Indian Journal of Medical Microbiology, (2005) 23 (1):63-65 Case Report SEPTIC ARTHRITIS DUE TO ARCANOBACTERIUM HAEMOLYTICUM R Goyal, *NP Singh, M Mathur Abstract Diphtheroids or “coryneform” bacilli are usually considered to be nonpathogenic “normal flora” of human skin and mucous membranes. Because bacterial cultures are frequently contaminated with these organisms the correct diagnosis and treatment may be delayed by the failure to recognize serious infections caused by them. Few confirmed cases of orthopaedic infections due to Arcanobacterium haemolyticum infection have been reported, partly because of inadequate identification of this bacterium. We report a case of septic arthritis due to A. haemolyticum. Key words: Arcanobacterium haemolyticum, septic arthritis Arcanobacterium haemolyticum, formerly known as left knee with decreased range of motion. The peripheral Corynebacterium haemolyticum was first isolated from blood leukocyte count was 12,000/mm3 with 84% nasopharynx and skin of American soldiers in the south neutrophils and 16% monocytes. ESR (69 mm/hour) and pacific in 1946. It was elevated to the genus CRP (8.9 mg/dL) values were elevated. Knee radiograph Arcanobacterium on the basis of genetic analysis in showed soft tissue swelling with joint narrowing and 1982, and has been associated with pharyngitis, osteophyte formation. Synovial fluid aspirated from the recurrent throat infections, wound infections, affected joint revealed total leukocyte count of 98,000/ septicaemia, endocarditis and osteomyelitis.1 Although mm3 with 98% segmented neutrophils and 2% it is the etiological agent of distinct human infections, monocytes. Gram stain of the aspirated fluid showed the organism is frequently overlooked, probably because gram positive bacilli along with pus cells. No fungal of tendency of microbiology laboratories to report elements were seen. Ziehl Neelsen staining was negative diphtheroid organisms of Corynebacterium spp. as for acid-fast bacilli. Empiric therapy with intravenous contaminants or normal flora, resulting in missed or amikacin (intravenous, 500 mg, 12 hourly) and augmentin delayed diagnosis.1,2 We present a case of septic arthritis (amoxycillin - clavulanate, intravenous, 1.2 gm, 8 hourly) caused by Arcanobacterium haemolyticum. The was started. purpose of this report is to increase the awareness of the pathogenic potential of this organism in bone and The culture of the aspirated fluid revealed small joint infections. pinpoint colonies on 5% sheep blood agar after 24 hours of incubation, which increased in size to 0.5mm with a Case Report narrow zone of β hemolysis after 48 hours of incubation. The isolate was identified as Arcanobacterium A 44-year-old male presented with a two day history haemolyticum on the basis of biochemical tests.3,4 Blood of severe pain in left knee joint along with hot swollen cultures and throat swab cultures did not grow A. knee and fever. There was no history of trauma and the haemolyticum. The organism was sensitive to penicillin, patient was a known case of osteoarthritis for last two augmentin, erythromycin, ciprofloxacin, cefotaxime and years for which he was receiving analgesics. In view of vancomycin. After antimicrobial susceptibility report the increasing pain and knee stiffness he was advised amikacin was withdrawn and intravenous augmentin, 1.2 three doses of weekly intra-articular triamcinolone (40 gm, eight-hourly was given, and the patient had mg) injection. His joint symptoms improved after first diminished pain and joint swelling with decreasing CRP injection but he developed severe pain in left knee along during the subsequent three days. After three days of with fever after the second intra-articular steroid intravenous augmentin, oral augmentin, (625 mg eight- injection. hourly) was continued for a week. The patient had On physical examination his temperature was 40°C. uneventful recovery. He had a markedly oedematous, tender and hyperaemic Discussion *Corresponding author (email: <[email protected]>) A. haemolyticum is a gram positive to gram variable Department of Microbiology , University College of Medical Sciences, Guru Tegh Bahadur Hospital, Delhi -110 095, India. pleomorphic rod, non-motile and non-sporulating. In Received:29-04-2004 fresh cultures (<48 hours) organisms are strongly gram- Accepted: 19-05-2004 positive but in older cultures (>48 hours) organisms www.ijmm.org 64 Indian Journal of Medical Microbiology Vol.23, No.1 appear both gram positive and gram negative.1 Optimum easily differentiated as Actinomyces pyogenes growth is obtained on blood or serum enriched medium hydrolyses gelatin rapidly, produce acid from xylose and at 37°C and is enhanced by culturing the organism in produce β-glucoronidase.3 the presence of 5-10% CO2. On horse or sheep blood agar, colonies are circular, discoid, opaque and whitish A. haemolyticum has recently been accepted as an with a rough surface and friable consistency and important human pathogen but has been reported averages 0.1 mm with little or no hemolysis after 24 hours infrequently, as a cause of well defined infections, incubation. At 48 to 72 hours, colonies reach 0.5 mm with probably because of failure to correctly identify the 1 a narrow 1 mm zone of β haemolysis. However, on 5% pathogen in the clinical specimens. A. haemolyticum human blood agar prominent haemolysis is seen within has been implicated as an important cause of pharyngitis 24 hours. The organism is catalase, oxidase, indole and in adolescents and young adults, frequently causing an urease negative, and produces acid but not gas from exanthema that may mimic a viral exanthema, toxic glucose, lactose, trehalose, salicin and maltose but does erythema or drug eruption which usually resolves in a 5 not ferment mannitol or xylose. Sucrose fermentation is few days with or without therapy. Serious infections variable. It hydrolyses starch, produces opalescence on such as brain abscesses, meningitis, septicaemia, lecithovitellin agar, gelatin is not liquefied within 14 days endocarditis and osteomyelitis occur less frequently 1,6-8 and nitrate is not reduced. It grows poorly on tellurite but are fatal if not treated early. Other less serious agar, gives no hemolysis in CAMP test (reverse CAMP infections include chronic skin ulcers, cellulitis and otitis 1,4 test positive) and produces deoxyribonucleases.3,4 A. media. haemolyticum closely resembles Actinomyces pyogenes The role of this organism in orthopaedic infections that is also gram-positive, catalase negative and produce β is not clearly established and is limited to few reports hemolytic colonies. However, the two organisms are (Table). Table: Characteristics of patients with Arcanobacterium haemolyticum infection Reference Year Age/Sex Site of infection Associated factors Outcome 1 1961 A/M Osteomyelitis Fracture Treated 7 1977 71/F Foot ulceration with Diabetes Treated vertebral osteomyelitis 8 1990 24/F Ankle joint infection Trauma Treated 10 1995 16/M Subperiosteal abscess – Treated 9 2003 45/M Chronic osteomyelitis – – A. haemolyticum has been isolated from pus drained was not isolated from abscess itself.10 The pathogenesis from ankle joint, which had resulted probably due to of the present case is not entirely clear, probably the spread of infection from abrasion over medial malleolus.10 patient acquired A. haemolyticum infection from his Ceilley reported A.haemolyticum from a woman with colonized skin or contaminated needle during intra- diabetic ulcer who developed vertebral osteomyelitis and articular steroid injection. the organism was isolated from blood and first lumbar vertebrae and he has also mentioned of a case who In view of increasing recognition of the pathogenic developed osteomyelitis following a fracture.1,8 Recently, potential of diphtheroids in clinical disease, all the Biswas et al reported a case of chronic osteomyelitis due aerobic nonspore forming gram positive bacilli obtained to A.haemolyticum and the patient responded to in pure culture from sterile sources should be identified. clindamycin.9 Subperiosteal abscess has been reported The correct identification and antibiotic sensitivity as a complication of orbital cellulitis but the organism testing of such isolates is essential for the proper management of infected individuals. www.ijmm.org January, 2005 Goyal et al – A.haemolyticum Septic Arthritis 65 References 1. Wagner DC. Arcanobacterium haemolyticum: biology of 6. Altmann G, Bogokowsky B. Brain abscess due to the organism and diseases in man. Pediatr Infect Dis J Corynebacterium haemolyticum. Lancet 1973;1:378-9. 1991; 10:933-39. 7. Hoosen AA, Rassol MN. Roux L. Post traumatic ankle 2. Linder R. Rhodococcus equi and Arcanobacterium joint infection with Arcanobacterium haemolyticum: a case haemolyticum: two “coryneform” bacteria increasingly report. J Infect Dis 1990;162:780-1 recognized as agents of human infections. Emerg Infect Dis 1997; 3:145-53. 8. Ceilley RI. Foot ulceration and vertebral osteomyelitis with Corynebacterium haemolyticum. Arch Dermatol 3. Cowan & steel. Manual for the identification of medical 1977; 113: 646-7. bacteria. 3rd ed. Barrow GI, Feltham RKA. Eds. (Cambridge University Press, London) 1993; 51-93. 9. Biswas D, Gupta P, Gupta P, Prasad R, Arya M. A case of chronic osteomyelitis due to Arcanobacterium 4. Bhat C, Hemashettar BN, Patil CS. Arcanobacterium haemolyticum. Ind J Med Microbiol 2003; 21:209-10. haemolyticum in chronic wound infection. Ind J Med Microbiol 1997; 15(1): 41-42. 10. Ford JG, Yeatts RP, Givner LB. Orbital cellulitis, Subperiosteal abscess, sinusitis, and septicemia caused by 5. Gaston DA, Zurowski SM. Arcanobacterium Arcanobacterium haemolyticum. Am J Ophthalmol haemolyticum pharyngitis and exanthema. Arch Dermatol 1995;120:261-2. 1996; 132:61-64. www.ijmm.org.