Human infections with Actinomyces pyogenes (Corynebacterium pyogenes)

349

DIAGN MICROBIOLINFECTDIS 1992;15:349-354

H u m a n Infections with

Actinomyces

pyogenes ( Corynebacterium pyogenes) Bente Gahrn-Hansen and Wilhelm Frederiksen

Actinomyces pyogenes (Corynebacterium pyogenes), a well-known pathogen in many animals, was isolated from 11 Danish patients since 1968. Bacteriologic characteristics and clinical pictures of the patients are described. Ability to hydrolyze gelatine, to produce AS-glucuronidase, to reach with antisera against group-G streptococci, and to produce acid from

xylose differentiates A. pyogenes from Arcanobacterium haemolyticum, with which it has at times been confused. Actinomyces pyogenes is an established, but often misrecognized, human pathogen that should be better known to clinical microbiologists.

INTRODUCTION

pyema, and pneumonia (Ballard et al., 1947; Chlosta et al., 1970; Jootar et al., 1978; Lipton and Isalska, 1983; Norenberg et al., 1978; Vega and Gavan, 1970). Some of the earlier reports on infections with A. pyogenes lack sufficient microbiologic data to ensure a definitive distinction of A. pyogenes from A. haemolyticum, a species known to cause infection only in humans. We here review the literature on h u m a n infections with A. pyogenes with special reference to the distinction from A. haemolyticum and describe the clinical pictures and bacteriologic findings of 11 Danish patients with infections with A. pyogenes.

In recent years, corynebacteria other than Corynebacterium diptheriae have emerged as important pathogens. Several species produce well-defined clinical syndromes such as sore throat (Corynebacterium ulcerans and Arcanobacterium haemolyticum ), pneumonitis (Corynebacterium equi), endocarditis and septicemia in granulocytopenic patients (Corynebacterium jeikeium) (Lipsky et al., 1982), and encrusted cystitis (CDC group D2) (Soriano et al., 1985). Recently, Coyle and Lipsky (1990) presented a comprehensive review on the subject. Actinomyces pyogenes at times seems to have been confounded with A. haemolyticum, formerly known as C. haemolyticum, but reclassified by Collins et al. (1982). Corynebacterium pyogenes, transferred to the genus Actinomyces as A. pyogenes in 1982 (Reddy et al., 1982), causes a variety of infections in sheep, pigs, and cattle (Smith, 1966; S6rensen, 1974), but has only rarely been implicated with h u m a n infections. The few cases reported in humans include septicemias, endocarditis, meningitis, arthritis, emFrom the Department of ClinicalMicrobiology(B.G.-H.), Odense UniversityHospital, Odense; and the Department of Diagnostic Bacteriology(W.F.), Statens Seruminstitut, Copenhagen, Denmark. Address reprint requests to Dr. B. Gahrn-Hansen, Department of ClinicalMicrobiology,Odense UniversityHospital, J.B. Winsl6wsvej 19,2, DK-5000Odense C, Denmark. Received 28 March 1991; revision accepted 25 July 1991. © 1992 ElsevierScience PublishingCo., Inc. 655 Avenue of the Americas, New York, NY 10010 0732-8893/92/$5.00

MATERIALS A N D M E T H O D S Patients and Bacterial Strains Infections with A. pyogenes have been registered in 11 Danish patients since 1968. Data on these patients were collected retrospectively from the clinical records. Ten of the strains were isolated from patients in Northern Jutland, whereas the last strain was found in a patient from Funen. Eight of the strains had been lyophilized and constitute the field strains included in this study. Three strains were not available. The origin of the patient strains are seen in Table 1 (patients 1-11). The type strain NCTC 5224 (ATCC 19411, porcine isolate) and two other reference strains, NCTC 6448 (ATCC 8104, bovine isolate) and NCTC 6451 (ATCC 8108, porcine isolate), were also included.

350

B. Gahrn-Hansen and W. Frederiksen

TABLE 1 Data of 11 Cases of H u m a n Infections with Actinomyces pyogenes Patient No.

Age/Sex (yr)

Type of Infection

Predisposing Conditions

1 2

42 48

F F

Abdominal abscess Otitis media

Cervical carcinoma Cholesteatoma

3

64

M

Cystitis

Prostatic carcinoma, urinary catheter

4

22

M

5

48

M

Superficial abscess in abdomen Mastoiditis Septicemia

Appendectomia 3 yr earlier Cholesteatoma

6 7 8 9 10

68 78 15 78 15

M F M M M

Sigmoiditis, cystitis Superficial abscess Appendicitis Cholecystitis Appendicitis, peritonitis

Diverticulitis None known None known Cholelithiasis None known

11

57

F

Otitis media

Cholesteatoma

Clinical Outcome

Culture

Treatment

Actinomycespyogenes Actinomycespyogenes, Pseudomonas species, Klebsiella species Actinomyces pyogenes, Proteus mirabilis, anaerobic Gramneg. rods Actinomycespyogenes

Surgery, Su, C Surgery, P

Cure Cure

No treatment

Death

Surgery, P, S

Cure

Surgery, A

Cure

P No treatment Surgery, P Surgery Surgery, A

Cure Cure Cure Cure Cure

Surgery, A

Cure

Actinomycespyogenes, Proteus mirabilis, Actinomyces pyogenes Actinomyces pyogenes Actinomyces pyogenes Actinomyces pyogenes Actinomyces pyogenes Actinomyces pyogenes Escherichia coli, streptococci, anaerobic Gramnegative rods Actinomycespyogenes

F, female;M, male; Su, sulphonamides;P, penicillin;C, chloramphenicol;and A, ampicillin.

Morphology and Growth Agar plates containing 5% horse blood were used as standard medium. The plates were incubated in an aerobic atmosphere containing 5% CO2 at 35°C for 18-48 hr, and the presence of hemolysis was recorded. Microscopic appearance was determined from Gram-stained smears. Motility was evaluated microscopically in serum-supplemented broth after overnight incubation.

Biochemical Tests The production of acid from carbohydrates and hydrolysis of starch was tested in serum-supplemented peptone water with 1% carbohydrate and phenol red as indicator (Hiss media) and incubated at 35°C for 7 days. The following carbohydrates were included: xylose, glucose, sucrose, maltose, lactose, and mannitol. Only tubes showing a bright yellow within 7 days were recorded as positive. Tests for ability to reduce nitrate to nitrite, liquefaction of gelatin, and production of catalase and urease were done as described by Lautrop et al. (1979). Production of [3glucuronidase (PGUA test) was detected by the method of Kilian and B~low (1976). Esculin hydrol-

ysis was tested on agar slants with 0.1% esculin and 0.05% ferric citrate. Ability to produce soluble hemolysin was tested by incubating ten drops of an overnight tryptone broth culture together with ten drops of a 10% saline suspension of washed horse erythrocytes for 1 hr at 35°C. After centrifugation for 2 min at 3000 rpm, a positive result was indicated by complete lysis of the erythrocytes. Interaction with [3-hemolysin of Staphylococcus aureus was tested on double-layer agar plates with heart infusion agar covered with a top layer of 5% sheep blood agar incubated at 35°C in aerobic atmosphere containing 5% CO2. The test was performed as a CAMP test (Christie et al., 1944), and triangular inhibition of [3hemolysis at the conjunction site was recorded as "anti-CAMP" reaction.

Antibiotic Susceptibility The eight strains available were tested for susceptibility to penicillin, ampicillin, carbenicillin, piperacillin, cephalothin, cefuroxime, cefotaxime, erythromycin, tetracycline, chloramphenicol, amikacin, gentamicin, netilmicin, streptomycin, tobramycin, trimethoprim, and ciprofloxacin by a direct agar diffusion test, with Neo-sensitabs (Rosco A/S, Taas-

351

Case Report

trup, Denmark) according to the antibiotic tablets and semiconfluent growth on Danish blood agar (Statens Seruminstitut, Copenhagen) using a breakpoint system (Casals, 1983).

RESULTS Patients and Infections Patient 5 (Table 1), a 48-year-old man, had a 30-year history of chronic bilateral suppurative otitis media. He was admitted to the otologic department because of ear pain, headache, nausea, dizziness, malaise, and fever. Physical examination showed a temperature of 39°C, a purulent left otitis, and a purulent sinusitis of the left sinus maxillaris. Laboratory investigations revealed a white blood cell count of 13,700/mm 3 with 83% neutrophils and 5% band forms, and an erythrocyte sedimentation rate of 87 mm/hr. Blood cultures were obtained and the left processus mastoideus was explored. Ear swab, aspirated pus from the mastoid, and blood cultures yielded growth of A. pyogenes sensitive to penicillin, ampicillin, tetracycline, erythromycin, and streptomycin. Treatment with I g of ampicillin intravenously every 8 hr was started, and the fever subsided within few days. After 14 days, the treatment was stopped and the patient was discharged afebrile, but still suffering from bilateral otorrhea. The case stories of most of the other patients were less remarkable and the conditions not as severe. Four patients had mixed infections, but in the others A. pyogenes was found in pure culture. It can therefore be assumed to have played a causal role in the pathologic condition. One patient (no. 3, Table 1) died from his primary disease, whereas the others recovered on surgery and/or antibiotic treatment. Patient 6 (Table 1) had a long-lasting disease with A. pyogenes isolated from a number of sites, including the intestine. He also finally recovered from his infection.

Bacteriology After overnight incubation, all strains characteristically formed weakly hemolytic pinpoint colonies on 5% horse blood agar. After incubation for 48 hr, the colonies were - 1 mm in diameter, whitish, and with clear zones of ~-hemolysis. A constant finding after 48 hr incubation was a slight corrosion of the agar seen when the colony was removed. On microscopic examination, the organisms were nonmotile, Grampositive pleomorphic rods, but coccal forms were also seen. The biochemical reactions of the eight h u m a n strains and three reference strains are summarized

in Table 2. For comparison, the reactions of A. haemolyticum are included. The data of these strains derive from Fell et al. (1977), L/immler and B16bel (1988), and from our own experience in the Department of Diagnostic Bacteriology. The A. pyogenes strains were all catalase negative, as were the A. haemolyticum strains. They acidified several carbohydrates, but not mannitol. All of the A. pyogenes, but none of the A. haemolyticum strains, produced acid from xylose. Strains of A. pyogenes rapidly liquefied gelatin (within 48 hr) and uniformly produced ~-glucuronidase. None of the strains of A. haemolyticum examined did so. Actinomyces pyogenes neither showed a CAMP reaction nor the "anti-CAMP" reaction typical of A. haemolyticum. All 11 strains of A. pyogenes were capable of producing soluble hemolysin and reacted with antisera against group-G streptococci (J. Henrichsen, personnel communication). All A. pyogenes strains were resistant to trimethoprim. Apart from one h u m a n strain that was also resistant to streptomycin and erythromycin, strains were uniformly susceptible to the other antibiotics examined.

DISCUSSION Human infections with A. pyogenes are uncommon, and the microorganism has hitherto primarily been considered a zoonotic pathogen (Smith, 1966; S¢~rensen, 1974). Actinomyces pyogenes has not been described as part of the normal h u m a n flora (Lipsky et al., 1982), in contrast to the situation in many animals, where it is a part of the normal flora. Vega and Gavan (1970) reviewed the literature on human infections with A. pyogenes until 1970 and reported on 36 published cases. The validity of the diagnosis in some of these cases has later been questioned, as the reports lack sufficient microbiologic data to ensure a definite distinction from A. haemolyticum. The first case was described in 1940 by Forgeot et al. (1940). The organism was isolated from several abscesses in a shepherd who died from the infection. The strain rapidly liquefied gelatin and fermented various carbohydrates. This may well have been a strain of A. pyogenes. Ballard et al. (1947) reported on a case of septicemia occurring in a 37year-old man with a gangrenous foot. The description of the organism, however, suggests that it may instead have been a strain of A. haemolyticum, as in the case report (empyema) by Chlosta et al. (1970). The colonial appearance and the inability of the organism to liquefy gelatin show that it was probably a strain of A. haemolyticum as described by Jobanputra and Swain (1975). Also, the case of pneumonitis reported by Vega and Gavan (1970) could have

352

TABLE 2

B. G a h r n - H a n s e n a n d W. F r e d e r i k s e n

Biochemical Characteristics of Three Reference Strains a n d Eight H u m a n Isolates of Actinomyces pyogenes a Actinomyces pyogenes

Reference Strains n = 3

Human Strains n = 8c

Arcanobacterium haemolyticum b

Hemolysis on 5% horse blood Motility at 35°C Nitrate reduction Catalase production Production of ~-glucuronidase

3/3" 0/3 0/3 0/3 3/3

8/8 0/8 0/8 0/8 8/8

+ 0 0 0 0e

Hydrolysis of Urea Esculin Starch Gelatine

0/3 0/3 3/3 3/3

0/8 0/8 8/8 8/8

0 NI + 0

Acid from Xylose Glucose Sucrose Maltose Lactose Mannitol

3/3 3/3 2/3 3/3 3/3 0/3

8/8 8/8 5/8 8/8 8/8 0/8

0 + 0 + + 0

Anti-CAMP

0/3

0/8

+

aFor comparison, the reactions of Arcanobacterium haemolyticum are included. bData recorded from Fell et al. (1977) and our own experience. qsolates from patients 1, 4, 5, 6, 8, 10, and 11 in Table 1. aNumber of positive strains of the total number of strains. CData recorded from our own experience (four strains including the type strain). NI, not investigated. b e e n caused b y a strain of A. haemolyticum a n d not A. pyogenes as the isolate w a s not able to liquefy gelatin. Laufe (1954) r e p o r t e d 32 cases of acute ulcerative vulvovaginitis. F r o m 11 of these, hemolytic c o r y n e f o r m s w e r e isolated. Colonial a p p e a r a n c e a n d biochemical reactions m a k e the diagnosis A. pyogenes possible. The r e v i e w b y Vega a n d G a v a n (1970) did not include ten patients infected w i t h A. pyogenes rep o r t e d b y G~irtner a n d K n o t h e (1960). The latter c o m p a r e d their strains w i t h o n e b o v i n e strain of A. pyogenes. O n the basis of data g i v e n on colony m o r p h o l o g y , acidification of xylose, a n d gelatin liquefaction, it m u s t be a s s u m e d that eight strains w e r e A. haemolyticum a n d t w o strains A. pyogenes. G a r t n e r a n d K n o t h e (1960) t h o u g h t that their strains w e r e either A. pyogenes or h u m a n variants of it. Since the s t u d y b y Vega a n d G a v a n (1970), w e are a w a r e of only six publications o n infections d u e to A. pyogenes. O n l y the r e p o r t b y B a r n h a m (1988) on a case of b a c t e r e m i a in a p a t i e n t w i t h carcinoma of the colon p r o v i d e s sufficient microbiologic data to establish the diagnosis A. pyogenes. In r e p o r t s on

a fatal case of endocarditis b y Jootar et al. (1978), on s e v e n cases of i m p e t i g o contagiosa b y E1 Z a w a h r y et al. (1972), a n d o n a case of meningitis in a 76year-old f a r m e r b y Lipton a n d Isalska (1983), the laboratory data are insufficient. A r e p o r t on a case of septic arthritis in a 70-year-old m a n b y N o r e n b e r g et al. (1978) completely lacks microbiologic data. Yearly o u t b r e a k s of leg ulcers in Thailand (Kotrajaras et al., 1982; Kotrajaras a n d Tagami, 1987) w e r e c a u s e d b y isolates that w e r e at first r e p o r t e d u n a b l e to liquefy gelatin, later r e p o r t e d as gelatin liquefying. The reported carbohydrate fermentation pattern differs from the one seen in A. pyogenes, b u t m a y be d u e to different media. Barksdale et al. (1957) r e g a r d e d A. haemolyticum as a m u t a n t of A. pyogenes, a n d others r e p o r t e d it u n d e r the n a m e "Corynebacterium pyogenes var. hominis." For a discussion, see Lipsky et al. (1982). C u m m i n s a n d Harris (1965), on the basis of cell wall analysis, s u g g e s t e d that b o t h species w e r e closely related to the streptococci. Serologic cross-reaction b e t w e e n A. pyogenes a n d g r o u p - G streptococci a n d A. haemolyticum a n d group-B streptococci h a s also b e e n

Case Report

demonstrated (present study; L/immler and B16bel, 1986 and 1988). We do not k n o w h o w our patients acquired A. pyogenes. They have not been asked specifically about their possible exposure to animal pathogens. Their occupation also was not a clue. However, animal pathogens and zoonotic organisms are easily transmitted to h u m a n s t h r o u g h m a n y food items, as present experience with, for example, Salmonella shows. Transmitted potential pathogens will t h e n turn up in pathologic processes in h u m a n s with a certain frequency, and m a y sometimes cause or contribute to infection. As d e m o n s t r a t e d in the present study, w h e n A. pyogenes and A. haemolyticum are compared, they are easily differentiated, but a single strain m a y pose difficulties to the unexperienced microbiologist. If microscopy is not routinely done on f3-hemolytic colonies, A. pyogenes m a y also easily be misidentified as a hemolytic Streptococcus. The constant finding of production of a soluble hemolysin also described by Roberts et al. (1967) m a y contribute to this confusion. Valuable tests for distinguishing A. pyogenes from A. haemolyticum are the ability of A. pyogenes to (within

353

48 hr) hydrolyze gelatin rapidly, to produce acid from xylose, to produce J3-glucuronidase (L~immler and B16bel, 1986), and to react with antisera against group-G streptococci; a n d the ability of A. haemolyticum to inhibit the action of staphylococcal ~3-hemolysin in the CAMP test. The colonial appearance of the two species is also different: colonies of A. haemolyticum appear grayish with a granular surface and are larger than the pinpoint, whitish colonies of A. pyogenes. The case reports and the patient information in our series point to A. pyogenes as a h u m a n pathogen that sometimes produces or contributes to severe disease. Considering the few reliable reports that have been published and our experience in a limited geographical area over a few years, it m u s t be ass u m e d that this organism is a misrecognized h u m a n pathogen. More Gram stains of specimens a n d cultures should lead to a rising n u m b e r of recognized A. pyogenes cases. The authors thank Dr. Tove HfJjbjergfor access to her laboratory results on four strains of A. haemolyticum, including the type strain.

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B. G a h r n - H a n s e n and W. Frederiksen

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