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A Case of Costochondral Abscess due to Corynebacterium minutissimum in an HIV-infected Patient
Case Reports 04 Schaaf HS, Geldenhuys A, Gie RP, Cotton MF. Culture-positive tuberculosis in human immunodeficiency virus type 1-infected children. Pediatr Infect Dis J 1998; 17: 599–604. 05 Jeena PM, Mitha T, Bamber S, Werley A, Coutsoudis A, Coovadia HM. Effects of the human immunodeficiency virus on tuberculosis in children. Tuberc Lung Dis 1996; 77: 437–443. 06 Centers for Disease Control and Prevention. 1994 Revised classification system for human immunodeficiency virus infection in children less than 13 years of age. MMWR 1994; 43(RR-12): 1–10. 07 Donald PR, Schoeman JF, van Zyl LE, de Villiers JN, Pretorius M, Springer P. Intensive short course chemotherapy in the management of tuberculous meningitis. Int J Tuberc Lung Dis 1998; 2: 704–711. 08 Warren R, Richardson M, Sampson S et al. Genotyping of Mycobacterium tuberculosis with additional markers enhances accuracy in epidemiological studies. J Clin Microbiol 1996; 34: 2219–2224. 09 Van Embden JDA, Cave MD, Crawford JT et al. Strain identification of Mycobacterium tuberculosis by DNA fingerprinting: Recommendations for a standardized methodology. J Clin Microbiol 1993; 31: 406–409. 10 Seifart HI, Gent WL, Parkin DP, van Jaarsveld PP, Donald PR. High-performance liquid chromatography determination of isoniazid, acetylisoniazid and hydrazine in biological fluids. J Chromatogr B 1995; 674: 269–275. 11 Small PM, Shafer RW, Hopewell PC, Singh SP, Murphy MJ, Desmond E, Sierra MF. Exogenous reinfection with multidrug-resistant Mycobacterium tuberculosis in patients with advanced HIV infection. N Eng J Med 1993; 328: 1137–1144. 12 Taylor B, Smith PJ. Does AIDS impair the absorption of antituberculosis agents? Int J Tuberc Lung Dis 1998; 2: 670–675. 13 Sahai J, Gallicano K, Swick L et al. Reduced plasma concentrations of antituberculosis drugs in patients with HIV infection. Ann Intern Med 1997; 127: 289–293. 14 American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1994; 149: 1359–1374. 15 Malkin JE, Prazuck T, Simmonet et al. Tuberculosis and human immunodeficiency virus infection in West Burkina Faso: clinical presentation and clinical evolution. Int J Tuberc Lung Dis 1997; 1: 68–74.
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16 Van den Broek J, Mfinanga S, Moshiro C, O’ Brien R, Mugomela A, Lefi M. Impact of human immunodeficiency virus on the outcome of treatment and survival of tuberculosis patients in Mwanza, Tanzania. Int J Tuberc Lung Dis. 1998; 2: 547–552. 17 Pulido F, Pena J-M, Rubio R, Moreno S, González J, Guijarro C, Costa J-R, Vásquez J-J. Relapse of tuberculosis after treatment in human immunodeficiency virus-infected patients. Arch Intern Med 1997; 157: 227–232. 18 Jacobs RF, Sunakorn P, Chotpita Yasunonah T, Pope S, Kelleher K. Intensive short course chemotherapy for tuberculosis meningitis. Pediatr Infect Dis J 1992; 11: 194–198. 19 Biddulph J. Short course chemotherapy for childhood tuberculosis. Pediatr Infect Dis J 1990; 9: 794–801. 20 Alarón F, Escalante L, Pérez Y, Banda H, Chacón G, Dueñas G. Tuberculosis meningitis: short course of chemotherapy. Arch Neurol 1990; 47: 1313–1317. 21 Gangadharam PRJ. Mycobacterial dormancy (editorial). Tuberc Lung Dis 1995; 76: 477–479. 22 De Wit D, Wootton M, Dhillon J, Mitchison DA. The bacterial DNA content of mouse organs in the Cornell model of dormant tuberculosis. Tuberc Lung Dis 1995; 76: 555–562. 23 Iseman MD. Is standard chemotherapy adequate in tuberculosis patients infected with HIV? Am Rev Respir Dis 1987; 136: 1326. 24 Pinching AJ. The acquired immune deficiency syndrome with special reference to tuberculosis. Tubercle 1987; 68: 65–69. 25 Lee T, Masobe P, Schneider H. Proposals for the feasible management of tuberculosis in HIV-seropositive South Africans. South Afr J Med 1995; 85: 68–71. 26 Chintu C, Zumla A. Childhood tuberculosis and infection with the human immunodeficiency virus. J R Coll Physicians Lond 1995; 29: 92–95. 27 Shafer RW, Jones WD. Relapse of tuberculosis in a patient with the acquired immunodeficiency syndrome despite 12 months of antituberculous therapy and continuation of isoniazid. Tubercle 1991; 72: 149–151. 28 Khouri YF, Mastrucci MT, Hutto C, Mitchell CD, Scott GB. Mycobacterium tuberculosis in children with human immunodeficiency virus type 1 infection. Pediatr Infect Dis J 1992; 11: 950–955.
doi:10.1053/jinf.2000.0679, available online at http://www.idealibrary.com on
A Case of Costochondral Abscess due to Corynebacterium minutissimum in an HIV-infected Patient A. Bandera*1, A. Gori1, M. C. Rossi1, A. Degli Esposti1, G. Ferrario1, G. Marchetti1, L. Tocalli2 and F. Franzetti1 1
Institute of Infectious Diseases and Tropical Medicine, “Luigi Sacco” Hospital, University of Milan, Milan, Italy, 2 Department of Microbiology, “Luigi Sacco” Hospital, University of Milan, Milan, Italy
Corynebacterium minutissimum, known as the causative agent of erythrasma, has recently been reported as a clinically significant pathogen in the immunocompromised host. We report for the first time the possible involvement of a multidrug-resistant C. minutissimum strain in a costochondral abscess occurring in an HIV-infected patient. © 2000 The British Infection Society
* Please address all correspondence to: Alessandra Bandera. Clinic of Infectious Diseases, “Luigi Sacco” Hospital, University of Milan, Via G.B. Grassi 74, 4 20157 Milan, Italy. Accepted for publication 7 April 2000.
Introduction Corynebacterium minutissimum is an aerobic, non-sporing, Gram-positive rod, whose habitat is the human skin. Corynebacterium minutissimum is associated with erythrasma, a © 2000 The British Infection Society
Case Reports
104
common superficial infection of the skin. The organism has been cultured from the skin in 36% of normal males without evidence of infection. The predisposing factors are humidity, maceration, obesity, and poor hygiene.1 Corynebacterium species have become clinically significant pathogens in patients with central venous catheter-related bacteremia, endocarditis, and other invasive infections.2 Moreover, the observation of treatment failures and the emergence of multiple antimicrobial-resistant C. minutissimum strains have been recently reported.3,4 Here we present a case of costochondral abscess due to a multidrug-resistant strain of C. minutissimum in an HIV-infected patient, which is, to our knowledge, the first report of this infection in an HIV-infected subject.
Case Report A 36-year-old male, HIV-1 positive since 1993 presented with a swelling in the right parasternal region with a cutaneous fistula discharging pus. His absolute neutrophil count (ANC) was 4288/l; CD4 T-cell count was 225/l, and HIV-1 RNA370 copies/ml. He was receiving lamivudine, stavudine, and nelfinavir. In 1995 he developed cytomegalovirus retinitis and HSV-2 meningitis and in 1996, disseminated Mycobacterium avium complex infection was diagnosed. In January 1997 he developed a septicaemia caused by Candida spp. originating from a long-term central venous access that was used for 7 months. Microscopic and cultural examinations of blood and of pus collected from the fistula were negative. A chest CT scan showed an inflammatory lesion of the subcutaneous tissue involving the parasternal cartilaginous part of the seventh right rib. The patient was empirically treated with oral amoxicillin and subsequently with rifampicin and ciprofloxacin, with no modification in his clinical condition. During the following months, the patient experienced pain and recurrent purulent discharge. In October 1998, 3 months after the first observation, a surgical excision of the seventh right rib was performed. The excised tissue showed diffuse perivascular inflammatory infiltration in the superficial dermis and chronic inflammation in the underlying fibromuscular and cartilagineous structures. The microscopic and culture examination did not identify any micro-organism. The patient was then treated again with oral amoxicillin and clavulanic acid for 15 days. In the months following the excision of the rib, the surgical wound did not heal and continued to discharge pus. Moreover, in February 1999 the patient developed a similar swelling in the left parasternal region with subsequent cutaneous fistulization and emission of pus, without any cultural isolate. A surgical removal of this abscess was performed. Histological and microbiological data were similar to the previous specimen. A sample of pus obtained from the origin of the fistula revealed small pleomorphic Gram-positive bacilli, which were later identified as C. minutissimum. The isolate was susceptible to amikacin, tetracycline and vancomycin, but resistant to ampicillin, chloramphenicol, cotrimoxazole, erithromycin, and penicillin. The antimicrobial sensitivities were determined by disk diffusion testing on Mueller–Hinton agar supplemented with 5% sheep blood. According to the National Committee for Clinical Laboratory Standards (NCCLS) interpretation, criteria used to determine resistance or susceptibility were those established for staphylococci. The patient started a regimen of intravenous vancomycin (1.0 g twice daily) and amikacin (1.0 g once a day) for 14 days. At the end of the antibiotic treatment both operative wounds
healed and the patient was discharged from the hospital in good condition. No relapse of the abscess was observed during a 12 month follow-up period.
Discussion Corynebacterium species other than C. diphtheriae are known to produce severe and life-threatening infections. During recent years, an increasing number of cases with non-diphtheria corynebacteria as causes of serious opportunistic infection have been reported.5 This can be explained by: (i) the large number of immunocompromised patients whose diagnosis and treatment have become ever more intensive and invasive, (ii) increased ability to identify these species in the laboratory, and (iii) the recognition of the pathogenic potential of coryneform bacteria. Recently we diagnosed two cases of C. minutissimum infection. The first was in a patient affected by acute myeloid leukaemia who developed a sepsis from a peripheral insertion catheter, adding to the growing body of evidence that C. minutissimum can cause severe disease in oncological immunosuppressed patients. More importantly, the patient that we have described here represents the first case of C. minutissimum costochondritis in HIV-positive subjects. Up to now, two cases of soft tissues abscesses caused by C. minutissimum have been described in immunocompetent patients: one of which was a severe and recurrent breast abscess after biopsy of a solitary breast mass6 and the other was a deep abscess after cervical discectomy.7 Cases of osteomyelitis caused by Corynebacteria have been reported, but none of them documented an association with C. minutissimum. In all reported cases local septic lesions followed invasive procedures, such as craniotomy,8 vertebral biopsy9 and vascular graft.10 Our patient had a skin defect represented by a long-term central venous access, in a site not directly correlated with the costochondral localization of the abscesses. Although the long-term venous access may have served as a portal of entry for C. minutissimum, the origin of the extensive and recurrent abscesses in this patient remains unexplained. Many case reports of disease caused by C. minutissimum are considered to be inappropriately documented, because they lack information on colony morphology and biochemical reactions.5 In our case, the identification of C. minutissimum was confirmed by the following properties: non-haemolytic, non-lipophilic, smooth colonies of about 1–1.5 mm in diameter after 24 h of incubation on sheep blood agar; positive catalase reaction and nitrate-, esculin-, urea- and motility-negative reactions. Carbohydrate fermentation studies revealed fermentation of glucose, sucrose, maltose and fructose, and lack of fermentation of xylose, lactose and mannitol. The antimicrobial susceptibility pattern of coryneform bacteria has not been systematically studied. Multi-resistance has been well documented in C. jeikeium and C. urealyticum strains,2,11 and some data add C. amycolatum to the list of species with a reduced susceptibility to many antimicrobial agents.12 Corynebacterium minutissimum is generally susceptible to penicillins, first-generation cephalosporins, erythromycin, clindamycin, ciprofloxacin, tetracycline, and vancomycin, but C. minutissimum multi-resistant strains have been recently described.3,4 In our cases the two isolates were resistant to multiple antibiotics. Both of our patients had a previous history of multiple antibiotic treatment. The observation of glycopeptide-sensitive strains of C. minutissimum that we describe here, along with similar data in the
Case Reports literature, could justify the use of these antibiotics as first line drugs in invasive infections associated with previous hospitalization and/or long term use of antibiotics.
Acknowledgements We are grateful to Dr. Stefano Rusconi and Elizabeth Kaplan for critical reading of the manuscript and valuable advice.
References 01 Guarderas J, Karnad A, Alvarez S, Berk SL. Corynebacterium minutisimum bacteremia in a patient with chronic myeloid leukemia in blast crisis. Diagn Microbiol Infect Dis 1986; 5: 327–330. 02 Coyle MB, Lipsky BA. Coryneform bacteria in infectious disease: clinical and laboratory aspects. Clin Microbiol Rev 1990; 3: 227–246. 03 Cavendish J, Cole JB, Ohl CA. Polymicrobial central venous catheter sepsis involving a multiantibiotic-resistant strain of Corynebacterium minutissimum. Clin Infect Dis 1994; 19: 204–5. 04 Van Bosterhaut B, Cuvelier R, Serruys E, Pouthier F, Wauters G. Three cases of opportunistic infection caused by propionic acid producing Corynebacterium minutissimum. Eur J Clin Microbiol Infect Dis 1992; 11: 628–631.
105
05 Funke G, vonGraevenitz A, Clarridge JE, Bernard KA. Clinical microbiology of Coryneform bacteria. Clin Microbiol Rev 1997; 10: 125–159. 06 Berger SA, Gorea A, Stadler J, Dan M, Zilberman M. Recurrent breast abscesses caused by Corynebacterium minutissimum. J Clin Microbiol 1984; 20: 1219–1220. 07 Golledge CL, Philips G. Corynebacterium minutissimum infection. J Infect 1991; 23: 73–76. 08 Wilson IF, Candia GJ, Worthington MG, Sullivan JG: Chronic osteomyelitis due to corynebacteria in a postcraniotomy bone flap. Clin Infect Dis 1999; 28: 1323–1324. 09 Fleuriau Chauten PB, Commons AS, O’ Neil DJ. Fine-needle aspiration biopsy of chondroblastic osteosarcoma of the vertebral column complicated by Corynebacterium infection: a case report. Diagn Cytopathol 1999; 20: 38–43. 10 Clarke R, Quamruddin A, Taylor M, Panigrahi H. Septic arthritis caused by Corynebacterium amycolatum following vascular graft sepsis. J Infect 1999; 38: 126–127. 11 Soriano F, Zapardiel J, Nieto E. Antimicrobial susceptibilities of Corynebacterium species and other non-spore-forming Grampositive bacilli to 18 antimicrobial agents. Antimicrob Agents Chemother 1995; 39: 208–214. 12 Funke G, Punter V, vonGraevenitz A. Antimicrobial susceptibility patterns of some recently established coryneform bacteria. Antimicrob Agents Chemother 1996; 40: 2874–2878.
doi:10.1053/jinf.2000.0687, available online at http://www.idealibrary.com on
Orbital Hydatid Cyst: Treatment and Prevention of Recurrences with Albendazole plus Praziquantel M. E. Jiménez-Mejías*1, J. C. Alarcón-Cruz2, F. J. Márquez-Rivas2, J. Palomino-Nicás1, J. M. Montero2 and J. Pachón1 1
Service of Infectious Diseases, and 2the Service of Neurosurgery, University Hospital Virgen del Rocio, Sevilla, Spain A case of successful treatment of orbital echinococcosis without evidence of recurrence on prolonged follow-up is presented. The management of orbital hydatid cyst is discussed. © 2000 The British Infection Society
Introduction
Case Report 1
Orbital echinococcosis is an uncommon disease. Its diagnosis is not easily obtained, due to clinical polymorphism, frequently negative serological tests, and the fact that the disease is rare.2 Surgical removal of an orbital hydatid cyst is frequently complicated by cyst rupture, spillage of contents, and secondary recurrences. In such cases, treatment with benzimidazole-carbamates has been used, with variable results.3 We present a new case of hydatid cyst of orbit, ruptured during surgical removal, treated with albendazole and praziquantel, and without recurrence after 6 years of follow-up. * Please address all correspondence to: Manuel Enrique Jiménez-Mejías, Servicio de Enfermedades Infecciosas, Hospital Virgen del Rocío, Avda. Manuel Siurot s/n, 41013 Sevilla, Spain. Accepted for publication 12 May 2000.
A 22-year-old farmer was admitted with a 1-month history of pain, swelling and visual impairment of the left eye. The general physical examination showed no abnormalities. The left eye showed proptosis without chemosis, an afferent pupillary defect, and inability to turn the eye inward, upward, and outward. Fundoscopic examination revealed a blurred optic disc, papilloedema, engorged retinal veins, and enlargement of the blind spot. Visual acuity of the left eye was decreased to 0.1. The right eye was normal. Haematological examination showed 7.2109/l white blood cells, 0.18109/l eosinophils, 5.1 1012/l erythrocytes, and 267109/l platelets. Erythrocyte sedimentation rate (ESR) was 3 mm. Transaminases, alkaline phosphatase, and bilirubin were normal. Chest X-ray and abdominal ultrasonography showed no hydatid cyst. Ocular ultrasonography of the left orbit showed a well-defined, unilocular, anechoic © 2000 Harcourt Publishers Ltd
103
16 Van den Broek J, Mfinanga S, Moshiro C, O’ Brien R, Mugomela A, Lefi M. Impact of human immunodeficiency virus on the outcome of treatment and survival of tuberculosis patients in Mwanza, Tanzania. Int J Tuberc Lung Dis. 1998; 2: 547–552. 17 Pulido F, Pena J-M, Rubio R, Moreno S, González J, Guijarro C, Costa J-R, Vásquez J-J. Relapse of tuberculosis after treatment in human immunodeficiency virus-infected patients. Arch Intern Med 1997; 157: 227–232. 18 Jacobs RF, Sunakorn P, Chotpita Yasunonah T, Pope S, Kelleher K. Intensive short course chemotherapy for tuberculosis meningitis. Pediatr Infect Dis J 1992; 11: 194–198. 19 Biddulph J. Short course chemotherapy for childhood tuberculosis. Pediatr Infect Dis J 1990; 9: 794–801. 20 Alarón F, Escalante L, Pérez Y, Banda H, Chacón G, Dueñas G. Tuberculosis meningitis: short course of chemotherapy. Arch Neurol 1990; 47: 1313–1317. 21 Gangadharam PRJ. Mycobacterial dormancy (editorial). Tuberc Lung Dis 1995; 76: 477–479. 22 De Wit D, Wootton M, Dhillon J, Mitchison DA. The bacterial DNA content of mouse organs in the Cornell model of dormant tuberculosis. Tuberc Lung Dis 1995; 76: 555–562. 23 Iseman MD. Is standard chemotherapy adequate in tuberculosis patients infected with HIV? Am Rev Respir Dis 1987; 136: 1326. 24 Pinching AJ. The acquired immune deficiency syndrome with special reference to tuberculosis. Tubercle 1987; 68: 65–69. 25 Lee T, Masobe P, Schneider H. Proposals for the feasible management of tuberculosis in HIV-seropositive South Africans. South Afr J Med 1995; 85: 68–71. 26 Chintu C, Zumla A. Childhood tuberculosis and infection with the human immunodeficiency virus. J R Coll Physicians Lond 1995; 29: 92–95. 27 Shafer RW, Jones WD. Relapse of tuberculosis in a patient with the acquired immunodeficiency syndrome despite 12 months of antituberculous therapy and continuation of isoniazid. Tubercle 1991; 72: 149–151. 28 Khouri YF, Mastrucci MT, Hutto C, Mitchell CD, Scott GB. Mycobacterium tuberculosis in children with human immunodeficiency virus type 1 infection. Pediatr Infect Dis J 1992; 11: 950–955.
doi:10.1053/jinf.2000.0679, available online at http://www.idealibrary.com on
A Case of Costochondral Abscess due to Corynebacterium minutissimum in an HIV-infected Patient A. Bandera*1, A. Gori1, M. C. Rossi1, A. Degli Esposti1, G. Ferrario1, G. Marchetti1, L. Tocalli2 and F. Franzetti1 1
Institute of Infectious Diseases and Tropical Medicine, “Luigi Sacco” Hospital, University of Milan, Milan, Italy, 2 Department of Microbiology, “Luigi Sacco” Hospital, University of Milan, Milan, Italy
Corynebacterium minutissimum, known as the causative agent of erythrasma, has recently been reported as a clinically significant pathogen in the immunocompromised host. We report for the first time the possible involvement of a multidrug-resistant C. minutissimum strain in a costochondral abscess occurring in an HIV-infected patient. © 2000 The British Infection Society
* Please address all correspondence to: Alessandra Bandera. Clinic of Infectious Diseases, “Luigi Sacco” Hospital, University of Milan, Via G.B. Grassi 74, 4 20157 Milan, Italy. Accepted for publication 7 April 2000.
Introduction Corynebacterium minutissimum is an aerobic, non-sporing, Gram-positive rod, whose habitat is the human skin. Corynebacterium minutissimum is associated with erythrasma, a © 2000 The British Infection Society
Case Reports
104
common superficial infection of the skin. The organism has been cultured from the skin in 36% of normal males without evidence of infection. The predisposing factors are humidity, maceration, obesity, and poor hygiene.1 Corynebacterium species have become clinically significant pathogens in patients with central venous catheter-related bacteremia, endocarditis, and other invasive infections.2 Moreover, the observation of treatment failures and the emergence of multiple antimicrobial-resistant C. minutissimum strains have been recently reported.3,4 Here we present a case of costochondral abscess due to a multidrug-resistant strain of C. minutissimum in an HIV-infected patient, which is, to our knowledge, the first report of this infection in an HIV-infected subject.
Case Report A 36-year-old male, HIV-1 positive since 1993 presented with a swelling in the right parasternal region with a cutaneous fistula discharging pus. His absolute neutrophil count (ANC) was 4288/l; CD4 T-cell count was 225/l, and HIV-1 RNA370 copies/ml. He was receiving lamivudine, stavudine, and nelfinavir. In 1995 he developed cytomegalovirus retinitis and HSV-2 meningitis and in 1996, disseminated Mycobacterium avium complex infection was diagnosed. In January 1997 he developed a septicaemia caused by Candida spp. originating from a long-term central venous access that was used for 7 months. Microscopic and cultural examinations of blood and of pus collected from the fistula were negative. A chest CT scan showed an inflammatory lesion of the subcutaneous tissue involving the parasternal cartilaginous part of the seventh right rib. The patient was empirically treated with oral amoxicillin and subsequently with rifampicin and ciprofloxacin, with no modification in his clinical condition. During the following months, the patient experienced pain and recurrent purulent discharge. In October 1998, 3 months after the first observation, a surgical excision of the seventh right rib was performed. The excised tissue showed diffuse perivascular inflammatory infiltration in the superficial dermis and chronic inflammation in the underlying fibromuscular and cartilagineous structures. The microscopic and culture examination did not identify any micro-organism. The patient was then treated again with oral amoxicillin and clavulanic acid for 15 days. In the months following the excision of the rib, the surgical wound did not heal and continued to discharge pus. Moreover, in February 1999 the patient developed a similar swelling in the left parasternal region with subsequent cutaneous fistulization and emission of pus, without any cultural isolate. A surgical removal of this abscess was performed. Histological and microbiological data were similar to the previous specimen. A sample of pus obtained from the origin of the fistula revealed small pleomorphic Gram-positive bacilli, which were later identified as C. minutissimum. The isolate was susceptible to amikacin, tetracycline and vancomycin, but resistant to ampicillin, chloramphenicol, cotrimoxazole, erithromycin, and penicillin. The antimicrobial sensitivities were determined by disk diffusion testing on Mueller–Hinton agar supplemented with 5% sheep blood. According to the National Committee for Clinical Laboratory Standards (NCCLS) interpretation, criteria used to determine resistance or susceptibility were those established for staphylococci. The patient started a regimen of intravenous vancomycin (1.0 g twice daily) and amikacin (1.0 g once a day) for 14 days. At the end of the antibiotic treatment both operative wounds
healed and the patient was discharged from the hospital in good condition. No relapse of the abscess was observed during a 12 month follow-up period.
Discussion Corynebacterium species other than C. diphtheriae are known to produce severe and life-threatening infections. During recent years, an increasing number of cases with non-diphtheria corynebacteria as causes of serious opportunistic infection have been reported.5 This can be explained by: (i) the large number of immunocompromised patients whose diagnosis and treatment have become ever more intensive and invasive, (ii) increased ability to identify these species in the laboratory, and (iii) the recognition of the pathogenic potential of coryneform bacteria. Recently we diagnosed two cases of C. minutissimum infection. The first was in a patient affected by acute myeloid leukaemia who developed a sepsis from a peripheral insertion catheter, adding to the growing body of evidence that C. minutissimum can cause severe disease in oncological immunosuppressed patients. More importantly, the patient that we have described here represents the first case of C. minutissimum costochondritis in HIV-positive subjects. Up to now, two cases of soft tissues abscesses caused by C. minutissimum have been described in immunocompetent patients: one of which was a severe and recurrent breast abscess after biopsy of a solitary breast mass6 and the other was a deep abscess after cervical discectomy.7 Cases of osteomyelitis caused by Corynebacteria have been reported, but none of them documented an association with C. minutissimum. In all reported cases local septic lesions followed invasive procedures, such as craniotomy,8 vertebral biopsy9 and vascular graft.10 Our patient had a skin defect represented by a long-term central venous access, in a site not directly correlated with the costochondral localization of the abscesses. Although the long-term venous access may have served as a portal of entry for C. minutissimum, the origin of the extensive and recurrent abscesses in this patient remains unexplained. Many case reports of disease caused by C. minutissimum are considered to be inappropriately documented, because they lack information on colony morphology and biochemical reactions.5 In our case, the identification of C. minutissimum was confirmed by the following properties: non-haemolytic, non-lipophilic, smooth colonies of about 1–1.5 mm in diameter after 24 h of incubation on sheep blood agar; positive catalase reaction and nitrate-, esculin-, urea- and motility-negative reactions. Carbohydrate fermentation studies revealed fermentation of glucose, sucrose, maltose and fructose, and lack of fermentation of xylose, lactose and mannitol. The antimicrobial susceptibility pattern of coryneform bacteria has not been systematically studied. Multi-resistance has been well documented in C. jeikeium and C. urealyticum strains,2,11 and some data add C. amycolatum to the list of species with a reduced susceptibility to many antimicrobial agents.12 Corynebacterium minutissimum is generally susceptible to penicillins, first-generation cephalosporins, erythromycin, clindamycin, ciprofloxacin, tetracycline, and vancomycin, but C. minutissimum multi-resistant strains have been recently described.3,4 In our cases the two isolates were resistant to multiple antibiotics. Both of our patients had a previous history of multiple antibiotic treatment. The observation of glycopeptide-sensitive strains of C. minutissimum that we describe here, along with similar data in the
Case Reports literature, could justify the use of these antibiotics as first line drugs in invasive infections associated with previous hospitalization and/or long term use of antibiotics.
Acknowledgements We are grateful to Dr. Stefano Rusconi and Elizabeth Kaplan for critical reading of the manuscript and valuable advice.
References 01 Guarderas J, Karnad A, Alvarez S, Berk SL. Corynebacterium minutisimum bacteremia in a patient with chronic myeloid leukemia in blast crisis. Diagn Microbiol Infect Dis 1986; 5: 327–330. 02 Coyle MB, Lipsky BA. Coryneform bacteria in infectious disease: clinical and laboratory aspects. Clin Microbiol Rev 1990; 3: 227–246. 03 Cavendish J, Cole JB, Ohl CA. Polymicrobial central venous catheter sepsis involving a multiantibiotic-resistant strain of Corynebacterium minutissimum. Clin Infect Dis 1994; 19: 204–5. 04 Van Bosterhaut B, Cuvelier R, Serruys E, Pouthier F, Wauters G. Three cases of opportunistic infection caused by propionic acid producing Corynebacterium minutissimum. Eur J Clin Microbiol Infect Dis 1992; 11: 628–631.
105
05 Funke G, vonGraevenitz A, Clarridge JE, Bernard KA. Clinical microbiology of Coryneform bacteria. Clin Microbiol Rev 1997; 10: 125–159. 06 Berger SA, Gorea A, Stadler J, Dan M, Zilberman M. Recurrent breast abscesses caused by Corynebacterium minutissimum. J Clin Microbiol 1984; 20: 1219–1220. 07 Golledge CL, Philips G. Corynebacterium minutissimum infection. J Infect 1991; 23: 73–76. 08 Wilson IF, Candia GJ, Worthington MG, Sullivan JG: Chronic osteomyelitis due to corynebacteria in a postcraniotomy bone flap. Clin Infect Dis 1999; 28: 1323–1324. 09 Fleuriau Chauten PB, Commons AS, O’ Neil DJ. Fine-needle aspiration biopsy of chondroblastic osteosarcoma of the vertebral column complicated by Corynebacterium infection: a case report. Diagn Cytopathol 1999; 20: 38–43. 10 Clarke R, Quamruddin A, Taylor M, Panigrahi H. Septic arthritis caused by Corynebacterium amycolatum following vascular graft sepsis. J Infect 1999; 38: 126–127. 11 Soriano F, Zapardiel J, Nieto E. Antimicrobial susceptibilities of Corynebacterium species and other non-spore-forming Grampositive bacilli to 18 antimicrobial agents. Antimicrob Agents Chemother 1995; 39: 208–214. 12 Funke G, Punter V, vonGraevenitz A. Antimicrobial susceptibility patterns of some recently established coryneform bacteria. Antimicrob Agents Chemother 1996; 40: 2874–2878.
doi:10.1053/jinf.2000.0687, available online at http://www.idealibrary.com on
Orbital Hydatid Cyst: Treatment and Prevention of Recurrences with Albendazole plus Praziquantel M. E. Jiménez-Mejías*1, J. C. Alarcón-Cruz2, F. J. Márquez-Rivas2, J. Palomino-Nicás1, J. M. Montero2 and J. Pachón1 1
Service of Infectious Diseases, and 2the Service of Neurosurgery, University Hospital Virgen del Rocio, Sevilla, Spain A case of successful treatment of orbital echinococcosis without evidence of recurrence on prolonged follow-up is presented. The management of orbital hydatid cyst is discussed. © 2000 The British Infection Society
Introduction
Case Report 1
Orbital echinococcosis is an uncommon disease. Its diagnosis is not easily obtained, due to clinical polymorphism, frequently negative serological tests, and the fact that the disease is rare.2 Surgical removal of an orbital hydatid cyst is frequently complicated by cyst rupture, spillage of contents, and secondary recurrences. In such cases, treatment with benzimidazole-carbamates has been used, with variable results.3 We present a new case of hydatid cyst of orbit, ruptured during surgical removal, treated with albendazole and praziquantel, and without recurrence after 6 years of follow-up. * Please address all correspondence to: Manuel Enrique Jiménez-Mejías, Servicio de Enfermedades Infecciosas, Hospital Virgen del Rocío, Avda. Manuel Siurot s/n, 41013 Sevilla, Spain. Accepted for publication 12 May 2000.
A 22-year-old farmer was admitted with a 1-month history of pain, swelling and visual impairment of the left eye. The general physical examination showed no abnormalities. The left eye showed proptosis without chemosis, an afferent pupillary defect, and inability to turn the eye inward, upward, and outward. Fundoscopic examination revealed a blurred optic disc, papilloedema, engorged retinal veins, and enlargement of the blind spot. Visual acuity of the left eye was decreased to 0.1. The right eye was normal. Haematological examination showed 7.2109/l white blood cells, 0.18109/l eosinophils, 5.1 1012/l erythrocytes, and 267109/l platelets. Erythrocyte sedimentation rate (ESR) was 3 mm. Transaminases, alkaline phosphatase, and bilirubin were normal. Chest X-ray and abdominal ultrasonography showed no hydatid cyst. Ocular ultrasonography of the left orbit showed a well-defined, unilocular, anechoic © 2000 Harcourt Publishers Ltd