LETTERS

J. Natalia Jiménez, 8. Chen H, Liu Y, Jiang X, Chen M, Wang report describes a male infant with Lázaro A. Vélez, H. Rapid change of methicillin-resis- early-onset sepsis caused by G. tant Staphylococcus aureus clones in José R. Mediavilla, a Chinese tertiary care hospital over a adiacens. Molecular genetic studies Ana M. Ocampo, 15-year period. Antimicrob Agents Che- identifi ed the same organism in fl ora Johanna M. Vanegas, mother. 2010;54:1842–7. doi:10.1128/ isolated from the maternal cervix, Erika A. Rodríguez, AAC.01563-09 which suggests vertical transmission. 9. Ruimy R, Angebault C, Djossou F, Du- Barry N. Kreiswirth, pont C, Epelboin L, Jarraud S, et al. Are After 36 weeks’ gestation, a and Margarita M. Correa host genetics the predominant determi- male infant, weighing 2,850 g, was Author affi liations: Universidad de Antioquia, nant of persistent nasal Staphylococcus born by repeat caesarean section to a aureus carriage in humans? J Infect Dis. Medellín, Colombia (J.N. Jiménez, L.A. 37-year-old woman who was negative 2010;202:924–34. doi:10.1086/655901 Vélez, A.M. Ocampo, J.M. Vanegas, E.A. 10. van der Mee-Marquet N, François P, for group B ; she began Rodríguez, M.M. Correa); and University Domelier-Valentin AS, Coulomb F, De- labor without rupture of membranes. of Medicine and Dentistry of New Jersey, creux C, Hombrock-Allet C, et al. Emer- Apgar scores were 9 and 9 at 1 and gence of unusual bloodstream infections Newark, New Jersey, USA (J.R. Mediavilla, 5 minutes, respectively. Respiratory associated with pig-borne-like Staphylo- B.N. Kreiswirth) coccus aureus ST398 in France. Clin In- distress developed in the infant within fect Dis. 2011;52:152–3. doi:10.1093/cid/ an hour of birth. Peripheral blood and DOI: http://dx.doi.org/10.3201/eid1710.110638 ciq053 cerebrospinal fl uid (CSF) samples References were obtained, and intravenous Address for correspondence: J. Natalia Jiménez, ampicillin (150 mg/kg every 12 h) 1. Springer B, Orendi U, Much P, Hoger G, Grupo de Microbiología Molecular, Escuela and gentamicin (4 mg/kg every 24 Ruppitsch W, Krziwanek K, et al. Meth- de Microbiología, Universidad de Antioquia, icillin-resistant Staphylococcus aureus: a h) were administered. Leukocyte Bloque 5, Ofi cina 135, Calle 67 No. 53-108, 3 new zoonotic agent? Wien Klin Wochen- count was 27,000/mm with 79% schr. 2009;121:86–90. doi:10.1007/ Medellín, Colombia; email: judynatalia@ polymorphonuclear leukocytes and s00508-008-1126-y yahoo.com 2% band forms; platelet count was 2. Witte W, Strommenger B, Stanek C, 3 Cuny C. Methicillin-resistant Staphy- 223,000/mm . CSF cell counts were 3 3 lococcus aureus ST398 in humans and leukocytes/mm and 18 erythrocytes/ animals, central Europe. Emerg In- mm3. fect Dis. 2007;13:255–8. doi:10.3201/ Respiratory distress progressed eid1302.060924 3. Cui S, Li J, Hu C, Jin S, Li F, Guo Y, et al. rapidly, and at 20 hours of life, Isolation and characterization of methicil- mechanical ventilation was instituted. lin-resistant Staphylococcus aureus from Chest radiograph demonstrated swine and workers in China. J Antimicrob diffuse, bilateral interstitial infi ltrates Chemother. 2009;64:680–3. doi:10.1093/ adiacens and jac/dkp275 consistent with pneumonia. Persistent 4. Khanna T, Friendship R, Dewey C, Weese Early-Onset Sepsis pulmonary hypertension was JS. Methicillin-resistant Staphylococcus in Neonate diagnosed by echocardiography. aureus colonization in pigs and pig farm- Peripheral blood culture yielded G. ers. Vet Microbiol. 2008;128:298–303. doi:10.1016/j.vetmic.2007.10.006 To the Editor: (API 20 STREP, bioMérieux 5. Smith TC, Male MJ, Harper AL, Kroeger and , formerly known Clinical Diagnostics, Durham, NC, JS, Tinkler GP, Moritz ED, et al. Methi- as nutritionally variant streptococci, USA) that was sensitive to vancomycin. cillin-resistant Staphylococcus aureus are normal fl ora of the human upper Repeat blood samples were obtained (MRSA) strain ST398 is present in mid- western U.S. swine and swine workers. respiratory, gastrointestinal, and before and after antimicrobial PLoS ONE. 2009;4:e4258. doi:10.1371/ urogenital tracts (1). G. adiacens has drug treatment was changed to journal.pone.0004258 been associated with bacteremia and vancomycin, 10 mg/kg every 12 h, 6. Bhat M, Dumortier C, Taylor B, Miller endovascular, central nervous system, and gentamicin, 4 mg/kg every 24 h. M, Vasquez G, Yunen J, et al. Staphylo- coccus aureus ST398, New York City ocular, oral, bone and joint, and CSF culture and repeat blood cultures and Dominican Republic. Emerg In- genitourinary infections (1–4). had no growth. Vancomycin and fect Dis. 2009;15:285–7. doi:10.3201/ Although streptococci are a gentamicin were administered for 14 eid1502.080609 frequent cause of early-onset sepsis days. The patient eventually recovered 7. van Belkum A, Melles DC, Peeters JK, van Leeuwen WB, van Duijkeren E, Hui- in newborns, non–group B or D and was discharged after 25 days jsdens XW, et al. Methicillin-resistant streptococci comprise only ≈1% of of hospitalization. The biochemical and -susceptible Staphylococcus aureus cases of early-onset neonatal sepsis; identifi cation of G. adiacens in the sequence type 398 in pigs and humans. the condition is primarily associated blood culture was confi rmed by 16S Emerg Infect Dis. 2008;14:479–83. with (5). This rRNA gene sequencing.

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Cervical samples for culturing were obtained from the mother 4 days after delivery. After samples were plated on blood and chocolate agar, colonies were harvested from the primary plates, and pooled bacterial DNA was isolated for further analyses. A primer pair was designed to amplify a 422-bp fragment unique to G. adiacens. These primers (sense, 5 ′ -GGTTTATCCTTAGAAAG GAGGT-3′, and antisense, 5′-GAGC ATTCGGTTGGGCACTCTAG-3′) were used to amplify G. adiacens from DNA prepared from the bacterial pools isolated from maternal cervix and, as control, from DNA prepared from the infant’s blood culture isolate. DNA amplicons underwent Figure. PCR amplifi cation of Granulicatella adiacens DNA. DNA was prepared from the indicated, PCR-amplifi ed with G. adiacens–specifi c primers, and subjected agarose gel electrophoresis with to agarose gel electrophoresis with ethidium bromide staining and ultraviolet light ethidium bromide staining and were visualization. Lane 1, water, negative control; lane 2, G. adiacens–positive control, ATCC visualized under ultraviolet light. PCR 49175; lane 3, DH5α Escherichia coli–negative control (Invitrogen, Carlsbad, CA, USA) amplifi cation showed DNA amplicons 18263–012; lane 4, Enterobacter sakazakii–negative control, ATCC BAA-894 (American for the patient’s blood culture, his Type Culture Collection, Manassas, VA, USA); lane 5, patient’s blood culture isolate; lane 6, DNA isolated from a pool of bacteria obtained from the cervix of the patient’s mother. mother’s cervical swab sample, and DNA amplicons were amplifi ed only from the positive control, the patient’s blood culture, a positive control but not for negative and his mother’s cervical swab specimen. Sequence analysis confi rmed all 3 amplicons controls (Figure). Capillary nucleotide as G. adiacens. DNA sequence analysis confi rmed all 3 amplicons as G. adiacens (not conditions, 55% of G. adiacens isolates higher rates of illness and death. On shown). were susceptible to , 63% the basis of studies demonstrating Nutritionally-variant streptococci were susceptible to ceftriaxone, 96% synergy in vitro and in vivo, empiric have been diffi cult to identify because were susceptible to meropenem, and combination therapy with vancomycin they have unique culture requirements, 100% were susceptible to vancomycin and an aminoglycoside has been they exhibit pleomorphic phenotypic (4). A more recent report indicates suggested until susceptibility data features (1), and they demonstrate that the resistance of G. adiacens to are available (10), particularly when satellitism around colonies of β-lactam and macrolide antimicrobial treating serious conditions such as other bacteria. This has led to drugs may be increasing (3). endocarditis (3). misidentifi cation or nonidentifi cation Treatment of G. adiacens infection Reports have increased of serious by using commercially available may be diffi cult. In vitro antimicrobial infections caused by Granulicatella phenotypic testing, prompting the drug susceptibility patterns do not and Abiotrophia, including this report recommendation that 16S rRNA gene correlate well with clinical response to of early onset neonatal sepsis due to G. sequencing be used for G. adiacens treatment, and G. adiacens infections adiacens. One recent study described identifi cation (6). often respond poorly to antimicrobial 8 isolates associated with invasive The Clinical and Laboratory drug treatment. Higher rates of infection in a 4-year period (3). Standards Institute does not bacteriologic failure and relapse rates Increased awareness and identifi cation recommend disk-diffusion testing after treatment have been observed of G. adiacens are likely contributing to determine the susceptibility of G. for G. adiacens infection than for to this increased recognition, with adiacens to antimicrobial drugs and infections with streptococci and earlier cases not detected or diagnosed. suggests broth microdilution MIC other related genera (9). G. adiacens 16S rRNA gene sequencing may testing in cation-adjusted Mueller- endocarditis has been associated with facilitate or confi rm Granulicatella Hinton broth with 2.5%–5% lysed a more severe clinical course than and Abiotrophia spp. as the etiologic horse blood and 0.001% pyridoxine endocarditis caused by enterococci agents of infection. hydrochloride (7,8). Under these or viridans group streptococci, with

1972 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 10, October 2011 LETTERS

Matthew J. Bizzarro, 9. Stein DS, Nelson KE. Endocarditis In July 2008, an 89-year-old man Deborah A. Callan, due to nutritionally defi cient strepto- in Missouri, USA, with a history of cocci: therapeutic dilemma. Rev Infect Patricia A. Farrel, Dis. 1987;9:908–16. doi:10.1093/cli- hypertension received a prescription Louise-Marie Dembry, nids/9.5.908 for metolazone and was given and Patrick G. Gallagher 10. Bouvet A. Human endocarditis due to methotrexate (2.5 mg orally, 3×/wk) nutritionally variant streptococci: Strep- Author affi liations: Yale University School because of a pharmacy error. Two tococcus adjacens and Streptococcus of Medicine, New Haven, Connecticut, defectivus. Eur Heart J. 1995;16 (Suppl weeks later, he showed confusion, USA (M.J. Bizzarro, L.-M. Dembry, P.G. B):24–27. speech diffi culty, and had a fever. Gallagher); and Yale–New Haven Hospital, When hospitalized 3 weeks after New Haven (M.J. Bizzarro, D.A. Callan, Address for correspondence: Patrick G. symptom onset, the patient was drowsy P.A. Farrel, L.-M. Dembry, P.G. Gallagher) Gallagher, Department of Pediatrics, Yale but able to answer questions and University School of Medicine, 333 Cedar St, had a supple neck, plantar responses DOI: http://dx.doi.org/10.3201/eid1710.101967 PO Box 208064, New Haven, CT 06520-8064, in extension, and a temperature of USA; email: [email protected] 38.8°C. Methotrexate treatment was References then stopped. 1. Christensen JJ, Facklam RR. Granuli- Routine laboratory test results catella and Abiotrophia from were within reference ranges, with human clinical specimens. J Clin Mi- the exception of a serum aspartate crobiol. 2001;39:3520–3. doi:10.1128/ JCM.39.10.3520-3523.2001 aminotransferase level of 92 U/L 2. Gensheimer WG, Reddy SY, Mulconry (reference range 0–37 U/L) and an M, Greves C. Abiotrophia/Granulica- alanine aminotransferase level of 78 tella tubo-ovarian abscess in an adoles- Lymphocytic U/L (reference range 0–65 U/L). Two cent virginal female. J Pediatr Adolesc Gynecol. 2010;23:e9–12. doi:10.1016/j. Choriomeningitis blood cultures were sterile, a chest jpag.2009.05.007 with Severe radiograph showed cardiomegaly, and 3. Zheng X, Freeman AF, Villafranca J, cranial computed tomography without Shortridge D, Beyer J, Kabat W, et al. Manifestations, contrast showed moderate cerebral Antimicrobial susceptibilities of invasive pediatric Abiotrophia and Granulicatella Missouri, USA atrophy. isolates. J Clin Microbiol. 2004;42:4323– The patient was empirically 6. doi:10.1128/JCM.42.9.4323-4326.2004 To the Editor: Lymphocytic given intravenous ceftriaxone (1 g) 4. Tuohy MJ, Procop GW, Washington JA. choriomeningitis virus (LCMV) is an and intravenous azithromycin (500 Antimicrobial susceptibility of Abiotro- arenavirus maintained zoonotically mg, 1×/d for 7 days). Two days after phia adiacens and Abiotrophia defectiva. in house mice (Mus musculus) and Diagn Microbiol Infect Dis. 2000;38:189– he was hospitalized, cranial magnetic 91. doi:10.1016/S0732-8893(00)00194-2 may also be carried by pet rodents, resonance imaging showed mild- 5. Bizzarro MJ, Raskind C, Baltimore RS, especially hamsters (1–3). Infection to-moderate, chronic, small vessel Gallagher PG. Seventy-fi ve years of of healthy humans usually results in ischemia and involutional changes. neonatal sepsis at Yale: 1928–2003. Pe- nonspecifi c febrile illness. However, diatrics. 2005;116:595–602. doi:10.1542/ Serologic test results for HIV and peds.2005-0552 LCMV infection can cause severe West Nile virus were negative. On the 6. Woo PC, Fung AM, Lau SK, Chan BY, symptoms, including aseptic fourth hospital day, lumbar puncture Chiu SK, Teng JL, et al. Granulica- meningitis (4). yielded clear, colorless cerebrospinal tella adiacens and Abiotrophia defec- Early data suggested <8% of tiva bacteraemia characterized by 16S fl uid (CSF) containing 1 erythrocyte rRNA gene sequencing. J Med Micro- central nervous system manifestations and 98 leukocytes/high-powered fi eld biol. 2003;52:137–40. doi:10.1099/ of viral etiology were caused by (1% neutrophils, 95% lymphocytes, jmm.0.04950-0 LCMV (5). In contrast, in a more 4% monocytes); protein level was 7. Jorgensen JH, Hindler JF. New consensus recent study of 91 cases of encephalitis guidelines from the Clinical and Labora- 127 mg/dL (reference range 15–45 tory Standards Institute for antimicrobial among persons with potential rodent mg/dL), and glucose level was 40 susceptibility testing of infrequently iso- contact, LCMV was not detected (6). mg/dL (reference range 43–70 mg/ lated or fastidious bacteria. Clin Infect We describe 2 recent unrelated LCMV dL). CSF test results for bacteria, Dis. 2007;44:280–6. doi:10.1086/510431 infections with central nervous system 8. Clinical and Laboratory Standards Insti- cryptococcal antigen, and herpes tute. Methods for antimicrobial dilution manifestations, which were associated simplex virus (HSV) and PCR and disk susceptibility testing of infre- with rodent exposures, as a reminder result for Borrelia burgdorferi were quently isolated or fastidious bacteria; that LCMV should be considered negative. CSF and serum submitted approved guideline–second edition. 30: in cases of aseptic meningitis of (M45–A2). Wayne (PA): The Institute; to the Centers for Disease Control and 2010. unknown etiology. Prevention showed LCMV-specifi c

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 10, October 2011 1973