Download Corynebacterium pseudodiphtheriticum—A Skin

938
Brief Reports
She was treated with meperidine (15 mg intravenously), and her
symptoms subsided. She did not have any other adverse effects
during treatment and remained afebrile during the rest of the
hospitalization. After 8 days of therapy and 15 doses of foscarnet
(total dose, 43.8 g), the lesions were healed, and the patient was
discharged; medications at this time were the oral agents she had
received before admission.
Subsequent viral cultures of genital specimens yielded HSV-2
susceptible to acyclovir, and the patient continued receiving oral
acyclovir therapy for the remainder of her pregnancy. She gave
birth to a baby girl by cesarean section at term. The baby appeared
healthy at birth and was HIV-negative. The baby has been followed up by a pediatric infectious diseases service and was noted
to be developing normally throughout her first year, with no
obvious adverse effects (especially skeletal) related to her in utero
exposure to foscarnet.
The use of any antiviral for treatment of HSV infection in
pregnancy, except acyclovir, is discouraged. Acyclovir is the only
antiviral agent that has been studied in clinical trials during pregnancy. Foscarnet is not recommended for use in pregnancy. An
extensive search of the literature via MEDLINE and of the Centers
for Disease Control and Prevention’s database yielded no cases of
foscarnet treatment of infection due to acyclovir-resistant HSV in
pregnancy. Astra Pharmaceuticals has two cases in their surveillance data on the use of foscarnet in pregnancy (Roomi Nusrat,
unpublished data). An HIV-negative female with an intrauterine
pregnancy of 32 weeks’ gestation who had acyclovir-resistant
HSV encephalitis and retinitis was treated with foscarnet (60
mg/kg intravenously q8h) for 17 days. The baby was delivered at
term, was healthy, and received prophylactic acyclovir for 10 days.
Corynebacterium pseudodiphtheriticum—A Skin Pathogen
Corynebacterium pseudodiphtheriticum may be found as part of
the normal oropharyngeal flora in humans but is recognized as a
human pathogen. Infections caused by this organism include endocarditis [1], pneumonitis [2], and bronchotracheitis [3]. To our
knowledge, it has never been reported as a skin pathogen. We
describe a patient with an ulcerating skin lesion due to C. pseudodiphtheriticum.
A 75-year-old man was admitted to the hospital with a spreading
10-cm semicircular painless ulcerating lesion on the dorsum of his
left hand and a smaller nonulcerating lesion on his right hand. The
lesion on the left hand had started as a raised plaque and then
ulcerated and enlarged, healing centrally and expanding outward.
The lesion had been present for 3 weeks and was unresponsive to
treatment with oral amoxicillin/clavulanic acid. One week before
admission, he developed perioral and unilateral eyebrow erythema.
Reprints or correspondence: Dr. Carolyn Hemsley, Department of Microbiology, John Radcliffe Hospital, Headington, Oxford, United Kingdom, OX2
9DU ([email protected]).
Clinical Infectious Diseases 1999;29:938 –9
© 1999 by the Infectious Diseases Society of America. All rights reserved.
1058 – 4838/99/2904 – 0039$03.00
CID 1999;29 (October)
An HIV-positive female with an intrauterine pregnancy of 25
weeks’ gestation who had vulvovaginal infection due to acyclovirresistant HSV-2 was treated with foscarnet (40 mg/kg intravenously q8h) beginning at week 29 –30 of pregnancy; no further
follow-up data are available.
Presently, there are no studies of foscarnet use in pregnancy.
The toxicity to the fetus cannot be predicted or extrapolated from
animal studies, especially because the levels achieved in rats were
lower than those achieved in humans at the recommended dose.
However, foscarnet is a pyrophosphate analogue that accumulates
in bones, and evidence of skeletal abnormalities was seen in the
fetus of animals treated with foscarnet during pregnancy. Nephrotoxicity is also a concern, but it can usually be avoided with
adequate hydration.
In summary, we believe that this is the first reported case of
intravenous foscarnet treatment of acyclovir-resistant HSV infection during pregnancy. Although the routine use of foscarnet
during pregnancy cannot be recommended, when medically indicated, its use may be safe for both mother and fetus.
Africa Alvarez-McLeod, Joseph Havlik, and Karen E. Drew
Division of Infectious Diseases, Cobb County Board of Health/
Immunology Clinic, and Division of Infectious Diseases and Department
of Pharmacy, WellStar Kennestone Hospital, Marietta, Georgia
Reference
1. Hardy WD. Foscarnet treatment of acyclovir-resistant herpes simplex virus
infection in patients with acquired immunodeficiency syndrome: preliminary results of a controlled, randomized, regimen-comparative trial.
Am J Med 1992;92(suppl 2A):30S–5S.
During this time, he had been systemically well. He was a bachelor
who kept 120 chickens, 7 pigeons, and 2 dogs. The chickens often
pecked the back of his hands.
Physical examination was unremarkable except for the hands
(figure 1) and a facial rash. He was apyrexial and had no lymphadenopathy. Biopsy specimens of the lesions were obtained, and
empirical therapy with intravenous cefuroxime and metronidazole
was started, pending the results of microbiological analysis. A
roentgenogram of the left hand showed no evidence of bony
involvement, and laboratory tests revealed a WBC count of 10.6 3
109/L with neutrophilia, normal renal and liver function, and a
C-reactive protein level of 33 mg/L.
Gram staining of pus from the right hand revealed gram-positive
rods, and culture of the pus yielded pure growth of C. pseudodiphtheriticum. Cultures of three separate samples of tissue yielded the
same organism. Fungal and mycobacterial cultures were negative.
Histological analysis of the biopsy specimens of the hand showed
acute inflammation, small dermal abscesses, and gram-positive
organisms invading the dermis.
The lesions responded to treatment with cefuroxime, later
changed to oral clindamycin, with complete healing and minimal
scarring. He completed a 2-week course of therapy and remained
well with no recurrence 4 weeks after finishing treatment.
Corynebacteria constitute part of the normal flora of the human
CID 1999;29 (October)
Brief Reports
939
pure growth from several samples and was seen on gram-stained
histological sections invading the dermis. The skin lesions responded well to appropriate antibiotic therapy. The organism may
have been inoculated into the skin by the pecking action of the
chickens.
C. pseudodiphtheriticum, originally named Corynebacterium
hofmannii, was first isolated in 1888 by von Hoffman from the
human nasopharynx. Since then, it has been reported as causing
native and prosthetic valve endocarditis [1], necrotizing tracheitis
[3], pulmonary infections [2], and urinary tract infections [4].
Unlike Corynebacterium diphtheriae or some of the other nondiphtheria corynebacteria [5], C. pseudodiphtheriticum has not
been previously reported as a skin pathogen.
The diagnosis of disease caused by a skin commensal may be
overlooked but must be considered in the face of microbiological
and histological findings.
Carolyn Hemsley, Sonia Abraham, and
Sarah Rowland-Jones
Department of Microbiology, John Radcliffe Hospital, Headington,
Oxford, United Kingdom
References
Figure 1. Hand of a patient with Corynebacterium pseudodiphtheriticum infection.
skin and mucous membranes but are also well recognized as
opportunistic pathogens. We believe that C. pseudodiphtheriticum
was acting as a primary pathogen in our case as it was isolated in
Isolation of Exophiala (Wangiella) dermatitidis in a Case
of Otitis Externa
Acute otitis externa is a frequently occurring infection, mainly seen
in the hot season and most often caused by Pseudomonas aeruginosa
or Staphylococcus aureus [1]. In contrast, fungi such as Aspergillus
niger and Candida parapsilosis are mostly involved in chronic otitis
externa [1]. To our knowledge, we report here the first case of chronic
otitis externa with Exophiala (Wangiella) dermatitidis involvement.
A 19-year-old woman consulted an otolaryngologist because of
a 4-day history of otalgia with partial loss of hearing. Otoscopy
revealed severe inflammation of both auditory channels and dark
punctate infiltrations of the mucosa. Empirical therapy with amoxi-
Reprints or correspondence: Dr. G. Haase, Institute of Medical Microbiology,
University Hospital RWTH Aachen, D-52057 Aachen, Germany (haase@
alpha.imib.rwth-aachen.de).
Clinical Infectious Diseases 1999;29:939 – 40
© 1999 by the Infectious Diseases Society of America. All rights reserved.
1058 – 4838/99/2904 – 0040$03.00
1. Morris A, Guild I. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine
strains. Rev Infect Dis 1991;13:887–92.
2. Manzella JP, Kellog JA, Parsey KS. Corynebacterium pseudodiphtheriticum:
a respiratory tract pathogen in adults. Clin Infect Dis 1995;20:37– 40.
3. Colt HG, Morris JF, Marston BJ, Sewell DL. Necrotizing tracheitis caused
by Corynebacterium pseudodiphtheriticum: unique case and review.
Rev Infect Dis 1991;13:73– 6.
4. Nathan AW, Turner DR, Aubrey C. Corynebacterium hofmannii—
infection after renal transplantation. Clin Nephrol 1991;17:315– 8.
5. Lipsky BA, Goldberger AC, Tomkins LS, Plorde JJ. Infections caused by
nondiphtheria corynebacteria. Rev Infect Dis 1982;4:1220 –35.
cillin (1.5 g t.i.d.) and topical ofloxacin and gentamicin for 2 weeks
produced no improvement. Therefore, swab specimens from both
auditory channels were obtained for microbiological investigation,
and therapy was switched to orally administered ciprofloxacin
(250 mg b.i.d.). Slight improvement was seen within the next
week. Because of isolation of a black yeast and P. aeruginosa from
the swabs, topically administered antimycotic treatment with Solutio Castellani and nystatin was initiated; within 9 days, there was
dramatic improvement, and the patient felt well. Swab specimens
obtained at that time as well as 2 months later were negative.
Dark-pigmented yeastlike colonies with a smooth, waxy surface
first appeared on Sabouraud glucose agar after 5 days of incubation at
37°C with diffusion of brown pigment into the agar. The fungus grew
at 42°C but showed no utilization of inorganic nitrate (i.e., no growth
on Czapek-Dox agar). Microscopically, hyphae with mostly intercalary flask-shaped conidiogenous cells were seen besides abundant
yeast cells. The annellated zones were narrow, and the ellipsoidal
conidia measured 3–4 3 2–3 mm. All these features are indicative of
E. dermatitidis [2]. Sequencing of the internal transcribed spacer 1
(ITS1) region of the nuclear rRNA gene was performed as recently
described [3] and revealed the species-specific sequence of E. der-