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Arcanobacterium g/dL, alanine aminotransferase 108 this grouping supported the phenotyp- U/L, and total bilirubin 2.57 mg/dL. ic identification. pyogenes Sepsis Blood and the ear secretion were sub- During the 7 days after admis- in Farmer, Brazil mitted for culture. Cefepime was pre- sion, the patient’s condition worsened, scribed, 2 g/twice a day. cefepime was withdrawn, and am- To the Editor: Three blood cultures grew gram- picillin 6 g/day plus gentamicin 240 pyogenes is a normal inhabitant of positive bacilli, initially identified mg/day were prescribed. The patient the mucous membranes of domestic as spp., sensitive became afebrile, gradually recovered, , such as , , swine, to , ampicillin, ceftriaxone, and was discharged after 28 days of and goats (1). Diseases caused by this gentamicin, clindamycin, vancomycin, therapy. agent have been reported for persons and resistant to erythromycin, as deter- Our patient had otitis media that who live in rural areas and have un- mined by disk-diffusion test. Ear dis- progressed to sepsis, which was di- derlying illnesses such as cancer and charge culture grew Proteus mirabilis, agnosed by clinical, laboratory, and diabetes (2–4). A recent literature sensitive to β-lactams, cephalosporins, imaging findings. The causative agent review (3), elicited by a case of A. and . Subcultures may have been undetectable in ear pyogenes endocarditis, found 13 un- of the gram-positive bacilli on sheep discharge if it was overshadowed by equivocal cases of human blood agar grew pinpointed, grayish, a strain of P. mirabilis, a fastidious with this agent; many patients had a β-hemolytic colonies, identified as A. organism that also colonizes or co-in- history of close contact with domestic pyogenes by use of API Coryne 2.0 fects this site. Endocarditis could not animals. However, septicemia was not kit (bioMérieux, Durham, NC, USA; be ruled out because transesophageal reported. code 4732761). Although susceptibil- echocardiography was not available. In June 2006, a 27-year-old im- ity standards are not available for this A. pyogenes is usually suscep- munocompetent man was hospital- organism, it was considered suscep- tible to benzyl penicillin, ampicillin, ized in Campinas (São Paulo, Brazil) tible to penicillin and ampicillin by gentamicin, and and re- for fever, cough with purulent bloody combining the disk-diffusion test with sistant to trimethoprim/sulfamethox- sputum, and discharge from and pain the MICs, as determined by the Etest azole, streptomycin, and tetracyclines in both ears. The patient was a farmer (0.06 mg/L for penicillin, 0.023 mg/L (10). The isolate from this patient was who lived in the rural Amazon area for ampicillin). sensitive to β-lactams, ceftriaxone, and had extensive contact with cattle Partial 16S rDNA was amplified and gentamicin. However, suscepti- and swine. For the past 3 days he by using primers p27f and BAC1401r bility standards are not available be- had been taking amoxicillin, 1.5 g/ and sequenced by using primers cause A. pyogenes rarely causes dis- day, for chronic otitis media. At the 1100r, 765fs, and 10f. Sequences ease in humans. The patient had taken time of hospital admission, his tem- were compared with those available in oral amoxicillin before admission, perature was 38.9°C, respiratory rate GenBank by using gapped BLASTN but his condition had not improved; 24 breaths/min, and blood pressure 2.0.5 software (5). Identification to subsequent addition of cefepime was 100/70 mm Hg. He had palpable hepa- the level was defined as a also unsuccessful. The organism was tosplenomegaly, but no murmur was 16S rDNA sequence identity >97%. probably sensitive to ampicillin, con- detected in the precordium. Computed Phylogenetic analysis was performed sidering the low MIC and the expect- tomography (CT) scan of his chest by using MEGA version 4.0 (6) after ed serum concentration of the drug, showed multiple pulmonary nodules multiple alignments of data by Clust- but diffusion into the middle ear may and alveolar infiltrates with small cav- alX (7); gaps were treated as missing have been poor or the local conditions ities suggestive of septic infarctions. data. Clustering was performed by the caused by the cholesteatoma may have Abdominal CT scan confirmed hepa- neighbor-joining method (8). Boot- influenced the poor outcome of initial tosplenomegaly with focal lesions in strap analysis was used to evaluate tree therapy. Treatment with intravenous the spleen. CT scan of the middle ear topology of the neighbor-joining data ampicillin plus gentamicin produced showed bilateral cholesteatoma and by performing 1,000 resamplings (9). full recovery. mastoiditis. No abnormalities were BLASTN analysis of the 16S sequence Clinical laboratories do not rou- found during 2 transthoracic echocar- of the isolate showed 99% identity tinely attempt to identify this organism. diography procedures. Laboratory with the 16S sequence of A. pyogenes However, even in the absence of sub- values were PaO 63.4 mm Hg, hemo- 2 (accession no. X79225). Phylogenetic stantial concurrent illness, A. pyogenes globin 11.9 g/dL, thrombocytes 109 × analyses with MEGA grouped this iso- must be considered as an etiologic 3 3 3 3 10 /mm , leukocytes 11.05 × 10 /mm late with A. pyogenes NCTC 5224 in agent of several human , es- with a left shift, serum albumin 2.6 a branch separated from other species; pecially septicemia, for patients with a

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 7, July 2009 1131 LETTERS history of close contact with domestic 9. Felsenstein J. Confidence limits on phy- gamma release assay (IGRA) result animals, mainly cattle and swine. logenies: an approach using the boot- (QuantiFERON-TB in Tube test; Cell- strap. Evolution Int J Org Evolution. 1985;39:783–9. estis International, Carnegie, Victoria, Carlos Emilio Levy, 10. Yoshimura H, Kojima A, Ishimaru M. An- Australia) and an unremarkable chest Rogerio Jesus Pedro, timicrobial susceptibility of Arcanobac- radiograph. On November 30, 2007, Angela Von Nowakonski, terium pyogenes isolated from cattle and she was given prednisone (40 mg/d Luciana Maria Holanda, pigs. J Vet Med. 2000;47:139–43. DOI: 10.1046/j.1439-0450.2000.00315.x for 2 weeks, then tapered) and pre- Marcelo Brocchi, scribed 3 doses of infliximab because and Marcelo Carvalho Ramos Address for correspondence: Marcelo Carvalho of severe inflammation seen during Author affiliation: Universidade Estadual de Ramos, UNICAMP, Internal Medicine, PO Box colonoscopy (5 mg/kg on November Campinas, Campinas, São Paulo, Brazil 6111, Campinas, São Paulo 13083-970, Brazil; 30, 2007, January 4, 2008, and Febru- DOI: 10.3201/eid1507.081072 email: [email protected] ary 15, 2008). She was hospitalized on April 25, 2008, at which time she had References ascites; the fluid contained 1.4 × 109/L leukocytes (79.5% lymphocytes) but 1. Nattermann H, Horsch F. The Corynebac- was negative for acid-fast bacilli on terium pyogenes infection in cattle. I. Inci- dence of the [in German]. Arch direct examination and PCR testing for Exp Veterinarmed. 1977;31:405–13. complex. 2. Ide A, Decostere A, Stuer P, Stuer E, De Laparoscopy on May 2, 2008, showed Laere A, Verlinde T, et al. Arcanobac- Reactivation of extensive peritoneal inflammation. terium pyogenes spondylodiscitis in a veterinary surgeon: plea for cooperation Bovine Tuberculosis Peritoneal biopsy samples contained between medical and veterinary microbi- in Patient Treated acid-fast bacilli and caseating granu- ologists in identification of causal agents lomas; PCR for M. tuberculosis com- of zoonotic infections. Clin Microbiol with Infliximab, plex was positive. At this time, results News. 2006;28:163–7. DOI: 10.1016/j. clinmicnews.2006.10.004 Switzerland of a repeat QuantiFERON-TB in Tube 3. Plamondon M, Martinez G, Raynal L, test and a skin test (TST) Touchette M, Valiquette L. A fatal case To the Editor: Increased risk were negative, but a T-SPOT.TB (Ox- of Arcanobacterium pyogenes endocardi- for reactivation of tuberculosis (TB) ford Immunotec, Abingdon, UK) test tis in a man with no identified after treatment with tumor contact: case report and review of the lit- was positive (6-kDa early secretory erature. Eur J Clin Microbiol Infect Dis. factor (TNF) antagonists, particularly antigenic target [ESAT-6], >20 spots; 2007;26:663–6. DOI: 10.1007/s10096- infliximab, is well documented (1). 10-kDa culture filtrate protein [CFP- 007-0354-9 We describe a case of peritoneal TB, 10], 11 spots). M. bovis ssp. bovis was 4. Hermida Ameijeras A, Romero Jung P, probably resulting from reactivation Cabarcos Ortiz de Barron A, Treviño Cast- grown in cultures of peritoneal biopsy allo M. One case of pneumonia with Ar- of infection af- samples. For culture, the MGIT 960 canobacterium pyogenes [in Spanish]. An ter infliximab treatment. In retrospect, automated culture system (Becton Med Interna (Madrid). 2004;21:334–6. reactivation might have been prevent- Dickinson, Sparks, MD, USA) was 5. Altschul SF, Madden TL, Schäffer AA, able had physicians been aware of the Zhang J, Zhang Z, Miller W, et al. Gapped used. The isolate was identified by BLAST and PSI-BLAST: a new genera- patient’s history of regularly drinking use of a multiplex PCR-based, solid- tion of protein database search programs. fresh cow’s milk from a local farm in phase, reverse-hybridization assay Nucleic Acids Res. 1997;25:3389–402. Switzerland during 1944–45, when (GenoType MTBC, Hain Lifescience DOI: 10.1093/nar/25.17.3389 bovine TB was prevalent. 6. Tamura K, Dudley J, Nei M, Kumar S. GmbH, Nehren, Germany), excluding MEGA4: Molecular Evolutionary Genet- The patient was a 69-year-old M. bovis BCG (2). The patient was ics Analysis (MEGA) software version Swiss woman who was examined for discharged May 30, 2008. In January 4.0. Mol Biol Evol. 2007;24:1596–9. weakness, abdominal pain, increas- 2009, she was much improved after DOI: 10.1093/molbev/msm092 ing abdominal girth, and weight loss 7. Thompson JD, Gibson TJ, Plewniak F, treatment with /rifampin/ Jeanmougin F, Higgins DG. The CLUST- in April 2008. Her history included a ethambutol for 3 months and moxi- AL X Windows interface: flexible strate- diagnosis of Crohn disease in 1978 floxacin/rifampin for 5 months. gies for multiple sequence alignment aid- and treatment with , This case of presumed reactiva- ed by quality analysis tools. Nucleic Acids cyclosporine, and mercaptopurine. Res. 1997;25:4876–4882. DOI: 10.1093/ tion of peritoneal TB caused by M. nar/25.24.4876 In November 2007, during a recur- bovis in a patient treated with inflix- 8. Saitou N, Nei M. The neighbor-joining rence of Crohn disease and while re- imab highlights the need to be aware method: a new method for reconstruct- ceiving treatment with azathioprine, of local epidemiology with regard ing phylogenetic trees. Mol Biol Evol. the patient had a negative interferon 1987;4:406–25. to transmissible infectious diseases.

1132 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 7, July 2009