LETTERS 2010 had distinct random amplifi ed components in the host defense of 7. Yakrus MA, Hernandez SM, Floyd patterns that differed from those HIV-noninfected patients against MM, Sikes D, Butler WR, Metchock B. Comparison of methods for identi- generated from isolates A–G (Figure). rapidly growing mycobacterial fi cation of Mycobacterium abscessus A previous study in Taiwan showed infections, including those caused by and M. chelonae isolates. J Clin Micro- that the incidence (no. cases/100,000 M. abscessus (10). biol. 2001;39:4103–10. doi:10.1128/ inpatients and outpatients) of all In summary, we report a case JCM.39.11.4103-4110.2001 8. Chou CH, Chen HY, Chen CY, Huang pulmonary disease caused by NTM of bacteremic lymphadenitis caused CT, Lai CC, Hsueh PR. Clinical features increased signifi cantly from 2.7 (1.26) by M. abscessus in a patient with and outcomes of disseminated infections in 2000 to 10.2 (7.94) in 2008 (6). The Sjögren syndrome. Our data provide caused by nontuberculous mycobacteria most common organism in localized evidence that the interior surface of in a university hospital in Taiwan, 2004– 2008. Scand J Infect Dis. 2011;43:8–14. pulmonary infection and disseminated showerheads may serve as a source doi:10.3109/00365548.2010.519345 infection was Mycobacteriam avium of infection by this waterborne and 9. van Ingen J, Blaak H, de Beer J, de Roda cellular complex, and M. abscessus aerosolized microorganism. Husman AM, van Soolingen D. Rapidly predominated in skin and soft tissue growing nontuberculous mycobacteria Yu-Min Kuo, Aristine Cheng, cultured from home tap and shower water. infection and lymphadenitis (6,8). Appl Environ Microbiol. 2010;76:6017– The rise in pulmonary infections Po-Chang Wu, 9. doi:10.1128/AEM.00843-10 or colonization by NTM over Song-Chou Hsieh, 10. Chan ED, Bai X, Kartalija M, Orme IM, recent decades, particularly among Szu-Min Hsieh, Po-Ren Hsueh, Ordway DJ. Host immune response to and Chia-Li Yu rapidly growing mycobacteria, an emerg- immunocompromised populations, ing cause of chronic lung disease. Am J is reported to be partly associated Author affi liations: National Taiwan Respir Cell Mol Biol. 2010;43:387–93. with the increased use of showers University Hospital, Taipei, Taiwan doi:10.1165/rcmb.2009-0276TR (3–5,9). Recently, a few studies have DOI: http://dx.doi.org/10.3201/eid1711.110050 shown a link between pulmonary M. Address for correspondence: Po-Ren Hsueh, Departments of Laboratory Medicine and avium complex infections and home References showerhead water microbiology (3,4). Internal Medicine, National Taiwan University Although pulmonary disease caused 1. Uji M, Matsushita H, Watanabe T, Su- Hospital, National Taiwan University College by M. abscessus did not develop in zumura T, Yamada M. A case of primary of Medicine, No. 7, Chung-Shan South Rd, Sjögren’s syndrome presenting with Taipei, Taiwan; email: [email protected] the patient reported here, multiple middle lobe syndrome complicated by respiratory specimens showed nontuberculous mycobacteriosis [in Japa- evidence of pulmonary colonization. nese]. Nihon Kokyuki Gakkai Zasshi. The fact that cultures of the swabs 2008;46:55–9. 2. Tan HH, Tan A, Theng C, Ng SK. Cutane- taken from the interior surface of 4 ous Mycobacterium haemophilum infec- showerheads were positive for M. tions in immunocompromised patients in abscessus but that cultures of the a dermatology clinic in Singapore. Ann shower water were negative for the Acad Med Singapore. 2004;33:532–6. 3. Nishiuchi Y, Maekura R, Kitada S, Tama- Antimicrobial Drug organism support previous fi ndings ru A, Taguri T, Kira Y, et al. The recovery that assemblages of NTM can occur of Mycobacterium avium–intracellulare Resistance in inside biofi lm that forms on the interior complex (MAC) from the residential Corynebacterium surface of showerheads (5). The same bathrooms of patients with pulmonary MAC. Clin Infect Dis. 2007;45:347–51. diphtheriae mitis strains of M. abscessus isolated from doi:10.1086/519383 different showerheads suggested 4. Falkinham JO, Iseman MD, Haas P, To the Editor: Corynebacterium the possibility of contamination in Soolingen D. Mycobacterium avium in diphtheriae is the agent of pharyngeal the environment by the aerosolized a shower linked to pulmonary disease. J Water Health. 2008;6:209–13. and cutaneous diphtheria. We did microorganism from respiratory 5. Feazel LM, Baumgartner LK, Peterson a retrospective analysis of the secretions of the patient. KL, Frank DN, Harris JK, Pace NR. Op- antimicrobial drug susceptibilities The mechanisms of susceptibility portunistic pathogens enriched in show- of 46 C. diphtheriae isolates sent to mycobacterial infection in the erhead biofi lms. Proc Natl Acad Sci U S A. 2009;106:16393–9. doi:10.1073/ during 1993 through 2010 to the patient with Sjögren’s syndrome pnas.0908446106 French National Reference Centre remain unknown (1,2). Previous 6. Lai CC, Tan CK, Chou CH, Hsu HL, of Toxigenic Corynebacteria. The studies suggest that toll-like receptor Liao CH, Huang YT, et al. Increasing in- isolates came from metropolitan 2, dectin-1, tumor necrosis factor–α, cidence of nontuberculous mycobacteria, Taiwan, 2000–2008. Emerg Infect Dis. France and French overseas interferon-γ, leptin, T-cells, and 2010;16:294–6. departments and territories. Only 1 possibly neutrophils are major isolate, C. diphtheriae biovar mitis, 2078 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 17, No. 11, November 2011 LETTERS FRC24, expressed the following anti- dissemination of antimicrobial drug a strain expressing trimethoprim microbial drug susceptibility profi le: resistance; class 1 is the most widely resistance. Furthermore, the FRC24 susceptible to penicillin, amoxicillin, found in clinical isolates. Integrons integron contains the antiseptic ciprofl oxacin, clindamycin, erythro- have been mainly described among (quaternary ammonium compounds) mycin, gentamicin, imipenem, gram-negative bacteria; only a few resistance gene qacH. As cutaneous kanamycin, rifampin, tetracycline, studies have reported integrons in carriage of C. diphtheriae is frequent and vancomycin and resistant Corynebacterium spp. (6,7). in tropical countries such as Mayotte, at an uncommonly high level After bacterial genomic DNA this bacterium could be exposed to to trimethoprim, sulfamethoxazole, extraction (DNeasy Blood & quaternary ammonium compounds and co-trimoxazole with Etest Tissue Kit; QIAGEN, Courtaboeuf, contained in disinfectants, hygienic (bioMérieux, Marcy l’Etoile, France) France), a multiplex Taqman-based hand washes, and cosmetic products. MICs of >32, >1,024, and >32 mg/L, quantitative PCR approach able to These products exert a selective respectively. detect the 3 main classes of integrons pressure, which might play a This FRC24 isolate was isolated was performed (8). We found that role in selecting qac-containing in 2008 from a cutaneous wound on FRC24 harbored a class 1 integron. strains, as has been suggested for a vaccinated 11-month-old child in Analysis of the GC array showed that Staphylococcus spp. (10). For Mayotte, an overseas department this integron harbored 2 GCs: dfrA16 staphylococci, the MICs of quaternary located in the Indian Ocean. Cutaneous of 588 bp conferring resistance to ammonium compounds are >2 mg/L. carriage of C. diphtheriae is frequent trimethoprim and qacH of 511 bp With FRC24, we tested for the in tropical countries where cutaneous conferring resistance to quaternary MIC of cetyltrimethylammmonium diphtheria is endemic; cutaneous ammonium compounds (GenBank bromide and found a MIC of 4 mg/L, carriage represents a common mode of accession no. FR822749). To our suggesting that qacH is expressed in transmission of the bacterium. FRC24 knowledge, this GC array has not FRC24. was identifi ed by using the API been previously reported, even among The sequencing of the genetic Coryne strip (bioMérieux). FRC24 reports of other gram-negative isolates. environment of this integron is a toxigenic isolate; toxigenicity Moreover, a qac determinant has been showed that it was framed by 2 was confi rmed by both tox gene found only once in a Corynebacterium copies of the insertion sequence detection and Elek test (1). Multilocus species, C. pseudogenitalium IS6100 disrupting at the left-hand sequence typing was performed, and (which harbors a qacH variant in the side the intI1 integrase gene (online the sequence type (ST) of the isolate chromosome [GenBank accession Appendix Figure, wwwnc.cdc.gov/ is ST91. This ST contains only this no. ABYQ02000013]), but not in EID/article/17/11/11-0282-FA1.htm). isolate and is part of lineage II, as are an integron background. GC arrays IS6100 has been described in a wide all mitis and gravis biovars (2). were followed by the qacEΔ1 (which spectrum of host organisms, including To date, resistance to also confers resistance to quaternary Corynebacterium spp. (6,7), thus trimethoprim, sulfamethoxazole, ammonium compounds), sul1 enabling this integron to be effi ciently or co-trimoxazole seems to be rare (resistance to sulfamethoxazole), transferred to various bacteria. among the C. diphtheriae species, and orf5 determinants as found in Our fi ndings show that C. but few data are available (3). As most class 1 integrons (4). In class 1 diphtheriae is able to harbor integrons, trimethoprim resistance is often integrons, 13 Pc variants have been which is of clinical relevance. Indeed, encoded by integron-driven dfr described (5). In the FRC24 integron, this genetic feature would give determinants, we looked for integrons. the dfrA16 expression was mediated the isolates the capacity to easily Integrons are bacterial genetic through a strong Pc variant (PcWTGN-10) acquire new GCs, such as ere GCs elements able to capture and express (5) that enables the high-level encoding resistance to erythromycin, antimicrobial drug resistance gene resistance observed for trimethoprim. which is one of the antimicrobial cassettes (GCs) (4). GC movements As previously demonstrated, the qacH drugs recommended for diphtheria are catalyzed by an integron- GC possessed its own promoter (9).