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Concise Communications 109

Tuberculosis should be considered when broad- coccobacillus, Roseomonas gilardii, in an immuno- spectrum antibiotherapy is ineffective and no evident compromised patient and we also review the literature cause is found for urinary infection following ECL. in order to delineate the epidemiology and pathogenic role of Roseomonas spp. isolated from blood samples. A. Chaumeron ', J. Peceny I, 0. Rauzy2, L. Cuzin', Case report B. Marchou I, J. Ch. Auvergnat ' A 59-year-old man with M1-type acute myelogenous 'Department of Infectious Diseases leukemia developed fever (39°C) while on chemo- (Pr Auvergnat), Purpan Hospital, therapy, 4 months after the implantation of a Hickman Toulouse, France; catheter. One out of the four blood cultures obtained 21nternal Medecine (Pr Carles), through a peripheral vein grew pink-pigmented bacteria Purpan Hospital, and the patient was afebrile when discharged after 10 Toulouse, France days of intravenous imipenem and tobramycin followed by oral ciprofloxacin for 5 days. The patient was re- Revised version accepted 16 August 1997 admitted 2 weeks later with a new febrile episode (39"C), and a similar microorganism was isolated in References two out of three blood cultures. The patient defervesced 1. Federmann M, Kley HK. Mhary tuberculosis after extra- with intravenous ceftazidime for 13 days followed by corporeal shock-wave lithotripsy. N Engl J Med 1990; 323: oral ciprofloxacin for 10 days and was discharged. 1212. A third episode occurred 2 weeks after the second 2. Morano Amado LE, Amador Barciela L, Fernandez AR, discharge. Lysis-centrifugation blood cultures obtained Sapina Llamas IM, Vazquez Alvarez 0, Fernandez Martin J. Extracorporeal shock-wave lithotripsy complicated with through both catheter lumens showed colonies too darytuberculosis. J Urol 1993; 149: 1532-4. numerous to count. A simultaneous peripheral blood 3. Coptcoat MJ, Webb DR, Kellett MJ, et al. The complica- sample treated with lysis-centrifugation showed no tions of extracorporeal shock-wave lithotripsy: management growth. The Hickman catheter was removed after 10 and prevention. Br J Urol 1986; 58: 578-80. days but unfortunately the tip was not sent for culture. 4. Lenk J, Schubert G, Oesterwitz H, Brien G. Urolithiasis The patient was discharged with oral ciprofloxacin and associated with urogenital tuberculosis: clinical and micro- cloxacillin for 7 days. Five months later he has not had biological aspects. Urol Res 1988; 16: 157-9. further episodes of bacteremia. All pink-pigmented 5. Ahuja SS, Ahuja SK, Phelps KR, Thelmo W, Hill R. bacteria grown from blood cultures of the three Hernodynamic confirmation of septic shock in disseminated episodes of bacteremia were identified as Roseomonas tuberculosis. Crit Care Med 1992; 6(20): 901-3. 6. George S, Papa L, Sheds L, Magnussen CR. Septic shock gilardii. due to disseminated tuberculosis. Clin Infect Dis 1996; 22: In all cases, pink-pigmented colonies grew after 48 188-9 h of incubation at 37°C on Columbia blood agar plates. 7. Godwin JE, Coleman AA, Sahn SA. Miliary tuberculosis The Gram stain revealed Gram-negative, non-vacuo- presenting as hepatic and renal failure. Chest 1991; 99: 752- lated coccoid rods, arranged in pairs. The organism 4. grew on MacConkey agar and weakly on Columbia 8. Hussain W, Mutimer D, Harrison R, Hubscher S, Neuberger blood agar at 42°C. Catalase and oxidase tests were J. Fulmiiiant hepatic failure caused by tuberculosis. Gut positive, although the latter test was delayed for 30 s. 1995; 36: 792-4. The organism was non-fermentative on triple sugar 9. Lefering R, Neubauer EA. Steroid controversy in sepsis iron agar, and the API 20NE identification system and septic shock: a metaanalysis. Crit Care Med 1995; 23: (BioMtrieux, Marcy L'Etoile, France) gave positive 1294-303. results for urease production, and oxidation of glucose, arabinose, malate and citrate, while nitrate reduction, glucose fermentation, indole production, arginine di- hydrolase, p-glucosidase (esculinase), gelatinase and p- Bacteremia due to Roseomonas spp. galactosidase tests and oxidation of mannose, mannitol, N-acetylglucosamine, maltose, gluconate, caprate, adi- Clin Microbiol Infect 1998; 4: 109-1 12 pate and phenylacetate were negative (code number Pink-pigmented, oxidative Gram-negative bacteria have 0241045). The API computer database identified the occasionally been isolated from various clinical samples microorganism as Pseudomonas mesophilica, and citrate [l]. However, their clinical significance is still fre- oxidation was the only unacceptable test. Because this quently debated [2]. We report a case of catheter- database does not include the genus Roseomonas, further related bacteremia due to a pink Gram-negative tests were performed to confirm the identification. 110 Clinical Microbiology and Infection, Volume 4 Number 2, February 1998

Fatty acid analysis was pedonned by gas-liquid chronia- (54mg/mL), aztreoiiam (18 mg/niL) and imiperlenl tography as described previously [I ], and identification (54 mg/mL), and they were resistant to cefuroxime of the fatty acid methyl esters was confirmed by (> 16 mg/mL), cefotaxinie (>32 mg/mL), ceftazidinie computer-calculated equivalent carbon-chain-length (> 16 mg/mL) and triInethoprini/sulfaniethoxazole values. The cellular fatty acid composition of the strains (>2/32 mg/mL). No increase in the MICs was observed ~vasidentical to that of previously described pink in the susceptibility patterns of the three isolates after coccoid groups I, I1 and 111, revealing the presence antimicrobial therapy. of ~-OH-CI~(~,CIX:IH. Z-OW-C~X-I, C~~:,III 11,12 and In the MEDLINE index from January 197U to ~-OH-CI~,O~,II,I~,all absent in ,~etlzy(abucteviirm December 1996 we were able to find 10 5atisfactorily riterophilici.rm, and the absence of 3-0H-Cl~0 (present documented cases (1 1 including ours) of Roscor?zorzus in this species of Metliylobartericrnz) [ 11. These data, spp. bacteremia, and these are summarized in Table I. together with the lack of both acetate utilization and Nine cases involved adults and two involved children acid production from methanol, confirmed that our (a previously healthy 9-month-old boy with epiglottitis isolates belonged to the genus Roseamo~as.According and a 15-year-old girl with acute lymphocytic leukemia), to the biochemical characteristics obtained with the median age was 56 years (ranging between 9 the API 20NE system and oxidation of glycerol, the months and 73 years) [2,3].Six patients were female microorganisms were identified as Roseomoms gilardii. and five were male. In nine cases the patients presented All isolates in our case were susceptible to with an underlying disease (eight were inirnuno- ampicillin (50.5mg/InL), amoxicillin/clavulanic acid compromised patients): four of them presented with (S2/1 mg/mL). cefazolin (~4mg/mL), gentamicin acute leukemia [2,4,3], one was diagnosed with cancer, (51 ing/niL), tobramycin (51 mg/mL), amikacin one was diagnosed with Crohn's disease IS], one pre- (54 mg/mL), ciprofloxacin ( s 1 mg/mL), tetracycline sented with end-stage renal disease in hernodialysis [6],

Table 1 C:limcal characteristics of .patients with Ros~oitiunasspp. bacterernia

Underlying Clinical rhcunlemd Anhrnicrobidl Outcollle Yfx/I

Nigsria (11 None Fryer, cpiglottitir 13loorl Ampicillin Curcd USA 19/F Breast cancer Fcvrr, chills BloOd'.r No datd Cured

UFA 62/€ Crohn's disease Fc\er, chills Blood' i. Nct data Curd U5A 57/F AML Fever. chills Blood' No data Cured USA 1O/F AML Fcver. chills nioodd Piperacrllin, Curd gentamicin us.4 6WM Iiitra-abdoiiunal Fexer, schock Blood' Cefatiiandole Ilcath (+3) abscesw

USA 56/M End-stage renal Shock, naucea, Hlood" i. Vanconiycin, L)eath (f 1) disease in voiiiiting dyspnea gcntaiiiicirr hemodi alysis USA 73/F Diabetes mellitu, F~bei-,bronchitis Blood

USA 36/M None Fever Ulood USA 15/F ALL Fever blood^'

Spdlil 59/M AML Fevcr. Threc Blood' irldpsiiia rpi

.'Nine iiionthc I' AML, aCute iiiyclogriious leukeinia; ALL, acute lymphocytic lcukeiir1.i ' Blood cultures obtained through an mdwelling vascular catheter. <:atheter-related bactcrenila. "Purportedly catheter-related bactereinia. ' Norocoiiiially acquired bacterernia. I IMI! innpenern; TOB, tobmmycin: C:IP, ciprofloxacin; CAZ, ceftazidime: TEI, tcicoplanin; VA, vdncoinycui: OX, oxacillin Concise Communications 111 one was habetic [2] and one without immunosup- tetracycline) were susceptible to imipenem, amino- pression had a pancreatic abscess [4]. The two cases glycosides and tetracycline. In our case, despite the without underlying disease were a 9-month-old boy three consecutive courses of adequate antimicrobial with epiglottitis and a previously healthy patient [2]. agents, bacteremia recurred until the catheter was Eight cases were nosocomially acquired. Four of them removed. Unfortunately, there is no information about were diagnosed as catheter-related bacteremias, another what happened with the catheters in seven catheter- three were purportedly catheter-related, and no infor- related bacteremias caused by Roseomonas spp. reported mation was available for one. Among the 11 cases, nine in the literature. had a favorable outcome and two patients developed Pink coccoid oxidase-positive microorganisms septic shock and died before the blood cultures became should not be simply disregarded as contaminants. positive. Microbiologists and clinicians should be aware of the Pink-pigmented, oxidative Gram-negative bacteria potential clinical significance of these microorganisms, have been isolated from various clinical and environ- particularly when isolated in the blood of patients with mental sources. This group includes bacteria with indwelling intravascular devices. different growth and biochemical characteristics [4,7]. In 1993, Rihs et a1 [6] proposed the new genus Acknowledgments Roseonionas (formerly ‘pink coccoid’ CDC groups I to We thank Maria Francisca Vicente and Ignacio Gonzilez IV). Members of this genus are Gram-negative, non- for the gas-liquid chromatography. fermentative, pink-pigmented, coccoid rods, similar to hlethylobacterium mesophilicum (Pseudomonas mesophilica), FranciscoJ. Vasalto, Luis Alcalh, although they differ from it on the basis of cellular Emilia Cercenado, fatty acid composition [l], non-vacuolated coccoid Fernando Garcia-Garrote, morphology on Gram stain, growth at 42”C, growth Marta Rodriguez-Cr&ems, on MacConkey agar, lack of acetate utilization and Emilio Bouza lack of acid production from methanol [7,8]. This Servicio de Microbiologia y new genus includes three named species, Roseomonas Enfermedades Infecciosas, gilardii, Roseomonas cervicalis and Roseomonas fauriae, and Hospital General ‘Gregorio Maraiibn’, three unnamed genomospecies [6]. The natural habitat Madrid, Spain of Roseomonas spp. is not clearly known, although occasional isolates from contaminated saline and plastic Accepted 25 August 1997 ice balls have been reported [l]. Even though isolation of Roseomonas spp. froin clinical samples is uncommon, they have been isolated References from the genitourinary tract, wounds, abscesses and 1. Wallace PL, Hollis DG, Weaver RE, Moss CW. Biochemical and chemical characterization of pink-pigmented oxidative blood [3-5,8]. Recently, Struthers et a1 [2] described bacteria. J Clin Microbiol 1990; 28: 689-93. an overview of cases in which Roseomonas spp. were 2. Struthers M, Wong J, Janda M. An initial appraisal of the isolated froin different clinical samples from 35 patients; clinical significance of Roseomonas species associated with however, in most cases they indicated that the clinical human infections. Clin Infect Dis 1996; 23: 729-33. significance of the isolates was uncertain and suggested 3. Odugbemi T, Nwofor C, Joiner KT. Isolation of an un- that there is a need for detailing the association of identified pink-pigmented bacterium in a clinical specimen. Roseomonas species with specific disease processes. J Clin Microbiol 1988; 26: 1072-3. Information on antimicrobial susceptibilities of the 4. Korvick JA, Rihs JD, Gilardi JL, Yu VL. A pink-pigmented, genus Roseomonas is very scarce (4-61. Rihs et a1 tested oxidative, nonmotile bacterium as cause of opportunistic 26 antimicrobial agents against 42 strains. Some strains infections. Arch Intern Med 1989; 149: 1449-51. were susceptible to penicihns and first-generation 5. Stefansson ED, Agy MB, McGonagle LA. Gram-negative cephalosporins; however, these drugs showed, in organisms that form pink, mucoid colonies cultured from the blood of three chronically ill patients [abstract 6671. In: general, poor in vitro activity against most isolates. Program and abstracts of the 28th Interscience Conference Penicillins combined with a P-lactamase inhibitor were on Antimicrobial Agents and Chemotherapy, Los Angeles, active against many of the isolates [6]. The strain CA. Washington, DC: American Society for Microbiology, isolated in our case was susceptible to ampicillin 1988: 226. and first-generation cephalosporins. Most strains were 6. Rihs JD, Brenner DJ, Weaver RE, Steigerwdt AG, Hollis susceptible to quinolones and 35% were susceptible to DG, Yu VL. Roseomonas, a new genus associated with trimethoprim/sulfamethoxazole. All strains but two bacteremia and other human infections. J Clin Microbiol (one was resistant to tobramycin and another to 1993; 31: 3275-83. 112 Clinical Microbiology and Infection, Volume 4 Number 2, February 1998

7. Gilardi GL, Faur YC. Arctdo~twariiiesophilica and an utl- for the first two hospital days. On the evening of the named caxon, cliriical irolates of pink-pigmented oxidatlve third hospital day, his temperature spiked to 38.4% bacteria. J Chn Microbiol 1984; 10: 616-9. and two blood cultures for niycobacteria were drawn 8. Barzaga KA, Schoch PE, Cunha BA. Bacteremia due to from two different sites, 4 h apart (Bactec 13A mediuiii, CIX Group I1 pink coccoid bacilli. Cliii Infect Dis 1993; Becton Dickinson, Cockeysville, MD) Growth of a 16: 735-6. small, coral-pigmented, Gram-variable, motile, vacuo- lated bacillus was obtained from both cultures by subculture to Sabouraud, buffered charcoal-yeast extract Methylobacterium bacteremia in AIDS and 7H10 agars (Becton-Dickinson, Cockeysvdle, MD). Subcultures to sheep blood, chocolate and MacConkey Clin Miirobiol Infect 1998; 4: 112-1 13 agars were negative. However, this isolate was positive ,Lfetlii'/oborteviiri~i species are rare human pathogens, on rabbit blood agar with no heniolysis. The isolate primarily causing infection in patients with severe grew in 10% methanol, grew at 25" and 37 "C,but did undrrlying diseace and/or in the immunocompromised not grow at 42°C. The organism was aerobic, oxidase, state 11 -41, to our knowledge, only 21 cases of human catalase and urease positive and nitrate negative, typical ~nethylobacteriuminfection have been reported in the of isolates from the genus h.lethylobacteriuin [3]. The world's literature. Underlying diseases reported in these isolate was identified as ,2ilrtliylobdcteriurItri~~spp. by the patients include renal failure, tuberculosis, and malignant Centers for Disease Control and Prevention (Atlanta, neoplasms of the lung and uterus [3].Additionally, Georgia). several methylobacterium infections have been reported We feel that the case described here was a true in leukeniia patients after bone marrow transplantation methylobacterium infection. The patient did have [3].One case of cutaneous infection was reported in concurrent sinusitis and cytomegalovirus retinitis, and an irnmuiiocompetent patient 151, and one case from a HIV-related fever cannot be absolutely excluded, but patient with AIDS (31. Here we describe a case of the magnitude of the fevers would argue against the inethylobacterium bacteremia in a patient with AIDS. first two possibilities, and the acute onset and eventual At Episcopal Hospital in Philadelphia, Pennsylvania, resolution of the fevers with treatment would argue a 35-year-old Hispanic male with AIDS presented with against the last. The fact that two tets of blood cultures, a 5-day history ofinternlittent fever (as high as 39.4"F), drawn 4 h apart, from two different sites, grew the and blurred vision. The patient had a history of HIV same organism is also strong evidence of a true positivity and AIDS, which were documented 9 months bacteremia and probably true infection. The portal of prior to this admission, when he was diagnosed with entry in this patient was not certain, but his occupation Pneimocystix caririii pneumonia. Three weeks prior to in waste collection (during the performance of which admission, the patient had undergone a laparoscopic he described frequent hand lacerations) suggests a cholecystectoniy for cliolelithiasis. He was taking possible source. pentamidine, ranitidine, and alprazolani. The patient :I.lethylobncteriirrn species are saprophytic, pink- was employed as a custodian at the airport and reported pigmented, Gram-negative bacilli that rarely cause fiequent occupational hand lacerations; he denied intra- human disease [ 1-31, Most cases of human infection venous drug use or homosexuality. have been in patients who are inimunocomproniised On examination, he exhibited tachycardia and due to severe underlying disease. or are irn- had a blood pressure of 106/70. His teniperature was munosuppressed; however, one case of cutaneous 37.6"C. Bilateral retinal hemorrhages were noted, more methylobacterium infection has been reported in extensive on the left than on the right. There were an iinmunoconipetent individual 151. The genus right basilar rhonchi. He was anemic (hemoglobin Merliylobarterium includes eight species, ~~4etlzylobucteviirrt1 12.5 g/dL, hematocrit 39%) but had a nornial peripheral extorqcrms, .tf. fijisu uiacfts, M. incsoplz ilicir m , M.or;ear i o - blood white cell count (4750/nini3) and differential; phihrriz. M. radiotokrans, '14. rltodiriunt, rliodcsiunirrn however, the absolute CD.1 count on admission was and A!. zatrrzanii [a]. The classification is based on 6/mnl'. Initial bacterial blood cultures showed no morphology, biochemical characteristics, and DNA growth, and urinalysis and urine culture were negative. homology, which provided the basis for the relocation A lunibar puncture was performed, and did not show of some species from other genera, including evidence of infection. The patient was examined by an Pseirdotnonns and Vibvio. !bfefh)~/obactprr'i~vnspecies in- ophthalmologist, who noted right-sided retinitis and clude organisnis formerly classified as: Pselrdomorlus ditfuse retinal ischemia, without necrosis, vessel sheath- n?esophili~a,Pseirdomonas fnethanolica, Vibrio extorqueris, ing, or vitritis. Protoinonas spp., Protaniinobaiter riibra, and Mycoplasinu The patient's temperature remained below 37.8"C rlAbYA [2J.