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Corynebacterium minutissimum endocarditis: A case report and review
Journal of Infection (2007) 54, e79ee81
www.elsevierhealth.com/journals/jinf
CASE REPORT
Corynebacterium minutissimum endocarditis: A case report and review George Aperis a,b,*, Ioannis Moyssakis c a Massachusetts General Hospital, Division of Infectious Diseases, Gray-Jackson Building, GRJ-516, 55 Fruit Street, Boston, MA 02114, USA b Laikon General Hospital, First Propaedeutic Department of Internal Medicine, Athens, Greece c Laikon General Hospital, Department of Cardiology, Athens, Greece
Accepted 21 April 2006 Available online 6 June 2006
KEYWORDS Corynebacterium minutissimum; Bacterial endocarditis; Corynebacterium non-diftheriae
Summary We present a rare case of infectious endocarditis in a 40-year old male with native valve, caused by Corynebacterium minutissimum. The diagnosis was established with transesophageal echocardiogram. The patient was managed successfully with antibiotic therapy. ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Case report
It is well known that Corynebacterium minutissimum is the cause of erythrasma, a macular skin rash.1 Neverthless, there have been reports of a few cases of other human infections with Corynebacterium minutissimum.2 Corynebacterium minutissimum endocarditis has been described only once by Herschorn and Brucker.3 Our case is the second reported.
A 40-year old, previously healthy man was admitted to our hospital for fever of 4 months duration. It lasted for about 7 days, then subsided with antibiotics (amoxicillin/clavulanate) and recurred after antibiotics administration was stopped. The patient also reported bone pain, arthralgias and non-productive cough. There were no rigors or chills. This occurred four times until 15 days before admission, when the temperature reached 40 C with the same symptoms, but did not respond to antibiotics. On clinical examination poor oral hygiene was noted. The blood pressure was 110/70 mmHg, the pulse was 120 beats/min and the temperature was 39.5 C. Auscultation revealed a 2/6 pansystolic murmur at the apex of the heart, whereas the ECG and chest X-ray were normal. There were no pathologic findings on lung examination,
* Corresponding author. Massachusetts General Hospital, Division of Infectious Diseases, Gray-Jackson Building, GRJ-516, 55 Fruit Street, Boston, MA 02114, USA. Tel.: þ1 16177243743; fax: þ1 16177267416. E-mail address: [email protected] (G. Aperis).
0163-4453/$30 ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2006.04.012
e80
G. Aperis, I. Moyssakis
Table 1 Pathogen C. C. C. C. C. C.
Reports of endocarditis due to Corynebacterium non-diphtheriae species No of Native/prosthetic Treatment patients valve (N/P)
accolens 1 afermentans 1 amycolatum 2 jeikeium 1 minutissimum 2 striatum 10
C. xerosis Total
2 19
1N 1P 2N 1N 2N 8N/2P
2N 19N/3P
Outcome
Antimicrobial chemotherapy and surgery Cure Antimicrobial chemotherapy and surgery Cure Antimicrobial chemotherapy Cure (1)/death (1) Antimicrobial chemotherapy and surgery Death Antimicrobial chemotherapy Cure Antimicrobial chemotherapy (7), Cure (9)/death (1) antimicrobial chemotherapy and surgery (3) Antimicrobial chemotherapy Cure (1)/death (1) Cure (15)/death (4)
funduscopic examination and abdominal examination. No evidence of peripheral embolic disease was seen. The patient had anemia, leukocytosis and elevated Creactive protein and erythrocyte sedimentation rate. Urine examination was normal. All six sets of blood cultures grew for Corynebacterium minutissimum, sensitive to penicillin and gentamicin (MIC 0.02 mg/ml for penicillin). A transesophageal echocardiogram showed a large vegetation attached to the anterior leaflet of the mitral valve. Treatment for bacterial endocarditis was initiated with 3 million unit of aqueous penicillin intravenously every four hours for 4 weeks and 120 mg of gentamicin every twelve hours for a week. The clinical course was uncomplicated and a repeat echocardiogram 2 months later showed decrease in vegetation’s size. A year later, the patient had no clinical evidence of disease recurrence.
Discussion and review Corynebacteria are group of organisms that include 20 genera. The identification of Corynebacterium or other coryneform bacteria poses a challenge to the microbiologist because they are common commensals in the skin and mucous membranes, they are fastidious and slow growing and, when isolated, they may be considered as contaminants.4,5 Corynebacteria are rare causes of bacterial endocarditis. Cases of Corynebacterium non-diphtheriae endocarditis reported in the English-language medical literature since 1994 were identified by a search in PUBMED with the terms Corynebacterium endocarditis, Corynebacterium non-diphtheriae endocarditis and endocarditis. In 1994 Petit et al. reviewed 126 cases of C. diphtheriae and non-diphtheriae endocarditis.6 Among those cases, in 107 skin was the portal of entry and the infection was preceded by surgery (43 patients had prosthetic valves) or intravenous injection of illicit drugs resulting in bacteremia. In our review we included only cases of C. non-diphtheriae endocarditis. Other coryneform pathogens were excluded. The results are summarized on Table 1. Among those 19 cases reported here, 11 were females and 8 were males aged between 11 and 88 years (mean 55 years). The clinical presentation was typical in most cases, but in some reports, presentation was mimicked other systemic diseases, such as systemic vasculitis,12 or atypical
References 7 8 9,10 11 3 9,12e19
20,21
symptoms of severe infection such as lethargy and malaise.13 Most patients had severe underlying disease such as chronic renal failure,16 paraplegia,17 diabetes mellitus, congestive heart failure,18 history of infectious endocarditis or medical intervention involving such as placement of femoral graft,16 ventriculostriatal shunt,17 patent ductus arteriosus,21 pacemaker implantation,19 femoral access for coronary angiography11 neurosurgical operation of aneurysm of the CNS,14 but patients with negative history have also been reported,15 including our case. Antimicrobial chemotherapy and/or surgery resulted in successful outcome in 15 out of 19 patients, while 4 patients succumbed. The first reported case of Corynebacterium minutissimum endocarditis was of a 31-year old woman with history of rheumatic heart disease, who was presented with decreased vision and photophobia due to retinopathy after a recent dental surgery.3 Antimicrobial treatment resulted in successful outcome. The oral cavity was probably the portal of entry of the organism, as it possibly was in our case too. In conclusion Corynebacterium minutissimum appears to be a low infectivity microorganism that colonizes the skin and mucous membranes. This organism causes erythrasma, but also bacteremia and endocarditis. It is sensitive to penicillin and intravenous administration of penicillin results in successful outcome of endocarditis.
References 1. Bortolussi R, Kennedy W. Corynebacterium minutissimum. In: Armstrong Donald, Cohen Jonathan, editors. Infectious diseases. 1st ed. Mosby; 1999. 2. Brown A. Other corynebacteria and rhodococci: Corynebacterium minutissimum. In: Principles and practice of infectious diseases. 5th ed., vol. 2. Churcill Livingstone; 2000. p. 2200. 3. Herschorn BJ, Brucker AJ. Embolic retinopathy due to Corynebacterium minutissimum endocarditis. Br J Ophthalmol 1985; 69:29e31. 4. Coyle MB, Lipsky BA. Coryneform bacteria in infectious diseases: clinical and laboratory aspects. Clin Microbiol Rev 1990;3:227e46. 5. Pitcher DG. Rapid identification of cell wall components as a guide to the classification of aerobic coryneform bacteria from human skin. J Med Microbiol 1977;10:439e45.
Corynebacterium minutissimum endocarditis 6. Petit PL, Bok JW, Thompson J, Buiting AGM, Coyle MB. Nativevalve endocarditis due to CDC coryneform group ANF-3: report of a case and review of corynebacterial endocarditis. Clin Infect Dis 1994;19:897e901. 7. Claeys G, Vanhouteghem H, Riegel P, Wauters G, Hamerlynck R, Dierick J, et al. Endocarditis of native aortic and mitral valves due to Corynebacterium accolens: report of a case and application of phenotypic and genotypic techniques for identification. J Clin Microbiol 1996;34:1290e2. 8. Sewell DL, Coyle MB, Funke G. Prosthetic valve endocarditis caused by Corynebacterium afermentans subsp. lipophilum (CDC coryneform group ANF-1). J Clin Microbiol 1995;33:759e61. 9. Knox KL, Holmes AH. Nosocomial endocarditis caused by Corynebacterium amycolatum and other nondiphtheriae corynebacteria. Emerg Infect Dis 2002;8:97e9. 10. Daniels C, Schoors D, Van Camp G. Native valve endocarditis with aorta-to-left atrial fistula due to Corynebacterium amycolatum. Eur J Echocardiogr 2003;4:68e70. 11. Ross MJ, Sakoulas G, Manning WJ, Cohn WE, Lisbon A. Corynebacterium jeikeium native valve endocarditis following femoral access for coronary angiography. Clin Infect Dis 2001;32: E120e1. 12. Stoddart B, Sandoe JA, Denton M. Corynebacterium striatum endocarditis masquerading as connective tissue disorders. Rheumatology (Oxford) 2005;44:557e8. 13. Houghton T, Kaye GC, Meigh RE. An unusual case of infective endocarditis. Postgrad Med J 2002;78:290e1.
e81 14. Kocazeybek B, Ozder A, Kucukoglu S, Kukucates E, Yuksel H, Olga R. Report of a case with polymicrobial endocarditis related to multiresistant strains. Chemotherapy 2002;48: 316e9. 15. Rufael DW, Cohn SE. Native valve endocarditis due to Corynebacterium striatum: case report and review. Clin Infect Dis 1994;19:1054e61. 16. Shah M, Murillo JL. Successful treatment of Corynebacterium striatum endocarditis with daptomycin plus rifampin. Ann Pharmacother 2005;39:1741e4. 17. Tattevin P, Cremieux AC, Muller-Serieys C, Carbon C. Native valve endocarditis due to Corynebacterium striatum: first reported case of medical treatment alone. Clin Infect Dis 1996;23:1330e1. 18. Juurlink DN, Borczyk A, Simor AE. Native valve endocarditis due to Corynebacterium striatum. Eur J Clin Microbiol Infect Dis 1996;15:963e5. 19. Melero-Bascones M, Munoz P, Rodriguez-Creixens M, Bouza E, et al. Corynebacterium striatum: an undescribed agent of pacemaker-related endocarditis. Clin Infect Dis 1996;22: 576e7. 20. Pessanha B, Farb A, Lwin T, Lioyd B, Virmani R. Infectious endocarditis due to Corynebacterium xerosis. Cardiovasc Pathol 2003;12:98e101. 21. Malik AS, Johari MR. Pneumonia, pericarditis, and endocarditis in a child with Corynebacterium xerosis septicemia. Clin Infect Dis 1995;20:191e2.
www.elsevierhealth.com/journals/jinf
CASE REPORT
Corynebacterium minutissimum endocarditis: A case report and review George Aperis a,b,*, Ioannis Moyssakis c a Massachusetts General Hospital, Division of Infectious Diseases, Gray-Jackson Building, GRJ-516, 55 Fruit Street, Boston, MA 02114, USA b Laikon General Hospital, First Propaedeutic Department of Internal Medicine, Athens, Greece c Laikon General Hospital, Department of Cardiology, Athens, Greece
Accepted 21 April 2006 Available online 6 June 2006
KEYWORDS Corynebacterium minutissimum; Bacterial endocarditis; Corynebacterium non-diftheriae
Summary We present a rare case of infectious endocarditis in a 40-year old male with native valve, caused by Corynebacterium minutissimum. The diagnosis was established with transesophageal echocardiogram. The patient was managed successfully with antibiotic therapy. ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Case report
It is well known that Corynebacterium minutissimum is the cause of erythrasma, a macular skin rash.1 Neverthless, there have been reports of a few cases of other human infections with Corynebacterium minutissimum.2 Corynebacterium minutissimum endocarditis has been described only once by Herschorn and Brucker.3 Our case is the second reported.
A 40-year old, previously healthy man was admitted to our hospital for fever of 4 months duration. It lasted for about 7 days, then subsided with antibiotics (amoxicillin/clavulanate) and recurred after antibiotics administration was stopped. The patient also reported bone pain, arthralgias and non-productive cough. There were no rigors or chills. This occurred four times until 15 days before admission, when the temperature reached 40 C with the same symptoms, but did not respond to antibiotics. On clinical examination poor oral hygiene was noted. The blood pressure was 110/70 mmHg, the pulse was 120 beats/min and the temperature was 39.5 C. Auscultation revealed a 2/6 pansystolic murmur at the apex of the heart, whereas the ECG and chest X-ray were normal. There were no pathologic findings on lung examination,
* Corresponding author. Massachusetts General Hospital, Division of Infectious Diseases, Gray-Jackson Building, GRJ-516, 55 Fruit Street, Boston, MA 02114, USA. Tel.: þ1 16177243743; fax: þ1 16177267416. E-mail address: [email protected] (G. Aperis).
0163-4453/$30 ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2006.04.012
e80
G. Aperis, I. Moyssakis
Table 1 Pathogen C. C. C. C. C. C.
Reports of endocarditis due to Corynebacterium non-diphtheriae species No of Native/prosthetic Treatment patients valve (N/P)
accolens 1 afermentans 1 amycolatum 2 jeikeium 1 minutissimum 2 striatum 10
C. xerosis Total
2 19
1N 1P 2N 1N 2N 8N/2P
2N 19N/3P
Outcome
Antimicrobial chemotherapy and surgery Cure Antimicrobial chemotherapy and surgery Cure Antimicrobial chemotherapy Cure (1)/death (1) Antimicrobial chemotherapy and surgery Death Antimicrobial chemotherapy Cure Antimicrobial chemotherapy (7), Cure (9)/death (1) antimicrobial chemotherapy and surgery (3) Antimicrobial chemotherapy Cure (1)/death (1) Cure (15)/death (4)
funduscopic examination and abdominal examination. No evidence of peripheral embolic disease was seen. The patient had anemia, leukocytosis and elevated Creactive protein and erythrocyte sedimentation rate. Urine examination was normal. All six sets of blood cultures grew for Corynebacterium minutissimum, sensitive to penicillin and gentamicin (MIC 0.02 mg/ml for penicillin). A transesophageal echocardiogram showed a large vegetation attached to the anterior leaflet of the mitral valve. Treatment for bacterial endocarditis was initiated with 3 million unit of aqueous penicillin intravenously every four hours for 4 weeks and 120 mg of gentamicin every twelve hours for a week. The clinical course was uncomplicated and a repeat echocardiogram 2 months later showed decrease in vegetation’s size. A year later, the patient had no clinical evidence of disease recurrence.
Discussion and review Corynebacteria are group of organisms that include 20 genera. The identification of Corynebacterium or other coryneform bacteria poses a challenge to the microbiologist because they are common commensals in the skin and mucous membranes, they are fastidious and slow growing and, when isolated, they may be considered as contaminants.4,5 Corynebacteria are rare causes of bacterial endocarditis. Cases of Corynebacterium non-diphtheriae endocarditis reported in the English-language medical literature since 1994 were identified by a search in PUBMED with the terms Corynebacterium endocarditis, Corynebacterium non-diphtheriae endocarditis and endocarditis. In 1994 Petit et al. reviewed 126 cases of C. diphtheriae and non-diphtheriae endocarditis.6 Among those cases, in 107 skin was the portal of entry and the infection was preceded by surgery (43 patients had prosthetic valves) or intravenous injection of illicit drugs resulting in bacteremia. In our review we included only cases of C. non-diphtheriae endocarditis. Other coryneform pathogens were excluded. The results are summarized on Table 1. Among those 19 cases reported here, 11 were females and 8 were males aged between 11 and 88 years (mean 55 years). The clinical presentation was typical in most cases, but in some reports, presentation was mimicked other systemic diseases, such as systemic vasculitis,12 or atypical
References 7 8 9,10 11 3 9,12e19
20,21
symptoms of severe infection such as lethargy and malaise.13 Most patients had severe underlying disease such as chronic renal failure,16 paraplegia,17 diabetes mellitus, congestive heart failure,18 history of infectious endocarditis or medical intervention involving such as placement of femoral graft,16 ventriculostriatal shunt,17 patent ductus arteriosus,21 pacemaker implantation,19 femoral access for coronary angiography11 neurosurgical operation of aneurysm of the CNS,14 but patients with negative history have also been reported,15 including our case. Antimicrobial chemotherapy and/or surgery resulted in successful outcome in 15 out of 19 patients, while 4 patients succumbed. The first reported case of Corynebacterium minutissimum endocarditis was of a 31-year old woman with history of rheumatic heart disease, who was presented with decreased vision and photophobia due to retinopathy after a recent dental surgery.3 Antimicrobial treatment resulted in successful outcome. The oral cavity was probably the portal of entry of the organism, as it possibly was in our case too. In conclusion Corynebacterium minutissimum appears to be a low infectivity microorganism that colonizes the skin and mucous membranes. This organism causes erythrasma, but also bacteremia and endocarditis. It is sensitive to penicillin and intravenous administration of penicillin results in successful outcome of endocarditis.
References 1. Bortolussi R, Kennedy W. Corynebacterium minutissimum. In: Armstrong Donald, Cohen Jonathan, editors. Infectious diseases. 1st ed. Mosby; 1999. 2. Brown A. Other corynebacteria and rhodococci: Corynebacterium minutissimum. In: Principles and practice of infectious diseases. 5th ed., vol. 2. Churcill Livingstone; 2000. p. 2200. 3. Herschorn BJ, Brucker AJ. Embolic retinopathy due to Corynebacterium minutissimum endocarditis. Br J Ophthalmol 1985; 69:29e31. 4. Coyle MB, Lipsky BA. Coryneform bacteria in infectious diseases: clinical and laboratory aspects. Clin Microbiol Rev 1990;3:227e46. 5. Pitcher DG. Rapid identification of cell wall components as a guide to the classification of aerobic coryneform bacteria from human skin. J Med Microbiol 1977;10:439e45.
Corynebacterium minutissimum endocarditis 6. Petit PL, Bok JW, Thompson J, Buiting AGM, Coyle MB. Nativevalve endocarditis due to CDC coryneform group ANF-3: report of a case and review of corynebacterial endocarditis. Clin Infect Dis 1994;19:897e901. 7. Claeys G, Vanhouteghem H, Riegel P, Wauters G, Hamerlynck R, Dierick J, et al. Endocarditis of native aortic and mitral valves due to Corynebacterium accolens: report of a case and application of phenotypic and genotypic techniques for identification. J Clin Microbiol 1996;34:1290e2. 8. Sewell DL, Coyle MB, Funke G. Prosthetic valve endocarditis caused by Corynebacterium afermentans subsp. lipophilum (CDC coryneform group ANF-1). J Clin Microbiol 1995;33:759e61. 9. Knox KL, Holmes AH. Nosocomial endocarditis caused by Corynebacterium amycolatum and other nondiphtheriae corynebacteria. Emerg Infect Dis 2002;8:97e9. 10. Daniels C, Schoors D, Van Camp G. Native valve endocarditis with aorta-to-left atrial fistula due to Corynebacterium amycolatum. Eur J Echocardiogr 2003;4:68e70. 11. Ross MJ, Sakoulas G, Manning WJ, Cohn WE, Lisbon A. Corynebacterium jeikeium native valve endocarditis following femoral access for coronary angiography. Clin Infect Dis 2001;32: E120e1. 12. Stoddart B, Sandoe JA, Denton M. Corynebacterium striatum endocarditis masquerading as connective tissue disorders. Rheumatology (Oxford) 2005;44:557e8. 13. Houghton T, Kaye GC, Meigh RE. An unusual case of infective endocarditis. Postgrad Med J 2002;78:290e1.
e81 14. Kocazeybek B, Ozder A, Kucukoglu S, Kukucates E, Yuksel H, Olga R. Report of a case with polymicrobial endocarditis related to multiresistant strains. Chemotherapy 2002;48: 316e9. 15. Rufael DW, Cohn SE. Native valve endocarditis due to Corynebacterium striatum: case report and review. Clin Infect Dis 1994;19:1054e61. 16. Shah M, Murillo JL. Successful treatment of Corynebacterium striatum endocarditis with daptomycin plus rifampin. Ann Pharmacother 2005;39:1741e4. 17. Tattevin P, Cremieux AC, Muller-Serieys C, Carbon C. Native valve endocarditis due to Corynebacterium striatum: first reported case of medical treatment alone. Clin Infect Dis 1996;23:1330e1. 18. Juurlink DN, Borczyk A, Simor AE. Native valve endocarditis due to Corynebacterium striatum. Eur J Clin Microbiol Infect Dis 1996;15:963e5. 19. Melero-Bascones M, Munoz P, Rodriguez-Creixens M, Bouza E, et al. Corynebacterium striatum: an undescribed agent of pacemaker-related endocarditis. Clin Infect Dis 1996;22: 576e7. 20. Pessanha B, Farb A, Lwin T, Lioyd B, Virmani R. Infectious endocarditis due to Corynebacterium xerosis. Cardiovasc Pathol 2003;12:98e101. 21. Malik AS, Johari MR. Pneumonia, pericarditis, and endocarditis in a child with Corynebacterium xerosis septicemia. Clin Infect Dis 1995;20:191e2.