Rhodococcus equi infection in non-HIV-infected patients. Two case reports and review

ORIGINAL ARTICLE

Rhodococcus equi infection in non-HIV-infected patients. Two case reports and review Claudio Farina', Silvia Ferruxxi2, Filippo Mamprin3 and Francesca I/aiEati3 lServizio di Microbiologia, 2Divisione di Medicina I, 3Divisione di Cardiochirurgia, Ospedali Riuniti,

Bergamo, Italy

Objective: To review two recent cases in HIV-negative subjects in the light of literature reports (52 patients without HIV infection till 1994).

Methods: Epidemiology (animal contacts, risk factors, year, country), clinical presentation, diagnostic methods (X-ray, tomography, microbiological techniques), therapeutic approach (antibiotics, surgery) and outcome were evaluated on the basis of clinical literature reports. Results: Tumors constituted an important predisposing factor and less frequently hepatobiliary pathology, rheumatologic diseases, iatrogenic causes, psychiatric pathology and trauma. Exposure to animals was reported by 55% of the patients. Pneumonia and pleurisy, without preferential localization, were detected in 50% of the patients. Etiologic diagnosis was usually obtained after an invasive collection. Combined medical therapy and surgery were required by 27.8% of the patients, and 16.7% of the patients died. Conclusions: In recent years the number of Rhodococcus egoicases has been rising also in HIV-negative patients. The infection is ubiquitous. Accurate diagnosis and the prompt selection of the most appropriate therapy depend on close cooperation between clinicians and microbiologists. Key words: Epidemiology, review, Rhodococcus equi

fellow, in the fifih edition of Bergey's Manual of Systematic Bacteriology, rendered official the term nocardioform actinomycetes, covering many bacterial genera, including Rkodocoms [3]. The first description of R. equi as an animal pathogen, causing pyogranulomatous pulmonitis in foals, dates back to 1923 [4]. The first human case, however, was reported much later, by Golub et al., in 1967, who described it in an immunodepressed patient [5]. By 1986 [61 there had been numerous reports of R. equi infection in patients with pathologies related to human immunodeficiency virus (HIV). Ffty-two cases have been described in patients who were negative for HIV [7-441. Our observation of two cases of R. equi infection in patients without HIV infection suggested a review of the epidemiologic, chical and diagnostic data on this increasingly fiequent infection.

INTRODUCTION Bacteria of the genus Rkodocoaus are Gram-positive microorganisms, obligate aerobes, mesophilic, chemoorganotrophic, immobile, partially alcohol/acid fast (in certain stages of their growth cycle), with a mycelium which can break up into bacillary or coccoid elements. They were first reported in 1889 when Zopf described a microorganism initially referred to as rkodockrous, meaning pink-tinged; this term is no longer used [l]. Rkodococcus has been assigned to various genera: Corynebacterium, Gordona, Mycobucterium, Nocardia, etc. However, in 1974 Tsukamura suggested the current denomination used for the genus, comprising the telluric species rkodockrous (subsequently considered a type species) [2]. GoodCorresponding author and reprint requests:

CASE REPORT No. 1

Claudio Farina, Servizio di Microbiologia, Ospedali Riuniti, Largo Barozzi, 1-24128 Bergamo, Italy

A 68-year-old woman, resident in a country area, reported contact with farmyard a n i m a l s and horses. The patient had been diagnosed as having non-

Tel: +39.35.269505 Fax: +39.35.269666 Accepted 14 August 1996 12

F a r i n a e t a l : R e v i e w o f R. e q u i i n f e c t i o n

Hodgkin's lymphoma 17 years earlier, and had received repeated cycles of chemo- and radiotherapy. In June 1992 she presented an erythematous intiltrative lesion near the umbilicus, close to an area of recent radiotherapy; it had partially regressed in response to amoxycfin and clavulanic acid, but had then rapidly progressed, causing an abscess. Although the patient was given diaminocihn, 1,200,000 U every 2 weeks, as an outpatient, and erythomycin 1 g twice-dady for 10 days, with daily topical application of polyvinylpyrrolidone iodme, the abscess spontaneously discharged after 1 month, leaving a sinus. She was admitted to hospital with fever (40.2"C), and empirical antibiotic therapy was started with sulbactam/ampicillin 2 g twice-daily. Her erythrocyte sedimentation rate (ESR) was 80rnm/h and she had peripheral neutrophilia (WBC 2740/mm3, neutrophds 81%). Serologic tests found no HIV antibodies. Blood cultures of samples taken on the first and fifth day in hospital and of purulent material fiom the periumbilical fistula were positive for R. equi. O n the basis of in vitro antibiotic sensitivity testing results, the patient was treated with pefloxacin 400 mg twice-daily, until she was discharged on day 15. Three months later the patient presented an unexpected fever again, and despite treatment with teicoplanin 400 mg, she died at home. No autopsy was done.

CASE REPORT No. 2 A 50-year-old man with chronic active hepatitis (HCVAb positive) received an orthotopic heart transplant with continuous normothermal potassium retroperfusion for New York Heart Association (NYHA) class IV dilatatory myocardiopathy. During surgery, five epicardial pacemaker wires were positioned, three ventricular and two atrial. The patient subsequently received cyclosporin A. In the immediate postoperative phase he suffered vascular shock &om peripheral vasoplegia, and hyperthermia (39.5 "C). Blood cultures were all negative. O n day 15 he presented fever (38°C) and complained of spontaneous pain and pain on palpation in the left parasternal area, localmed to the mid-zone, but radiating to the left shoulder. Inspection of the surgical wound showed nothing noteworthy and there was no appreciable sternal displacement. There was neutrophil leukocytosis (WBC 9980/mrn3, neutrophils 76.4%), and his ESR was 112 mm/h. The atrial pacemaker wires and one ventricular wire were removed, and culture grew R . equi. Blood cultures were negative. Symptoms regressed spontaneously and by day 20 the patient no longer had fever. However, on day 30 he

13

still had some slight redness and swelling at the lower third of the surgical wound, causing pain at the left sternal margin. A scan with labeled leukocytes showed an accumulation at this site. The patient was therefore treated with ciprofloxacin, 500 mg twice-dady. Computer scan (tomodensitometry) of the mediastinum showed an oval low-density area, about 15 mm in diameter, within the anterolateral wall of the right ventricle; this was not easy to interpret, and culture of seropurulent matter sampled &om the medioproximal region of the sternal wound gave no bacterial growth. The patient later suffered herpes zoster infection in the left cexvicobrachial region and Legionella pneumophila infection. Serologic tests before surgery and during followup gave negative results for HIV antibodies.

MICROBIOLOGICAL METHODS Blood samples were inoculated into BACTEC Plus 26 and 27 flasks (Becton Dickinson, Diagnostic Instrument Systems, Sparks, MD, USA); signs ofgrowth were evident after 72 h of incubation at 35 "C. Subculture of these samples, like the first culture of pus, incubated in a COz-enriched atmosphere for 24 h, yielded small colonies (diameter 1 to 2 m),smooth, glossy and moderately mucous, convex with regular edges, and tending to confluence &er 48 to 72 h. Microscopic examination showed pleiomorphic Gram-positive coccobaciUi, and no spores. API Coryne kits (Bio-Mirieux s.a., Marcy l'Etoile, France) detected the following enzymatic activities: nitratoreductase, alkahne phosphatase, alpha-glucosidase, urease, and catalase; there was no carbohydrate fermentation capacity. The strains had myristate lipase (C14) activity, tested by the Bio-Mirieux API ZYM system. O n the basis of these biochemical features, and the gross and microscopic appearance of the colonies, the microorganism was identified as R. equi. The isolates were tested for antibiotic sensitivity by the agar diffusion method according to NCCLS procedures. Both strains were resistant to penicillin, first-generation cephalosporins and clindamycin, but sensitive to macrolides, quinolones, vancomycin, thirdgeneration cephalosporins, piperacillin and imipenem.

DISCUSSION Bacteria of the genus Rhodococcus are saprophytes found in earth and vegetation, where they break down organic plant substances, in fiesh and salt water, and in the intestinal contents of mammals, mainly herbivores, and hematophage arthropods [45]. Some species of Rhodococcus are phytopathogens; others cause infection

14

C l i n i c a l M i c r o b i o l o g y a n d I n f e c t i o n , V o l u m e 3 N u m b e r 1 , F e b r u a r y 1997

in herbivores (horses, sheep and cattle), pigs and fish; others have been isolated h m human respiratory material [3]. Infection with R. equi is of interest in veterinary medicine, occurring almost exclusively in foals, where it frequently causes rapidly progressive suppurative bronchopneumonia, with multiple abscesses, and sometimes colitis and granulomatous mesenteric lymphadenitis. There are occasional reports of ‘tubercular-like’ episodes in pigs and cattle, and in other locations in dogs, cats, reptiles and koala bears [45]. In human pathology Rhodococcus spp. infection is very idequent. However, in recent years the numbers of cases have been rising, possibly because of increased attention being given to this pathogen, but also because of the rising numbers of patients, especially immunodepressed ones, exposed to the infection. About fifty cases of HIV patients infected with R. equi were found in the international literature up to the end of 1994, many of them in Medterranean countries. R. equi is often the cause of the first opportunistic infection [46-491, especially when the patient’s absolute CD4 lymphocyte count is less than 100 mm3. It has thus been suggested that isolation of R. equi is a diagnostic indication of AIDS, and R. equi might be included in CDC classification group 4c1. R. equi infection in non-HIV patients presents particular epidemiologic and clinical features, and generally the prognosis is better than in seropositive cases [46]. We found 52 cases reported in the literature, covering three decades up to the end of 1994, all HIV negative [5,7-441. Eight of 54 were observed from 1965 to 1974,15 in the next decade, and 31 in the years 1985-94. The dection was diagnosed in 33 males and 21 females (female-to-male ratio 1 : 1.5), aged from 7 months to 76 years (mean 40, median 40.5 years). The infection was ubiquitous, and the Merent geographc distribution of the isolates appears to reflect local microbiological practice more than the existence of specific reservoirs: 32 cases were described in North America; 11 were from Europe; five were &om Oceania; and the remaining three were from Asia or South America (one from Brazil). Table 1 shows the epidemiologic and clinical features of these cases. Malignant blood disorders (Hodgkin’s and nonHodgkm’s lymphomas, leukemia and sarcoma) accounted for 17 of 54 of the underlying diseases; solid tumorsadenocarcinoma and ependymoblastomaaccounted for only two cases. Less frequently, there was hepatobiliary pathology resulting h m alcoholism, cirrhosis or gallbladder diseases (five cases); rheumatologic diseases-rheumatoid arthritis, polyarthritis and sarcoidosis-accounted for four cases. Iatrogenic causes

are becoming more frequent: organ transplant (nine cases), valve replacements and continuous ambulatory peritoneal dialysis (CAPD) (one each). One patient presented two risk factors-renal transplant and Hodgkm’s lymphoma. Two cases had concomitant psychiatric illness, one of them involving self-injury, which suggested a traumatic pathogenic mechanism. Post-traumatic infections thus amounted to six cases, and in these the clinical course was particularly serious, with endophthalmitis and sepsis, or subcutaneous lesions like mycetomas. Two patients had chronic respiratory dseases and six had no identifiable risk factor. Exposure to animals,possible reservoirs of R. equi, was reported by 22 of the 40 patients who were asked about this. One case of R. equi infection was described in a laboratory technician who, however, had had no contact with experimental animals or microorganisms. It would appear that in most cases-as confirmed by the two we report here-contamination is due to direct contact with R. equi through burns, surgery, or dnect trauma, or to the inhalation of bacterial cells with dust or environmental debris, even if no animal reservoir is actually present. In 27 of the 54 cases, presentation involved the respiratory tract, with pneumonia or, more rarely, pleurisy. Radiologic examination found cavitary progression in 13 of 27 cases, stabihed infiltrates in 12, and atelectasis in one. There seemed to be no preferential localization in the lungs. Etiologic diagnosis was usually based on specimens obtained invasively (16 of 54 pus or vitreous; 15 out of 54 biopsy). Respiratory specimens were also usually collected invasively: seven by bronchial or pulmonary biopsy, five fiom pus h m cavitation, two horn bronchal lavage, four fiom pleural fluid, and two from transtracheal puncture. In three cases R. equi was isolated from sputum culture, but only in one case was the positive material the basis for diagnosis. Blood and bone marrow cultures were positive in 20 of 53 cases, in 10 of them without contirmation &om other positive specimens. One case was diagnosed at autopsy. Two patients relapsed, one of them four times. One patient, with psychiatric pathology, presented eight successive episodes of sepsis. Fifteen cases (27.8%) required combined medical therapy and surgery; in the remainder, antibiotics, with a variety of long-term regimens, resolved the clinical picture. There were nine deaths (16.7%), usually patients in very poor general condition. Etiologic hagnosis was often difficult, since R. equi is often dismissed as a contaminant in the sample, and rhodococcosis is rarely considered in differential diagnosis, especially in HIV-negative patients. How-

Dogs

Not detected

Horses

None

Not evaluated

Not evaluated

Dog; horses

Not detected

Not detected

Horses

Horse, pig

Not evaluated

Not evaluated

None

None

None

Kidney transplant

Kidney transplant

Kidney transplant

Heart transplant

Heart transplant

Prosthetic valve replacement HD

HD

HD

HD

3/F

38/M

40/F

39/F

45/F

38/M

30/M

52/M

8

9

10

11

15 50/M

16 51/M

18 26/M

18/M

7

14 42/M

34/M

6

13 62/M

52/M

5

12 64/M

53/F

4

19

20

21

22

17

47/F

Horses

Kidney transplant

ALL

HD

None

Not evaluated

Kidney transplant/HD Cattle

Pig

Kidney transplant

Not evaluated

Laboratory researcher

None

28/M

3

Kidney transplant

Cat

None

2

2/F

9/M

1

Pigs?

Animal contact

None

Patient Age/sex Risk factor

Fever Pneumonia, pleuritic Fever, cough Pneumonia Fever, sternal wound infection So) tissue infection Fever Endocarditis Fever, dyspnea, cough Pneumonia Fever, dyspnea, cough Pustular lesions Pneumonia, soft tissue infction Fever Sepsis Fever; cough Pneumonia Fever Sepsis Fever Pneumonia

Lung biopsy

Cavitation (LUL) Multiple nodules Not done

Infiltrate (LLL)

Bronchial washing

Blood/sputum

Bronchial biopsy

Infiltrate (RML) Infiltrate (RML)

Bone marrow

Lung biopsy; blood; skin Surgical tissue; PC pus

Aortic valve vegetations

Wires

Negative

Cavitation (RML)

Infiltrate (RUL)

Not reported

Negative

Lung biopsy, blood

Lung autopsy

Infiltrate (RML) Cavitation (RUL)

Urine. muscle necrosis

Paraspinal abscess pus

Lung nodule pus Brain pus

Skin biopsy

Bronchial biopsy; P C PUS

PC pus

Pus

Sputum

Lysis metaphysis

Not reported

Cavitation (RLL) Brain abscesses

Not done

Infiltrate (LUL)

Cavitation (LUL)

Not done

Cavitation (LLL)

Synovial/bone biopsy

Osteal reaction

Blood

Lymph node biopsy

Not done

Fever, neck swehng Cervical lymphadenitis Painless swelling hand Osteomyelitis Cough, dyspnea, chest pain Pneumonia Fever, cough, neck swelling Sepsis, cervical lymphadenitis Fever, chills, cough Pneumonia Arm kactudislocation &ft fissue infection Fever, chest pain, cough Pneumonia Fever, dyspnea, chest pain, lethargy, cough Pneumonia Burn Burn infection Asymptomatic relapse: headache Pneumonia; CNS infect. Myalgia, fever, UAP Soj tissue infrtion Thigh enlargement Osteomyelitis @mu!)

Culture

X-ray

Clinical presentation/ Clinicd diagnosis

Table 1 Epidemiological and clinical features of rhodococcosis

Oxa, then C C + C

Not specified

Not specified

SXT

then E+Tet P, then E

E,

P+GN

Va+Cip then Cip+Anc Cip

Fu+Toh then E+RF P, then E+Va then E+ TMP-SXT IMP+Tob

E+TMP-SXT, then C+Va+GN

AMX

then E+GN

AMX,

No

Va+RF

E

Ofl+Cef+Lat, then Ofl+Tic E, then CTX

E+AMX

INH, then

Doxy

Antibiotics

None

None

None

None

Lobectomy

Valve replacement Lobectomy

None

None

None

Sequestr.

Drainage

Lobectomy Drainage

None

None

Lobectomy

Drainage

None

None

None

None

None

Surgery

Died

Died

Cured

Died

Cured

Cured

Cured

Cured

Cured

Died

Cured

Cured

Relapse Cured

Relapsed (4)

Died

Cured

Cured

Cured

Cured

Cured

Cured

Cured

Outcome

1974/USA

1979/France

1979/USA

1977/USA

1975/USA

11

17

16

15

12

13

21

NK/uK 1974/USA

C

43

39

29

32

22

20

14

8

42

44

44

33

18

7

Ref,

1992/Italy

199l/Spain

1991/Spain

1986/USA

1985/N. Zealand

1980/USA

1975/N. Zealand

197WAustralia

197l/USA

NK/Italy

NK/USA

NK/USA

1987/Japan

1976/USA

1965/Denmark

Year/Country

a

Ln

2:

W 3

-I

-.

W

n

Table 1 continued ~~

23

6/F

24

9/F

25 26

ALL. myringotomy ALL?

Not evaluated

68/F

NHL

Horses

6/M

CML

Not evaluated

Not evaluated

27

73/F

CLL

None

28

64/M

LL

Farmer

29

36/M

APL

Hones

30

58/M

AML

None

Fever, cough Pneumonia Fever Sepsis Fever, skin abscess Sofr tissue infeaion Fever, tachypnea. cough Pneumonia Fever, cough Pneumonia Cachexia, ascites Pleuritis Myalgia, fever Sepsis Fever

Cavitation (RUL) Nodule (LLL) Not reported

Lung biopsy, blood

E+RF

None

Cured

1988/Canada

30

Blood

Not reported

None

Cured

1990/NK

34

Negative

Pus; blood

S A M , then Pef

None

Died

1992/Italy

C

Infiltrate (LLL)

Pleural fluid

CAZ+Net

Drainage

Cured

NK /USA

37

+On,then P Iditrate (RLL)

Transtracheal fluid

TMP-SXT

None

Cured

1977/USA

15

Infiltrate (RLL)

Blood/pleural fluid

T MP-SXT

None

Died

19791USA

22

Negative

Blood

E+RF

None

cured

1990/USA

41

Negative

Blood, catheter tip

Pef+Tob+Va

None

Cured

1990/France

36

Iditrate (LLL)

Blood; pleural fluid

CF+GN

None

Died

1974/USA

13

Cavitation (LUL)

PC pus; blood

A+GN

None

Died

1971/USA

9

LPE

Pleural pus

A+Clo then A+Tob

Drainage

Cured

1980/N. Zealand

32

Negative

Blood

AZT+SAM

None

Cured

NWUSA

44

1ntent.accent.

Blood

Va

None

Cured

NK/USA

37

Not reported

Foot pus and biopsy

TMP+SXT

None

Cured

1985/Brazil

26

Not reported

Vitreous fluid

GN

Vitrectomy

Cured

1985/USA

27

Not reported

Vitreous fluid

CFZ+GN

Viwctomy

Cured

NK/USA

31

Not done

Knee joint fluid

CFZ

Arthrotomy

Cured

NK/USA

44

Not done Infiltrate (RUL)

Wound pus Transtracheal fluid

CF INH+ETH

None None

Cured Unchanged

NK/USA 1977/USA

44 15

Not reported

Blood

None

Cured

1988lSweden

35

Cavitation (Rh4L)

Blood

TMP-SXT +IMP E+GN+RF

None

Cured

NK/USA

40

Infiltrate (LLL)

Lingular mass

Doxy+Va

None

Cured

1985/USA

25

Cavitation (RUL)

Sputum

None

Died

NK/USA

38

Cavitation (LUL)

Blood and rib biopsy

CFZ, then INH+ RF+ETH E+RF

None

Cured

1982/Sweden

28

Not reported

Pus

None

None

Cured

1981/Germany

19

sepsis

31

53/F

R C sarcoma

None

32

39/M

LS

Horses

33 53/M

LS

Foals

34

52/F

Adenocarcinoma

Not detected

35

3/F

Ependymoblastoma

Not evaluated

36

62/M

Trauma

Farmer

37

9/M

Trauma

None

38

29/M

Trauma

Not mluated

39

4/M

Trauma

Not detected

40 41

9/M 70/M

Trauma COPD

Not detected Not detected

42

33/F

Factitious illness

Not evaluated

43

76/F

Schizophrenia

Not detected

44

69/M

RA

Farmer

45

51lF

RA

None

46

54/F

Sarcoidosis

Cattle. swine

47

69/F

Poliarthritis

Not evaluated

Fever, vomiting, cough Pneumonia Fever, dyspnea. cough Pneumonia Empyema, then tentorial herniation Pneumonia; CNS infect. Fever, vomiting Sepsis Fever, cough Sepsis Left foot tumor Mycetoma Eye pain Endophthalmitis Corneal laceration Endophthalmitis Knee pain, fever Articular infrrfion Lymphangitis Fever, dyspnea, cough Pneumonia Fever Sepsis (8 times) Respiratory distress Pneumonia Cough, hemoptysis Pneumonia Dyspnea. chest pain Pneumonia Hemoptysis, fever Pneumonia Gluteal abscess So$ tissue infiction

+ CAZ

F a r i n a e t al: R e v i e w o f

R. e q u i

infection

17

II

ever, clinical microbiologists and attending physicians should always bear in mind that R. equi is no longer a rare opportunistic microorganism, particularly after transplants or in leukemia. Accurate diagnosis and the prompt selection of the most appropriate therapy depend on close cooperation between clinicians and microbiologists.

I1

References 1. Zopf W. Ueber Ausscheidung von fettfarbstoffen. Lipo-

z

z

d c

B

.-U n

chrome seitensgewisser Spaltpilze. Berichte der Deutschen Botanische Gesellschaft 1891; 4: 22-8. 2. Tsukamura M. A further numerical taxonomic study of the rhodococcus group. Jap J Microbiol 1974; 18: 37-44. 3. Goodfellow M. Genus Rhodococcus Zopf 1981, 28AL.In Sneath PHA, Mair NS, Sharpe ME, Holt JG, eds. Bergey's manual of systematic bacteriology, Williams & Wilkins, Baltimore, USA 1986: 2362-71. 4. Magnusson H. Spezifische infektiose Pneumoniae beim Fohlen. Ein neuer Eitererreger beim Pferde. Arch WissenschafPrakt Tierheil 1923; 50: 22-38. 5. Golub B, F a k G, Spink W. Lung abscess due to Corynebacterium equi. Report of first human infection. Ann Intern Med 1967; 66: 1174-7. 6. Samies JH, Hathaway BN, Echols RM, Veazey JM, Pilon VA. Lung abscess due to Corynebactm'um equi. Report of the first case in a patient with acquired immune deficiency syndrome. Am J Med 1986; 80: 685-8. 7. Thomsen VF, Henriques U, Magnusson M. Corynebartm'um equi Magnusson isolated from a tuberculoid lesion in a c u d with adenitis coli. Dan Med Bull 1968; 15: 135-8. 8. Williams GD, Flanigan WJ. Campbell GS. Surgical management of localized thoracic mfections in immunosuppressed patients. Ann Thoracic Surg 1971; 12: 471-5. 9. Marsch JC, von Graevenitz A. Recurrent Corynebacten'um equi infection with lymphoma. Cancer 1973; 3: 147-9. 10. Germain P, Deville J, Remy G, Dropsy G. A propos d'une observation d'infection humaine h Corynebarterium equi. Mtd Mal Infect 1975; 5-6: 294-7. 11. Gardner SE, Pearson T, Hughes WT. Pneumonitis due to Corynebactm'um equi. Chest 1976; 70: 92-4. 12. Carpenter JL, Blom J. Corynebartm'um equi pneumonia in a patient with Hodgkin's disease. Am Rev Resp Dis 1976; 114: 235-9. 13. Berg R, Chmel H, Mayo J, Armstrong D. Corynebactm'um equi infection complicating neoplastic disease. Am J Clin Path01 1977; 68: 73-7. 14. Savdie E, Pigott P, Jennis E Lung abscess due to Corynebactm'um equi in a renal transplant recipient. Med J Aust 1977; 1: 817-19. 15. Haburchak DR, Jefiey B, H i g b e e p , Everett ED. Infections caused by rhodocorns. Am J Med 1978; 65: 298-302. 16. Colby W, Hunt S, Pelzmann K, Carrington CB. Malakoplakia of the lung. Respiration 1980; 39: 295-9. 17. Chatelain R , Hild J, Woehl B, Wiederkehr JL, Mengus C. Septictmie h Corynebactm'um equi chez un malade trait6 par immunodtpresseurs pour maladie de Hodgkin. MCd Mal 1[nfect 1980; 10: 182-4.

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Clinical M i c r o b i o l o g y a n d I n f e c t i o n , Volume 3 N u m b e r 1, F e b r u a r y 1997

18. Broughton RA, Wilson HD, Goodman NL, Hedrkk JA.

Septic arthritis and osteomyelitis caused by an organism of the genus Rhodococcus. J Clin Microbiol 1981; 13: 209-13. 19. Burger H, Muller HE. R h o d o c o m s isoliert aus glutaalabszess. Infection 1982; 10: 343-6. 20. Ellis-Pegler RB,Pan DH, Orchard VA. Recurrent skin infection with Rhodococcus in an immunosuppressed patient. J Infect 1983; 6: 39-41. 21. Moore-Gillon J, Eykyn SI, Phillips 1. Prosthetic valve endocarditis. Br Med J 1983; 287: 739-41. 22. Van Etta LL, Filice GA, Ferguson RM, Gerding DN. Corynebarterium equi: a review of 12 cases ofhuman infection. Rev Infect Dis 1983: 5: 1012-18. 23. Peloux Y, Durand JM, Fosse T. PCritonite h Corynebarterium (Rhodocoms) equi chez un cirrhotique. Semin HBp (Paris) 1985; 61: 2441-2. 24. Le Bar WD, Pensler MI. Pleural efision due to Rhodocoms equi. J Infect Dis 1986; 154: 919-20. 25. MacGregor JH, Samuelson WM, Sane DC, Godwin JD.

Opportunistic lung infection caused by Rhodocoms (Corynebactm'um) equi. Kad~ology1986; 160: 83-4.

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