Brevibacterium spp. were considered apathogenic until a few reports of infections in immunocompromised patients were published. Herein, we present a case of a catheter-related septicemia with Brevibacterium casei in an immunocompetent patient receiving continuous iloprost infusion for pulmonary arterial hypertension and review the clinical presentation of this mainly emerging opportunistic pathoge

Fischler, M.

Pagano, M.

Speich, R.

Ulrich, S.

Zbinden, R.

RERO DOC Digital Library

Infection 34 · 2006 · No. 2 © URBAN & VOGEL 103Central Venous Catheter Infection with Brevibacterium sp. in an Immunocompetent Woman: Case Report and Review of the LiteratureS. Ulrich, R. Zbinden, M. Pagano, M. Fischler, R. SpeichAbstractBrevibacterium spp. were considered apathogenic until a few reports of infections in immunocompromised patients were published. Herein, we present a case of a catheter-related septicemia with Brevibacterium casei in an immunocom-petent patient receiving continuous iloprost infusion for pulmonary arterial hypertension and review the clinical presentation of this mainly emerging opportunistic pathogen.Infection 2006; 34: 103–106DOI 10.1007/s15010-006-5027-6IntroductionPatients with indwelling foreign material bear considerable risk of acquiring bloodstream infections. Among a wide range of causative agents, Brevibacterium spp. are rarely found and were considered apathogenic until a few reports of clinically relevant infections with Brevibacterium spp. were reported mainly in immunocompromised patients [1]. Herein, we report a case of a central venous catheter (CVC) related blood stream infection with Brevibacterium casei in an immunocompetent patient and review the lit-erature with emphasis on the clinical presentation of this emerging, mainly opportunistic pathogen.Case ReportA 62-year-old violinist with severe pulmonary hypertension who was being treated with continuous intravenous iloprost via a non-tunneled central venous catheter (CVC) presented with flu-like symptoms, productive cough and chills at our outpatient clinic. She was afebrile and routine blood analyses including C-reactive protein (CRP) were normal. Pulmonary infection was suspected and antibiotic therapy with moxifloxacin 400 mg twice daily was prescribed empirically for 5 days. But the patient’s general con-dition failed to recover, although remaining afebrile. Slightly el-evated neutrophils (8.2 × 103/ml) and CRP (8 mg/dl) were found as the only pathologic blood value and chest X-ray was without infiltrates. When she developed fever and chills several weeks after her first symptoms, the patient was hospitalized. Her body temperature was 38.4 °C (101.12 °F), heart rate 78 beats/min, blood pressure 159/60 mmHg, respiratory rate 24 breaths/min and the arterial oxygen saturation 85% while breathing ambient air. The lungs were clear on auscultation, a middle-loud systolic heart murmur was heard as previous. There was no erythema, pus or tenderness at the site of the CVC insertion. Blood for culture was obtained from two separate peripheral venipuncture sites. CRP had increased to 38 mg/dl; neutrophil count had normalized. Anti-biotic therapy with moxifloxacin 400 mg twice daily was restarted empirically. Body temperature and CRP rapidly normalized.Growth of Brevibacterium sp. was reported in both of the aerobic blood cultures. Antibiotic therapy was changed to intra-venous vancomycin (1 g twice daily) and the CVC was changed. The same Brevibacterium sp. was cultured on the CVC that was removed, and the bacteria were further specified as Brevibacte-rium casei. CVC-associated septicemia with B. casei was diag-nosed. After 10 days of intravenous vancomycin, antibiotic therapy was switched to oral moxifloxacin 400 mg twice daily for another 20 days according to microbiological sensitivity testing. Duringthis time, the patient recovered consistently. None of the following monthly surveillance blood cultures revealed B. caseiand up to 6 months later, the patient remained without further infectious complications.MicrobiologyThe patient’s isolates of both the peripheral blood samples and CVC tip showed gram-positive short coryneform rods forming whitish gray colonies with a distinctive cheese-like smell typical of Brevibacterium sp. Their identity was confirmed by conventional tests, i.e., production of methanethiol and hydrolysis of casein and tyrosine [2]. The isolate was identified as B. casei by use of carbohydrate Infection Case ReportSilvia Ulrich (corresponding author), M. Fischler, R. Speich Dept. of Internal Medicine, University Hospital of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; Phone: (+41/44)255-4162, Fax: -8519, e-mail: silvia.ulrich@usz.chR. Zbinden, M. PaganoInstitute of Medical Microbiology, University of Zurich, Zurich, SwitzerlandReceived: March 8, 2005 • Revision accepted: May 10, 2005S. Ulrich et al. Brevibacterium sp. Infection104 Infection 34 · 2006 · No. 2 © URBAN & VOGELassimilation tests as previously described [2].  were 0.75 mg/ml and 0.19 mg/l, respectively. Interpretative breakpoints are not available for coryneform bacteria, but our results of decreased susceptibilities to beta-lactams are in line with the data of Funke et al. [3]. We assume from the clinical improvement of our patient that the isolate was susceptible to vancomycin and moxifloxacin.Table 1Clinical pictures of infections with Brevibacterium species.Reference Type of InfectionBrevibacte-rium speciesMain underlying diseaseClinical symptomsIndwelling foreign materialSymptom onset to treatmentTime to recurrence (days)Treatment regimen(s)McCaughey [13]Septicemia Epidermidis Zollinger–Elli-son Syndrome Weight loss, post-prandial vomit-ing, fever, slight erythema around CVCaCVCa > 15 days No ErythromycinLina [14] Septicemia Not specifiedLymphoblastic lymphomaFever, diplopia, retroocular painCVCa > 23 days 28 Teicoplanin and amikacin 20 days, Teicoplanin 21 daysReinert [10] Septicemia Casei Testicular Chorion-carcinomaHigh fever, pancy-topeniaCVCa Few days 13 Piperacillin and teicoplanin 10 days, piperacillin and tobramycin 10 daysKaukoranta-Tolvanen [12]Septicemia Casei Non-Hodgkin’s    LymphomaInitially high, recurrent fever, tachycardia, CRPb up to 42 mg/dl, pancytopeniaCVCa > 18 days 16 Not mentionedCastagnola  [1]Septicemia Casei Neuro-blastoma Fever, neutrophil count above 1,000/cm3CVCa Not mentionedNo Not mentionedAntoniou [18]Peritonitis Iodinum CAPDc Fever, abdominal pain and tender-ness, urticaria, pruritus, CRPb 17.2 mg/dlCAPDc -CatheterRapid onsetNo Intraperitoneal cefuroxime 375 mg/exchange 2 days, than cipro-floxacin 50 mg/exchange 6 daysWauters [17]Peritonitis Otitidis CAPDc due to nephro-sclerosisModerate abdomi-nal pain, subfebril body temperature, effluent with 160 white blood cells/mm3 (46% PMNd)CAPDc -CatheterSeveral daysNo Intraperito-neal cefazolin                 and gentamicinBrazzola [11]Septicemia Casei AIDSe Persisting fever, dehydrationPort-à-Cath> 10 days No Ciprofloxacin 14 daysOgunc [15] Septicemia Not specifiedChronic lymphatic leucemiaHigh fever, slight leucocytosis (with 85% lymphocytes)Not mentionedNot reportedNo Not mentionedJanda [4] Septicemia Casei AIDSe Weight loss, dysphagia, ody-nophagia, fatigue for 1 month, fe-ver, pancytopeniaCVCa > 30 days No Vancomycin 8 daysContinued next pageS. Ulrich et al. Brevibacterium sp. InfectionInfection 34 · 2006 · No. 2 © URBAN & VOGEL 105DiscussionBrevibacterium spp. are gram-positive, irregular, rod-shaped, non-acid-fast bacteria which resemble coryne-bacteria. At the present time, ten species are classified in this genus: B. linens, B. iodinum, B. epidermidis, B. casei, B. mcbrellneri, B. otitidis, B. avium, B. paucivorans, B. luteolum and B. sanguinis [4–7]. The main habitat of Brevi-bacterium sp. are dairy products, where the bacteria contrib-ute to the aroma and color. They are also found on human skin surfaces, genital hair and otorrhea [6, 8, 9]. Brevibacterium spp. had not been considered as hu-man pathogens until about a decade ago. Since then, a few cases have been reported with Brevibacterium spp. caus-ing disease in humans [1, 4, 10–18] (Table 1). Symptomatic bacteremia with Brevibacterium spp. are almost exclusively described in immunocompromised patients [1, 4, 10–12, 14, 15], two of them infected with HIV type 1 [4, 11], the oth-ers induced by treatment of malignant disease [10, 12, 14, 15]. All but one had an indwelling CVC as an additional risk factor [1, 4, 10–14]. Only three patients with Brevi-bacterium sp. bacteremia [13, 16] were not conventionally immunocompromised but suffered from severe disease. All of these three, seven of the eight immunocompromised pa-tients with bacteremia and the two patients with peritonitis [17, 18] had indwelling foreign material (CVC [1, 4, 10–14], prosthetic mitral and aortic valve [16], or continuous am-bulatory peritoneal dialysis catheter [17, 18]) as risk factors for infection.The clinical presentation of Brevibacterium sp. in-fection varied with the underlying disease (Table 1). All patients presented with elevated body temperature, some of the patients with chills; most patients had additional unspecific symptoms such as weakness, general discom-fort, weight loss and reduced appetite. Exacerbation of symptoms related to underlying disease was also observed (gastrointestinal discomfort in CPAP patients, dyspnea and cough in our patient with pulmonary hypertension). Moderately elevated CRP-levels were reported in only three patients (our patient [12, 18]). Only the patient with lymphocytic leukemia presented with leukocytosis. Al-though it is comprehensible that elevation of inflammatory markers (CRP, leukocytes) were only moderate or absent in this predominantly immunocompromised patient, Bre-vibacterium spp. seem to only mildly activate the immune response in their hosts; the CRP in our immunocompe-tent patient was only slightly elevated. The time from onset of symptoms to diagnosis and therapy varied between rapid onset with fever and chills, and lingering disease with unspecific symptoms for up to 2 months. Recurrence was reported in about a quarter of the patients (Table 1). Indwelling foreign material can be a risk factor of catheter-related bloodstream infections (CR-BSI). Beside common causative pathogens, a variety of unusual patho-gens may also be encountered, particularly in immunocom-pro-mised patients [19]. The observation of Brevibacteriumsp. in blood cultures of patients with corresponding clinical symptoms is new and adds this species to the list of unusual pathogens. Accordingly, apart from in vitro susceptibility tests [20], little is known about the preferable antibiotic therapy and its required duration in vivo. Vancomycin was the therapeutic agent most frequently reported for around 8 days in septicemia and up to 6 weeks in endocarditis. Others used other glycopeptides (teicoplanin), penicil-lin-derivates (piperacillin) or chinolones (ciprofloxacin, moxifloxacin) or combinations. The choice and duration of therapy will strongly depend on clinical symptoms, site of infection and underlying disease. We present this case report as patients suffering from infections caused by Brevibacterium sp. may present with sparse and often unrecognized symptoms, possibly related to the underlying disease. Underestimation of these unspe-cific but relevant clinical symptoms and misinterpretation as apathogenic organisms may considerably delay diagno-sis and treatment of this emerging, mainly opportunistic pathogen. Therefore, it is important to sensitize  physi-cians and microbiologists to this environmental pathogenic Table 1 (continued)Reference Type of InfectionBrevibacte-rium speciesMain underlying diseaseClinical symptomsIndwelling foreign materialSymptom onset to treatmentTime to recurrence (days)Treatment regimen(s)Dass [16] Endocarditis Otitidis Prosthetic mi-tral and aortic valve replace-mentFever and chills for 4 days, mal-aise, loss of ap-petite, fatigueProsthetic valve4 days No Vancomycin 6 weeks  and gentamicin 2 weeksOur patient Septicemia Casei Continuous iv-iloprost in pulmonary hypertensionFever, chills, fatigue, cough, dyspnea previous 1–2 month, CRPb max 36 mg/dlCVCa > 1 monthsNo Vancomycin 10 days followed by moxifloxacin 21 daysa Central venous catheter; b C-reactive protein; c continuous ambulatory peritoneal dialysis; d polymorph nuclear neutrophils; e acquired immunodeficiency syndrome S. Ulrich et al. Brevibacterium sp. Infection106 Infection 34 · 2006 · No. 2 © URBAN & VOGELmicroorganism possibly severely affecting profoundly ill patients.References1. Castagnola E, Conte M, Venzano P, Garaventa A, Viscoli C, Barretta MA, Pescetto L, Tasso L, Nantron M, Milanaccio C, Giacchino R: Broviac catheter-related bacteraemias due to unusual pathogens in children with cancer: case reports with literature review. J Infect 1997; 34: 215–218.2. Funke G, Carlotti A: Differentiation of Brevibacterium spp. encountered in clinical specimens. J Clin Microbiol 1994; 32: 1729–1732.3. Funke G, Punter V, von Graevenitz A: Antimicrobial susceptibil-ity patterns of some recently established coryneform bacteria. Antimicrob Agents Chemother 1996; 40: 2874–2878.4. Janda WM, Tipirneni P, Novak RM: Brevibacterium casei bacte-remia and line sepsis in a patient with AIDS. J Infect 2003; 46: 61–64.5. Wauters G, Charlier J, Janssens M, Delmee M: Brevibacterium paucivorans sp. nov., from human clinical specimens. Int J Syst Evol Microbiol 2001; 51: 1703–1707.6. Wauters G, Avesani V, Laffineur K, Charlier J, Janssens M, Van Bosterhaut B, Delmee M: Brevibacterium lutescens sp. nov., from human and environmental samples. Int J Syst Evol Microbiol 2003; 53: 1321–1325.7. Wauters G, Haase G, Avesani V, Charlier J, Janssens M, Van Broeck J, Delmee M: Identification of a novel Brevibacterium species isolated from humans and description of Brevibacterium sanguinis sp. nov. J Clin Microbiol 2004; 42: 2829–2832.8. Pascual C, Collins MD: Brevibacterium avium sp. nov., isolated from poultry. Int J Syst Bacteriol 1999; 49 Pt 4: 1527–1530.9. McBride ME, Ellner KM, Black HS, Clarridge JE, Wolf JE: A new Brevibacterium sp. isolated from infected genital hair of pa-tients with white piedra. J Med Microbiol 1993; 39: 255–261.10. Reinert RR, Schnitzler N, Haase G, Lutticken R, Fabry U, Schaal KP, Funke G: Recurrent bacteremia due to Brevibacterium casei in an immunocompromised patient. Eur J Clin Microbiol Infect Dis 1995; 14: 1082–1085.11. Brazzola P, Zbinden R, Rudin C, Schaad UB, Heininger U: Brevi-bacterium casei sepsis in an 18-year-old female with AIDS. J Clin Microbiol 2000; 38: 3513–3514.12. Kaukoranta-Tolvanen SS, Sivonen A, Kostiala AA, Hormila P, Vaara M: Bacteremia caused by Brevibacterium species in an im-munocompromised patient. Eur J Clin Microbiol Infect Dis 1995; 14: 801–804.13. McCaughey C, Damani NN: Central venous line infection caused by Brevibacterium epidermidis. J Infect 1991; 23: 211–212.14. Lina B, Carlotti A, Lesaint V, Devaux Y, Freney J, Fleurette J: Persis-tent bacteremia due to Brevibacterium species in an immuno-compromised patient. Clin Infect Dis 1994; 18: 487–488.15. Ogunc D, Gultekin M, Colak D, Timuragaoglu A, Ongut G, Mutlu G, Hathi D, Undar L: Bacteremia caused by Brevibacterium spe-cies in a patient with chronic lymphocytic leukemia. Haemato-logia (Budap.) 2002; 32: 151–153.16. Dass KN, Smith MA, Gill VJ, Goldstein SA, Lucey DR: Brevibacte-rium endocarditis: a first report. Clin Infect Dis 2002; 35: e20–e21.17. Wauters G, Van Bosterhaut B, Avesani V, Cuvelier R, Charlier J, Janssens M, Delmee M: Peritonitis due to Brevibacterium otitidis in a patient undergoing continuous ambulatory peritoneal di-alysis. J Clin Microbiol 2000; 38: 4292–4293.18. Antoniou S, Dimitriadis A, Polydorou F, Malaka E: Brevibacterium iodinum peritonitis associated with acute urticaria in a CAPD patient. Perit Dial Int 1997; 17: 614–615.19. Mueller BU, Skelton J, Callender DP, Marshall D, Gress J, Longo D, Norton J, Rubin M, Venzon D, Pizzo PA: A prospective randomized trial comparing the infectious and noninfectious complications of an externalized catheter versus a subcutaneously implanted device in cancer patients. J Clin Oncol 1992; 10: 1943–1948.20. Troxler R, Funke G, von Graevenitz A, Stock I: Natural antibiotic susceptibility of recently established coryneform bacteria. Eur J Clin Microbiol Infect Dis 2001; 20: 315–323.

Central Venous Catheter Infection with Brevibacterium sp. in an Immunocompetent Woman: Case Report and Review of the Literature

http://doc.rero.ch/record/311839/files/15010_2006_Article_5027.pdf

Central Venous Catheter Infection with Brevibacterium sp. in an Immunocompetent Woman: Case Report and Review of the Literature

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library