
suspension was then cooled at 0°C for one hour
study. All isolates were Gram stained and
then centrifuged at 16 000 ×g for 20 minutes.
tested for catalase, oxidase activity, aerobic
The supernatant was removed and the DNA
growth, and anaerobic growth. In some cases,
was reprecipitated by the addition of 600 µl of
other tests were used such as Hugh and
chilled ethanol (−85°C). The DNA was
Leifson’s oxidation fermentation test, nitrate
pelleted by centrifugation at 16 000 ×g for 10
reduction, extracellular polysaccharide pro-
minutes and then washed in 500 µl 70% chilled
duction on TYC agar, and spore production.
ethanol (−85°C). The ethanol was removed
Isolates were identified using a range of
and the DNA was resuspended in 100 µl Tris/
commercial identification kits, namely: API 20
EDTA (TE) and stored at 4°C.
NE; Rapid ID 32 Strep; API Coryne; Rapid ID
32A (BioMérieux, Basingstoke, Hampshire,
UK), and the Rapid ANA II system (Prolab, DNA EXTRACTION: GRAM POSITIVE BACTERIA
Liverpool, UK). Microcodes generated using DNA was extracted from all Gram positive
API 20 NE, ID 32 Strep, API Coryne, or ID clinical isolates using the Puregene DNA
32A were analysed by BioMérieux. Microcodes isolation kit (Flowgen Instruments, StaVord-
generated using Rapid ANA II were analysed shire, UK), according to the manufacturer’s
by Prolab. Anaerobe identification also made instructions.
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Microbiological study of PLS 373
MEASUREMENT OF DNA Sequences resulting from amplification with
Samples (5 µl) of DNA were stained with primer RE-RTU3 were reverse transcribed and
ethidium bromide (1 µg ml−1 in 1 × trisphos- changed to the complement. Results from each
phate EDTA (TPE)) after electrophoresis in an primer were then aligned using GAP function
0.8% agarose gel and then visualised by and checked twice against each other to
ultraviolet light (ë = 254 nm) and photo- produce a consensus sequence. The consensus
graphed on Polaroid 667 film. The amount of sequence was submitted for a FASTA search to
DNA was determined by visual comparison determine the most likely relation.
with known amounts of uncut ë DNA (Sigma;
40–400 ng µl−1).
Results
PARTIAL 16S rRNA GENE SEQUENCE ANALYSIS A total of 108 pure cultures of predominant
Bacterial DNA was amplified in a Crocodile IIJ organisms was obtained for identification and
thermal cycler (Appligene, County Durham, comprised the genera and species listed in
UK). The reaction mix (total volume, 50 µl) tables 1–3. The bacterial species isolated
consisted of 2 µl of DNA, Taq polymerase (1.5 (including those determined by ELISA) were
units), 0.2 mM of each deoxynucleoside separated into aerobic, anaerobic, facultative,
triphosphate (dATP, dCTP, dGTP, dTTP), and capnophilic species and 17 genera were
MgCl2 (1.5 mM), 1× buVer IV, and 0.3 µM found to be present. The facultative micro-
of both primers: RE-TPU1 (5'-AGA organisms identified consisted mainly of spe-
GTTTGATCMTGGCTCAG) and RE- cies of streptococcus, including Streptococcus
RTU3 (5'-GWATTACCGCGGCKGCG)20 anginosus, S bovis, S constellatus, S mitis, and
(Oligonucleotide Synthesising Service, School S sanguis. Species of capnocytophaga and
of Biological Sciences, University of Manches- gemella were also identified. The obligately
ter, UK). The reaction mix was covered with an anaerobic flora consisted mostly of prevotella
equal volume (20 µl) of mineral oil to prevent species, namely: Prevotella intermedia, P nigres-
evaporation. Negative controls contained all cens, P melaninogenica, and “unidentified”
components of the reaction mix except the prevotella (formerly “PINLO”). In addition,
bacterial template DNA. The thermal cycling Peptostreptococcus anaerobius, Pstr micros and
profile was as follows: one cycle of four minutes species of mobiluncus were identified. Table 1
at 94°C, one minute at 55°C, one minute at gives a comprehensive list of species cultured
72°C; 29 cycles of one minute at 94°C, one for each patient. Gemella spp, Neisseria spp,
minute at 57°C, one minute at 72°C; one cycle
of one minute at 94°C, one minute at 57°C, Table 1 Complete list of bacterial species isolated from two
patients with Papillon-Lefèvre syndrome, displaying
and five minutes at 72°C. Polymerase chain association with patient
reaction (PCR) products (3 µl) were resolved
in 1.0 % agarose gels, stained with ethidium Patient 1 Patient 2
bromide, and visualised under ultraviolet light Obligate aerobes
(ë = 254 nm). A ë Pst1 digest was used as a Neisseria sp 2 0
size marker (270 ng/µl). Gels were photo- N cinerea 1 1
N elongata 0 1
graphed on Polaroid 665 and 667 films and the N flavescens 0 2
presence of the correct size fragment con- Neisseria sp possibly N subflava 1 0
firmed. QIAquick PCR purification kit (Qia- Obligate anaerobes
Eubacterium sp 0 1
gen, Crawley, Sussex, UK) was used to clean Porphyromonas gingivalis 1 0
the PCR product. The quantity of the product Prevotella sp possibly P oralis 1 0
was estimated by visual comparison in a 0.8% P intermedia 1 1
P melaninogenica 0 2
agarose gel with a known amount of ë DNA. P nigrescens 0 2
Concentrations of PCR products (30–90 ng) Peptostreptococcus sp 1 0
Pstr anaerobius 0 1
were amplified further in a Perkin Elmer Pstr micros 1 0
(Warrington, UK) model 2400 thermal cycler. Facultative
Two reaction mixes were set up for each PCR Actinobacillus actinomycetemcomitans 0 1
Actinomyces sp 1 0
product, one with each primer. The reaction A israelii 1 0
mix had a total volume of 20 µl, which Bacillus cereus 1 0
consisted of 8 µl ABI PRISM™ terminator Gemella haemolysans 1 0
G morbillorum 1 1
cycle sequence ready reaction mix (Perkin Kingella denitrificans 1 0
Elmer) or 4 µl ABI PRISM™ BigDye™ termi- Leuconostoc sp 0 1
nator cycle sequence ready reaction mix L mesenteroides 0 1
Mobiluncus sp 1 0
(Perkin Elmer) and either RE-RTU3 or Streptococcus sp (to genus only) 1 1
RE-TPU1 (0.15 µM). The PCR product was S anginosus 0 2
added and the volume made up with water. S bovis II 1 0
S constellatus 3 0
The thermal cycling profile was as follows: 25 S gordonii 0 1
cycles of 10 seconds at 96°C, five seconds at S intermedius 0 1
S milleri group 1 1
50°C, and four minutes at 60°C. The cycle S mitis 2 1
sequencing product was purified by ethanol S oralis 1 0
precipitation. The automated sequence analy- S salivarius subspecies P salivarius 1 1
S sanguis 3 1
sis was performed by Oswals DNA Service, Stomatococcus mucilaginosus 1 0
University of Southampton. Sequences were Suttonella indologenes 1 0
manipulated using the Genetics Computer Capnophilic
Capnocytophaga sp 1 0
Group (GCG) package version 8.0 (Wiscon-
sin, USA). The numbers refer to the total number of sites with the isolate.
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374 Robertson, Drucker, James, et al
Table 2 Predominant species isolated from patient 1 “Control” sites were not studied because in the
according to site sampled case of severe PLS there are no healthy control
Site A (upper right deciduous canine)
sites.
Actinomyces sp Peptostreptococcus sp Aerobes identified were species of bacillus
Bacillus cereus Prevotella sp and neisseria. The Gram positive, spore former
Capnocytophaga sp Streptococcus constellatus
Kingella denitrificans S mitis
Bacillus cereus is not considered part of the nor-
Neisseria cinerea S sanguis mal oral flora, although it has been reported in
Neisseria sp Streptococcus sp plaque samples.20 With no reports of an associ-
Site B (lower left deciduous canine)
Actinomyces israelii S milleri group ation with periodontal disease and because of
Mobiluncus sp S oralis its universal occurrence and the formation of
Neisseria sp S sanguis spores, the possibility that this is a contaminant
Streptococcus constellatus
Site C (upper left deciduous 1st molar) cannot be ruled out. Neisseria spp—N sicca/
Streptococcus bovis II Stomatococcus mucilaginosus subflava10 and N pharyngis21—have been re-
S constellatus Neisseria subflava ported previously in other patients with PLS.
S sanguis
Site D (lower left deciduous 1st molar) In our study, the identification of isolates as
Gemella haemolysans Peptostreptococcus micros either species of neisseria or prevotella was sec-
G morbillorum Streptococcus sanguis
Prevotella intermedia
ond only to identification as streptococcus.
Site E (lower right deciduous canine) Five genera of obligately anaerobic bacteria
Suttonella indologenes Capnocytophaga sp were identified—eubacterium, peptostrepto-
Actinomyces meyeri
Site F (lower right deciduous 1st molar)
coccus, porphyromonas, prevotella, and
Streptococcus mitis S salivarius subspecies salivarius treponema. Species of eubacterium have been
isolated from subgingival plaque22 and are
Table 3 Predominant species isolated from patient 2 associated with oral health, gingivitis,23 and
separated according to site of sample periodontal disease in humans,24 25 although
little evidence is available for an association
Site A (upper right permanent 1st molar) with PLS. One study13 has failed to isolate
Eubacterium sp P nigrescens
Leuconostoc sp Peptostreptococcus anaerobius eubacterium from plaque samples despite the
Neisseria cinerea S anginosus use of selective media, although low numbers
N elongata S intermedius
N flavescens S salivarius subspecies savlivarius
were cultured from mouth rinse samples,
Prevotella melaninogenica Actinomyces meyeri suggesting that eubacterium was present in the
Streptococcus sanguis oral cavity of patients with PLS. Unidentified
Site B (upper right permanent canine)
P melaninogenica S milleri group
Peptostreptococcus spp have been isolated from
P nigrescens S mitis the subgingival plaque of patients with perio-
Streptococcus gordonii Streptococcus sp dontal disease25 and Pstr micros has been
Site C (lower right permanent canine)
Leuconostoc mesenteroides associated with gingivitis.23 Peptostreptococcus
Site D (lower left canine) micros10 and unspeciated peptococcaceae13 have
Peptostreptococcus micros also been identified previously from patients
Site E (lower left first molar)
Actinomyces meyeri with PLS.
Porphyromonas gingivalis is an accepted peri-
odontal pathogen,26 27 which was detected by
Peptostreptococcus spp, P intermedia, and Strepto- monoclonal antibodies in one of the patients.
coccus spp were isolated from both patients. The use of monoclonal antibodies to P gingiva-
Actinomyces spp, Bacillus spp, Capnocytophaga lis in a previous study10 detected this species in
spp, Kingella spp, Mobiluncus spp, P gingivalis, one of the two patients. It has also been isolated
and Stomatococcus spp were isolated only from previously from patients with PLS using
patient 1, whereas A actinomycetemcomitans, culture methods.10 13
Eubacterium spp, Leuconostoc spp, P nigrescens, Prevotella intermedia, P melaninogenica, P ni-
and P melaninogenica were isolated only from grescens, and P oralis were identified in our
patient 2. Tables 2 and 3 show the correlation present study. Prevotella oralis, P oris, P loe-
between the species identified and the site schii,10 P intermedia,10 13 and other unspeciated
sampled in the patients. black pigmented anaerobes9 13 17 have been
Culture provided qualitative data only. How- associated previously with PLS. In earlier stud-
ever, monoclonal antibodies provided quanti- ies, P nigrescens was probably misidentified as
tative data and detected P gingivalis in low P intermedia. Prevotella melaninogenica has not
numbers in all six sites sampled in patient 1; been isolated previously from PLS samples but
A actinomycetemcomitans was detected in one it occurs in subgingival plaque28 and has been
site in low numbers in patient 2. Prevotella associated with gingivitis26 and periodontal dis-
intermedia was detected in low numbers from ease29. Prevotella intermedia was detected both
both patients—in one of six sites from patient 1 by culture and ELISA in our study, methods by
and three of six sites from patient 2. which it has previously been detected in PLS.10
The occurrence of spirochaetes in the plaque Unspeciated spirochaetes were seen within
was confirmed by microscopy. gingival smears during our study and have been
reported previously in patients with PLS.13 14
Actinobacillus actinomycetemcomitans is an
Discussion accepted periodontopathogen,23 27 30 which has
A range of bacteria was found in the subgingi- been associated particularly with prepubertal
val plaque of both these patients with PLS. In periodontitis31 and localised juvenile periodon-
addition, the periodontopathic bacteria P gin- titis.32 It has been associated with PLS on many
givalis, P intermedia, and A actinomycetemcomi- occasions10 12 13 15 16 and is considered an impor-
tans were detected, albeit in low numbers. tant pathogen for the periodontal component
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Microbiological study of PLS 375
of PLS.32 We detected this organism using actinomyces because of a positive Gram
monoclonal antibodies, but only in one sample reaction and a similar GLC profile.
from patient 2. Therefore, the presence of Members of the genus capnocytophaga have
A actinomycetemcomitans might not be neces- been frequently associated with gingivitis,23
sary for PLS to progress. This argument could periodontal disease,27 and juvenile periodonti-
also apply to P gingivalis, which was only tis.29 Species of this organism have been
detected in patient 1. reported in patients with PLS.10 11 Capnocyto-
We identified three actinomyces species that haga ochracea10 has been isolated, but most
have been associated with PLS previously.10 studies have identified isolates only to the
Actinomyces spp form part of the resident oral genus level. Paradoxically, capnocytophaga has
microflora of humans33 and are therefore also been found to be associated negatively
isolated from the healthy oral cavity and with periodontal disease.40
associated with gingivitis.23 Species not isolated here but reported in
Gemella morbillorum has been isolated previ- other studies10 11 13 include Fusobacterium spp,
ously from patients with PLS and is also asso- Eikenella corrodens, veillonella, and Bacillus gra-
ciated with a healthy mouth,23 whereas no cilis. The recognised periodontal pathogens
association with periodontal disease or PLS has P gingivalis and A actinomycetemcomitans were
been reported for G haemolysans. The likeli- found in low numbers in our patients with
hood of gemella causing similar infections to PLS. It is possible that A actinomycetemcomitans
those caused by viridans streptococci has been acts together with human herpesviruses in the
noted,34 so that the isolation of this micro- development of the syndrome,41 but our
organism from patients with PLS is not present study did not include virological exam-
surprising. ination. Furthermore, a “massive occurrence
Kingella species include known upper respi- of A actinomycetemcomitans” has been noted in
periodontal pockets in PLS, although the same
ratory tract commensals35; however, there are
species was present also in the mouths of
no reports of the isolation of members of this
siblings and a parent without PLS.42 Similarly,
genus from patients with PLS and only limited
in a group of 12 Saudi-Arabian adolescents
associations with periodontal disease. The pri-
with PLS, there was no PLS specific profile of
mary habitat of K oralis is human dental plaque
the subgingival infection because the bacterial
and it been isolated from supragingival and composition resembled that characterising
subgingival plaque taken both from healthy deep pockets in adult patients with periodonti-
oral cavities and patients with periodontitis.36 tis.43 It is possible that recognised periodontal
The genus leuconostoc contains species pathogens might be involved in PLS. However,
similar to streptococci and often identified ini- the severity of periodontitis in patients with
tially as S sanguis type II as well as S salivarius PLS cannot be explained simply by the
and S pneumoniae, when using automated presence of any of the bacteria found in this
identification systems.37 Leuconostoc has not study, even the recognised periodontopatho-
been previously identified in PLS samples. gens. These patients are known to have a higher
However, this genus has been reported to be a risk of developing disease when compared with
cause of bacteraemia in patients already other individuals, suggesting that host factors
critically ill with acute leukaemia, renal failure, determine the individual’s disease susceptibil-
and human immunodeficiency virus infec- ity. The inherited components of PLS induce
tion.37 It has been suggested that the incorrect both immune and epithelial defects.41 We con-
identification of leuconostoc as viridans strep- clude that PLS occurs in genetically suscepti-
tococci means that the pathogenic associations ble individuals whose periodontal disease is
of this genus have been underestimated.37 Dur- associated with periodontal pathogens but the
ing our study, both viridans streptococci species of periodontopathogen is not of over-
(S constellatus, S mitis, S oralis, and S sanguis) riding importance.
and S salivarius were identified using Rapid ID
32 Strep; however, additional testing would be Thanks to M Armstrong at the Manchester Royal Infirmary for
required to check that none of these isolates initial cultivation of samples.
was a species of leuconostoc.37 Of the ten
streptococcal species identified here, S bovis, 1 Papillon MM, Lefevre P. Deux cas de kératodermie palmaire
S mitis, “S milleri group”, and S sanguis10 have et plantaire symétrique familiale (maladie de Meleda) chez
le frère et la soeur. Coexistence dans leux deux cas
been associated with PLS previously; other d’altérations dentaires graves. Bulletin de Société de Derma-
studies12 13 have detected streptococci but not tologie et de Syphiligraphie 1924;31:82–7.
2 GriYths WAD, Leigh IM, Marks R. Papillon-Lefèvre
identified them further. Previously, S oralis has syndrome. In: Champion RH, Burton JL, Ebling FJG, eds.
Textbook of dermatology, 5th ed. Vol. 2. Oxford: Blackwell
been associated with gingivitis.23 Scientific Publications, 1992:1377–9.
One isolate was identified as Stomatococcus 3 Gorlin RJ, Sedano H, Anderson VE. The syndrome of
palmar-plantar hyperkeratosis and premature destruction
mucilaginosus, an organism found within the of the teeth. J Pediatr 1964;65:895–908.
oral microflora,38 although it has not been pre- 4 Hattab FN, Rawashdeh MA, Yassin M, et al. Papillon-
Lefévre syndrome: a review of the literature and report of
viously associated with the periodontal flora in four cases. J Periodontol 1995;66:413–20.
PLS. The variable catalase reaction can delay 5 Posteraro AF. Papillon-Lefèvre syndrome. J Am Dent Assoc
1992;76:16–19.
identification and cause confusion with staphy- 6 Haneke E. The Papillon-Lefèvre syndrome: keratosis
lococcal and streptococcal species, which has palmoplantaris with periodontopathy. Hum Genet 1979;51:
1–35.
led to the underestimation of its prevalence. 7 Hart TC, Shapira L. Papillon-Lefevre syndrome. Periodon-
Mobiluncus has been isolated from extra- tology 2000 1994;6:88–100.
vaginal sources39 other than the mouth. This 8 Mendieta C, Reeve CM. Periodontal manifestations of sys-
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A microbiological study of Papillon-Lefévre
syndrome in two patients
K L Robertson, D B Drucker, J James, A S Blinkhorn, S Hamlet and P S Bird
J Clin Pathol 2001 54: 371-376
doi: 10.1136/jcp.54.5.371
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