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Corynebacterium jeikeium infection in Trinidad
Journal
of Hospital
Infection
(1993) 24, 327-329
Letter
to the Editor
Sir, Corynebacferium
jeikeium
infection
in Trinidad
Since the first description of Corynebacterium jeikeium (JK) in 1976, by Hande et al.,’ there has been an increasing number of reports of infections caused by this organism, followed not infrequently by sepsis and, in several cases, death.2 The organism occurs as a normal commensal of the skin flora,3 but under appropriate conditions is an opportunistic pathogen in granulocytopenic hosts, * in patients with prosthetic devices4 as well as those having undergone cardiac surgery,‘t6 and bone marrow transplantation2s7 There is evidence that the organism may be transmitted by person-to-person contact, and this may be enhanced by antibiotic pressure which selects for these multiply resistant organisms thus leading to their overgrowth at the expense of other skin flora.3v7 We report here two cases of infection due to C. jeikeium which are the first to be described from Trinidad. The first case was a four-year-old boy with acute lymphoblastic leukaemia (ALL) for 2 years and on maintenance therapy with 6-mercaptopurine, methotrexate and co-trimoxazole, who was re-admitted to the paediatric ward in August 1991 for investigation of fever and bitemporal headache. During administration of intravenous antineoplastic chemotherapy (a vinca alkaloid) he sustained a chemical burn to his left forearm, which developed into a 3-4cm necrotic ulcer with surrounding soft tissue inflammation. Laboratory data showed Hbg = 8.0 g 1-l and a total white cell count (WBC) 1.7 x lo9 1-l with 28% polymorphs. Culture from flat, grey to white glistening the lesion grew very small, smooth, non-haemolytic l-2 mm diameter colonies on sheep blood agar after 48 h incubation in 5% CO, at 37°C. They were Gram-positive bacilli. Biochemically, the organism was non-reactive (Table I), multiply antibiotic resistant, identified as C. jeikeium and confirmed by the reference laboratory Caribbean Epidemiological Research Center (CAREC). The ulcer healed after surgical debridement and topical antibiotic therapy with novobiocin cream and intravenous vancomycin (10 mg Kg-’ 6 h- ‘). The second case was a six-year-old girl with a 3-year history of ALL who was re-admitted to the paediatric unit of the San Fernando General of high fever. She was Hospital in January 1991, for investigation ill-looking, febrile and had a few palpable cervical nodes. The cerebrospinal 0195%6701~93/OX0327+03
c
10X.0010
327
1993 The Hospital
infection
Soaety
Letter Table
I.
to the Editor
Biochemical characteristics of Corynebacterium jeikeium
Test of substrate Type of haemolysis Oxygen requirement Motility Growth on MacConkey Gram reaction Catalase Oxidase Urease Nitrate reduction Urea hydrolysis Indole production Citrate utilization Aesculin hydrolysis Methyl red Voges-Proskauer Gelatin hydrolysis Sugar fermentation: Glucose Maltose Xylose Lactose Sucrose ONPG hydrolysis
Result
agar
Non-haemolytic Aerobic Non-motile No growth Positive, coccobacilli + -
fluid was culture negative, but blood cultures taken from three different sites revealed Gram-positive bacilli identified as C. j&e&z, with similar characteristics as found in case 1. Laboratory investigation showed Hbg 9.8 g 1-l and total WBC of 0.8 X lo9 I-’ with 9% polymorphs. The patient was treated with vancomycin intravenously as described previously and her fever resolved on the third day of hospitalization. There was no obvious site of cutaneous infection and no apparent sequelae were seen at the time she was discharged fourteen days after admission. Corynebacterium jeikeium was identified on the basis of morphological characteristics, and the biochemical investigations given in Table I. Of the 20 antibiotics used in the sensitivity testing, the organism was sensitive to novobiocin, tetracycline and polymyxin (no vancomycin disc was available) and resistant to penicillin G, ampicillin, carbenicillin, piperacillin, co-amoxiclav, aztreonam, nalidixic acid, norfloxacin, cephalothin, cefaclor, streptomycin, gentamicin, neomycin, lincomycin, erythromycin, chloramphenicol and co-trimoxazole. There are no previous reports of isolation of this organism in Trinidad, but a number of reports describe the isolation of C. jeikeium from skin lesions.3 Stamm et ~1.’ described 32 bone marrow transplant patients, which included 11 with cutaneous infection, and a number of other studies link cutaneous infection with septicaemia.8,2 In many instances, however, no
Letter to the Editor
329
overt cutaneous pathology is described, whereas a number of studies have provided information on the occurrence, distribution and significance of these organisms.9~‘0 Because of the organism’s frequent multiple antibiotic resistance and the relatively high prevalence of immunocompromised patients which includes those with the acquired immune deficiency syndrome and haematological malignancies, the need for close microbiological surveillance of all granulocytopenic patients who present with febrile episodes cannot be over-emphasized. The diagnosis of true diphtheroid sepsis can be difficult because diphtheroids are common inhabitants of the skin and mucous membranes. However, when such organisms are isolated from blood or other body fluids in immunocompromised patients, as described above, whose situation suggests infection, a full microbiological characterization should be done. Most commonly isolated corynebacterium strains are sensitive to penicillin, cephalosporins and erythromycin as well as other antibiotics, but C. jeikeium is characteristically resistant to these antibiotics and others. F. A. Orrett J. M. Fosi-Mbantenkhu
Department
of Pathology and Microbiology, Eric Williams Medical Sciences Complex, Churchill Rosevelt Highway, Champs Fleurs, Trinidad, West Indies.
References I. Hande KR, Witebsky FG, Brown MS, et al. Sepsis with a new species of Corynebacterium, AN. Intern Med 1976; 85: 423-426. 2. Pearson TS, Braine HG, Rathbun HK. Corynebacterium sepsis in oncology patients: predisposing factors, diagnoses and treatment. JAM/l 1977; 238: 1737-I 740. 3. Dan M, Somer I, Knobel B, Gutman R. Cutaneous manifestations of infection with Corynebacterium group JK. Rev Infect Dis 1988; 10: 1204-I 207. 4. Riebel W, Frantz N, Adelstein D, Spagnuolo PJ. Corynebacterium JK: A cause of nosocomial device-related infection. Rev Infect Dis 1986; 8: 42-49. 5. Davis A, Binder MJ, Burrows JT, et al. Diphtheroid endocarditis after cardiopulmonary bypass surgery for the repair of cardiac valvular defects. Antimicrobial Agents Chemother 1963; 648-656. 6. Gronemeyer PS, Weissfeld AS, Sonnenwirth AC. Corynebacterium group JK bacterial infection in a patient with an epicardial pacemaker. AmJ Clin Patholl980; 74: 838-842. 7. Stamm WE, Tompkins LS, Wagner KF, Counts GW, Thomas ED, Myers JD. Infection due to corynebacterium species in marrow transplant patients. Ann Intern Med 1979; 91: 167-173. 8. Guarino MJ, Qazi R, Woll JE, Rubins J. Septicemia, rash and pulmonary infiltrates secondary to corynebacterium group JK infection. Am J Med 1987; 82: 132-134. 9. Quinn JP, Arnow PM, Weil D, Rosenbluth J. Outbreak of J.K. diphtheroid infections associated with environmental contamination. J Clin Micro&o1 1984; 19: 668-671. 10. Kingston ME, Mackay D. Skin clues in the diagnosis of life-threatening infections. Rev Znfect Dis 1986; 8: l-l 1.
of Hospital
Infection
(1993) 24, 327-329
Letter
to the Editor
Sir, Corynebacferium
jeikeium
infection
in Trinidad
Since the first description of Corynebacterium jeikeium (JK) in 1976, by Hande et al.,’ there has been an increasing number of reports of infections caused by this organism, followed not infrequently by sepsis and, in several cases, death.2 The organism occurs as a normal commensal of the skin flora,3 but under appropriate conditions is an opportunistic pathogen in granulocytopenic hosts, * in patients with prosthetic devices4 as well as those having undergone cardiac surgery,‘t6 and bone marrow transplantation2s7 There is evidence that the organism may be transmitted by person-to-person contact, and this may be enhanced by antibiotic pressure which selects for these multiply resistant organisms thus leading to their overgrowth at the expense of other skin flora.3v7 We report here two cases of infection due to C. jeikeium which are the first to be described from Trinidad. The first case was a four-year-old boy with acute lymphoblastic leukaemia (ALL) for 2 years and on maintenance therapy with 6-mercaptopurine, methotrexate and co-trimoxazole, who was re-admitted to the paediatric ward in August 1991 for investigation of fever and bitemporal headache. During administration of intravenous antineoplastic chemotherapy (a vinca alkaloid) he sustained a chemical burn to his left forearm, which developed into a 3-4cm necrotic ulcer with surrounding soft tissue inflammation. Laboratory data showed Hbg = 8.0 g 1-l and a total white cell count (WBC) 1.7 x lo9 1-l with 28% polymorphs. Culture from flat, grey to white glistening the lesion grew very small, smooth, non-haemolytic l-2 mm diameter colonies on sheep blood agar after 48 h incubation in 5% CO, at 37°C. They were Gram-positive bacilli. Biochemically, the organism was non-reactive (Table I), multiply antibiotic resistant, identified as C. jeikeium and confirmed by the reference laboratory Caribbean Epidemiological Research Center (CAREC). The ulcer healed after surgical debridement and topical antibiotic therapy with novobiocin cream and intravenous vancomycin (10 mg Kg-’ 6 h- ‘). The second case was a six-year-old girl with a 3-year history of ALL who was re-admitted to the paediatric unit of the San Fernando General of high fever. She was Hospital in January 1991, for investigation ill-looking, febrile and had a few palpable cervical nodes. The cerebrospinal 0195%6701~93/OX0327+03
c
10X.0010
327
1993 The Hospital
infection
Soaety
Letter Table
I.
to the Editor
Biochemical characteristics of Corynebacterium jeikeium
Test of substrate Type of haemolysis Oxygen requirement Motility Growth on MacConkey Gram reaction Catalase Oxidase Urease Nitrate reduction Urea hydrolysis Indole production Citrate utilization Aesculin hydrolysis Methyl red Voges-Proskauer Gelatin hydrolysis Sugar fermentation: Glucose Maltose Xylose Lactose Sucrose ONPG hydrolysis
Result
agar
Non-haemolytic Aerobic Non-motile No growth Positive, coccobacilli + -
fluid was culture negative, but blood cultures taken from three different sites revealed Gram-positive bacilli identified as C. j&e&z, with similar characteristics as found in case 1. Laboratory investigation showed Hbg 9.8 g 1-l and total WBC of 0.8 X lo9 I-’ with 9% polymorphs. The patient was treated with vancomycin intravenously as described previously and her fever resolved on the third day of hospitalization. There was no obvious site of cutaneous infection and no apparent sequelae were seen at the time she was discharged fourteen days after admission. Corynebacterium jeikeium was identified on the basis of morphological characteristics, and the biochemical investigations given in Table I. Of the 20 antibiotics used in the sensitivity testing, the organism was sensitive to novobiocin, tetracycline and polymyxin (no vancomycin disc was available) and resistant to penicillin G, ampicillin, carbenicillin, piperacillin, co-amoxiclav, aztreonam, nalidixic acid, norfloxacin, cephalothin, cefaclor, streptomycin, gentamicin, neomycin, lincomycin, erythromycin, chloramphenicol and co-trimoxazole. There are no previous reports of isolation of this organism in Trinidad, but a number of reports describe the isolation of C. jeikeium from skin lesions.3 Stamm et ~1.’ described 32 bone marrow transplant patients, which included 11 with cutaneous infection, and a number of other studies link cutaneous infection with septicaemia.8,2 In many instances, however, no
Letter to the Editor
329
overt cutaneous pathology is described, whereas a number of studies have provided information on the occurrence, distribution and significance of these organisms.9~‘0 Because of the organism’s frequent multiple antibiotic resistance and the relatively high prevalence of immunocompromised patients which includes those with the acquired immune deficiency syndrome and haematological malignancies, the need for close microbiological surveillance of all granulocytopenic patients who present with febrile episodes cannot be over-emphasized. The diagnosis of true diphtheroid sepsis can be difficult because diphtheroids are common inhabitants of the skin and mucous membranes. However, when such organisms are isolated from blood or other body fluids in immunocompromised patients, as described above, whose situation suggests infection, a full microbiological characterization should be done. Most commonly isolated corynebacterium strains are sensitive to penicillin, cephalosporins and erythromycin as well as other antibiotics, but C. jeikeium is characteristically resistant to these antibiotics and others. F. A. Orrett J. M. Fosi-Mbantenkhu
Department
of Pathology and Microbiology, Eric Williams Medical Sciences Complex, Churchill Rosevelt Highway, Champs Fleurs, Trinidad, West Indies.
References I. Hande KR, Witebsky FG, Brown MS, et al. Sepsis with a new species of Corynebacterium, AN. Intern Med 1976; 85: 423-426. 2. Pearson TS, Braine HG, Rathbun HK. Corynebacterium sepsis in oncology patients: predisposing factors, diagnoses and treatment. JAM/l 1977; 238: 1737-I 740. 3. Dan M, Somer I, Knobel B, Gutman R. Cutaneous manifestations of infection with Corynebacterium group JK. Rev Infect Dis 1988; 10: 1204-I 207. 4. Riebel W, Frantz N, Adelstein D, Spagnuolo PJ. Corynebacterium JK: A cause of nosocomial device-related infection. Rev Infect Dis 1986; 8: 42-49. 5. Davis A, Binder MJ, Burrows JT, et al. Diphtheroid endocarditis after cardiopulmonary bypass surgery for the repair of cardiac valvular defects. Antimicrobial Agents Chemother 1963; 648-656. 6. Gronemeyer PS, Weissfeld AS, Sonnenwirth AC. Corynebacterium group JK bacterial infection in a patient with an epicardial pacemaker. AmJ Clin Patholl980; 74: 838-842. 7. Stamm WE, Tompkins LS, Wagner KF, Counts GW, Thomas ED, Myers JD. Infection due to corynebacterium species in marrow transplant patients. Ann Intern Med 1979; 91: 167-173. 8. Guarino MJ, Qazi R, Woll JE, Rubins J. Septicemia, rash and pulmonary infiltrates secondary to corynebacterium group JK infection. Am J Med 1987; 82: 132-134. 9. Quinn JP, Arnow PM, Weil D, Rosenbluth J. Outbreak of J.K. diphtheroid infections associated with environmental contamination. J Clin Micro&o1 1984; 19: 668-671. 10. Kingston ME, Mackay D. Skin clues in the diagnosis of life-threatening infections. Rev Znfect Dis 1986; 8: l-l 1.