Infectious Disease Reports 2016; volume 8:6368 Erysipelothrix rhusiopathiae several weeks.2 Human disease is classified into three forms: a localized cutaneous form Correspondence: Francesco Luzzaro, bacteremia without (erysipeloid) caused by traumatic penetration Microbiology and Virology Unit, A. Manzoni endocarditis: rapid of E. rhusiopathiae, a generalized cutaneous Hospital, Via dell’Eremo 9/11, 23900 Lecco, Italy. identification from positive form and a septicemic form. The latter type of Tel.: +39.0341.489630 - Fax: +39.0341.489601. disease has been previously associated with a E-mail: [email protected] blood culture by MALDI-TOF high incidence of endocarditis. In a previous Key words: Erysipelas; skin and soft tissue infec- mass spectrometry. A case study concerning invasive infection cases tions; antimicrobial treatment; empirical therapy. since 1912, it was reported that about 90% of report and literature review Contributions: LP performed laboratory diagnosis cases of E. rhusiopathiae bacteremia result in and drafted the manuscript; SB, CM and BP per- 3 Luigi Principe, Silvia Bracco, endocarditis. This association has been formed susceptibility tests, analysed data and Carola Mauri, Silvia Tonolo, Beatrice Pini, recently questioned, since some cases of E. contributed to laboratory diagnosis; ST provided Francesco Luzzaro rhusiopathiae bacteremia without subsequent clinical information about the patient; FL con- endocarditis have been reported in the most ceived of the study, participated in its design and Microbiology and Virology Unit, A. recent literature.4-8 Here we report a case of E. coordination, and critically revised the draft man- Manzoni Hospital, Lecco, Italy rhusiopathiae bacteremia, probably started uscript. from an erysipeloid form, in which endocardi- tis did not develop. Furthermore, we used the Conflict of interest: the authors declare no poten- PubMed Database to search for recent case tial conflict of interest. Abstract reports of bloodstream infections caused by E. Received for publication: 17 December 2015. rhusiopathiae. Revision received: 25 January 2016. Erysipelothrix rhusiopathiae is a Gram-posi- Accepted for publication: 25 January 2016. tive bacillus that is infrequently responsible for infections in humans. Three forms have This work is licensed under a Creative Commons been classified: a localized cutaneous form Case Report Attribution-NonCommercial 4.0 International (erysipeloid) caused by traumatic penetration Licenseonly (CC BY-NC 4.0). of E. rhusiopathiae, a generalized cutaneous An Italian citizen (male, 74 years old) pre- form and a septicemic form. The latter type of ©Copyright L. Principe et al., 2016 sented to the emergency department of the Licensee PAGEPress, Italy disease has been previously associated with a San Leopoldo Mandic Hospital in Merate Infectious Disease Reports 2016; 8:6368 high incidence of endocarditis. Here we report (Lecco, Italy) on August, 2014. The patientuse was doi:10.4081/idr.2016.6368 a case of E. rhusiopathiae bacteremia in a 74- in treatment with oral anticoagulant therapy year-old man, probably started from an due to cardiopathy and cerebral vasculopathy. erysipeloid form, in which endocarditis did not On admission, he had a low grade fever develop. This case presents some particular (38.4°C), hearth rate 100 beats per minute, and uncommon features: i) no correlation with blood pressure 125/75 mm of Hg, white blood was performed directly from positive blood cul- animal source; ii) correlation between bac- cell count 4.2×109/L. In addition, he showed ture bottle by matrix-assisted laser desorption teremia and erysipeloid lesion; iii) absence of difficulty in his movement due to a polymor- ionization time-of-flight (MALDI-TOF) mass endocarditis. MALDI-TOF mass spectrometry phic erythema on the right leg characterized spectrometry (VITEK MS, bioMérieux) using allowed to obtain a rapid identification (within by well-defined and raised borders with a local- the following procedure. An aliquot (2.5 mL) of 4 hours from bottle positivity) of E. rhu- ized edematous skin portion and reddening. the blood culture was transferred in a tube siopathiae. Together with direct antimicrobial Based on laboratory and clinical data (modi- with gel separator (BD Vacutainer® Blood susceptibility testing, this approach could fiedcommercial early warning score = 4), the presence of Collection Tubes, Becton, Dickinson and improve the rate of appropriate therapy for sepsis was suspected.9 Together with other Company, Milan, Italy) and centrifuged at 3500 bloodstream infections due to this fastidious interventions (as appropriate for sepsis condi- rpm for 10 minutes. The supernatant was dis- pathogen. tion), two blood cultures were performed and carded and the pellet was inoculated on two Nonsent to the laboratory where they were prompt- blood agar plates incubated at 36°C in O2 and ly incubated in the BacT/ALERT instrument 5% CO2, respectively. After a short term incu- (bioMérieux, Marcy l’Etoile, France). No bio- bation period (4 hours), microbial identifica- Introduction logical samples from leg were sent to the tion was obtained by the VITEK MS directly microbiology laboratory. Therapy with ceftriax- from bacterial growth on agar plates. Erysipelothrix rhusiopathiae is a Gram-posi- one (1 g twice daily) plus azithromycin (500 Microorganisms recovered from agar plates tive bacillus that is infrequently responsible mg daily) was then initiated. The patient were directly applied to VITEK MS target slide for infections in humans. Human disease, recalled that the lesion, then classified as in duplicate (two spots for each isolate) and although rare, can originate from animal or erysipelas, had been present for about two were covered with one microliter of CHCA (α- environmental sources. To this regard, animal months. No contact with animals were report- Cyano-4-hydroxycinnamic acid) matrix. sources are often associated with occupational ed. However, physicians observed that the E. rhusiopathiae was identified according to exposure (butchers, fishermen, fish handlers, patient lived in non-optimal hygienic condi- the observation of Gram-variable rods as veterinarians), with pigs as the most impor- tions. After a 48 h incubation period, an aero- obtained by Gram staining. Next to rapid iden- tant reservoir.1 On the other hand, soil, food bic bottle from blood cultures performed at the tification with VITEK MS, a suspension, adjust- scraps and water contaminated by infected emergency department was flagged positive by ed to a 0.5 McFarland turbidity standard, was animals represent the most common environ- the BacT/ALERT instrument (bioMérieux). created directly from bacterial growth and used mental sources. The organism is widespread Direct microscopic examination based on for direct antimicrobial susceptibility testing and occurs in decomposing organic matter. Gram staining evidenced the presence of by Etest strips (bioMérieux) using the Notably, E. rhusiopathiae can survive in soil for Gram-variable rods. Bacterial identification Mueller-Hinton Fastidious agar (bioMérieux). [page 8] [Infectious Disease Reports 2016; 8:6368] Case Report The minimum inhibitory concentrations of 7 case, bacteremia developed subsequently an Of note, although E. rhusiopathiae is usually antibiotics were evaluated, including penicillin erysipeloid lesion. highly susceptible to penicillins and G, cefotaxime, imipenem, ciprofloxacin, lev- Third, E. rhusiopathiae bacteremia is most cephalosporins, all death patients described in ofloxacin, clindamycin, and vancomycin. Since commonly associated with severe clinical ill- Table 2 had been treated with such beta-lactam no specific criteria were available for E. rhu- ness and is often complicated with endocardi- antibiotics. Based on data collected from the siopathiae, results were arbitrarily interpreted tis.1 More than one half of patients with sys- recent literature (Table 2), the overall mortali- according to EUCAST criteria and non-species temic infection had predisposing factors such ty rate for bacteremia was 12.5%. Three out of related breakpoints.10 alcohol or drug dependence, immunosuppres- four deaths occurred in patients with endo- As shown in Table 1, antimicrobial agents sion, and chronic liver disease (Table 2). carditis, whereas the remaining occurred in a used for empirical treatment resulted highly Furthermore, our search showed that more patient with sepsis and oropharyngeal cancer. active against the etiological agent isolated than one third of the patients (34.4%) with A previous study reported a mortality rate of from blood. A transesophageal echocardiogra- invasive E. rhusiopathiae infections developed 38% in patients with E. rhusiopathiae endo- phy did not reveal valve vegetation. Ten days endocarditis (Table 2). This rate is much lower carditis.3 In our search the mortality rate for E. after admission, the patient was discharged than that reported by Gorby and Peacock, in rhusiopathiae endocarditis accounted for without fever and in good conditions. The fol- which about 90% of cases of E. rhusiopathiae 27.3% (Table 2). This rate may partly be low-up conducted seven months after dis- bacteremia result in endocarditis.3 However, in explained by the use of vancomycin, often in charge showed good clinical conditions (tak- contrast to these evidences, in our case the combination with gentamicin, in the empirical ing into account his underlying illness). The patient did not present any of these clinical therapy of endocarditis