JOURNAL OFCLINICAL MICROBIOLOGY, May1988, p. 896-900 Vol.26, No. 5 0095-1137/88/050896-05$02.00/0
Prevalence and Persistence of
Neisseria cinerea
and
Other
Neisseria spp.
in
Adults
JOAN S. KNAPPl2t* AND EDWARD W. HOOK1112t
NeisseriaReference
Laboratory'
andDepartmentof
Medicine,2University
of Washington, Seattle, Washington
98195Received26May1987/Accepted 26 January 1988
Neisseria cinerea is a commensal Neisseria sp. which was first described in 1906 but was subsequently misclassified as a subtype of Branhamella catarrhalis. N. cinerea resembles Neisseria gonorrhoeae in both cultural and biochemical characteristicsand, thus, may also have beenmisidentified as N.gonorrhoeae. Of 202 patients whose oropharynges were colonized by Neisseria spp., N. cinerea was isolated in 57(28.2%)patients, including 25 (30.1%) of 83 women, 22 (23.9%) of 92 heterosexual men,and10(37.0%)of 27homosexualmen inSeattle, Wash., in 1983 to 1984.N. cinereawasisolated fromthe urethra ofonlyone(1.1%) patient. The oropharynges of many individualswerecolonizedpersistentlybystrainsof N. cinerea and other Neisseria spp.
Neisseria cinerea was first described in 1906 (23), but strains of this species were subsequently misidentified as Branhamella (Neisseria) catarrhalis (14, 15, 26) because nitrate reduction was
nfot
used as a differential test forthe classification of Neisseria spp. until 1961 (3). Although isolatesresembling
N. cinerea werereferredtoasNeisseria pseudocatarrhalis in 1934 (F. M. Huntoon, Abstr. Annu. Meet. Am. Soc. Bacteriol., 1934, M50,p.108),
thisspecies
was not recognized again until 1962 (8) and was not de-scribed in the United States until 1984
(18).
We have been interested inN. cinereabecausealthough strainsarecolistin sensitive(18),they have recently been isolated onselective media forpathogenic
Neisseria spp. and resembleNeisseria gonorrhoeaeinboth culturalandbiochemicalcharacteristics (13, 18). Strains ofN. cinerea may be misidentified as N. gonorrhoeaewhen many tests available fortherapid
identi-fication ofgonococciareused(10-13,18-20),
withresulting
serious socialand medicolegal consequences (13).
We undertook a study in two parts to determine the prevalence ofN. cinereaintheoropharynxand
genital
sites andto determine theability
ofN. cinerea topersist
in theoropharynx
with otherNeisseria spp.MATERIALS AND METHODS
Strains. Inthe firstpart ofthe study, we determined the prevalence ofN. cinereain 209unselected patients attending the Seattle-King County Sexually Transmitted Diseases ClinicatHarborviewMedical Center betweenOctober1982 andFebruary1983.Cervical andpharyngeal specimens from women and urethral and pharyngeal specimens from men wereinoculatedon a new medium,LBVT.SNR, which was selective forcommensal Neisseria spp. (described below).
Oropharyngeal
specimens from the first 109 patients were plated only on LBVT.SNR medium, but oropharyngeal specimens from the next 100 patients were also plated on*Correspondingauthor.
tPresent address: Sexually Transmitted Diseases Laboratory Program, Center for Infectious Diseases,Centers for Disease Con-trol, Atlanta, GA30333.
tPresent address: Divisionof Infectious Diseases, Johns
Hop-kinsHospital, Baltimore, MD21205.
modifiedThayer-Martin mediumto ensuremaximum recov-ery of Neisseria meningitidis, which was recovered at a lower frequency than expected from homosexual men among the first 109 patients. Allurogenital specimens were also inoculated onThayer-Martin medium.
In the second phase of the study, oropharyngeal speci-mens werecollected weekly, for 15weeks, from 16 volun-teers in our laboratories to determine whether N. cinerea persisted in the oropharynx or whether it colonized the oropharynxtransientlyand thus would be isolatedrarely.All specimenswereinoculateddirectlyonLBVT.SNRmedium and modified Thayer-Martin medium. All volunteers gave verbalinformed consent before specimencollection.
LBVT.SNR medium for theselective isolation of commensal Neisseriaspp. The medium base, LB medium,contained1% Bacto-Tryptone (Difco Laboratories), 0.5% yeast extract (Difco), 0.5% sodium chloride, and 1.5% Bacto-Agar (Difco).Theingredientsweredissolved,5.0 mlof neutralred indicator (0.3% [wt/vol]) per liter was added, and the me-diumwassterilizedby autoclaving for15minat121°C.After coolingto56°C, sucrose wasadded to the base medium to a final concentration of 1% (wt/vol), and vancomycin and trimethoprimwereeach addedto afinal concentrationof3.0
Ftg/ml.
Thecomplete
medium, designatedLBVT.SNR,
wasused to isolate strains of commensal Neisseria spp. and B. catarrhalis and to test for polysaccharide production from sucrose. Known strainsofcommensalNeisseriaspp. and B. catarrhalis were used to evaluate the selective medium. Strains ofmost specieswerestockcultures inthe Neisseria Reference Laboratory and included strains of Neisseria
perflava
and Neisseria sicca provided by Ulrich Berger, Hygiene Institute, University of Heidelberg, Heidelberg, FederalRepublic of Germany.Isolation of commensal Neisseriaspp. and B. catarrhalis on LBVT.SNR medium. Specimens were plated directly onto LVBT.SNRmedium, placed in acandle extinction jar, and incubatedat37°C. After 44 to 48 h ofincubation, at least one colony representative of eachmorphologictype was subcul-tured onto supplemented GC-base medium (GCK; 24). To ensure maximumrecovery ofisolates of N. cinerea and to detect concurrent colonizationby N. cinerea, N. meningiti-dis, andNeisseria lactamica, several translucent, pink col-onies characteristic ofthese specieswere isolated. A small
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TABLE 1. Colonial morphologic characteristicsofcommensalNeisseiria spp. and B.
(catarrHialis
grown on LBVT.SNRmedium selective at37°C for48 hinaCO.-enriched atmosphereColor when stained Finalcolor"
Species Diam (mm) Color Elevation Surface Opacity
'th
stoine ofmediumN. nu(zOsa, N. sic(-a, N.peflatah 1-2 Yellow-pink Convex Glistening Opaque Blue-black Pink
N.flav'a,N. subflav'a" 1-2 Orange Flat Matt Opaque Noreaction Orange
N.flavescenis 1 Orange Convex Glistening Opaque Blue-black Nochange
N. lacIatmi(a, N. nmeningitidis, 1-2 Pink Convex Glistening Translucent No reaction Nochange N. (inieie(a
B.
(altairrhablis
1-2 Pink Convex Matt Opaque Noreaction NochangeFinalcolor of medium inoculated withapure culture of each species.
N.peiflava, N.subflavabiovar
pe:flava.
N.flaoa,N.subjiavabiovarflaoa." N.
subi
ava,N.subfl/aa
biovarsubi
/aa.
section of the culture plate was then flooded with Lugol's
iodine to detect polysaccharide-negative colonies ofB.
ca-tarrhalisthat hadacolonial morphologicappearancesimilar
to that of the polysaccharide-producing Neisseria spp. on
this medium. In this way,itwaspossibletodetectstrains of the polysaccharide-positive N. polysaccharea (21) that also produce pink, translucent colonies on this medium. All
isolates of gram-negative, oxidase-positive diplococci were
identified by their pattern of acid production from
glucose,
maltose, sucrose, fructose, and lactose (17), reduction of
nitrate (17), and production ofpolysaccharide from sucrose on LBVT.SNR medium (18). Colistin disk susceptibility
tests were performedon strains resemblingN. cinerea (18).
Sucrose-positive, nitrate-negative isolates, Neisseria sieh-flavabiovarpeiflava (Neisseriapeiflava) andN. sicca,were
recorded as N. peiflava-N. sicca because these species
could not bedifferentiated biochemically.
Statistical analysis. Statistical analyseswereperformed by using achi-square test.
RESULTS
Growth of commensalNeisseria spp. and B. catarrhalison
LBVT.SNR medium. Five strains each ofN. lactamnica, N. cinerea, N. sicca, Neisseria mnucosa, N. subflava biovars
subflat'a (N. subflava), flava (Neisseriaflav'a), and petflav'a (N. perflava), and B. catarrhalis and one strain each of
Neisseriaflavescens and Neisseria polysaccharea
repeat-edly grew well on LBVT.SNR medium both alone and in
combination witheachother. Some strains of N. ineningiti-disdidnotgrowaswellon LBVT.SNRmedium asonGCK
medium. LBVT.SNRmedium didnot supportgrowth of N. gonorrhoeae strains. The colonial morphologic characteris-tics ofNeisseria spp. and B. catarrhalis after growth on
LBVT.SNR medium at 37°C for 48 h in a CO,-enriched atmosphere aresummarized in Table 1. All strainsproduced
colonies 1 to2mm indiameter. Although many,but notall, N. sicca coloniesproduce wrinkled, adherent colonies,few colonies of this type werefoundin the isolatesstudied, and
we presumed that most of the N.perflava-N. sicca isolates
were N. peiflava. We isolated a few strains ofN. muicosa
that produced wrinkled, adherent colonies similar to those
described for N. sicca.
Strains of different Neisseriaspp. ormultiplestrainsofN.
perflava-N. sicca were isolated from the oropharynges of
individuals.The colonialmorphologyofisolates and
produc-tion ofpolysaccharide were useful for initial differentiation
between strains and species on the isolation medium. The
final color of the culture medium was not useful for differ-entiating betweenspecies because the color of the indicator reflected the proportion of sucrose-positive and N.
flava
colonies present. If N.flai'a was present, thefinal color of themediumwasorange.If N.flai'a wasnotpresent,the final color of the medium was pink because of acid
production
from sucrose by the N. peiflfava-N. sicca and N. lifllO5s(
strains.
Isolation of commensal Neisseria spp. from clinical speci-mens. Gram-negative, oxidase-positive diplococci were
iso-lated from the oropharynges of 202 (96.6%) of 209persons,
including83 women,92 heterosexualmen, and 27
homosex-ualmen. Of these patients, onlyone woman hadpharyngeal
gonorrhea. Thefrequencyofisolation of Neisseria spp. and
B. catarrhalis from the 202 patients is shown in Table 2. Colonies representative of different colonial morphologic
types of N. peiflav'a-N. sicca isolated from individuals
TABLE 2. Frequencyofisolation of Neisseriia spp. and B.
eu(z-r-rHalis from the oropharynges of 202 adults attending the
Seattle-King CountySexually Transmitted DiseasesClinic, Harborview MedicalCenter, 1982to1983
No.(7c) ofindividuals colonized
Species Men Women
Heterosexual Homosexual (t =83)'
(n =92)` (n =27)`
N.peiflava"-N. si(-(-a' 89(97) 26(96) 79(95) N. inc(osa 21 (23) 6(22) 23(28)
N. flava" 26(28) 9(33) 18(22)
N. (inetrea 25 (27) 10(37) 22(27)
N. mneningitidis 4 (7) 4(29) 0
N. lactani(ca 1(1) 0 1(1)
B. (caarrhcalis 4(4) 1(4) 4 (5)
`Thesedenominatorsarefor al species,with theexceptionof N.
menin-gitidis.Thedenominators for N. nefingitiddisare54,14. and 30, respectively.
N.pefflara.N.subflavabiovarpet/aflrva.
N. siccastrainscannotbedistinguishedfromN.sub/ara biovarpe:fl/ava
onthe basis of biochemicaltests; onthe basis of colonialmorphology, very
few isolateswereN.sicca.
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898 KNAPP AND HOOK
J.
gXgNo. (%)ofAdufts
E (
en
E 8 Colonized2E222
i
Cà(N=202)
83 (41.1) 23 (11.4)
22 (11.0)
16 (8.0)
10 (5-0) 9 (4.5)
9 (4.5)
5 (2.5)
3
(1.5)
S S
~~~~~~~~3
(1-5)
2 (1.0)
u 2 (1.0)
1 5
(7.4)
FIG. 1. Frequency and colonizationpatternsof the oropharyn-geal neisserial flora from 202 adults in Seattle, Washington, from
1982 to 1983, by Neisseria spp. and Branhalmella caiarrhalis.
Shadedboxes represent the isolation of thecorresponding species
from thenumberofpatientsindicated.Thepatternsofcolonization
are arranged in order ofdecreasing frequency ofisolation. Some
patterns of colonization, indicated by the asterisk, were each
detected inonlyonepatient andincluded thefollowingisolates: 11
N.perflava,9N. mucosa,7 N.flava,6N.cinerea,5N.
mneningiti-dis,2N. lactamica, and6 B. catarrhalis.
remained morphologically distinct when subcultured onto
GCKmedium and were considered to be different strains. More than one colony form of N. perflava-N. sicca was isolatedfrom 155 (76.7%) of 202individuals. Kingella
deni-trificans was notisolated.
N. cinerea was isolated from the oropharynges of 25
(30.1%) of 83 women, 22 (23.9%) of 92 heterosexual men, and10(37.0%)of 27homosexual men. Althoughdifferences
werenotsignificant,N.cinereawasisolatedmorefrequently
fromhomosexualmenthan fromeitherheterosexualmen(P
= 0.32) or women(P = 0.29). N. meningitidiswas theonly
otherNeisseria sp. isolatedmorefrequentlyfrom
homosex-ual men. There was no difference in the frequency of
isolation of other Neisseria spp. according to gender or
sexualpreference. N. cinereawasisolated from theurethra
ofonlyone heterosexual man, and nootherNeisseria spp.
were isolated fromgenital specimens.
The frequency ofconcurrent colonization ofthe
oropha-rynges ofpatients byN. cinerea andotherNeisseriaspp. or
B. catarrhalis is shown in Fig. 1. N. cinerea was isolated
with mostotherspeciesonatleastoneoccasion. None ofthe
colistin-sensitive species were isolated on Thayer-Martin
medium in this study.
Two general patterns of neisserial oropharyngeal flora
wereobserved. Atotal of41%ofindividualswerecolonized
by
strains of N.perflava-N.
sicca alone. Some individualswerecolonized heavilybyasmanyasthreeorfourdifferent
strainsofN.
perflava-N.
sicca, and rarely by other species.Other individuals were colonized by a variety of species,
each of which was isolated in low numbers. In general,
detection of N. cinerea in patients heavily colonized with
sucrose-positive Neisseria spp. was more difficult than in those who were not. There were no differences between homosexual men, heterosexual men, and women with
re-spect tothe patternsofcolonization
by
otherNeisseria spp. Persistence ofN. cinerea inadults. In the secondphase
of these studies, cultures were obtained from 16 volunteers weekly to determine whether N. cinerea persisted in the oropharynx; Neisseriaspp. wereisolated from 15(93.8%)
of 16 volunteers. As observed in the first phase ofthestudy,
volunteers were either heavily colonized by N.
perflava-N.
sicca or were sparsely colonizedbyavariety ofspecies and the patternofcolonizationwasgenerally consistent foreach personthroughout the
study period.
N. cinereawasisolated from 10 (62.5%) of 16 volunteersduring
thestudy
but wasnotisolated in each week. N. cinereawasisolated inatleast 3 weeksfrom six (37.5%) individuals whowere
consistently
colonized sparselyby a variety ofspecies.
DISCUSSION
Inthis study, N. cinerea was a commoninhabitant ofthe oropharynges of adults butwas rarely isolated from
genital
sites. N. cinerea was isolated more frequently from homo-sexual menthan from heterosexual men orwomen, but the differencewas notsignificant.StrainsofN.cinereawerenot
presentinlargenumbersin anyspecimenand
concomitantly
colonized the oropharynx withother Neisseria spp.
Serially
cultured samples from volunteers
generally
had consistent patterns of colonization by Neisseria spp. characterized either by heavy colonization with several strains of N. perflava-N. sicca or by sparse colonization with alarger
numberofspecies.
Noprospective studies of the commensal neisserial flora of the oropharynx have been made since nitrate reduction wasintroduced as a differential test for the identification of Neisseria spp. (3), the redescription of N. cinerea (18) and N. mucosa (22),orthedescription ofN. lactamica(16). We isolated N. cinerea morefrequently thanprevious investiga-torsdid. Inprevious studies, specimenswere inoculatedon
nonselective media such asblood agar orasciticagar(9, 14, 15).Our own preliminary studies were made by usingsheep blood agar (data not shown).Cultureswereheavily contam-inated by normal flora; it was difficult both to isolate Neis-seria spp. that occurred in relatively small numbers in the oropharynx and to differentiate between Neisseria spp. on thebasis of their colonial morphology on sheep blood agar. Earlystudies of the neisserialflora of the oropharynx were also limited by the use of inappropriate serum-containing media to detect acid production from carbohydrates bythe oxidative Neisseria spp. (14, 15, 25, 26). Because oftheir inability to obtain consistent patterns of acid production from carbohydrates from many strains, even withprolonged incubation, Wilson and Smith (25) suggested that the "fer-mentation" tests did not provide a reliable method for distinguishing between Neisseria species and that N. catarrh-alis, N.flavus, N. cinereus, N. mucosus, and N. siccusbe combined into a single species, "Neisseria pharyngis." Berger subsequently showed that Neisseria spp. were oxi-dative and thus produced less acid than fermentative orga-nisms (1). By using a medium formulated to detect acid production fromNeisseria spp., he found that they produced less acid from the monosaccharides glucose and fructose, than from the disaccharides maltose and sucrose (4) and that, because strains of N. flava and N. subflava also produced ammonia from peptone (9), they would neutralize
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anyacid produced in media that had been used previously. Berger (5) also suggested that, although N. flava and N. subflava appeared to be variants of the one species, they were distinctly different from N.
perflava
and N. sicca. Serologic studies also supported these findings (7).AlthoughB. catarrhalis subtypes, which almost certainly included N. cinerea, were isolated in early studies (14, 15, 26), the proportions of isolates belonging to each subtype were not determined. Thus, it is impossible to estimate the frequency ofoccurrence ofN. cinereafromthese studies.
Berger and Wulf (9) characterized the neisserial flora isolated on sheep blood agarfrom the oropharynges of202 individuals. Strains of N.
perflava-N.
sicca were isolated from 88% ofpatients, andon the basis ofserologic studies, it was estimated that 55% ofthese strains were N.perflava
and45% were N. sicca, although many N. sicca strains did notproduce wrinkled colonies. Thefrequencies of isolation ofN.
perflava
and N. sicca werealmost certainly overesti-mated in these studies, however, because strains of N. mucosa were not differentiated. Strains ofN.flava and N. subflava were isolated from 4 and 11% of individuals, respectively. Asaccharolytic isolates(B.
catarrhalis and N. cinerea) accounted for only 3% of strains. It is unclear whether the isolates represented one isolate from each patient or multiple isolates from fewer patients. Because none of the six asaccharolytic isolates reacted with B. catarrhalis-specificorN.flavescens-specificantiserum(9),it is likelythatthese isolateswere N. cinerea. No information is given about patterns of colonization ofthesepatients by
N. cinerea and other Neisseria spp.
Using a selective medium for B.
catarrhalis,
Berger (2) isolated "N.catarrhalis"from 15% ofpatients. Becausethis medium did notpermit differentiation between the "saccha-rolytic" Neisseria spp., there is no information on the coexistence ofNeisseria spp. in healthy adults. In a retro-spective study of these isolates, Berger and Paepcke (8) found that strains ofN. cinerea accounted for 93% of the asaccharolytic isolates obtained previously (2).The useofa selective medium that also permitted differ-entiation between many commensal Neisseria spp. en-hancedthedetectionandisolation ofN. cinereainourstudy and also permitted an immediate appreciation ofthe com-plexity of the neisserial flora of the oropharynx. The fre-quency of isolation ofstrains ofN. cinerea, both in persons colonized heavily by strains ofN.
perflava-N.
sicca and in those persons colonized moresparsely
by
avariety
ofspecies,
may be a conservative estimate of the true preva-lence of this species. Strains of N. cinereagenerally
oc-curred in small numbers in all cultures from which the species was isolated. Strains ofN. cinerea may have been presentinthe personsheavily
colonizedby
sucrose-positive
species
but may not have been observed because of over-growth. In those personssparsely
colonizedby
severalspecies,
it ispossible
that strains of N. cinerea werepresent in such lownumbers thatthey
were not detected.Thesedata
confirm
thecomplexity
of the neisserialflora
of the oropharynx and demonstrate that N. cinerea is a fre-quent inhabitant of theoropharynx
in adults. The exact frequency of isolation ofN. cinereaisaffectedby
thetypeof neisserial flora ofthepatient
from whom thespecimen
is collected. In a recent survey,N. cinerea was isolated from the oropharynges of27% of adults in DeKalbCounty,
Ga. (datanotshown).
Thus,
itdoes notappearthat N. cinerea will beisolatedonlyinlimitedgeographic regions.
Although
strains ofN. cinerea wereisolated
infrequently
fromgenital
specimens and were not isolated on
gonococcus-selective
medium
during
thisstudy,
thepossibility
that thisspecies
maybeisolatedmustbeconsidered when strains
resembling
the gonococcus are isolated from adults at low risk for
gonorrhea.
Thelaboratory
identificationofN.gonorrhoeae
from
patients
at low risk forgonorrhea
must becarefully
substantiated
by
using
testsappropriate
fordifferentiating
between N. cinerea and N.
gonorrhoeae.
LITERATURE CITED
1. Berger, U. 1960. Uber den Kohlenhydrat Stoffwechsel von
Neisseria undGemella. Zentralbl. Bakteriol. I. Abt. Orig. 180: 147-149.
2. Berger, U. 1961. Ein Elektivnahrboden fürNeisseria catarrh-alis. Zentralbl. Bakteriol. I. Abt. Orig. 183:135-138.
3. Berger, U. 1961. Reduktion von Nitrat und Nitrit durch
Neis-seria. Z. Hyg. 148:45-50.
4. Berger,U. 1961. ZurVariabilitat derZuckervergarungendurch
Neisserien.Arch. Hyg.(Berlin) 145:296-301.
5. Berger, U. 1962. Untersuchungen uber die Saurebildungdurch saccharolytische anspruchloseNeisserien. Arch. Hyg. (Berlin) 145:55-60.
6. Berger, U. 1963. DieanspruchlosenNeisserien. Ergeb. Mikro-biol. 36:7-167.
7. Berger,U.,and H. Brunhoeber.1961.
Neisseriaflava
(Bergeyetal. 1923): Artoder Varietat?Z. Hyg. 148:39-44.
8. Berger, U., and E. Paepcke. 1962.
Untersuchungen
uber die asaccharolytischenNeisseriendes menschlichenNasopharynx. Z. Hyg. 148:269-281.9. Berger,U.,and B.Wulf. 1961.
Untersuchungen
ansaprophytis-chen Neisserien. Z.Hyg. 147:257-268.
10. Boyce, J. M., and E. B. Mitchell, Jr. 1985. Difficulties in differentiatingNeisseria cinereafromNeisseria
gonorrhoeae
in rapidsystemsusedforidentifyingpathogenic
Neisseriaspecies.
J. Clin. Microbiol.22:731-734.
11. Boyce,J.M.,E. B.Mitchell, Jr.,J.S.Knapp,and T. M.Buttke.
1985. Production of `4C-labeled gas in BACTEC Neisseria
differentiation kits by Neisseria cinerea. J. Clin. Microbiol. 22:416-418.
12. Boyce, J.M.,M. R.Taylor,E. B.Mitchell, Jr.,andJ.S.Knapp.
1985.Nosocomialpneumoniacausedbya
glucose-metabolizing
strain ofNeisseria cinerea. J. Clin. Microbiol. 21:1-3. 13. Dossett, J.H.,P.C.Appelbaum, J.S.Knapp,andP. A. Totten.
1985. Proctitis associated withNeisseria cinerea misidentified
asNeisseriagonorrhoeaeinachild.J.Clin. Microbiol. 21:575-577.
14. Elser,W.J.,and F. M. Huntoon. 1909.Studieson
meningitis.
J.Med.Res. 20:371-541.
15. Gordon, J. E. 1921. The
gram-negative
cocci in "colds" and influenza. VII. Influenzastudies.J. Infect. Dis. 29:462-494. 16. Hollis,D.G.,G. L.Wiggins,and R. E. Weaver. 1969.Neisserialactamicus sp.n.,a
lactose-fermenting
species
resembling
Neis-seriameningitidis. Appl. Microbiol. 17:71-77.
17. Knapp, J. S., and K. K. Holmes. 1983. Modified oxidation-fermentation medium for detection of acid
production
fromcarbohydrates
by
Neisseria spp. andBranhamella catarrhalis. J. Clin. Microbiol. 18:56-62.18. Knapp,J.S., P. A. Totten,M. H. Mulks,and B. H. Minshew.
1984. Characterization ofNeisseria cinerea, a
nonpathogenic
species
isolated on Martin-Lewis medium selectiveforpatho-genic
Neisseria spp. J.Clin. Microbiol. 19:63-67.19. Minshew, B. H., J. L.
Beardsley,
and J. S.Knapp.
1985.Evaluation of GonoGen
coagglutination
testforserodiagnosis
ofNeisseria
gonorrhoeae:
identification ofproblem
isolates byauxotyping,
serotyping,
and with a fluorescent antibodyre-agent.
Diagn.
Microbiol. Infect. Dis. 3:41-46.20. Morello, J. A., S. A.Lerner, and M. Bohnhoff. 1976. Charac-teristics of
atypical
Neisseriagonorrhoeae
from disseminated and localizedinfections. Infect. Immun. 13:1510-1516. 21. Riou, J.-Y., and M.Guibourdenche. 1987. Neisseriapolysac-charea sp. nov. Int.J.
Syst.
Bacteriol. 37:163-165.22. Véron,M.,P.Thibault,and L.Second.1961.Neisseriamucosa
(Diplococcus mucosus
Lingelsheim).
Il. Étudeantigénic
eton April 11, 2020 by guest
http://jcm.asm.org/
900 KNAPP AND HOOK J. CLIN. MICROBIOL.
classification. Ann. Inst. Pasteur(Paris) 100:166-179.
23. Von Lingelsheim, W. 1906. Die bakteriologischen Arbeiten der
Kgl. Hygienischen Station zu Beuthen O. Schl. wahrend der
Genickstarreepidemie in Oberschlesien im Winter 1904/05.
Klin.Jahrb. 15:373-489.
24. White, L. A., and D. S. Kellogg, Jr. 1965. Neisseria
gonor-rhoeae identification in direct smears by a fluorescent
antibody-counterstain method.Apple. Microbiol. 13:171-174.
25. Wilson, G. S., and M. M. Smith. 1928. Observations on the gram-negative cocci of the nasopharynx, with a description of
Neisseriapharyvgis. J. Pathol. Bacteriol. 31:597-608.
26. Wilson, S. P. 1928. An investigation of certain gram-negative
cocci met within the nasopharynx, with special reference to
their classification. J. Pathol. Bacteriol. 31:477-492.