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The First Korean Case of Sphingobacterium Spiritivorum Bacteremia in a Patient with Acute Myeloid Leukemia

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The First Korean Case of Sphingobacterium Spiritivorum Bacteremia in a Patient with Acute Myeloid Leukemia Case Report Clinical Microbiology Ann Lab Med 2013;33:283-287 http://dx.doi.org/10.3343/alm.2013.33.4.283 ISSN 2234-3806 • eISSN 2234-3814 The First Korean Case of Sphingobacterium spiritivorum Bacteremia in a Patient with Acute Myeloid Leukemia Young Rae Koh, M.D.1, Shine Young Kim, M.D.1, Chulhun L Chang, M.D.1, Ho-Jin Shin, M.D.2, Kye-Hyung Kim, M.D.2, and Jongyoun Yi, M.D.1 Departments of Laboratory Medicine1 and Internal Medicine2, Pusan National University School of Medicine, Busan, Korea Sphingobacterium spiritivorum has been rarely isolated from clinical specimens of immu- Received: November 1, 2012 nocompromised patients, and there have been no case reports of S. spiritivorum infection Revision received: January 14, 2013 Accepted: April 30, 2013 in Korea to our knowledge. We report a case of S. spiritivorum bacteremia in a 68-yr-old woman, who was diagnosed with acute myeloid leukemia and subsequently received che- Corresponding author: Jongyoun Yi Department of Laboratory Medicine, Pusan ° motherapy. One day after chemotherapy ended, her body temperature increased to 38.3 C. National University Yangsan Hospital, A gram-negative bacillus was isolated in aerobic blood cultures and identified as S. spiri- 20 Geumo-ro, Mulgeum-eup, Yangsan tivorum by an automated biochemical system. A 16S rRNA sequencing analysis confirmed 626-770, Korea Tel: +82-55-360-1870 that the isolate was S. spiritivorum. The patient received antibiotic therapy for 11 days but Fax: +82-55-360-1880 died of septic shock. This is the first reported case of human S. spiritivorum infection in E-mail: [email protected] Korea. Although human infection is rare, S. spiritivorum can be a fatal opportunistic patho- gen in immunocompromised patients. © The Korean Society for Laboratory Medicine. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecom- mons.org/licenses/by-nc/3.0) which permits Key Words: Sphingobacterium spiritivorum, Bacteremia, Immunocompromised patient, unrestricted non-commercial use, distribution, and reproduction in any medium, provided the 16S rRNA sequencing original work is properly cited. INTRODUCTION the species from human clinical specimens has been rarely re- ported worldwide [5]. Furthermore, Sphingobacterium spiritivo- Sphingobacterium species are non-fermentative, gram-negative rum have been rarely isolated from clinical specimens of immu- rods that are positive for biochemical tests such as catalase and nocompromised patients, and there have been no case reports oxidase production, but are negative for that of indole [1]. Sphin- of S. spiritivorum infection in Korea to our knowledge. We report gobacterium species were previously described as unnamed a case of S. spiritivorum bacteremia in a patient, who had un- bacteria (part of Centers for Disease Control and Prevention dergone chemotherapy for acute myeloid leukemia. group IIk). Holmes et al. [2, 3] proposed the genus name Flavo- bacterium for the bacteria, while in 1983, Yabuuchi et al. [4] first CASE REPORT proposed the name Sphingobacterium for the genus. The genus Sphingobacterium was created to classify organisms that con- A 68-yr-old woman was admitted to our hospital for dyspnea tain large amounts of sphingophospholipid compounds in their that had lasted for 7 days. She had no history of smoking or pul- cell membranes, and have other taxonomic features that distin- monary diseases. A physical examination did not find lymph- guish them from Flavobacterium species [4]. adenopathy or organomegaly. An initial complete blood cell Sphingobacterium species have usually been isolated from count showed the following results: hemoglobin, 11.3 g/dL; white soil, plants, foodstuffs, and water sources, but the isolation of blood cell counts, 2.86×109/L (neutrophils, 40%; lymphocytes, http://dx.doi.org/10.3343/alm.2013.33.4.283 www.annlabmed.org 283 Koh YR, et al. Sphingobacterium spiritivorum bacteremia 9 57%; and monocytes, 3%); platelet counts, 47×10 /L. A periph- hr at 37°C with 5% CO2. Non-hemolytic, light yellow-colored col- eral blood smear revealed pancytopenia with no leukemic onies grew on the BAP (Fig. 1B). A few colonies also grew on blasts. the MAC. Catalase and oxidase tests were positive, but the in- A bone marrow (BM) examination was performed to evaluate dole test was negative. The organism was identified as S. spiri- pancytopenia. The BM aspirate smears and cytochemical stain- tivorum with 98.0% probability using the Vitek 2 Gram-Negative ing showed increased myeloblasts (40%) and other myeloid Identification card (BioMérieux inc., Marcy-l’Etoile, France). precursors. The patient was diagnosed with acute myeloid leu- To confirm the identity of the isolate, 16S ribosomal RNA kemia, not otherwise specified, based on the 2008 WHO classi- (rRNA) sequencing analysis was performed. InstaGene Matrix fication system [6]. (Bio-Rad Laboratories, Hercules, CA, USA) was used to extract She received chemotherapy of cytarabine 160 mg and idaru- the bacterial genomic DNA, and the first 500 base pairs on the bicin 20 mg for 3 days, and idarubucin 20 mg for 4 days. One 5′ end of the 16S rRNA gene were amplified and sequenced us- day after the chemotherapy ended, her body temperature in- ing MicroSeq 500 16S rDNA Bacterial Identification PCR and creased to 38.3°C. Her blood pressure, pulse rate, and respira- Sequencing Kits (Applied Biosystems, Foster City, CA, USA). tory rate were 90/70 mmHg, 110/min, and 20/min, respectively. The sequencing product was analyzed on a 3130 Genetic Ana- Her C-reactive protein (CRP) level increased to 6.31 mg/dL, and lyzer (Applied Biosystems) according to the manufacturer’s in- her procalcitonin level was 0.08 ng/mL (reference range: <0.05 structions. ng/mL). The resulting sequence of the patient-derived isolate was Four sets of blood cultures were collected: 2 sets from periph- compared with sequences stored in GenBank (http://www.ncbi. eral veins and 2 sets from the central venous catheter. The pa- nlm.nih.gov/genbank), EMBL (The European Molecular Biology tient received empirical antibiotic therapy with intravenous ce- Laboratory, http://www.ebi.ac.uk/embl), RDP-II (The Ribosomal fepime (2 g every 12 hr). After 1 day of incubation, gram-nega- Database Project, http://rdp.cme.msu.edu), and EzTaxon (http:// tive bacilli grew in an aerobic culture bottle that contained the www.eztaxon.org) databases. The percent identity between the culture from the central venous catheter. After 2 days of incuba- isolate from the patient and its closely related Sphingobacterium tion, Gram-negative bacilli also grew in an aerobic culture bottle species of the 4 databases are shown in Table 1. The GenBank containing the culture from the peripheral vein (Fig. 1A). The and RDP-II databases showed that the 16S rRNA gene se- positive culture broth was inoculated onto a blood agar plate quence of the isolate from the patient was 100% homologous (BAP) and a MacConkey agar plate (MAC) and incubated for 48 with that of S. spiritivorum strain NCTC 11386 (Accession num- A B Fig. 1. (A) Gram-negative bacilli from smear preparations of the positive blood cultures (Gram stain, ×1,000). (B) Yellow-colored colonies of Sphingobacterium spiritivorum on a blood agar plate. 284 www.annlabmed.org http://dx.doi.org/10.3343/alm.2013.33.4.283 Koh YR, et al. Sphingobacterium spiritivorum bacteremia ber: GenBank, NR044077.1; RDP-II, S000752320). The EMBL pared with those of reference strains of the most closely related and EzTaxon databases showed that the 16S rRNA gene se- Sphingobacterium species present in the GenBank databases. quence of the isolate from the patient was 100% homologous A phylogenetic tree was constructed by the neighbor-joining with that of S. spiritivorum strain ATCC 33861 (Accession num- method using the Microseq 500 bp 16S rRNA sequences (Fig. 2). ber: EMBL, ACHA02000013; EzTaxon, ACHA01000008). The Antimicrobial susceptibility was tested using the AST-N132 isolate from the patient showed percent identity of >99% with S. card from the Vitek 2 system (BioMérieux). The isolate was sus- spiritivorum and >0.8% separation from other species. Thus, ceptible to cefepime, ciprofloxacin, levofloxacin, meropenem, the isolate was confirmed to be S. spiritivorum [7]. minocycline, and trimethoprim-sulfamethoxazole; had moderate For phylogenetic analysis, the resulting sequence was com- susceptibility to cefotaxime, ceftazidime, imipenem, and ticarcil- lin-clavulanic acid; but was resistant to amikacin, aztreonam, Table 1. Sequence comparison between the isolate from the pa- tient and its most similar species colistin, gentamicin, piperacillin, piperacillin-tazobactam, ticar- cillin, and tobramycin. Database Most similar species (percent identity, %) The central venous catheter was removed. The antibiotic regi- GenBank Sp hingobacterium spiritivorum (100), Sphingobacterium anhuiense men was changed from cefepime to ciprofloxacin, because (92), Sphingobacterium composti (90), Sphingobacterium kita- hiroshimense (90), Sphingobacterium faecium (90) nephrotoxicity was suspected to be due to increased blood urea EMBL Sp hingobacterium spiritivorum (100), Sphingobacterium faecium nitrogen and creatinine levels. After 3 days, the patient’s fever (90), Sphingobacterium anhuiense (89), Sphingobacterium mul- subsided. Subsequent blood culture tests were negative for S. tivorum (88) spiritivorum and any other microorganism. However, on the fifth RDP-II Sp hingobacterium spiritivorum (100), Sphingobacterium
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