- Email: [email protected]
Case series of patients with Fusobacterium nucleatum bacteremia with emphasis on the presence of cancer
Anaerobe 39 (2016) 1e3
Contents lists available at ScienceDirect
Anaerobe journal homepage: www.elsevier.com/locate/anaerobe
Case series of patients with Fusobacterium nucleatum bacteremia with emphasis on the presence of cancer rard Erlangga Yusuf *, Ingrid Wybo, Denis Pie Department of Medical Microbiology and Infection Prevention, Universitair Ziekenhuis Brussel (University Hospital Brussels), Brussels, Belgium
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 November 2015 Received in revised form 25 January 2016 Accepted 2 February 2016 Available online 4 February 2016
Fusobacterium nucleatum is anaerobic oral microbiota that might be associated with cancer. We reported 22 consecutive cases of patients (mean age of 63.8 years (range 34e89), 59.1% male) with F. nucleatum bacteremia that were admitted to a university hospital over a 10-year period. In 17 (77.2%) of these patients, F. nucleatum was the sole possible pathogen. Seven of the 22 patients (31.8%) had active cancer: esophagus carcinoma (n ¼ 3), hematologic malignancies (n ¼ 1), gastrointestinal stromal tumor (n ¼ 1), melanoma (n ¼ 1), and breast cancer (n ¼ 1). In six out of seven patients (85.7%), the F. nucleatum was found within six months of the diagnosis of cancer. Four of seven (57.1%), patients with cancer were on chemotherapy. Three of 22 patients (13.4%) died within 1 month of F. nucleatum bacteremia due to cancer. In conclusion, F. nucleatum bacteremia occurs rarely and when it is found, it is often in patients with cancer, especially those with a recent diagnosis. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Fusobacterium nucleatum Anaerobes Bacteremia Epidemiology Cancer
1. Introduction Fusobacterium nucleatum is anaerobic Gram-negative rod that is considered as a member of the normal oral microbiota [1]. Occasionally, it can cause infections elsewhere in the body such as septic arthritis [2,3] and endocarditis [4]. Recently, it has been shown that F. nucleatum might also be associated with carcinoma [5,6]. Castellarin and co-workers found an over-representation of RNA of F. nucleatum in human colorectal carcinoma [5]. It has also been shown that an adhesion molecule of F. nucleatum, the so called FadA, can bind with E-cadherin resulting in activation of betacatenin that subsequently promotes colorectal carcinoma proliferation [6]. A limited number of epidemiological studies has been published on F. nucleatum bacteremia [7,8] and these studies showed an overrepresentation of cancer in patients with F. nucleatum bacteremia. However, since the aim of these studies was to describe the epidemiology of F. nucleatum bacteremia, no further information on the type of cancer can be found, nor whether the cancer was found before, during or after the finding of F. nucleatum in blood. Clearly, F. nucleatum might shed into the blood due to
* Corresponding author. Department of Microbiology and Infection Control, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, Belgium. E-mail address: [email protected] (E. Yusuf). http://dx.doi.org/10.1016/j.anaerobe.2016.02.001 1075-9964/© 2016 Elsevier Ltd. All rights reserved.
complication of cancer or cancer treatment such as oral mucositis [8] and the temporal relation between the diagnosis of cancer, its treatment, and the finding of F. nucleatum might be paramount. Therefore, the aim of this study is to report clinical and microbiological characteristics of patients with F. nucleatum bacteremia with emphasis on cancer characteristics. 2. Case series In a 10-year period (between October 1st, 2004 and September 30th, 2014), F. nucleatum bacteremia was found in 22 patients admitted to our hospital (Table 1). Patients were mostly male (59.1%) with the mean age of 63.8 years (range 34e89). The patients were admitted for various reasons, from infection to complication of carcinoma. F. nucleatum was found as the sole possible significant pathogen in 17 (77.2%) of the patients. Seven of 22 patients (31.8%) had active cancer: three had esophagus carcinoma, and four had other types of cancer: hematologic malignancies (n ¼ 1), gastrointestinal stromal tumor (n ¼ 1), melanoma (n ¼ 1), and breast cancer (n ¼ 1). Additionally, two patients had history of cancer that was considered at remission at the finding of F. nucleatum bacteremia: one with renal cell carcinoma and the other with Non-Hodgkin lymphoma, diagnosed 26 and 5 years prior to F. nucleatum bacteremia, respectively. In six out of seven patients (85.7%), F. nucleatum was found within six months of the diagnosis of cancer. Four of these five patients were on
2
E. Yusuf et al. / Anaerobe 39 (2016) 1e3
Table 1 Characteristics of patients with Fusobacterium nucleatum bacteremia. No. Age Clinical (y), diagnosis or sex reason for admission
Co-morbidities
Empirical/targeted Type of cancer Other organisms in antibiotic treatment blood culture at the moment of F. nucleatum bacteremia
Time of cancer diagnosis relative to F. nucleatum bacteremia
Cancer remission at the time F. nucleatum bacteremia
Chemotherapy at the time of F. nucleatum bacteremia
30-day Documented Outcome mucositis
1.
89, F
Cholangitis
Hypercholesterolemia
Renal cell carcinoma
5 years previous
Yes
No
e
Survive
2.
84, F
Cholangitis
None
e
e
e
e
Survive
Adult Still disease Pyelonephritis
Hypercholesterolemia, hypertension None
Amoxicillin/ Escherichia coli, Klebsiella clavulanic acid pneumoniae E. coli Amoxicillin/ clavulanic acid None
6 years previous e
No
e
Survive
None
Breast carcinoma None
No
None
Amoxicillin/ clavulanic acid Ciprofloxacin
e
e
e
Survive
Cholelithiasis
Chronic osteomyelitis None
None
e
e
e
e
Survive
Possible pneumonia Cellulitis arm
Alzheimer's disease
None
Ciprofloxacin and metronidazole None
None
e
e
e
e
Survive
None
None
None
None
e
e
e
e
Survive
Hypertension, SLE
Escherichia coli None
Unknown
None
e
e
e
e
Survive
Piperacillin/ tazobactam Streptococcus Amoxicillin/ anginosus clavulanic acid
Esophagus carcinoma Esophagus carcinoma
1 month previous 6 month previous
No
Yes
No
Survive
No
Yes
No
Survive
Klebsiella oxytoca
Amoxicillin/ clavulanic acid
None
e
e
e
e
Survive
None
Piperacillin/ tazobactam
None
e
e
e
e
Survive
None
Non Hodgkin lymphoma None
26 years previous e
Yes
No
e
Survive
e
e
e
Survive
None
e
e
e
e
Survive
None
e
e
e
e
Survive
4 months previous e
No
No
e
Died
e
e
e
Survive
2 months previous Gastrointestinal 3 months stromal tumor previous
No
Yes
No
Died
No
No
e
Survive
3.
40, F 4. 34, F 5. 70, F 6. 86, F 7. 61, F 8. 34, F 9. 69, F 10. 64, M
11. 83, M
12. 62, M 13. 63, M 14. 40, M 15. 74, M 16. 65, M 17. 66, M 18. 71, M 19. 44, M 20. 56, M
21. 88, M 22. 71, M
Respiratory distress Hematemesis
None
Hyperglycemia None due to corticosteroid therapy Cerebrovascular Diabetes mellitus type accident 2, COPD, hypertension, chronic renal failure. Complication of Diabetes mellitus type 2 diabetes mellitus type 2 Complication of Diabetes mellitus type liver abscess 2 Pneumonia None
None
Rhabdomyolisis Hypertension
None
Pneumonia
Fatty liver disease
None
Hematemesis
None
None
Amoxicillin/ clavulanic acid Amoxicillin/ clavulanic acid Amoxicillin/ clavulanic acid Amoxicillin/ clavulanic acid None
Complication of liver abscess Fever of unknown origin Complication of pancreatic resection surgery Pneumonia
None
None
Metronidazole
Esophagus carcinoma None
Sarcoidosis
None
Unknown
Melanoma
Diabetes mellitus
None
Piperacillin/ tazobactam
COPD
None
Piperacillin/ tazobactam and gentamicin Unknown
Fever of Hypercholesterolemia None unknown origin
None
e
e
e
e
Survive
Acute myeloid leukemia
1 month previous
No
Yes
No
Died
Abbreviations: COPD: chronic obstructive pulmonary disease, SLE: systemic lupus erythematosus.
chemotherapy when F. nucleatum was found in blood. Three of the 22 patients (13.4%) died within 1 month, all due to cancer. 3. Discussion This is the first case series on F. nucleatum bacteremia with the emphasis on the presence of cancer. F. nucleatum bacteremia is a rare finding. In a period of 10 years, we identified only 22 cases, i.e. incidence of 0.04% among all blood cultures in the same period. This finding is comparable with the published literature. A study performed at a tertiary-care hospital in the US identified 19
patients with Fusobacterium spp. in a period of 10 years [9]. Because of the rare occurrence, more studies are needed to investigate whether there is a link between F. nucelatum bacteremia and cancer in order to be able to perform a systematic review or a metaanalysis. Pooling evidence on the link between bacteremia and cancer has been performed before, for example in a meta-analysis on the association between colorectal carcinoma and S. bovis infection [10]. To the best of our knowledge, at this moment, only a limited number of epidemiological studies have been published on F. nucleatum bacteremia. A report from Taiwan, showed that 26 out of 57 patients (45.6%) with F. nucleatum bacteremia had cancer,
E. Yusuf et al. / Anaerobe 39 (2016) 1e3
mainly oropharyngeal and gastrointestinal [7]. In the present case series, F. nucleatum bacteremia was often found within 6 months of the cancer diagnosis. This might imply that when F. nucleatum in blood culture is found in a patient, the clinician should be aware of the possibility of cancer. It is possible that F. nucleatum find its way to the blood stream due to the cancer itself, for example from cancer of oropharyngeal region. In the present study, there were three patients with esophagus cancer, two of them had hematemesis. It is also possible that F. nucleatum is shed into the blood due to complication of cancer treatment, such as mucositis as shown in a study by Candoni and co-workers [8]. In our study almost the half of the patients were treated with chemotherapy when F. nucleatum was found in blood, but no documented mucositis was found. In the present case series, no patient with colorectal carcinoma was found that might support the evidence on the link between F. nucleatum bacteremia and colon carcinoma in fundamental research [5,6]. Like in published studies, we found F. nucleatum bacteremia occurs in middle aged patients. A study in the US and the other in Taiwan reported the mean age of 58.6 years [9] and 58.1 years [11], respectively. The reported mortality among patients with F. nucleatum bacteremia varies according to the studies. In our study, the mortality of 13.6% is in line with the mortality found in an 11-year retrospective study from Canada where death occurred in 10% of patients with F. nucleatum bacteremia [12]. Yet, in another study, high 30-day mortality rate of 47.4% was reported [7]. In conclusion, F. nucleatum bacteremia occurs rarely. When it is found, it is often in patients with cancer, especially in those with a recent diagnosis.
Funding This study is performed as part of our routine work. No additional funding is involved.
Conflict of interests None.
3
Acknowledgment We thank Mr. A. van Zeebroeck and Mr. J. Bouasse for their assistance with the data management.
References [1] Y.W. Han, Fusobacterium nucleatum: a commensal-turned pathogen, Curr. Opin. Microbiol. 23C (2015) 141e147, http://dx.doi.org/10.1016/j.mib.2014.11.013. [2] A.M. Chryssagi, C.B. Brusselmans, J.J. Rombouts, Septic arthritis of the hip due to Fusobacterium nucleatum, Clin. Rheumatol. 20 (2001) 229e231. http:// www.ncbi.nlm.nih.gov/pubmed/11434480. [3] E. Kroon, N.A. Arents, F.J. Halbertsma, Septic arthritis and osteomyelitis in a 10-year-old boy, caused by Fusobacterium nucleatum, diagnosed with PCR/ 16S ribosomal bacterial DNA amplification, BMJ Case Rep. 2012 (2012), http:// dx.doi.org/10.1136/bcr.12.2011.5335. [4] N.W. Shammas, G.W. Murphy, J. Eichelberger, D. Klee, R. Schwartz, W. Bachman, Infective endocarditis due to Fusobacterium nucleatum: case report and review of the literature, Clin. Cardiol. 16 (1993) 72e75. http:// www.ncbi.nlm.nih.gov/pubmed/8416766. [5] M. Castellarin, R.L. Warren, J.D. Freeman, L. Dreolini, M. Krzywinski, J. Strauss, et al., Fusobacterium nucleatum infection is prevalent in human colorectal carcinoma, Genome Res. 22 (2012) 299e306, http://dx.doi.org/10.1101/ gr.126516.111. [6] M.R. Rubinstein, X. Wang, W. Liu, Y. Hao, G. Cai, Y.W. Han, Fusobacterium nucleatum promotes colorectal carcinogenesis by modulating E-cadherin/bcatenin signaling via its FadA adhesin, Cell Host Microbe 14 (2013) 195e206, http://dx.doi.org/10.1016/j.chom.2013.07.012. [7] C.-C. Yang, J.-J. Ye, P.-C. Hsu, H.-J. Chang, C.-W. Cheng, H.-S. Leu, et al., Characteristics and outcomes of Fusobacterium nucleatum bacteremiaea 6-year experience at a tertiary care hospital in northern Taiwan, Diagn. Microbiol. Infect. Dis. 70 (2011) 167e174, http://dx.doi.org/10.1016/j.diagmicrobio.2010.12.017. [8] A. Candoni, C. Filì, R. Trevisan, F. Silvestri, R. Fanin, Fusobacterium nucleatum: a rare cause of bacteremia in neutropenic patients with leukemia and lymphoma, Clin. Microbiol. Infect. 9 (2003) 1112e1115, http://dx.doi.org/ 10.1046/j.1469-0691.2003.00717.x. [9] E.A. Goldberg, T. Venkat-Ramani, M. Hewit, H.F. Bonilla, Epidemiology and clinical outcomes of patients with Fusobacterium bacteraemia, Epidemiol. Infect. 141 (2013) 325e329, http://dx.doi.org/10.1017/S0950268812000660. [10] A. Boleij, M.M.H.J. van Gelder, D.W. Swinkels, H. Tjalsma, Clinical Importance of Streptococcus gallolyticus infection among colorectal cancer patients: systematic review and meta-analysis, Clin. Infect. Dis. 53 (2011) 870e878, http://dx.doi.org/10.1093/cid/cir609. [11] C.P. Su, P.Y. Huang, C.C. Yang, M.H. Lee, Fusobacterium bacteremia: clinical significance and outcomes, J. Microbiol. Immunol. Infect. 42 (2009) 336e342. http://www.ncbi.nlm.nih.gov/pubmed/19949758. [12] K. Afra, K. Laupland, J. Leal, T. Lloyd, D. Gregson, Incidence, risk factors, and outcomes of Fusobacterium species bacteremia, BMC Infect. Dis. 13 (2013) 264, http://dx.doi.org/10.1186/1471-2334-13-264.
Contents lists available at ScienceDirect
Anaerobe journal homepage: www.elsevier.com/locate/anaerobe
Case series of patients with Fusobacterium nucleatum bacteremia with emphasis on the presence of cancer rard Erlangga Yusuf *, Ingrid Wybo, Denis Pie Department of Medical Microbiology and Infection Prevention, Universitair Ziekenhuis Brussel (University Hospital Brussels), Brussels, Belgium
a r t i c l e i n f o
a b s t r a c t
Article history: Received 27 November 2015 Received in revised form 25 January 2016 Accepted 2 February 2016 Available online 4 February 2016
Fusobacterium nucleatum is anaerobic oral microbiota that might be associated with cancer. We reported 22 consecutive cases of patients (mean age of 63.8 years (range 34e89), 59.1% male) with F. nucleatum bacteremia that were admitted to a university hospital over a 10-year period. In 17 (77.2%) of these patients, F. nucleatum was the sole possible pathogen. Seven of the 22 patients (31.8%) had active cancer: esophagus carcinoma (n ¼ 3), hematologic malignancies (n ¼ 1), gastrointestinal stromal tumor (n ¼ 1), melanoma (n ¼ 1), and breast cancer (n ¼ 1). In six out of seven patients (85.7%), the F. nucleatum was found within six months of the diagnosis of cancer. Four of seven (57.1%), patients with cancer were on chemotherapy. Three of 22 patients (13.4%) died within 1 month of F. nucleatum bacteremia due to cancer. In conclusion, F. nucleatum bacteremia occurs rarely and when it is found, it is often in patients with cancer, especially those with a recent diagnosis. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Fusobacterium nucleatum Anaerobes Bacteremia Epidemiology Cancer
1. Introduction Fusobacterium nucleatum is anaerobic Gram-negative rod that is considered as a member of the normal oral microbiota [1]. Occasionally, it can cause infections elsewhere in the body such as septic arthritis [2,3] and endocarditis [4]. Recently, it has been shown that F. nucleatum might also be associated with carcinoma [5,6]. Castellarin and co-workers found an over-representation of RNA of F. nucleatum in human colorectal carcinoma [5]. It has also been shown that an adhesion molecule of F. nucleatum, the so called FadA, can bind with E-cadherin resulting in activation of betacatenin that subsequently promotes colorectal carcinoma proliferation [6]. A limited number of epidemiological studies has been published on F. nucleatum bacteremia [7,8] and these studies showed an overrepresentation of cancer in patients with F. nucleatum bacteremia. However, since the aim of these studies was to describe the epidemiology of F. nucleatum bacteremia, no further information on the type of cancer can be found, nor whether the cancer was found before, during or after the finding of F. nucleatum in blood. Clearly, F. nucleatum might shed into the blood due to
* Corresponding author. Department of Microbiology and Infection Control, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, Belgium. E-mail address: [email protected] (E. Yusuf). http://dx.doi.org/10.1016/j.anaerobe.2016.02.001 1075-9964/© 2016 Elsevier Ltd. All rights reserved.
complication of cancer or cancer treatment such as oral mucositis [8] and the temporal relation between the diagnosis of cancer, its treatment, and the finding of F. nucleatum might be paramount. Therefore, the aim of this study is to report clinical and microbiological characteristics of patients with F. nucleatum bacteremia with emphasis on cancer characteristics. 2. Case series In a 10-year period (between October 1st, 2004 and September 30th, 2014), F. nucleatum bacteremia was found in 22 patients admitted to our hospital (Table 1). Patients were mostly male (59.1%) with the mean age of 63.8 years (range 34e89). The patients were admitted for various reasons, from infection to complication of carcinoma. F. nucleatum was found as the sole possible significant pathogen in 17 (77.2%) of the patients. Seven of 22 patients (31.8%) had active cancer: three had esophagus carcinoma, and four had other types of cancer: hematologic malignancies (n ¼ 1), gastrointestinal stromal tumor (n ¼ 1), melanoma (n ¼ 1), and breast cancer (n ¼ 1). Additionally, two patients had history of cancer that was considered at remission at the finding of F. nucleatum bacteremia: one with renal cell carcinoma and the other with Non-Hodgkin lymphoma, diagnosed 26 and 5 years prior to F. nucleatum bacteremia, respectively. In six out of seven patients (85.7%), F. nucleatum was found within six months of the diagnosis of cancer. Four of these five patients were on
2
E. Yusuf et al. / Anaerobe 39 (2016) 1e3
Table 1 Characteristics of patients with Fusobacterium nucleatum bacteremia. No. Age Clinical (y), diagnosis or sex reason for admission
Co-morbidities
Empirical/targeted Type of cancer Other organisms in antibiotic treatment blood culture at the moment of F. nucleatum bacteremia
Time of cancer diagnosis relative to F. nucleatum bacteremia
Cancer remission at the time F. nucleatum bacteremia
Chemotherapy at the time of F. nucleatum bacteremia
30-day Documented Outcome mucositis
1.
89, F
Cholangitis
Hypercholesterolemia
Renal cell carcinoma
5 years previous
Yes
No
e
Survive
2.
84, F
Cholangitis
None
e
e
e
e
Survive
Adult Still disease Pyelonephritis
Hypercholesterolemia, hypertension None
Amoxicillin/ Escherichia coli, Klebsiella clavulanic acid pneumoniae E. coli Amoxicillin/ clavulanic acid None
6 years previous e
No
e
Survive
None
Breast carcinoma None
No
None
Amoxicillin/ clavulanic acid Ciprofloxacin
e
e
e
Survive
Cholelithiasis
Chronic osteomyelitis None
None
e
e
e
e
Survive
Possible pneumonia Cellulitis arm
Alzheimer's disease
None
Ciprofloxacin and metronidazole None
None
e
e
e
e
Survive
None
None
None
None
e
e
e
e
Survive
Hypertension, SLE
Escherichia coli None
Unknown
None
e
e
e
e
Survive
Piperacillin/ tazobactam Streptococcus Amoxicillin/ anginosus clavulanic acid
Esophagus carcinoma Esophagus carcinoma
1 month previous 6 month previous
No
Yes
No
Survive
No
Yes
No
Survive
Klebsiella oxytoca
Amoxicillin/ clavulanic acid
None
e
e
e
e
Survive
None
Piperacillin/ tazobactam
None
e
e
e
e
Survive
None
Non Hodgkin lymphoma None
26 years previous e
Yes
No
e
Survive
e
e
e
Survive
None
e
e
e
e
Survive
None
e
e
e
e
Survive
4 months previous e
No
No
e
Died
e
e
e
Survive
2 months previous Gastrointestinal 3 months stromal tumor previous
No
Yes
No
Died
No
No
e
Survive
3.
40, F 4. 34, F 5. 70, F 6. 86, F 7. 61, F 8. 34, F 9. 69, F 10. 64, M
11. 83, M
12. 62, M 13. 63, M 14. 40, M 15. 74, M 16. 65, M 17. 66, M 18. 71, M 19. 44, M 20. 56, M
21. 88, M 22. 71, M
Respiratory distress Hematemesis
None
Hyperglycemia None due to corticosteroid therapy Cerebrovascular Diabetes mellitus type accident 2, COPD, hypertension, chronic renal failure. Complication of Diabetes mellitus type 2 diabetes mellitus type 2 Complication of Diabetes mellitus type liver abscess 2 Pneumonia None
None
Rhabdomyolisis Hypertension
None
Pneumonia
Fatty liver disease
None
Hematemesis
None
None
Amoxicillin/ clavulanic acid Amoxicillin/ clavulanic acid Amoxicillin/ clavulanic acid Amoxicillin/ clavulanic acid None
Complication of liver abscess Fever of unknown origin Complication of pancreatic resection surgery Pneumonia
None
None
Metronidazole
Esophagus carcinoma None
Sarcoidosis
None
Unknown
Melanoma
Diabetes mellitus
None
Piperacillin/ tazobactam
COPD
None
Piperacillin/ tazobactam and gentamicin Unknown
Fever of Hypercholesterolemia None unknown origin
None
e
e
e
e
Survive
Acute myeloid leukemia
1 month previous
No
Yes
No
Died
Abbreviations: COPD: chronic obstructive pulmonary disease, SLE: systemic lupus erythematosus.
chemotherapy when F. nucleatum was found in blood. Three of the 22 patients (13.4%) died within 1 month, all due to cancer. 3. Discussion This is the first case series on F. nucleatum bacteremia with the emphasis on the presence of cancer. F. nucleatum bacteremia is a rare finding. In a period of 10 years, we identified only 22 cases, i.e. incidence of 0.04% among all blood cultures in the same period. This finding is comparable with the published literature. A study performed at a tertiary-care hospital in the US identified 19
patients with Fusobacterium spp. in a period of 10 years [9]. Because of the rare occurrence, more studies are needed to investigate whether there is a link between F. nucelatum bacteremia and cancer in order to be able to perform a systematic review or a metaanalysis. Pooling evidence on the link between bacteremia and cancer has been performed before, for example in a meta-analysis on the association between colorectal carcinoma and S. bovis infection [10]. To the best of our knowledge, at this moment, only a limited number of epidemiological studies have been published on F. nucleatum bacteremia. A report from Taiwan, showed that 26 out of 57 patients (45.6%) with F. nucleatum bacteremia had cancer,
E. Yusuf et al. / Anaerobe 39 (2016) 1e3
mainly oropharyngeal and gastrointestinal [7]. In the present case series, F. nucleatum bacteremia was often found within 6 months of the cancer diagnosis. This might imply that when F. nucleatum in blood culture is found in a patient, the clinician should be aware of the possibility of cancer. It is possible that F. nucleatum find its way to the blood stream due to the cancer itself, for example from cancer of oropharyngeal region. In the present study, there were three patients with esophagus cancer, two of them had hematemesis. It is also possible that F. nucleatum is shed into the blood due to complication of cancer treatment, such as mucositis as shown in a study by Candoni and co-workers [8]. In our study almost the half of the patients were treated with chemotherapy when F. nucleatum was found in blood, but no documented mucositis was found. In the present case series, no patient with colorectal carcinoma was found that might support the evidence on the link between F. nucleatum bacteremia and colon carcinoma in fundamental research [5,6]. Like in published studies, we found F. nucleatum bacteremia occurs in middle aged patients. A study in the US and the other in Taiwan reported the mean age of 58.6 years [9] and 58.1 years [11], respectively. The reported mortality among patients with F. nucleatum bacteremia varies according to the studies. In our study, the mortality of 13.6% is in line with the mortality found in an 11-year retrospective study from Canada where death occurred in 10% of patients with F. nucleatum bacteremia [12]. Yet, in another study, high 30-day mortality rate of 47.4% was reported [7]. In conclusion, F. nucleatum bacteremia occurs rarely. When it is found, it is often in patients with cancer, especially in those with a recent diagnosis.
Funding This study is performed as part of our routine work. No additional funding is involved.
Conflict of interests None.
3
Acknowledgment We thank Mr. A. van Zeebroeck and Mr. J. Bouasse for their assistance with the data management.
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