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Breast abscess caused by Propionibacterium avidum following breast reduction surgery: case report and review of the literature
Journal of Infection (2005) 51, e253–e255
www.elsevierhealth.com/journals/jinf
CASE REPORT
Breast abscess caused by Propionibacterium avidum following breast reduction surgery: case report and review of the literature Stavroula Panageaa,*, John E. Corkilla, Martin J. Hershmanb, Chris M. Parryc a
Department of Medical Microbiology, Royal Liverpool University Hospital, Liverpool L7 8XW, UK Department of Surgery, Royal Liverpool University Hospital, Liverpool L7 8XW, UK c Department of Medical Microbiology and Genitourinary Medicine, University of Liverpool, Liverpool L69 3GA, UK b
Accepted 1 April 2005 Available online 23 May 2005
KEYWORDS Propionibacterium avidum; Breast abscess
Abstract Propionibacterium avidum was isolated from bilateral breast abscesses following breast reduction surgery. This report highlights the potential pathogenicity of the normal microbial flora following surgical interventions. Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Propionibacteria are Gram-positive, non-spore forming, anaerobic or microaerophilic bacilli that normally inhabit the human skin, conjunctiva, mouth, and occasionally the intestine.1 They are organisms of low pathogenicity and common contaminants of blood and body fluids cultures. Only a minority of clinical isolates are clinically significant; in one series 12% were considered clinically significant and Propionibacterium acnes was isolated eight times more frequently than other Propionibacterium species.2 However, pure cultures, isolation from normally sterile sites, a positive direct Gram-stain and a strong leucocyte * Corresponding author. Tel.: C44 151 706 4410; fax: C44 151 706 5849. E-mail address: [email protected] (S. Panagea).
reaction strengthen a possible disease association.1 We report the isolation of Propionibacterium avidum from bilateral breast abscesses that developed following breast reduction surgery.
Case report A 40-year-old woman was admitted to our hospital 3 weeks after a bilateral breast reduction. She complained of intermittent fever and severe pain in both breasts that had gradually become worse following her operation. On examination, the patient appeared flushed and systemically unwell. Her temperature was 37.2 8C, blood pressure 107/61 mmHg, and pulse rate 109 bpm regular. Both breasts were erythematous, hot, tender and indurated. The rest of her physical examination and her past medical history were unremarkable. Her
0163-4453/$30.00 Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2005.04.005
e254 WBC was 22.5!109/l with 18.8!109/l neutrophils and CRP 135. A small amount of purulent material was aspirated from the left breast and sent to the Microbiology laboratory for culture and the patient was commenced on intravenous flucloxacillin and benzyl penicillin. Ultrasound examination of the breasts showed oedema and inflammation but no drainable collection of pus. A few days later, however, 100 ml of pus was aspirated from the right breast. Gram-stain of both pus samples showed numerous polymorphs and small numbers of Gram-positive rods. Routine bacterial culture yielded heavy pure growth of P. avidum. Blood cultures were negative. The wounds continued to discharge pus for a further week, however, repeat ultrasound examination did not show any collection. Following 5 days of intravenous antibiotics the patient was treated with oral amoxicillin–clavulanic acid for 4 weeks and had a good response. The wounds were healing satisfactorily on follow up 4 weeks later.
Culture and identification Routine bacterial culture of the pus yielded a heavy pure growth of a non-sporing irregularly shaped Gram-positive rod. The organism grew only anaerobically and produced b-haemolytic colonies after 48 h incubation. It was catalase and esculin positive, nitrate and urea negative and was identified as P. avidum by the API Coryne system. Nucleotide sequencing of the 16S rRNA gene was performed using the two universal primers (5 0 to 3 0 ) UN12 (GAC TCC TAC GGG AGG CAG CAG) and UN15 (CTG ATC CGC GAT TAC TAG CGA TTC).3 Partial sequencing (c.1000bp) of the 16S rRNA gene of the organism showed 98% homology with P. avidum (GenBank AJ003055) and 98% homology with Propionibacterium propionicum (GenBank AJ003058). However, identification of the organism as P. propionicum was discounted on biochemical characteristics (P. propionicum is catalase and esculin negative, nitrate positive and non-haemolytic). Antibiotic susceptibility testing using the BSAC disc diffusion method showed the organism to be sensitive to penicillin, ampicillin, erythromycin, tetracycline and vancomycin and resistant to metronidazole.
Discussion Propionibacteria are frequently considered contaminants when isolated from clinical specimens, however, in this case the isolation of P. avidum
S. Panagea et al. was considered significant as the organism was the single organism isolated from the pus as a heavy pure growth and was also seen on the direct Gram-stain. It caused significant morbidity to our patient and necessitated hospital admission and prolonged course of antibiotics. The pathogenicity of Propionibacterium species is not fully understood. They possess immunostimulatory mechanisms including activation of complement, stimulation of lysosomal enzymes release from human neutrophils and production of serumindependent neutrophil chemotactic factors. Despite being skin inhabitants with low virulence potential under certain circumstances they may be involved in infections. Recognized predisposing conditions for Propionibacterium species infections are the presence of foreign bodies, immunosuppression, preceding surgery, trauma, malignancy and diabetes.2 P. avidum tends to reside in the pilosebaceous follicles of the more humid areas of the skin such as the axilla, groin and perianal area. The frequency of recovery of the organism from the axilla increases with age and is associated with the onset of puberty.4 There have been only four case reports of P. avidum infections including two cases of splenic abscess,5,6 a case of sarcoilitis and psoas abscess7 and a perianal abscess.8 Three of them were deep-seated infections following haematogenous spread after surgical intervention5–7 and the fourth was a community acquired subcutaneous tissue infection in a cirrhotic patient.8 Surgery was the predisposing condition in our patient. Proximity of the surgical wound to the axilla may have facilitated colonization of the wound postoperatively and subsequently the development of the abscess, or alternatively, the organism was introduced during surgery, probably in high numbers given its low pathogenic potential. Although P. avidum is an organism of low virulence and a rare pathogen it can cause severe infections particularly in association with surgery. To our knowledge, this is the first reported case of breast abscess caused by P. avidum.
References 1. Funke G, von Graevenitz A, Clarridge III JE, Bernard KA. Clinical microbiology of coryneform bacteria. Clin Microbiol Rev 1997;10:125–59. 2. Brook I, Frazier EH. Infections caused by Propionibacterium species. Rev Infect Dis 1991;13:819–22. 3. Mahenthiralingam E, Bischof J, Byrne SK, Radomski C, Davies JE, Ao-Gay Y, et al. DNA-based diagnostic approaches for identification of Burkholderia cepacia complex,
Breast abscess caused by Propionibacterium avidum Burkholderia vietnamiensis, Burkholderia multivorans, Burkholderia stabilis, and Burkholderia cepacia genomovars I and III. J Clin Microbiol 2000;38:3165–73. 4. Nordstrom NK, Noble WC. Colonization of the axilla by Propionibacterium avidum in relation to age. Appl Environ Microbiol 1984;47:1360–2. 5. Dunne Jr WM, Kurschenbaum HA, Deshur WR, Samter TG, Williams JE, Zabransky RJ. Propionibacterium avidum as the etiologic agent of splenic abscess. Diagn Microbiol Infect Dis 1986;5:87–92.
e255 6. Vohra A, Saiz E, Chan J, Castro J, Amaro R, Bar J. Splenic abscess caused by Propionibacterium avidum as a complication of cardiac catheterization. Clin Infect Dis 1998;26: 770–1. 7. Estoppey O, Rivier G, Blanc CH, Widmer F, Gallusser A, So AK. Propionibacterium avidum sarcoiliitis and osteomyelitis. Rev Rhum Engl Ed 1997;64:54–6. 8. Wang TK, Woo PC, Yuen KY. Perianal abscess caused by Propionibacterium avidum in a cirrhotic patient. New Microbiol 2002;25:239–42.
www.elsevierhealth.com/journals/jinf
CASE REPORT
Breast abscess caused by Propionibacterium avidum following breast reduction surgery: case report and review of the literature Stavroula Panageaa,*, John E. Corkilla, Martin J. Hershmanb, Chris M. Parryc a
Department of Medical Microbiology, Royal Liverpool University Hospital, Liverpool L7 8XW, UK Department of Surgery, Royal Liverpool University Hospital, Liverpool L7 8XW, UK c Department of Medical Microbiology and Genitourinary Medicine, University of Liverpool, Liverpool L69 3GA, UK b
Accepted 1 April 2005 Available online 23 May 2005
KEYWORDS Propionibacterium avidum; Breast abscess
Abstract Propionibacterium avidum was isolated from bilateral breast abscesses following breast reduction surgery. This report highlights the potential pathogenicity of the normal microbial flora following surgical interventions. Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Propionibacteria are Gram-positive, non-spore forming, anaerobic or microaerophilic bacilli that normally inhabit the human skin, conjunctiva, mouth, and occasionally the intestine.1 They are organisms of low pathogenicity and common contaminants of blood and body fluids cultures. Only a minority of clinical isolates are clinically significant; in one series 12% were considered clinically significant and Propionibacterium acnes was isolated eight times more frequently than other Propionibacterium species.2 However, pure cultures, isolation from normally sterile sites, a positive direct Gram-stain and a strong leucocyte * Corresponding author. Tel.: C44 151 706 4410; fax: C44 151 706 5849. E-mail address: [email protected] (S. Panagea).
reaction strengthen a possible disease association.1 We report the isolation of Propionibacterium avidum from bilateral breast abscesses that developed following breast reduction surgery.
Case report A 40-year-old woman was admitted to our hospital 3 weeks after a bilateral breast reduction. She complained of intermittent fever and severe pain in both breasts that had gradually become worse following her operation. On examination, the patient appeared flushed and systemically unwell. Her temperature was 37.2 8C, blood pressure 107/61 mmHg, and pulse rate 109 bpm regular. Both breasts were erythematous, hot, tender and indurated. The rest of her physical examination and her past medical history were unremarkable. Her
0163-4453/$30.00 Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2005.04.005
e254 WBC was 22.5!109/l with 18.8!109/l neutrophils and CRP 135. A small amount of purulent material was aspirated from the left breast and sent to the Microbiology laboratory for culture and the patient was commenced on intravenous flucloxacillin and benzyl penicillin. Ultrasound examination of the breasts showed oedema and inflammation but no drainable collection of pus. A few days later, however, 100 ml of pus was aspirated from the right breast. Gram-stain of both pus samples showed numerous polymorphs and small numbers of Gram-positive rods. Routine bacterial culture yielded heavy pure growth of P. avidum. Blood cultures were negative. The wounds continued to discharge pus for a further week, however, repeat ultrasound examination did not show any collection. Following 5 days of intravenous antibiotics the patient was treated with oral amoxicillin–clavulanic acid for 4 weeks and had a good response. The wounds were healing satisfactorily on follow up 4 weeks later.
Culture and identification Routine bacterial culture of the pus yielded a heavy pure growth of a non-sporing irregularly shaped Gram-positive rod. The organism grew only anaerobically and produced b-haemolytic colonies after 48 h incubation. It was catalase and esculin positive, nitrate and urea negative and was identified as P. avidum by the API Coryne system. Nucleotide sequencing of the 16S rRNA gene was performed using the two universal primers (5 0 to 3 0 ) UN12 (GAC TCC TAC GGG AGG CAG CAG) and UN15 (CTG ATC CGC GAT TAC TAG CGA TTC).3 Partial sequencing (c.1000bp) of the 16S rRNA gene of the organism showed 98% homology with P. avidum (GenBank AJ003055) and 98% homology with Propionibacterium propionicum (GenBank AJ003058). However, identification of the organism as P. propionicum was discounted on biochemical characteristics (P. propionicum is catalase and esculin negative, nitrate positive and non-haemolytic). Antibiotic susceptibility testing using the BSAC disc diffusion method showed the organism to be sensitive to penicillin, ampicillin, erythromycin, tetracycline and vancomycin and resistant to metronidazole.
Discussion Propionibacteria are frequently considered contaminants when isolated from clinical specimens, however, in this case the isolation of P. avidum
S. Panagea et al. was considered significant as the organism was the single organism isolated from the pus as a heavy pure growth and was also seen on the direct Gram-stain. It caused significant morbidity to our patient and necessitated hospital admission and prolonged course of antibiotics. The pathogenicity of Propionibacterium species is not fully understood. They possess immunostimulatory mechanisms including activation of complement, stimulation of lysosomal enzymes release from human neutrophils and production of serumindependent neutrophil chemotactic factors. Despite being skin inhabitants with low virulence potential under certain circumstances they may be involved in infections. Recognized predisposing conditions for Propionibacterium species infections are the presence of foreign bodies, immunosuppression, preceding surgery, trauma, malignancy and diabetes.2 P. avidum tends to reside in the pilosebaceous follicles of the more humid areas of the skin such as the axilla, groin and perianal area. The frequency of recovery of the organism from the axilla increases with age and is associated with the onset of puberty.4 There have been only four case reports of P. avidum infections including two cases of splenic abscess,5,6 a case of sarcoilitis and psoas abscess7 and a perianal abscess.8 Three of them were deep-seated infections following haematogenous spread after surgical intervention5–7 and the fourth was a community acquired subcutaneous tissue infection in a cirrhotic patient.8 Surgery was the predisposing condition in our patient. Proximity of the surgical wound to the axilla may have facilitated colonization of the wound postoperatively and subsequently the development of the abscess, or alternatively, the organism was introduced during surgery, probably in high numbers given its low pathogenic potential. Although P. avidum is an organism of low virulence and a rare pathogen it can cause severe infections particularly in association with surgery. To our knowledge, this is the first reported case of breast abscess caused by P. avidum.
References 1. Funke G, von Graevenitz A, Clarridge III JE, Bernard KA. Clinical microbiology of coryneform bacteria. Clin Microbiol Rev 1997;10:125–59. 2. Brook I, Frazier EH. Infections caused by Propionibacterium species. Rev Infect Dis 1991;13:819–22. 3. Mahenthiralingam E, Bischof J, Byrne SK, Radomski C, Davies JE, Ao-Gay Y, et al. DNA-based diagnostic approaches for identification of Burkholderia cepacia complex,
Breast abscess caused by Propionibacterium avidum Burkholderia vietnamiensis, Burkholderia multivorans, Burkholderia stabilis, and Burkholderia cepacia genomovars I and III. J Clin Microbiol 2000;38:3165–73. 4. Nordstrom NK, Noble WC. Colonization of the axilla by Propionibacterium avidum in relation to age. Appl Environ Microbiol 1984;47:1360–2. 5. Dunne Jr WM, Kurschenbaum HA, Deshur WR, Samter TG, Williams JE, Zabransky RJ. Propionibacterium avidum as the etiologic agent of splenic abscess. Diagn Microbiol Infect Dis 1986;5:87–92.
e255 6. Vohra A, Saiz E, Chan J, Castro J, Amaro R, Bar J. Splenic abscess caused by Propionibacterium avidum as a complication of cardiac catheterization. Clin Infect Dis 1998;26: 770–1. 7. Estoppey O, Rivier G, Blanc CH, Widmer F, Gallusser A, So AK. Propionibacterium avidum sarcoiliitis and osteomyelitis. Rev Rhum Engl Ed 1997;64:54–6. 8. Wang TK, Woo PC, Yuen KY. Perianal abscess caused by Propionibacterium avidum in a cirrhotic patient. New Microbiol 2002;25:239–42.