- Email: [email protected]
When, why, and how far should coryneforms be identified?
13. Kurup, V. P., J. N. Fink, and D. M. Bauman. 1976. Thermophilic actinomycetes from the environment. Mycologia LXVIIl:662-666. 14. Kurup, V. P., G. E. Hollick, and E. Pagan. 1980. Thermoactinomyces intermedius: a new species of amylase negative thermophilic actinomycetes. Science-Ciencia 7:104- 108.
15. Kurup, V. P. et al. 1983. Allergenic fungi and actinomycetes in smoking materials and their health implications. Mycopathologia 82:61-64.
16. Lacey, J. 1971.77zermoactmomyces sacchari sp. nov., a thermophilic actinomycete causing bagassosis. J. Gen. Microbiol. 66:327-338. 17. Lacey, J., and M. E. Lacey. 1964. Spore concentrations in the air of farm buildings. Trans. Br. Mycol. Soc. 47:547-552. 18. Pepys, J. et al. 1963. Farmer's lung. Thermophilic actinomycetes as a source of farmer's lung hay antigen. Lancet ii:607-611. 19. Roberts, R. C., D. P. Zais, and D. A. Emanuel. 1976. Frequency of
precipitins to trichloroacetic acidextractable antigens from thermophilic actinomycetes in farmer's lung patients and asymptomatic farmers. Am. Rev. Respir. Dis. !14:23-28. 20. Treuhaft, M. W., and M. P. A. Jones, 1982. Comparison of methods for isolation and enumeration of thermophilic actinomycetes from dust. J. Clin. Microbiol. 16:995-999.
21. Wenzel, F, J. et al. 1974, Serologic studies in farmer's lung. Precipitins to the thermophilic actinomycetes. Am. Rev. Respir. Dis. 109:464-468.
Editorial
When, Why, and How Far Should Coryneforms be Identified? Jill E. Clarridge, Ph.D.
Chief, Microbiology Section Laboratory Service Veterans Administration Medical Center Houston, Texas 7721l Coryneforms are a group of bacteria that presumably resemble Corynebacterium diphtheriae in morphology. Most coryneforms are not associated with disease and are found as endogenous human flora. Because it is difficult to distinguish species within this group, clinical laboratories sometimes report "gram-positive pleomorphic rods," "Corynebacterium spp.," "coryneforms," or "diphtheroids" on the basis of Gram stain, colony morphology, and perhaps, a catalase test. Although we recognized the expediency of such a process, we questioned the accuracy. If coryneforms are defined as grampositive, non-acid-fast, asporogeneous, pleomorphic rods that are usually nonanaerobic and nonbranching, many genera having no taxonomic relatedness can be included in this group (1). On the other hand, if the group is limited to those with a "club-shape" during at least part of the life cycle, some of the true Corynebacteria spp. would be excluded and Cellulomonas,
Oerskovia, Arthrobacter, Brevibacterium, Microbacterium, and Curtobacterium, organisms that are generally found in soil or food, would be
32
0196-4399/86/$0.00 + 02.20
included (5). Mycobacterium, Nocardia, and Rhodococcus might be placed in the group if acid-fast stains are not done and branching is not evident. The strains of Actinomyces and Propionibacterium that are not strict anaerobes could also be included. In the broader definition, one would also include Listeria and Erysipelothr&. With this large number of organisms to consider, we decided to identify more completely clinical isolates that had a coryneform morphology (clubshaped, pleomorphic, and/or small regular and/or slightly branching grampositive rod) on Gram stain and that grew aerobically or in 6% CO 2 at 35°C on blood or colistin-nalidixic acid agar plates (3). Only organisms that were numerically significant were selected. For urine isolates this meant specimens with >104 organisms/mL and no more than one other species present. For other specimens, the coryneform organism had to appear on original plates as the predominant organism (ten times more than the next most common isolate) or copredominant with another species. Any isolate recovered from blood culture was considered potentially significant. Using standard methodology, identification was accomplished with the previously published criteria (4), and guides compiled by the Centers for Disease Control (17), a condensed form of which is shown in Table 1. Of 100 isolates examined, the following genera and numbers were represented: Cor>'nebacterium (40), Actinomyces (14), Lactobacillus (13), Ar-
1986 Elsevier Science Publishing Co.. l n c
canobacterium (5), Propionibacterium (4), Listeria (3), Nocardia (3), Erysipelothrix ( 1), Mycobacterium ( 1), Streptococcus (2), Gardnerella (1), unidentified (13). Although all of these organisms were included in the study by their characteristics after 24hr growth, the Listeria, Erysipelothrix, two of the Nocardia, and most of the Lactobacillus isolates were not initially thought to be coryneforms because of additional characteristics such as chaining or hemolysis. Here, and as reported elsewhere, (14, 16) the Acti-
nomyces, Arcanobacterium, Mycobacterium and Propionibacterium might have been misidentified as "diphtheroids". Most Corynebacterium isolates could not be identified to the species level. The named groups listed in decreasing order of frequency were Corynebacterium CDC group D-2, C. CDC group JK, C. minutissimus, C. xerosis, and single isolates of C.
striatum, C. pseudodiphthericum, C. aquaticum, C. CDC group G-1 and C. CDC group F-1. As data accumulate, it is increasingly evident that the identification of these gram-positive isolates to genus and sometimes species is clinically relevant. The Nocardia, Erysipelothrix, and Mycobacterium are rarely isolated without being involved in a disease process, As recognition increases, wound infections with Mycobacterium spp. are reported more commonly (14). In contrast, all the other genera that we isolated are considered as part of the normal flora. However, the Ar-
canobacterium, Propionibacterium,
Clinical Microbiology Newsletter 8:5,1986
Table I Simplified Table for
Corynebacterium Identification a'b Utilization o f glucose
Nitrate
Urease
C. diphtheriae
F
+
-
C, ulcerans C, p s e u d o t u b e r c u l o s i s
F F
V
+ +
C. xerosis
F
+
-
C. striatum C. minutissimum
F
+
-
F/O
-
C. kutscheri
F
C. renale C. bovis
F F
Org anism
Maltosea
Sucrose a
+
+
-
+ +
+ +
+
+
+
+
+
-
+
-
+
+
+ or -
+
+
+
+
+
+ -
+ V
+
V
-
F F F F F F F
+ + + V V -
+ + -
+ + + + + + +
V V + V + V
+ + -
C. CDC group A3
F
+ (100)
-
+
+
+
C. CDC group A4
F
V(13)
-
+
+
+
C. CDC group A5
F
V(20)
-
+
+
+
C. p s e u d o d i p h t h e r i c u m
C. CDC group D2
NU NU
+ -
C. C. C. C.
NU NU O NU
. + V .
0
V
C. C. C. C. C. C. C.
CDC CDC CDC CDC CDC CDC CDC
CDC CDC CDC CDC
group group group group group group group
group group group group
G 1c G2 c 11 I2 F1 F2 JK c
ANFI ANF3 B1 B2
C. aquaticum
Glucose a
+ +
.
.
. .
two strains assoc, with rats assoc, with cattle little data
many are antibiotic resistant esculin + , yellow V, motility + esculin + , yellow V, motility V esculin V, yellow V, motility V
. .
.
+ .
-
Tinsdale + Tinsdale + Tinsdale +
many are antibiotic resistant
. .
Comments
. +
V
V
+
+
. esculin V, motility V, yellow +
F = fermentative, O = oxidative, NU = nonutilizer, + = >90% positive, - = <10% positive, V = between 10 and 90% positive. b Adapted from (17). c May require serum for growth. a In our hands, the rapid method described by Thompson et al. (12) is useful.
and A c t i n o m y c e s
apparently have a
Corynebacterium,
e x c e p t for C.
s o c i a t e d w i t h c h r o n i c a b s c e s s e s (2, 13)
greater c a p a c i t y for ulcer o r a b s c e s s f o r m a t i o n (8, 10, 16). In several re-
d i p h t h e r i a e and the s e l e c t e d h i g h l y re-
or h a v e b e e n r e c o v e r e d f r o m speci-
sistant g r o u p s ( i . e . , C. C D C g r o u p J K
m e n s , such as urine or corneal scrap-
v i e w s (6, 10, 16) o n C o r y n e b a c t e r i a spp. or d i p h t h e r o i d s , a large p r o p o r tion o f the d o c u m e n t e d i n f e c t i o n s w e r e c a u s e d b y o r g a n i s m s that h a v e b e e n r e c l a s s i f i e d f r o m C o r y n e b a c t e r i u m to
and C. C D C g r o u p D - 2 ) , a c l e a r pattern o f p a t h o g e n i c i t y has not e m e r g e d . A variety o f C o r y n e b a c t e r i a s p p . , m a n y o f w h i c h c a n n o t b e a s s i g n e d to a k n o w n s p e c i e s , can c a u s e e n d o c a r d i t i s
ings. In s o m e c a s e s , d i s t i n g u i s h i n g c o l o n i z a t i o n f r o m infection is difficult. B e c a u s e m a n y clinically isolated c o r y n e f o r m s are not C o r y n e b a c t e r i u m
either o f t h e s e three g e n e r a or R h o d o -
or p r o s t h e s e s i n f e c t i o n s , situations in
coccus.
w h i c h a d h e r e n c e is a factor (9, 10, 11, 15, 16). O t h e r isolates h a v e b e e n as-
O n the o t h e r h a n d , within the g e n u s
Clinical MicrobiologyNewsletter8:5,1986
© 1986 ElsevierSciencePublishingCo., Inc.
spp. and b e c a u s e the g e n e r a d i f f e r significantly in p a t h o g e n i c i t y , o r g a n i s m s that are isolated f r o m usually sterile sites and in large n u m b e r s should be
0196-4399/86/$0.00 + 02.20
33
identified to the genus level. However, due to the scarcity of data, identification to species within the genus Corynebacterium (except for C. diphtheriae) will give few clues as to the treatment or severity of the disease. In addition, because tests are usually performed by conventional methods, the identification o f the isolate may be too delayed to be clinically useful. Susceptibility results are important, however, because the susceptibility pattern is not predictable. Penicillin, ampicillin, erythromycin, tetracycline, gentamicin, and vancomycin should be tested. Results for organisms that apparently do not grow on Mueller-Hinton agar must be interpreted with caution. Some of the gram-positive bacilli are so exquisitely susceptible that when the standard discs are used, zones may be so large that no growth at all is observed on the plate, Organisms repeatedly isolated from a patient should be identified sufficiently and rapidly so as to confirm that they are indeed the same. Both rapid microbiochemical tests (12) and the API 20S (Analytab Products, Inc., Plainview, NY) (7) have been suggested as faster alternatives to standard methods. Because of the continued taxonomic uncertainty, recording the biochemical profile or test results rather than just the name is advised. This procedure will allow correlation
of organisms with disease processes even though there may be nomenclature changes in the future.
References 1. Barksdale, L. 1981. The genus Co~nebacterium, pp. 1827-1837. In M. P. Start, H. Stolp, H. G. Truper, A. Balows, H. G. Schlegel (eds.), The prokaryotes. Springer-Verlag, Berlin. 2. Berger, S. A. et ai. 1984. Recurrent breast abscesses caused by Co~nebacterium minutissimum. J. Clin. Microbiol. 20:1219- 1220. 3. Clarridge, J. E., and B. B. Simon. 1983. Characteristics and significance of coryneform organisms isolated in a clinical laboratory. Abstracts Annual Meeting, ASM--C239. 4. Ciarridge, J. E., and A. S. Weissfeld. 1984. Aerobic asporogenous gram-positive bacilli. Clin. Microbiol. Newsl. 6:115-t 18. 5. Goodfellow, M., and D. Minnikin. 1981. Introduction to the coryneform bacteria in The prokaryotes. In M. P. Start et al. (eds.), The prokaryotes. Springer-Verlag, Berlin. 6. Kaplan, K., and L. Weinstein. 1969. Diphtheroid infections of man. Ann. Intern. Med. 70:919-29. 7. Kelly, M. C. et al. 1984. Rapid identification of antibiotic resistant Corynebacterium with the API 20S system. J. Clin. Microbiol. 19:245-247. 8. Kovatch, A. L., K. E. Schuit, and R. H. Michaeis. 1983. Corynebacterium hemolyticum. Peritonsillar abscess mimicking diphtheria. J. Am. Med. Assoc. 249:1757-1758.
9. Love, J. W. et al. 1981. Infective endocarditis due to Corynebacterium diphtheriae: report of a case and review of the literature. John Hopkins Med. J. 148:41-42. 10. Lipsky, B. A. et al. 1982. Infections caused by nondiphtheria corynebacteria. Rev. Infect. Dis. 4:1220-35. 11. Sirisanthana, V., and T. Sirisanthana. Co~nebacterium diphtheriae endocarditis. 1983. Ped. Infect. Disease 2:470-71. 12. Thompson, J. S., D. R. GatesDavis, and D. C. T. Yong. 1983. Rapid microbiochemical identification of Corynebacterium diphtheriae and other medically important corynebacterium, J. Clin. Microbiol. 18:926-929. 13. Tompkins, L. S. 1983. Co©'nebacterium hemolyticum. Clin. Microbiol. Newsl. 5:29-30. 14. Vance, D. 1983. Mycobacterium chelonei sternal infection. Clin. Microbiol. Newsl. 5:6-7. 15. Van Scoy, R. E. et ai. 1977. Coryneform bacterial endocarditis. Mayo Clin Proc. 52:216-19. 16. Washington, J. A., II. 1981. Bacteriology, clinical spectrum of disease and therapeutic aspects of coryneform bacterial infection, pp. 68-88. In J, S. Remington and M. N. Swartz (eds.), Current clinical topics in infectious diseases, Vol. 2, McGraw-Hill, New York. 17. Weaver, R. E., and D. G. Hollis. 1983. Gram-positive organisms: a guide to presumptive identification. Centers for Disease Control, Atlanta, GA.
Case Report
Branhamella catarrhalis Pneumonia with Bacteremia Gary V, Doern, Ph.D.
Department of Ctinical Microbiology and Division of Infectious Disease University of Massachusetts Medical Center Worcester. Massachusetts 01605 Roger E. Schmid, M.D.
Division of Infectious Disease Day Kimball Hospital Putnam, Connecticut 06260 Branhamella catarrhalis is now considered an important cause of broncho-
34
0196-4399/86/$0.0o + 02.20
pulmonary infections in humans. These include acute exacerbations of bronchitis and frank bacterial pneumonia, usually in patients with antecedent compromised respiratory tract function (10, 11, 13). However, B. catarrhalis bacteremia in association with lower respiratory tract infection is uncommon. Only two cases of patients with bacteremia as a complication of Branhamella pneumonia are reported in the literature (9, 14). Herein, we describe an elderly woman with Branhamella pneumonia who developed bacteremia. An 89-yr-old woman was admitted to
.~ 1986ElsevierSciencePublishingCo. Inc.
the Day Kimball Hospital after a week of increasing shortness of breath. Past medical history included a history of congestive heart failure, with previous episodes of acute pulmonary edema. On admission her temperature was 38.5°C, her pulse was 130/min, her blood pressure was 150/90 mm Hg, and her respiratory rate was 40/rain. Rales were heard in all lung fields. The heart rhythm was irregular. A cardiac murmur was not appreciated. Bilateral pedal edema (3 + ) was noted. Her skin was warm and moist. Initial laboratory studies revealed a leukocyte count of 12,400/ram 3 with
ClinicalMicrobiologyNewsletter8:5.1986
15. Kurup, V. P. et al. 1983. Allergenic fungi and actinomycetes in smoking materials and their health implications. Mycopathologia 82:61-64.
16. Lacey, J. 1971.77zermoactmomyces sacchari sp. nov., a thermophilic actinomycete causing bagassosis. J. Gen. Microbiol. 66:327-338. 17. Lacey, J., and M. E. Lacey. 1964. Spore concentrations in the air of farm buildings. Trans. Br. Mycol. Soc. 47:547-552. 18. Pepys, J. et al. 1963. Farmer's lung. Thermophilic actinomycetes as a source of farmer's lung hay antigen. Lancet ii:607-611. 19. Roberts, R. C., D. P. Zais, and D. A. Emanuel. 1976. Frequency of
precipitins to trichloroacetic acidextractable antigens from thermophilic actinomycetes in farmer's lung patients and asymptomatic farmers. Am. Rev. Respir. Dis. !14:23-28. 20. Treuhaft, M. W., and M. P. A. Jones, 1982. Comparison of methods for isolation and enumeration of thermophilic actinomycetes from dust. J. Clin. Microbiol. 16:995-999.
21. Wenzel, F, J. et al. 1974, Serologic studies in farmer's lung. Precipitins to the thermophilic actinomycetes. Am. Rev. Respir. Dis. 109:464-468.
Editorial
When, Why, and How Far Should Coryneforms be Identified? Jill E. Clarridge, Ph.D.
Chief, Microbiology Section Laboratory Service Veterans Administration Medical Center Houston, Texas 7721l Coryneforms are a group of bacteria that presumably resemble Corynebacterium diphtheriae in morphology. Most coryneforms are not associated with disease and are found as endogenous human flora. Because it is difficult to distinguish species within this group, clinical laboratories sometimes report "gram-positive pleomorphic rods," "Corynebacterium spp.," "coryneforms," or "diphtheroids" on the basis of Gram stain, colony morphology, and perhaps, a catalase test. Although we recognized the expediency of such a process, we questioned the accuracy. If coryneforms are defined as grampositive, non-acid-fast, asporogeneous, pleomorphic rods that are usually nonanaerobic and nonbranching, many genera having no taxonomic relatedness can be included in this group (1). On the other hand, if the group is limited to those with a "club-shape" during at least part of the life cycle, some of the true Corynebacteria spp. would be excluded and Cellulomonas,
Oerskovia, Arthrobacter, Brevibacterium, Microbacterium, and Curtobacterium, organisms that are generally found in soil or food, would be
32
0196-4399/86/$0.00 + 02.20
included (5). Mycobacterium, Nocardia, and Rhodococcus might be placed in the group if acid-fast stains are not done and branching is not evident. The strains of Actinomyces and Propionibacterium that are not strict anaerobes could also be included. In the broader definition, one would also include Listeria and Erysipelothr&. With this large number of organisms to consider, we decided to identify more completely clinical isolates that had a coryneform morphology (clubshaped, pleomorphic, and/or small regular and/or slightly branching grampositive rod) on Gram stain and that grew aerobically or in 6% CO 2 at 35°C on blood or colistin-nalidixic acid agar plates (3). Only organisms that were numerically significant were selected. For urine isolates this meant specimens with >104 organisms/mL and no more than one other species present. For other specimens, the coryneform organism had to appear on original plates as the predominant organism (ten times more than the next most common isolate) or copredominant with another species. Any isolate recovered from blood culture was considered potentially significant. Using standard methodology, identification was accomplished with the previously published criteria (4), and guides compiled by the Centers for Disease Control (17), a condensed form of which is shown in Table 1. Of 100 isolates examined, the following genera and numbers were represented: Cor>'nebacterium (40), Actinomyces (14), Lactobacillus (13), Ar-
1986 Elsevier Science Publishing Co.. l n c
canobacterium (5), Propionibacterium (4), Listeria (3), Nocardia (3), Erysipelothrix ( 1), Mycobacterium ( 1), Streptococcus (2), Gardnerella (1), unidentified (13). Although all of these organisms were included in the study by their characteristics after 24hr growth, the Listeria, Erysipelothrix, two of the Nocardia, and most of the Lactobacillus isolates were not initially thought to be coryneforms because of additional characteristics such as chaining or hemolysis. Here, and as reported elsewhere, (14, 16) the Acti-
nomyces, Arcanobacterium, Mycobacterium and Propionibacterium might have been misidentified as "diphtheroids". Most Corynebacterium isolates could not be identified to the species level. The named groups listed in decreasing order of frequency were Corynebacterium CDC group D-2, C. CDC group JK, C. minutissimus, C. xerosis, and single isolates of C.
striatum, C. pseudodiphthericum, C. aquaticum, C. CDC group G-1 and C. CDC group F-1. As data accumulate, it is increasingly evident that the identification of these gram-positive isolates to genus and sometimes species is clinically relevant. The Nocardia, Erysipelothrix, and Mycobacterium are rarely isolated without being involved in a disease process, As recognition increases, wound infections with Mycobacterium spp. are reported more commonly (14). In contrast, all the other genera that we isolated are considered as part of the normal flora. However, the Ar-
canobacterium, Propionibacterium,
Clinical Microbiology Newsletter 8:5,1986
Table I Simplified Table for
Corynebacterium Identification a'b Utilization o f glucose
Nitrate
Urease
C. diphtheriae
F
+
-
C, ulcerans C, p s e u d o t u b e r c u l o s i s
F F
V
+ +
C. xerosis
F
+
-
C. striatum C. minutissimum
F
+
-
F/O
-
C. kutscheri
F
C. renale C. bovis
F F
Org anism
Maltosea
Sucrose a
+
+
-
+ +
+ +
+
+
+
+
+
-
+
-
+
+
+ or -
+
+
+
+
+
+ -
+ V
+
V
-
F F F F F F F
+ + + V V -
+ + -
+ + + + + + +
V V + V + V
+ + -
C. CDC group A3
F
+ (100)
-
+
+
+
C. CDC group A4
F
V(13)
-
+
+
+
C. CDC group A5
F
V(20)
-
+
+
+
C. p s e u d o d i p h t h e r i c u m
C. CDC group D2
NU NU
+ -
C. C. C. C.
NU NU O NU
. + V .
0
V
C. C. C. C. C. C. C.
CDC CDC CDC CDC CDC CDC CDC
CDC CDC CDC CDC
group group group group group group group
group group group group
G 1c G2 c 11 I2 F1 F2 JK c
ANFI ANF3 B1 B2
C. aquaticum
Glucose a
+ +
.
.
. .
two strains assoc, with rats assoc, with cattle little data
many are antibiotic resistant esculin + , yellow V, motility + esculin + , yellow V, motility V esculin V, yellow V, motility V
. .
.
+ .
-
Tinsdale + Tinsdale + Tinsdale +
many are antibiotic resistant
. .
Comments
. +
V
V
+
+
. esculin V, motility V, yellow +
F = fermentative, O = oxidative, NU = nonutilizer, + = >90% positive, - = <10% positive, V = between 10 and 90% positive. b Adapted from (17). c May require serum for growth. a In our hands, the rapid method described by Thompson et al. (12) is useful.
and A c t i n o m y c e s
apparently have a
Corynebacterium,
e x c e p t for C.
s o c i a t e d w i t h c h r o n i c a b s c e s s e s (2, 13)
greater c a p a c i t y for ulcer o r a b s c e s s f o r m a t i o n (8, 10, 16). In several re-
d i p h t h e r i a e and the s e l e c t e d h i g h l y re-
or h a v e b e e n r e c o v e r e d f r o m speci-
sistant g r o u p s ( i . e . , C. C D C g r o u p J K
m e n s , such as urine or corneal scrap-
v i e w s (6, 10, 16) o n C o r y n e b a c t e r i a spp. or d i p h t h e r o i d s , a large p r o p o r tion o f the d o c u m e n t e d i n f e c t i o n s w e r e c a u s e d b y o r g a n i s m s that h a v e b e e n r e c l a s s i f i e d f r o m C o r y n e b a c t e r i u m to
and C. C D C g r o u p D - 2 ) , a c l e a r pattern o f p a t h o g e n i c i t y has not e m e r g e d . A variety o f C o r y n e b a c t e r i a s p p . , m a n y o f w h i c h c a n n o t b e a s s i g n e d to a k n o w n s p e c i e s , can c a u s e e n d o c a r d i t i s
ings. In s o m e c a s e s , d i s t i n g u i s h i n g c o l o n i z a t i o n f r o m infection is difficult. B e c a u s e m a n y clinically isolated c o r y n e f o r m s are not C o r y n e b a c t e r i u m
either o f t h e s e three g e n e r a or R h o d o -
or p r o s t h e s e s i n f e c t i o n s , situations in
coccus.
w h i c h a d h e r e n c e is a factor (9, 10, 11, 15, 16). O t h e r isolates h a v e b e e n as-
O n the o t h e r h a n d , within the g e n u s
Clinical MicrobiologyNewsletter8:5,1986
© 1986 ElsevierSciencePublishingCo., Inc.
spp. and b e c a u s e the g e n e r a d i f f e r significantly in p a t h o g e n i c i t y , o r g a n i s m s that are isolated f r o m usually sterile sites and in large n u m b e r s should be
0196-4399/86/$0.00 + 02.20
33
identified to the genus level. However, due to the scarcity of data, identification to species within the genus Corynebacterium (except for C. diphtheriae) will give few clues as to the treatment or severity of the disease. In addition, because tests are usually performed by conventional methods, the identification o f the isolate may be too delayed to be clinically useful. Susceptibility results are important, however, because the susceptibility pattern is not predictable. Penicillin, ampicillin, erythromycin, tetracycline, gentamicin, and vancomycin should be tested. Results for organisms that apparently do not grow on Mueller-Hinton agar must be interpreted with caution. Some of the gram-positive bacilli are so exquisitely susceptible that when the standard discs are used, zones may be so large that no growth at all is observed on the plate, Organisms repeatedly isolated from a patient should be identified sufficiently and rapidly so as to confirm that they are indeed the same. Both rapid microbiochemical tests (12) and the API 20S (Analytab Products, Inc., Plainview, NY) (7) have been suggested as faster alternatives to standard methods. Because of the continued taxonomic uncertainty, recording the biochemical profile or test results rather than just the name is advised. This procedure will allow correlation
of organisms with disease processes even though there may be nomenclature changes in the future.
References 1. Barksdale, L. 1981. The genus Co~nebacterium, pp. 1827-1837. In M. P. Start, H. Stolp, H. G. Truper, A. Balows, H. G. Schlegel (eds.), The prokaryotes. Springer-Verlag, Berlin. 2. Berger, S. A. et ai. 1984. Recurrent breast abscesses caused by Co~nebacterium minutissimum. J. Clin. Microbiol. 20:1219- 1220. 3. Clarridge, J. E., and B. B. Simon. 1983. Characteristics and significance of coryneform organisms isolated in a clinical laboratory. Abstracts Annual Meeting, ASM--C239. 4. Ciarridge, J. E., and A. S. Weissfeld. 1984. Aerobic asporogenous gram-positive bacilli. Clin. Microbiol. Newsl. 6:115-t 18. 5. Goodfellow, M., and D. Minnikin. 1981. Introduction to the coryneform bacteria in The prokaryotes. In M. P. Start et al. (eds.), The prokaryotes. Springer-Verlag, Berlin. 6. Kaplan, K., and L. Weinstein. 1969. Diphtheroid infections of man. Ann. Intern. Med. 70:919-29. 7. Kelly, M. C. et al. 1984. Rapid identification of antibiotic resistant Corynebacterium with the API 20S system. J. Clin. Microbiol. 19:245-247. 8. Kovatch, A. L., K. E. Schuit, and R. H. Michaeis. 1983. Corynebacterium hemolyticum. Peritonsillar abscess mimicking diphtheria. J. Am. Med. Assoc. 249:1757-1758.
9. Love, J. W. et al. 1981. Infective endocarditis due to Corynebacterium diphtheriae: report of a case and review of the literature. John Hopkins Med. J. 148:41-42. 10. Lipsky, B. A. et al. 1982. Infections caused by nondiphtheria corynebacteria. Rev. Infect. Dis. 4:1220-35. 11. Sirisanthana, V., and T. Sirisanthana. Co~nebacterium diphtheriae endocarditis. 1983. Ped. Infect. Disease 2:470-71. 12. Thompson, J. S., D. R. GatesDavis, and D. C. T. Yong. 1983. Rapid microbiochemical identification of Corynebacterium diphtheriae and other medically important corynebacterium, J. Clin. Microbiol. 18:926-929. 13. Tompkins, L. S. 1983. Co©'nebacterium hemolyticum. Clin. Microbiol. Newsl. 5:29-30. 14. Vance, D. 1983. Mycobacterium chelonei sternal infection. Clin. Microbiol. Newsl. 5:6-7. 15. Van Scoy, R. E. et ai. 1977. Coryneform bacterial endocarditis. Mayo Clin Proc. 52:216-19. 16. Washington, J. A., II. 1981. Bacteriology, clinical spectrum of disease and therapeutic aspects of coryneform bacterial infection, pp. 68-88. In J, S. Remington and M. N. Swartz (eds.), Current clinical topics in infectious diseases, Vol. 2, McGraw-Hill, New York. 17. Weaver, R. E., and D. G. Hollis. 1983. Gram-positive organisms: a guide to presumptive identification. Centers for Disease Control, Atlanta, GA.
Case Report
Branhamella catarrhalis Pneumonia with Bacteremia Gary V, Doern, Ph.D.
Department of Ctinical Microbiology and Division of Infectious Disease University of Massachusetts Medical Center Worcester. Massachusetts 01605 Roger E. Schmid, M.D.
Division of Infectious Disease Day Kimball Hospital Putnam, Connecticut 06260 Branhamella catarrhalis is now considered an important cause of broncho-
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0196-4399/86/$0.0o + 02.20
pulmonary infections in humans. These include acute exacerbations of bronchitis and frank bacterial pneumonia, usually in patients with antecedent compromised respiratory tract function (10, 11, 13). However, B. catarrhalis bacteremia in association with lower respiratory tract infection is uncommon. Only two cases of patients with bacteremia as a complication of Branhamella pneumonia are reported in the literature (9, 14). Herein, we describe an elderly woman with Branhamella pneumonia who developed bacteremia. An 89-yr-old woman was admitted to
.~ 1986ElsevierSciencePublishingCo. Inc.
the Day Kimball Hospital after a week of increasing shortness of breath. Past medical history included a history of congestive heart failure, with previous episodes of acute pulmonary edema. On admission her temperature was 38.5°C, her pulse was 130/min, her blood pressure was 150/90 mm Hg, and her respiratory rate was 40/rain. Rales were heard in all lung fields. The heart rhythm was irregular. A cardiac murmur was not appreciated. Bilateral pedal edema (3 + ) was noted. Her skin was warm and moist. Initial laboratory studies revealed a leukocyte count of 12,400/ram 3 with
ClinicalMicrobiologyNewsletter8:5.1986