LETTERS 7. Jones KL, Donegan S, Lalloo DG. Arte- apy (cyclophosphamide, epirubicin, region (corresponding to positions 27– sunate versus quinine for treating severe vicristine and prednisolone) were 907), as previously described (4,5). For malaria. Cochrane Database Syst Rev. 2007;(4):CD005967. administered from December 2006 amplifi cation, we used broad-range 8. World Health Organization. Guidelines through May 2007. No unfavorable primers 16S-27f (5′-AGA GTT TGA for the treatment of malaria. 2006 [cited sequelae occurred after chemotherapy, TCM TGG CTC AG-3′) and 16S-907r 2008 Sep 11]. Available from http://www. and the tumor showed a complete re- (5′-CCG TCA ATT CMT TTR AGT who.int/malaria/docs/TreatmentGuide- lines2006.pdf sponse. In August 2007, we admitted TT-3′). For sequencing 16S rDNA, we 9. Jelinek T. Intravenous artesunate recom- the patient to our hospital because of a used either the primer 16S-27f or 16S- mended for patients with severe malaria: spiking high fever (up to 40°C), chills, 519r (5′-GWA TTA CCG CGG CKG position statement from TropNetEurop. and pain in the left knee. On physical CTG-3′). We performed both forward Euro Surveill, 2005;10(11): p. E051124 5. 10. Lalloo DG, Somgadoa D, Pasvol G, examination, the patient had a tender, and reverse (5′ and 3′) sequencing. For Chiodini PL, Whitty CJ, Beeching NJ, warm, erythematous, and swollen left accurate analysis of the data, a 492-bp et al. UK malaria treatment guidelines. J knee. These symptoms progressed to variable region (corresponding to posi- Infect. 2007;54:111–21. DOI: 10.1016/j. other joints, including the left hip and tions 27– 519) was carefully analyzed jinf.2006.12.003 ankle. after it was compared with sequences Address for correspondence: Kristine Mørch, Laboratory data showed a normal of Mycobacterium spp. in the BLAST 9 Department of Medicine, Haukeland University leukocyte count (3.4 × 10 cells/L). database (www.ncbi.nlm.nih.gov), as Hospital, 5021 Bergen, Norway; email: kristine. The patient’s C-reactive protein level described (6). The results showed 99% [email protected] increased from 1.13 mg/dL (on the similarity between our isolate and day of admission) to 24.95 mg/dL (7 M. wolinskyi. days after admission). We drew 2 sets A few days later, we obtained of blood samples from a peripheral synovial fl uid by needle biopsy and vein for culture and incubated these cultured samples in BACTEC Aero- cultures (BACTEC 9240 Continuous bic Plus and Anaerobic Plus medium Monitoring Blood Culture System; (Becton Dickinson) and on trypticase Becton Dickinson, Sparks, MD, USA) soy agar. Within 3 days, these cultures Bacteremia Caused using BACTEC Aerobic Plus and An- were also positive for M. wolinskyi. by Mycobacterium aerobic Plus medium (Becton Dickin- Arthroscopically assisted arthrocente- wolinskyi son). Within 3 days, the cultures tested sis and debridement showed a turbid positive for acid-fast bacilli. joint and the debrided tissue showed To the Editor: Mycobacterium The isolate was identifi ed by 16S infl ammatory processes within the wolinskyi is a rapidly growing my- rRNA gene amplifi cation of an 880-bp synovial tissue and the presence of ac- cobacterium that belongs to the M. smegmatis group, which includes M. smegmatis sensu stricto and 2 species described in 1999 (M. goodii and M. wolinskyi) (1). Only 9 cases of infec- tion caused by M. wolinskyi have been reported (1–3), and these included 3 cases of bone infection and 1 case of infection of a hip prosthesis. All pa- tients had a history of surgery after traumatic injury and all specimens were isolated from the surgical wound. In our study, we used molecular diag- nostic tools and report a case of bacte- remia caused by M. wolinskyi. In November 2006, we diag- nosed non-Hodgkin lymphoma in a 22-year-old woman. A venous port was implanted, and 4 courses of Figure. Histologic image of debrided tissue of the patient, showing infl ammatory processes rituximab (anti-CD20 monoclonal within the synovial tissue and the presence of an acid-fast bacillus (magnifi cation ×400, antibody) plus additional chemother- acid-fast stain). 1818 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 11, November 2008 LETTERS id-fast bacilli (Figure). We grew cul- Acknowledgment by sequence analysis of the 16S ribosomal tures of acid-fast bacilli on trypticase We thank Ning-Sheng Lai for guid- RNA gene. Experience from a clinical laboratory. APMIS. 1999;107:231–9. soy agar after 2 to 4 days. The colo- ance and comments during the course of 6. Harmsen D, Dostal S, Roth A, Niemann S, nies were nonchromogenic, smooth treatment. Rothgänger J, Sammeth M, et al. RIDOM: to mucoid, and off-white to cream comprehensive and public sequence data- on Middlebrook 7H10 and trypticase base for identifi cation of Mycobacterium Yu-Chuan Chen, Ruwen Jou, species. BMC Infect Dis. 2003;3:26. DOI: soy agar. Wei-Lun Huang, 10.1186/1471-2334-3-26 We tested the in vitro antimicro- Shao-Tsung Huang, 7. Woods GL, Brown-Elliot BA, Desmond bial susceptibility using the broth dilu- Keng-Chang Liu, EP, et al. 2003. Susceptibility testing of tion method (7). The isolate suscepti- mycobacteria, nocardia and other actino- Chorng-Jang Lay, mycetes. Approved Standard M24-A, vol. ble to amikacin, cefoxitin, imipenem, Shu-Mei Chang, Chih-En Tseng, 23, no. 18. Wayne (PA): National Com- doxycycline, and ciprofl oxacin and re- Chun-Liang Lai, mittee for Clinical Laboratory Standards; sistant to sulfamethoxazole, clarithro- and Yu-Chieh Su 2003. mycin, and tobramycin. We initiated Author affi liations: Buddhist Tzu Chi Da- Address for correspondence: Yu-Chieh Su, treatment of the patient with moxi- lin General Hospital, Chiayi, Taiwan (Y.-C. Division of Hematology-Oncology, Department fl oxacin, minocycline, and amikacin Chen, K.-C. Liu, C.-J. Lay, S.-M. Chang, of Internal Medicine, Buddhist Tzu Chi Dalin 1 day after the athroscopy and the pa- C.-E. Tseng, C.-L. Lai, Y.-C. Su); Centers General Hospital, 2 Min Sheng Rd, Dalin Town, tient’s fever subsided within 72 hours. for Disease Control Department of Health, Chiayi, Taiwan, Republic of China; email: We continued amikacin therapy for 1 Taipei, Taiwan (R. Jou, W.-L. Huang); Chest [email protected] month and administered moxifl oxacin Hospital Health Executive Yuan, Tainan, and minocycline for 6 months. Taiwan (S.-T. Huang); and Tzu Chi Univer- This patient is unique because she sity School of Medicine, Hualien, Taiwan had a case of bacteremia caused by M. (K.-C. Liu, C.-J. Lay, S.-M. Chang, C.-E. wolinskyi, and she had no history of Tseng, C.-L. Lai, Y.-C. Su) major traumatic injury. The bacterium might have been introduced during im- DOI: 10.3201/eid1411.080003 plantation of the venous port or during Incubation Period minor trauma that went unnoticed. The References chemotherapeutic regimen adminis- for Human Cases of 1. Brown BA, Springer B, Steingrube VA, tered to our patient may have played a Wilson RW, Pfyffer GE, Garcia MJ, et Avian Infl uenza A role in the infection. Immunosuppres- al. Mycobacterium wolinskyi sp. nov. and (H5N1) Infection, sion by treatment with rituximab (an Mycobacterium goodii sp. nov., two new anti-CD20 monoclonal antibody) and rapidly growing species related to My- China cobacterium smegmatis and associated a steroid during chemotherapy may with human wound infections: a coopera- To the Editor: Since 1997, more have worsened the patient’s B-cell tive study from the International Working than 400 human cases of highly patho- Group on Mycobacterial Taxonomy. Int J function and thereby weakened her genic infl uenza A virus (H5N1) infec- immunity. Surgical debridement fol- Syst Bacteriol. 1999;49:1493–511. 2. Brown-Elliott BA, Wallace RJ Jr. Clini- tion have been reported worldwide, lowed by antimicrobial therapy for at cal and taxonomic status of pathogenic including 30 from mainland China. least 6 months is the suggested treat- nonpigmented or late-pigmenting rap- Ascertainment of the incubation pe- idly growing mycobacteria. Clin Micro- ment for M. wolinskyi infection, and riod for infl uenza virus (H5N1) is we followed this regimen. Because biol Rev. 2002;15:716–46. DOI: 10.1128/ CMR.15.4.716-746.2002 important to defi ne exposure periods of the frequency of relapse and resis- 3. Wallace RJ Jr, Nash DR, Tsukamura M, for surveillance of patients with sus- tance, we used combination therapy Blacklock ZM, Silcox VA. Human disease pected infl uenza virus (H5N1) infec- due to Mycobacterium smegmatis. J Infect with multiple antimicrobial agents. tion. Limited data on the incubation This case suggests that immuno- Dis. 1988;158:52–9. 4. Adekambi T, Drancourt M. Dissection of period suggest that illness onset oc- compromised patients may be vulner- phylogenetic relationships among 19 rap- curs <7 days after the last exposure to able to infection by rapidly growing idly growing Mycobacterium species by sick or dead poultry (1–4). For clus- 16S rRNA, hsp65, sodA, recA and rpoB mycobacterium such as M. wolinskyi. ters in which limited human-to-human In such cases, we suggest antimicrobial gene sequencing. Int J Syst Evol Micro- biol. 2004;54:2095–105. DOI: 10.1099/ virus transmission likely occurred, drug treatment, based on in vitro sus- ijs.0.63094-0 the incubation period appeared to be ceptibility. More data on antimicrobial 5. Holberg-Petersen M, Steinbakk M, Figen- 3–5 days (5–7) but was estimated to schau KJ, Eng J, Melby KK. Identifi cation drug susceptibility should be collected be 8–9 days in 1 cluster (5). In China, for treatment of this type of infection. of clinical isolates of Mycobacterium spp.