Download Corynebacterium striatum meningitis: report of two adult cases

ORIGINAL ARTICLE
Corynebacterium striatum meningitis: report of two
adult cases
Mustafa Sünbül, Şener Barut, Şaban Esen, Cafer Eroğlu and Hakan Leblebicioğlu
From the Department of Clinical Microbiology and Infectious Diseases, Ondokuz Mayis University, School of
Medicine, Samsun, Turkey
Correspondence to: Mustafa Sünbül, MD, Department of Clinical Microbiology and Infectious Diseases,
Ondokuz Mayis University, School of Medicine, 55139 Samsun, Turkey. Tel: + 90 362 4576000/2722; Fax: +90
362 4576041; E-mail: [email protected]
Microbial Ecology in Health and Disease 2000; 12: 57–59
Corynebacterium striatum is a known saprophytic cutaneous bacterium. However, during the last decade, this organism has been
increasingly recognized as a human pathogen. This organism has occasionally been reported as a cause of serious infection in man,
however, there are few reports about shunt infections. We describe the clinical and laboratory findings in two patients with C. striatum
meningitis after cerebrospinal fluid (CSF) shunt. The two patients had a ventricular external drainage. C. striatum were isolated in CSF
from both cases. The patients were treated with intravenous vancomycin, followed by shunt replacement. One patient died on the fifth
day of antibiotic therapy. The other patient recovered completely. Key words: Corynebacterium, ventricular external drainage, menigitis.
INTRODUCTION
Corynebacterium species are members of the normal skin
flora and generally found in the environment (1). Except
for Corynebacterium diphteriae, Corynebacterium species
are usually considered to be contaminants when recovered
in the clinical laboratory (2). However, during the last few
years Corynebacterium species have been increasingly isolated from infectious sites such as blood, catheter tips,
urine and cerebrospinal fluid (CSF) as the numbers and
survival of severely immunocompromised patients increase
as well as the numbers and types of medical devices used
in both immunocompromised and immunocompetant patients increase (3).
There are few reports of meningitis due to Corynebacterium species in the literature. These are mainly caused by
Corynebacterium JK pathogen and related to ventriculoperitoneal shunt infections (4, 5). Up to date, only two
reports of central nervous system (CNS) infections due to
C. striatum have been published (1, 6). We report two
cases of CNS infections due to C. striatum from our
hospital with external ventricular drainage.
Case 1
A 17 year old man was admitted to the emergency unit of
our hospital on 8th November 1998 with the complaint of
unconsciousness. As he had pulmonary arrest in the emergency unit he was intubated there. Cranial computerized
tomography (CCT) detected a linear fracture on the left
© Taylor & Francis 2000. ISSN 0891-060X
side of the frontal bone, cerebral contusion and intraventricular hemorrhage. His pupils were myotic and gave
weak reaction to light.
The day after admission a ventriculostomy was made
and external ventricular drainage was established. He was
then transferred to the intensive care unit. After 12 days,
the ventricular drain was removed. It was inserted again 5
days after as the patient had an hypotensive attack and
unisocori developed after removal of ventricular drain. He
became febrile two days after reinsertion. Laboratory tests
of blood showed a white blood cell count (WBC) of
17600/mm3 and a creatinin phosphokinase activity of 1135
U/dl (N:200 U/dl). The CSF sample was obtained from
the drain. The analysis of CSF revealed a WBC count of
220/mm3 (95% neutrophils). The glucose level was 97
mg/dl (simultaneous blood glucose 283 mg/dl), protein 229
mg/dl and chloride 88.8 mEq/L (N:120 – 130 mEq/L). After coccobasillary Gram positive rods were demonstrated
on the Gram staining of CSF, intravenous ampicillin and
ceftazidim were administered.
After 24 hour incubation of a CSF specimen the culture
yielded pure growth on sheep blood agar of a Gram
positive rod. The microorganism which had an appearance
of grayish white and smooth colonies was catalase positive, reduced nitrate and was methyl red positive. This
bacterium was identified as C. striatum by using the API
Coryne (bioMerieux, France) system. Biochemical characteristics of strain 1 and 2 are shown Table I. Susceptibility
testing was performed by disk diffusion technique. Results
Microbial Ecology in Health and Disease
58
M. Sünbül et al.
of antibiotic susceptibility regarding strain 1 and 2 are
shown in Table II.
When the bacterium was identified, ampicillin and ceftazidime were stopped and vancomycin (50 mg/kg/gün)
therapy was started. On the fourth day of vancomycin
therapy the CSF culture of ventricular external drainage
yielded C. striatum. On the fifth day of therapy the patient
was died.
Case 2
A 58-year old women was admitted to neurosurgery department with the complaints of headache, nausea and
vomiting. On her physical examination Babinski’s sign was
found positive on the left.
Magnetic resonance (MR) examination revealed a mass
lesion on the left thalamus and temporamandibular region.
The patient was operated in neurosurgery department on
17th November 1998. Subtotal mass excision was made.
Pathologic diagnosis was reported as oligodendroglioma.
The patient developed hemiplegia and aphasia in the postoperative period, and CCT revealed a residual mass lesion
in the temporaparietal region and dilatation of ventriculi.
An external drainage was placed into the lateral ventricule.
Administration of ceftriaxon was continued during the
external drainage period since it was started prophylactically before the operation. After insertion of the drain,
aphasia disappeared but on the third day patient became
febrile. On the fifth day of drainage, the patient was
assessed by the infectious disease consultant. During the
physical examination she was conscious and oriented. The
body temperature was 37.3°C, pulse rate 90/min and arterial blood pressure 140/80 mmHg. She had neck stiffness
Table I
Biochemical characteristics of strains by API
Nitrate reduction
Pyrasinamidase
Pyrolidonyl arylamidase
Alkalen phosphatase
Beta glucorinidase
Beta galactosidase
Alpha glucosidase
N acetyl beta glucosaminidase
Esculin
Urease
Gelatine (hydrolysis)
Glucose
Ribose
Xylose
Mannitol
Maltose
Lactose
Sucrose
Glycogen
Catalase
Strain 1
Strain 2
Positive
Positive
Negative
Positive
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Positive
Negative
Negative
Negative
Negative
Negative
Positive
Negative
Positive
Positive
Positive
Negative
Positive
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Positive
Negative
Negative
Negative
Negative
Negative
Positive
Negative
Positive
Table II
Antimicrobial susceptibility patterns of the strains
Penicillin
Trimethoprim-sulfamethoxazole
Ampicillin
Norfloxacin
Cefuroxime
Erythromycin
Vancomycin
Amoxicillin-clavulanate
Fusidic acid
Ofloxacin
Clindamycin
Gentamicin
Strain 1
Strain 2
Resistant
Resistant
Resistant
Resistant
Resistant
Resistant
Resistant
Susceptible
Susceptible
Susceptible
Susceptible
Susceptible
Susceptible
Susceptible
Resistant
Resistant
Resistant
Susceptible
Susceptible
Susceptible
Susceptible
Susceptible
Intermediate
Susceptible
and positive Kerning sign and hemiplegia at the right side.
WBC of 6900/mm3, hemoglobin 11 gr/dl, platelet 490000/
mm3. Biochemical tests of blood were normal. A CSF
sample obtained from the external drainage demonstrated
270/mm3 (98% neutrophils) and 12000/mm3 erythrocytes.
Protein level of CSF was 150 mg/dl, the glucose content
was 56 mg/dl (blood glucose 92 mg/dl) and chloride 111
mEq/L (N:120 – 130 mEq/L). Cocobasillary Gram positive
bacteria were seen on the Gram staining of CSF. Ceftriaxon was stopped and vancomycin (50 mg/kg/day) was
started immediately as the treatment of nosocomial Gram
positive meningitis. Culture of the CSF yielded abundant
growth of Gram positive bacteria which had no hemolysis
on blood agar plate; positive catalase and methyl red tests
and reduced nitrate. The bacterium was identified as C.
striatum by using API Coryne (bioMerieux, France) system (see Table I). The isolate was resistant to penicillin,
ampicillin, trimethoprim-sulfamethoxazole, and susceptible
to vancomycin and teicoplanin (see Table II). Molecular
characteristics of strain 1 and 2 were studied by using
arbitrarily primed polymerase chain reaction (AP PCR).
Both strains were showed the same pattern (Fig. 1). One
day after the assessment of patient, the external ventricular
drain was removed. The patient became afebrile within the
second day of vancomycin treatment. She improved clinically on subsequent days. Vancomycin was given for 14
days after which she was discharged.
DISCUSSION
C. striatum is a member of the normal flora that usually
colonizes the anterior nares, the skin of the face and the
upper part of the body (1, 3). Nondiphtheria corynebacteria cause infections in either immunocompromised patients
or patients to whom applied catheters and other medical
devices. During recent years, the number of these patients
has increased in hospitals and there have been some developments on the identification of coryneform bacteria. Re-
Corynebacterium striatum meningitis
Fig. 1. It was shown in arbitrarily primed PCR results of strain 1
and 2. Line 1: Molecular weight marker, line 2: strain 1(1/5 DNA
dilution). Line 3: strain 2 (1/5 DNA dilution). Line 4: strain 1.
Line 5: strain 2.
ports of infection caused by definite Nondiphtheria
corynebacteria have shown an increase (3, 7).
Up to now, meningitis of Corynebacterium species have
been mainly due to Corynebacterium JK. Almost all of
these infections occured in patients with ventriculoperitoneal shunts (4, 5).
Several cases of C. striatum infection have been reported; however, most of these cases were bacteremia or
respiratory tract infections (1, 7). To our knowledge, two
new reports of CNS infection due to C. striatum have also
been published (1, 6).
In our report we present two cases of CNS infection due
to C. striatum in which the patients had an external
ventricular drainage. The fact that there was direct communication between the skin and the CSF through the
drainage
catheter
could
explain
how
microorganisms had easily reached to CSF and caused meningitis. We state that C. striatum has a potential to cause
meningitis especially in patients with external ventricular
drainage.
Drainage was applied twice to the first patient. This
59
patient died. The fact that the patient had severe respiratory failure, conscious and nutritional problems associated
with the intraventricular hemorrhage could explain why he
died. In addition, it could be a reason that the drainage
had not been removed immediately after infection had
been diagnosed.
The corynebacteria strains were identified by using API
Coryne system. We also applied catalase, nitrate reduction
and metil red tests to the strains. The possibility of C.
striatum was especially increased by the positive methyl red
test. Apart from the C. xerosis, colony morphology of the
strains was whitish, moist and smooth (7). Their growth
was completed by 48 to 72 hours. These features also
contributed to the identification of the bacteria (7). Since
antibiotic susceptibility, biochemical and molecular characteristic are almost same, these two cases may be considered to be cross infection.
As a conclusion, C. striatum is being increasingly described as a potential pathogenic Corynebacterium species.
Its presence in clinical specimens should not be overlooked, especially in samples from patients with underlying
medical conditions. It has a potential to colonize prosthetic devices or catheters and may cause severe infections
of sterile body sites such as meningitis. Clinical microbiologists should give attention to such situations.
REFERENCES
1. Weis K, Labbe AC, Laverdiere M. Corynebacterium striatum
meningitis: Case report and review of an increasingly important Corynebacterium species. Clin Infect Dis 1996; 23: 1246–8.
2. The aerobic Gram positive bacilli. In: Koneman EW, Allen
SD, Janda WM, Schreckenberger PC, Winn WC (eds). A color
atlas and textbook of diagnostic microbiology 5th edition. New
York, 1997; 651 – 708.
3. Brown AE. Other Corynebacteria and Rodococcus. In: Mandell GL, Bennett JE, Dolin R eds., Principles and practise of
infectious diseases.4th edition. New York, 1995; 1872 – 80.
4. Greene KA, Clark RJ, Zabramski JM. Ventricular CSF shunt
infections associated with Corynebacterium jeikeium: Report of
three cases and review. Clin Infect Dis 1993; 16: 139 – 41.
5. Keren GK, Geva T, Bogokovsky B, Rubinstein E. Corynebacterium group JK pathogen in cerebrospinal fluid shunt infection: Report of two cases. J Neurosurg 1988; 68: 648 – 50.
6. Hoy CM, Kerr K, Livingston JH. Cerebrospinal fluid-shunt
infection due to Corynebacterium striatum. Clin Infec Dis 1997;
25: 1486 – 7.
7. Funke G, Von Graevenitz A, Clarridge III JE, Bernard KA.
Clinical microbiology of Coryneform bacteria. Clin Microbiol
Rev 1997; 10: 125 – 59.