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Native Valve Endocarditis Due to Corynebacterium Striatum

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Native Valve Endocarditis Due to Corynebacterium Striatum Case Report Infection & http://dx.doi.org/10.3947/ic.2016.48.3.239 Infect Chemother 2016;48(3):239-245 Chemotherapy ISSN 2093-2340 (Print) · ISSN 2092-6448 (Online) Native Valve Endocarditis due to Corynebacterium striatum confirmed by 16S Ribosomal RNA Sequencing: A Case Report and Literature Review Hyo-Lim Hong1, Hwi-In Koh1, and A-Jin Lee2 1Department of Internal Medicine; and 2Department of Laboratory Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea Corynebacterium species are non-fermentous Gram-positive bacilli that are normal flora of human skin and mucous mem- branes and are commonly isolated in clinical specimens. Non-diphtheriae Corynebacterium are regarded as contaminants when found in blood culture. Currently, Corynebacterium striatum is considered one of the emerging nosocomial agents im- plicated in endocarditis and serious infections. We report a case of native-valve infective endocarditis caused by C. striatum, which was misidentified by automated identification system but identified accurately by 16S ribosomal RNA sequencing, in a 55-year-old male patient. The patient had two mobile vegetations on his mitral valve, both of which had high embolic risk. Through surgical valve replacement and an antibiotic regimen, the patient recovered completely. In unusual clinical scenarios, C. striatum should not be simply dismissed as a contaminant when isolated from clinical specimens. The possibility of C. striatum infection should be considered even in an immunocompetent patient, and we suggest a genotypic assay, such as 16S rRNA se- quencing, to confirm species identity. Key Words: Corynebacterium; Endocarditis; RNA, Ribosomal, 16S Introduction Recently, there have been increasingly frequent reports of in- fection by non-diphtheriae Corynebacterium in immuno- Corynebacterium species are non-spore-forming aerobic compromised patients who were hospitalized or in immuno- Gram-positive bacilli that are spread widely in the environ- competent patients who had implanted medical devices. ment and constitute part of the normal flora on skin and mu- Corynebacterium striatum is a commonly-isolated coryne- cosa in humans [1, 2]. In a hospital setting, non-diphtheriae bacteria in the clinical microbiology laboratory, although con- Corynebacterium are commonly considered contaminants firmed infections from sterile sites are relatively rare [3]. C. when found in blood cultures because of their low virulence. striatum can cause pulmonary abscess, meningitis, septic ar- Received: July 7, 2016 Revised: July 19, 2016 Accepted: July 21, 2016 Corresponding Author : Hyo-Lim Hong, MD Department of Internal Medicine, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro, 17-gil Nam-gu, Daegu 42472, Korea Tel: +82-53-650-4708, Fax: +82-53-621-4106 E-mail : [email protected] This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and repro- duction in any medium, provided the original work is properly cited. Copyrights © 2016 by The Korean Society of Infectious Diseases | Korean Society for Chemotherapy www.icjournal.org 15-증례 -16-603 홍효림.indd 1 2016-09-29 오후 1:55:22 240 Hong HL, et al. • Infective endocarditis due to Corynebacterium striatum www.icjournal.org thritis, vertebral osteomyelitis, catheter-related blood stream of definitive laboratory guidelines for determining the antibi- infection and native- and prosthetic-valve endocarditis [2-5]. otic susceptibility. While the initial blood culture was regarded The aid of molecular diagnostic methods, especially the 16S as contaminated, when the same pathogen was isolated from rRNA and rpoB gene sequencing, has greatly improved the the consecutive blood culture, we determined that K. kristinae ability to detect C. striatum in clinical specimen [5, 6]. Here, might be the true pathogen. At this time, initial empiric ceftazi- we report a case of native-valve endocarditis caused by C. stri- dime and metronidazole were discontinued and intravenous atum, which was accurately identified by 16S ribosomal RNA vancomycin was maintained. Because K. kristinae is not a sequencing in a non-immunocompromised patient. common infective endocarditis pathogen, we also performed 16S rRNA sequencing analysis to confirm the identification of the pathogen in the blood isolates. The universal eubacterial Case Report primers fU1 (5’-TTGGAGAGTTTGATCCTGGCTC-3’) and rU2 (GGACTACCAGGGTATCTAA-3’) were used. The 16S rRNA A 55-year-old man with no significant medical history was gene sequence (766 bp) was blasted with NCBI Blast website transferred to our hospital with a 14-day history of fever and http://blast.ncbi.nlm.nih.gov/Blast.cgi. The sequence was lethargy. Over the previous 5 weeks, he had been treated for 99.00% identical to that of C. striatum was identified (GenBank traumatic subdural hemorrhage after a car accident. Two accession number JF342700.1). Transthoracic echocardiogra- weeks prior to transfer, a high fever suddenly developed and phy showed 2 mobile oscillating masses at the tip of the mitral persisted despite administration of broad-spectrum antibiot- valve leaflet. Transesophageal echocardiography revealed two ics including ceftriaxone, piperacillin-tazobactam, or mero- hypermobile echogenic masses on the anterior and posterior penem in combination with moxifloxacin. There was a healing mitral valve leaflets, 10 mm and 8 mm, respectively (Fig. 1). abrasion on his hand after the car accident, but there were no There was no involvement of either the subvalvular structure stigmata of endocarditis. He had no indwelling medical device or paravalvular structure. There was no evidence of any meta- and no medical history of allergy. static lesions at other sites. On admission to our hospital, his blood pressure was Thus, the patient was diagnosed with C. striatum infective 150/100 mmHg, pulse rate was regular at 100 beats per min- endocarditis not K. kristinae infective endocarditis. After van- ute, and temperature was 38.0℃. He was slightly drowsy and comycin was administrated, the fever subsided dramatically. confused but exhibited no neurologic deformity. Heart sounds Because of the high embolic risk, mitral valve replacement were regular without murmur, and breathing sounds were was performed. Interestingly, K. kristinae, which was found in normal. the blood cultures, was also cultured from mitral valve vegeta- His white blood cell count was 7,400/mm3 with 79.4% neutro- phils. Laboratory data were as follows: hemoglobin, 11.2 g/dL; platelets, 251,000/mm3; C-reactive protein, 79.7 mg/dL; procalci- tonin 0.18 ng/mL; and erythrocyte sedimentation rate, 52 mm/ h. Electrolyte levels and kidney and liver function tests were normal. Electrocardiogram showed normal sinus rhythm. Computed tomography (CT) of the chest showed pulmonary emphyse- ma, and abdominal CT was normal. Brain CT revealed a small, chronic subdural hematoma on the left frontal convexity. The patient initially received 2 g ceftazidime intravenously every 8 hours in combination with oral metronidazole (500 mg every 8 hours). On the third day of admission, 2 separate sets of blood cultures were positive for Gram-positive cocci. After Figure 1. Transesophageal echocardiogram findings. Large, hypermobile the second set of blood cultures, intravenous vancomycin (1 g vegetations were attached to the middle scallop of the anterior (arrowhead) every 12 h) was added empirically. On the sixth day, Kocuria and posterior mitral valve leaflets (arrow), 10 mm and 8 mm, respectively. kristinae was identified in both blood cultures using the Vitek Vegetation on the posterior mitral valve leaflet showed a 7 mm lineal mo- bile structure, which indicates a high embolic risk. 2 system (bioMérieux, Marcy-l’Etoile, France) in the absence LA, left atrium; LV, left ventricle; Ao, aorta. 15-증례 -16-603 홍효림.indd 2 2016-09-29 오후 1:55:23 www.icjournal.org http://dx.doi.org/10.3947/ic.2016.48.3.239 • Infect Chemother 2016;48(3):239-245 241 tion despite administration of vancomycin for 14 days. The sion received during a traffic accident, but had not required a patient completed 6 weeks of intravenous vancomycin for central venous catheter. prosthetic valve endocarditis. At a follow-up over one year lat- One interesting finding is thatC. striatum can be misidenti- er, the patient remained free of infection fied as K. kristinae using automated systems (bioMérieux Vitek 2 GP card). Identification of the genusCorynebacterium to species level is usually based on biochemical tests. Though Discussion API Coryne system is a useful tool for identifying Corynebac- terium species in the clinical laboratory, this may not incorpo- Non-diphtheriae Corynebacterium are commonly isolated rate all of the tests necessary for the identification of every Co- from clinical specimens but are typically considered contami- rynebacterium species. In recent years, the introduction of nants. In addition to C. diphtheriae, Corynebacterium are molecular methods, especially 16S rRNA gene and rpoB gene considered organisms that are normal inhabitants of human sequencing, has improved the ability to identification of Cory- skin and respiratory tract [1-3, 7]. Also, with the use of molec- nebacterium species [5, 6, 10]. In our case, the causative or- ular diagnostic methods, the taxonomy of Corynebacterium ganism was misidentified as K. kristinae by the commercial species has changed and has been
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