Journal List > Ann Clin Microbiol > v.19(1) > 1078552

Ann Clin Microbiol. 2016 Mar;19(1):28-31. English.
Published online March 24, 2016.  https://doi.org/10.5145/ACM.2016.19.1.28
Copyright © 2016 The Korean Society of Clinical Microbiology
Two Cases of Medical Device-Related Corynebacterium striatum Infection: A Meningitis and A Sepsis
Sholhui Park,1 Hae-Sun Chung,1 Eui Kyo Seo,2 Yeung Chul Mun,3 and Miae Lee1
1Department of Laboratory Medicine, Ewha Womans University School of Medicine, Seoul, Korea.
2Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea.
3Department of Neurosurgery, Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea.

Correspondence: Miae Lee, Department of Laboratory Medicine, Ewha Womans University School of Medicine, 1071, Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea. (Tel) 82-2-2650-5222, (Fax) 82-2-2650-5091, Email: miae@ewha.ac.kr
Received January 10, 2016; Revised February 25, 2016; Accepted March 07, 2016.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

Corynebacterium striatum is a commonly isolated contaminant in the clinical microbiology. However, it can be an opportunistic pathogen in immunocompromised and even immunocompetent hosts. The increasing prevalence of C. striatum infection has been associated with immunosuppression and prosthetic devices. We report a case of meningitis with cerebrospinal fluid drainage and a case of catheter-related bloodstream infection caused by C. striatum. The isolates were identified as nondiphtherial Corynebacterium species by VITEK 2 (bioMérieux, France) anaerobe and Corynebacterium card. The final identification by 16S rRNA gene sequencing analysis was C. striatum with 99.7% identity and 99.6% identity with C. striatum ATCC 6940, respectively. Both strains were sensitive to vancomycin and gentamicin, but multidrug-resistant to ciprofloxacin, penicillin, erythromycin and imipenem.

Keywords: Bloodstream infection; Corynebacterium striatum; Meningitis; 16S rRNA gene sequencing

INTRODUCTION

The genus Corynebacterium is a group of diverse organisms, which is a normal commensal of human skin and mucous membrane. Of which, Corynebacterium striatum is a frequently isolated species in clinical microbiology and considered as contaminant. However, it can be opportunistic pathogen in immunocompromised and immunocompetent hosts [1]. Ever since the first infection of C. striatum, pleuropulmonary infection, was found [2], this organism has been reported as the cause of a variety of invasive infections, including endocarditis [3], respiratory infection [4], catheter-related bloodstream infection, meningitis with cerebrospinal fluid (CSF) drain. C. striatum has been increasingly reported as true pathogen when patients are immunocompromised and have prosthetic devices [5]. Here, to our knowledge, we present the first case of meningitis with CSF drain in Korea and a case of catheter-related bloodstream infection caused by C. striatum.

CASE REPORTS

1. Case 1

A 74-year-old woman with a history of hypertension was admitted with a diagnosis of spontaneous subarachnoid hemorrhage. She had been hospitalized in neurological intensive care unit after coil embolization of aneurysm. On hospitalization day (HD) 7, she developed a fever of 38.1℃. On HD 8, she was made lumbar puncture with drain due to persistent fever with mental change. She suffered from persistent fever, but it failed to grow any microorganisms from blood, urine, CSF samples except for transtracheal aspirate; methicillin resistant Staphylococcus aureus. Intermittent leak was present from the spinal drain. On HD 14, CSF profile showed elevated white blood cell count 620/µL with 58% neutrophils, and increased protein level; 102 mg/dL. Peripheral white blood cell count was 12,860/µL with 87.4% neutrophils and C-reactive protein increased into 12.84 mg/dL. And then, intravenous vancomycin (750 mg per 12 hours) therapy was empirically initiated when cultures of CSF and the lumbar drain tip were performed. At that time, the inflammation sign of redness and swelling was noted in the lumbar drain insertion site. At the same time, gram positive rods were detected by Gram staining CSF fluid. On HD 15, parentral ceftazidime (2 g per 8 hours) was added, and diphtheroid species (strain 1) grew on blood agar plate (BAP) from the CSF culture. The overnight culture of the thioglycollate broth (NIH Thioglycollate Broth, Becton Dickinson, Sparks, MD, USA) for the lumbar drain tip was inoculated into BAP and MacConkey agar. On HD 16, the same diphtheroid species was yielded on BAP. Fever subsided after 3 days of intravenous vancomycin treatment. She was treated with vancomycin for 14 days and discharged with full recovery.

2. Case 2

A 48-year-old male patient with acute myeloid leukemia failed to achieve complete response. After fludara-busulfex conditioning via a left subclavian venous catheter, he underwent allogeneic peripheral blood stem cell transplantation (allo-PBSCT). Since then, he suffered from diarrhea and developed skin eruption on the 9 th day after allo-PBSCT. On the 15 th day, he developed a fever of 37.9 ℃. The blood profile showed pancytopenia; white blood cell count 540/µL, hemoglobin 6.2 g/dL, platelet count 4,000/µL. C-reactive protein level was elevated to 2.0 mg/dL. Peripheral and central catheter blood were drawn in doublet with urine, and cultured. And then, he was empirically administered with ceftazidime (2 g per 8 hours). After 24 hours incubation, gram positive rods (strain 2) were detected in all four aerobic blood culture bottles at the same time. Subcultures on BAP agar yielded diphtheroid species. Subsequent blood cultures on the 17 th day showed the same results while the culture through the catheter blood yielded the isolates 3.5 hours earlier than the peripheral blood culture. And then, additional teicoplanin (400 mg per 24 hours) was administered. Following blood cultures on the 20 th day showed negative results. Even though parentral antibiotics were changed to meropenem (1 g per 8 hours) and vancomycin (500 mg per 24 hours) on the 21 st day, he expired on the 22 nd day after allo-PBSCT due to acute graft-versus-host disease (GVHD).

3. Identification

Colonies after 24 hours of incubation on blood agar was convex, circular, shiny, moist with entire edges, white to gray and non-hemolytic, about 1 to 1.5 mm in diameter. The results of Gram stain of the cultured bacteria were gram positive rods. Two strains were identified as C. striatum by VITEK 2 (bioMérieux, Marcy l'Etoile, France) anaerobe and Corynebacterium card, although strain 2 was identified as Corynebacterium amycolatum initially. Both strains were positive for catalase and acid productive from glucose, sucrose, galactose, and mannose. They were negative for urease, esculin hydrolysis, and maltose fermentation. To confirm the identification of the isolates, we performed 16S rRNA gene sequencing as described from the previous study [6]. Using the EzTaxon server (http://www.ezbiocloud.net/eztaxon; [7]), both strains were identified as C. striatum with 99.7% identity and 99.6% identity with C. striatum (ATCC 6940) (Table 1).


Table 1
Identification of the isolates
Click for larger image

4. Antimicrobial susceptibility test

To study the antimicrobial susceptibility of the isolates, we evaluated the minimum inhibitory concentrations (MICs) by using Etest (bioMérieux) and Oxoid M.I.C. Evaluator Strip (Thermo Fisher Scientific, Basingstoke, UK). The suspensions of the isolates adjusted to 0.5 McFarland standard were inoculated onto Mueller-Hinton agar plates with 5% sheep blood (Asan Pharm, Seoul, Korea) and incubated at 37℃ for 20 hours. Results of antimicrobial susceptibility regarding strain 1 and strain 2 are shown in Table 2. Both strains were sensitive to vancomycin and gentamicin, but resistant to penicillin, imipenem, erythromycin, and ciprofloxacin.


Table 2
Antimicrobial susceptibility test of the isolates
Click for larger image

DISCUSSION

C. striatum had long been considered as a contaminant from normal skin or nasopharyngeal flora. This opportunistic pathogen needs to be paid attention when isolated from normally sterile body sites, purely cultured, or accompanying strong leukocyte reaction with positive Gram stain [8]. C. striatum have recently been reported as the pathogens of post-operative intra-abdominal infection [9], bacteremia in a patient with tracheostomy and gastrostomy tubes [10] and catheter-related bloodstream infection [11] in Korea, but not meningitis yet. To our knowledge, case 1 is the first case of C. striatum meningitis related with CSF drain in Korea. Laboratory tests in case 1 showed peripheral blood leukocytosis with neutrophilia, increased C-reactive protein level, CSF color change with increased white blood cell count. C. striatum was isolated from CSF sample and the drain tip simultaneously. In case 2, C. striatum was yielded from both peripheral blood and venous catheter blood, and following culture showed the same results with different time to positivity. In both cases, patients were in immunocompromised conditions having indwelling medical devices.

For more reliable identification to the species level, we performed 16S rRNA gene sequence analysis. Analysis of partial 16S rRNA gene sequence might fail to identify Corynebacterium to the species level, since corynebacteria show little polymophism of this gene [12]. When analyzed the whole gene sequence, most species in Corynebacterium can be distinguished [13]. We successfully identified two strains to the species level by analyzing the full length of 16S rRNA gene sequence.

Multidrug-resistant C. striatum has been implicated especially in long-term hospitalized patients [14], and the most frequent mechanism of antibiotic resistance in Corynebacterium species is the transmission of extrachromosomal genetic elements on large plasmids or on transposons [15]. Since the antimicrobial susceptibility of C. striatum is not predictable due to the emergence of multidrug resistance, antimicrobial susceptibility test should be performed for correct treatment. In these cases, both two strains were highly resistant to penicillin, imipenem, ciprofloxacin. All were resistant to erythromycin, but susceptible to gentamicin and vancomycin. As previously reported [14], we confirmed that the empirical treatment of choice for Corynebacterium species infection is vancomycin. Case 1 was treated with parentral vancomycin and fully recovered from the C. striatum infection. Case 2 expired due mainly to acute GVHD, therefore we could not assess the outcome of catheter-related bloodstream infection by C. striatum.

In our report, we present that C. striatum should be considered as pathogens in CSF and bloodstream in immunocompromised patients with medical devices. And in addition to phenotypic data, 16S rRNA gene sequencing could be a good tool for more reliable identification of genus Corynebacterium into species level. The C. striatum isolates were multidrug-resistant, but still vancomycin could be a choice of an empirical therapy.

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