AWAYA, GORO

MATSUDA, FUMIHIDE

MIMASU, YOKO

MITSUTAKE, YOKO

MIYAMOTO, TOSHIHIRO

NAGAYAMA, MAKI

SHIMIZU, KATSUJI

SHIRAKAWA, KAZUYO

WAKITA, SHIGEAKI

Kyoto University Research Information Repository

Title Eikenella corrodens tenosynovitis and osteomyelitis of thehand : A case reportAuthor(s)SHIMIZU, KATSUJI; AWAYA, GORO; MATSUDA,FUMIHIDE; MIYAMOTO, TOSHIHIRO; WAKITA,SHIGEAKI; MITSUTAKE, YOKO; NAGAYAMA, MAKI;MIMASU, YOKO; SHIRAKAWA, KAZUYOCitation日本外科宝函 (1984), 53(6): 800-806Issue Date1984-11-01URL http://hdl.handle.net/2433/208809RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityArch Jpn Chir 53(6), 800～806, Nov., 1984 Eikenella corrodens tenosynovitis and osteomyelitis of the hand 一－Acase report-KATSUJI SHIMIZU, GORO AWAYA, FUMIHIDE MATSUDA, TOSHIHIRO MIYAMOTO, SHIGEAKI WAKITA, YOKO MITSUTAKE*, MAKI NAGAYAMA*, A fourty-six YOKO MIMASU* and KAZUYO SHIRAKAWA* Department of Orthopaedic Surgery and *Bacteriological Laboratory, Kokura Memorial Hospital Received for Publication, July 16, 1984. Summary ing a laceration with oral contamination. Culture of the pus grew Ez"kenella corrodens, an organism that is normally found in oral secretions and has recently been recognized as pathogen. This is the first report in Japan of bone and joint infection caused by Ez"kenella corrodens. The significance of this organism in hand infection is also discussed. Introduction Eikenella corrodens, a small fastidious anaerobic gram-negative bacillus, is a part of the nor-mal oronasopharyngeal flora and is recently recognized as an occasional pathogen2•4> It has been recovered as the infecting agent in cases of endocarditis4ぺmeningitis2ペsubduralabscess丸山 andpulmonary infections8> Several reports from western countries also deal with bone and joint in-fection1•3•7•9•16•20> in orally contaminated wound. In our country, there are only a few reports of infection by this organism23•24> This is a report of a case in which Eikenella corrodens was isolated from an orally contaminated wound, in which tenosynovitis and osteomyelitis resulted, and to the best of our knowledge, there has been no report of skeletal E必enellacorrodens infection in Japan. Case Report On Jan. 25, 1983 a fourty-six-year-old male factory worker was admitted to Kokura Memorial Hospital with an infection in his right hand of 6 days’duration. The patient reported that his right ring finger was trapped between two garden stones w.hile he was moving them at home. Just after injury, his friend put the wound in his mouth to draw out“dirty blood", The patient did not seek medical attention for five days. Key Words: Eikenella corrodens, Hand, Infection, Tenosynovitis, Osteomyelitis. 索引語： Eikenellacorrodens，手，感染症，腿鞠炎，骨髄炎．Present address: Department of Orthopaedic Surgery, Kokura Memorial Hospital, 1 1 Kifunemachi Kokura-kitaku, Kitakyushu 802, Japan. 、EIKENELLA CORRODENS INFECTION OF THE HAND A B Fig. 1. (A) Necrotic ulcer over the third distal interphalangeal j0int and edema of the right ring五ngerand dorsum of the hand 6 days after being wounded. (B) penetrating wound in the middle phalanx and swelling in the palmar as-pect of the rin g五ngersame time as in A. 801 Abnormal physical findings were limited to the right hand except for axillary temperature of 38.0。C. There was browny edema of the right ring finger and entire dorsum of the hand. A necrotic ulcer was seen over the ring finger’s distal interphalangeal joint with fecal odor (Fig. 1-A). There was a small penetrating wound in the radial aspect of the middle phalanx and the volar aspect of the ring白ng巴rwas red and swollen along the flexor synovial sheath. The ring finger could not be extended freely (Fig. 1-B). There was no palpable lymphadenopathy in the epitrochlear or axillary areas. Admission laboratory data included WBC 7000/cu mm with 50% polymorphonuclear leukocytes, ESR 25 mm/hr, blood glucose 124 mg/di and CRP ( + ). Upon admission, intravenous cefazolin 4 g/day administered every 12 hours was begun, and the right hand was splinted and elevated. Glucose tolerance test revealed a diabetic pattern (75 g OGTT). EZ: enella corrodens was cultured from the wound on hospital days 2, 14, 22, 29 and 32. Fig. 2. Antero・posteriorroentgenogram of the middle phalanx of the right ring自ngerrevealing bone resorption and periosteal reaction. 802 日外宝第53巻第6号（昭和59年11月）Alpha-streptococcus was also isolated in most of the cultures. Although these organisms showed sensitivity to cefazolin, purulent discharge did not subside and the roentgenogram taken on the 20th hospital day revealed periosteal reaction and bone resorption in middle phalanx (Fig. 2). Surgical debridement of the ring finger was performed on 31st day. The wound was opened through radial mid-lateral incision and flexor tendon sheath was incised as proxiaml as the proxi-mal finger crease where tenosynovitis was noted. Necrotic part of the flexor tendon and middle phalanx were excised. The wound was packed open and antibiotics was changed to ceftizoxime i. v. to which these organism were also sensitive. Dressing change and gentle active exercise were begun on the 4th postoperative day. Intravenous antibiotics was administered for 8 days followed by parenteral antibiotics for 13 days. The culture on the 4th postoperative day revealed only microcuccus and on the 8th day, it was negative of any organism. The wound healed over in three weeks. Six months after operation, the hand kept fairly good function (Fig. 3-A, B) and there had been no subsequent evidence of recurrence sixteen months later. Eikenella corrodens; History and bacteriology of the present case. Ei：五enellacorrodens is a gram-negative, microaerophilic bacillus which only lately has received attention as a poss】blepathogen. The late recognition is due to delay in ident凶cationand characterization of the bacillus as well as difficulty in culturing it. HENRIKSEN1m in 1948 described anaerobic gram-negative bacilli which grew slowly on solid media as colonies depressed below the agar surface. In 1950, HoLM12) provisionally named these organisms“the corroding bacillus'; be-cause the colonies resembled“small, mat, corroded patches on the surface of the blood agar". EIKEN5九in1958, studied similar organisms, reported them to be strictly anaerobic, and placed them among the Bacteroides species. He called his strain “Bacteroides corrodens" and declared them to be a new species of Bacteroides. KING and TATUM仙， in1962, studied an organism they called HB-1. This group seemed almost identical to Eiken’s Bacteroides corrodens, although HB・1included both strictly anaerobic and facultatively anaerobic strains2l. HENRIKSEN11》， in1969, found Eiken's Bacteroides corrodens not to be a strict anaerobic and believed it should not be in the genus Bacteroides. JACKSON et al.13', in 1971, stated that the aerobic growth of thes巴organismswas A B Fig. 3. Active extension (A) and自exion(B) of the hand six months after surgery. Wound healed and fairly good function is preserved. EIKENELLA CORRODENS INFECTION OF THE HAND 803 Fig. 4. Small crater-shaped colonies on chocolate agar with hemin, characteristic to Ei"kenella corrodens (X 10). dependent on the hemin content of the media. They also studied DNA base composition of this and related organisms and proposed that facultatively anaerobic, gram-negative rods called Bacte1’ma escorrodens be transferred to a new genus, Ez"kenella, in honor of Eiken, because the facultatively anaerobic Ez"kenella organisms had a DNA guanine-plus-cytosine (G+C) content of 56 58 mo！箔and did not produce urease, whereas the anaerobic strains had DNA G+C content of28 30 mo！箔and were urease positive1引 Thus,there are apparently two different species which produce corroding colonies: (1) a strict anaerobe stil carrying the designation of Bacteroz"des corrodens, although recently a plea has been made for its name to be changed to Bacterozaes ureolytz・cslS>'and (2) a facultative anaerobe which is microaerophilic and grows best aerobically if hemin is added to the medium (E泌・enellacorrodens). Ez"kenella corrodens is characterized by JACKSON and GOODMAN凶 asfollows: gram-negative rods 0.3-0.4 by 1.5-4 nm growing as aerobes and facultative anaerobes. The organism grows characteristically as small corroding or pitting colonies of pinpoint size, but dome-shaped, non-pitting variants also are encountered. Colonies on blood agar grow to 0.5 mm in 24 hours and are non-hemolytic. Growth during primary isolation is favoured by a 5-105ぢcarbondioxide atmos-phere, and the organism typically requires hemin in concentration of 5-25 μg/100 ml of media for Table 1. Biochemical assay of Ei"kenella corrodens Result Organism from A TCC 23834 一一一一 handwound ._J_~.！！！！.＇！！！！a corrodens_)_ Oxidase + + Test Catalase ?、?????????????? ?????? ??????? ??????? ? ?????． ? ??? ＋ H2S production trace trace Lysine decarboxylase Ornithine decarboxylase Arginine dehydrolase ＋ ＋ ＋ ＋ 804 日外宝第53巻第6号（昭和59年11月）optimal aerobic growth. Eiシ~enella corrodens is oxidase-positive, catalase-negative, nitrate-reducing, urease-negative, gelatinase-negative, indole-negative, lysine-decarboxylase-positive, and does not ferment glucose or any other commonly used sugar. The Ei'kenella corrodens isolated from the hand wound of our patient was first cultured aerobically on a blood agar plate containing 5'ぢsheepred cells in trypticase soy agar. The organism grew aerobically and under 5-10猪 C02on chocolate agar with hemin (Fig. 4) and anaerobically on Gifu anaerobic medium. For fermentation studies, cystine trypticase agar was used. The ATCC control organism (Eikenella corrodens 23834) were run in parallel with the strain from the present case to assure standardization and the results are listed in Table 1. Discussion Eikenella corrodens have recently been recognized increasingly as pathogens引， howeverit is stil unfamiliar to clinicians. Most of the cases are the infection of such sites as have a contact with oronasopharynx where this organism is part of the normal bacterial flora. It is natural that the early description of skeletal infection by this organism was that occurred in mandibula consequent to open fracture3•m The other common site of skeletal infection is the hand, which is most likely to be contaminated by human bite. The first case of hand infection due to Eikenella corrodens was reported by JOHNSON and PANl王EY16lin 1976. Since then the number of the cases are increasing as its significance in the human bite wound is recognized1•7•9•20). GOLDSTEIN et al.9) reports 20箔 incidenceof Eikenella corrodens in fifteen cases of clenched-fist injury. Osteomyelitis of os calcis is also reported in that case a history of injury by tooth pick was noted2D The first report of Eikenella corrodens infection in our country was published in 1977 on a patient with lung abscess初 、 Sincethen only a few reports deal with this organism24l, and to the best of our knowledge, there has been no report on skeletal infection by Eikenella corrodens in Japan. In the present case, culture from the wound yielded Eikenella corrodens five times although most of them were associated with other organisms, among which α－streptococcus was found three times. The bacillus is reported frequently found in association with other organisms, both aerobic and anaerobic, and these organisms are considered to cooperate to produce infection2l Diabetic status of this patient may also have contributed to the establishment of the infection. The organism isolated from the present wound formed characteristic pitting colony on blood agar and al the biochemical test run parallel with A TCC control organism showed reported character of Eikenella corrodens. Consequently, it is obvious that Eikenella corrodens was the pathogen in the present case. The Eikenella corrodens infection did not seem to differ clinically from other infection. Diagnosis is impossible clinically and can only be established by laboratory examinations. Treat-ment is early surgical debridement and selection of proper antibiotics is of prime importance. The unusual antimicrobial susceptibility pattern of this organism must be considered in choosing therapeutic regimens. Ei'kenella is sensitive to chloramphenicol, gentamycin and erythromycin, and EIKENELLA CORRODENS INFECTION OF THE HAND 805 singularly resistant to clindamycin2＞、 Ourresult of the sensitivity test was in accordance with this (data not shown). The frequency of isolation of a given type of bacteria depends upon the suspicion of the clinician, the obtaining of an adequate specimen and the thoroughness of culture techniques. Some hand infections have been referred as“sterile”and the term“sterile abscess" is commonly used. This erroneous assumption is made on the basis of incomplete data, i.e., the routine aerobic culture. Ez"kenella corrodens should be suspected as a possible cause of any infection originating in area contiguous with the oronasopharynx or that is contaminated by its secretion. All the injuries with a history of oral contamination should be cultured in aerobic, anaerobic, and 105ぢC02 atmosphere, assuming the presence of Ez"kenella corrodens. Read at the annual meeting of the Japanese Society for Bone and Joint Infection, Kurume, Japan, July 16, 1983. Acknowledg位nentsGratitude is extended to Mr. K. Wake and Mrs. M. Sato, Department of Medical Photography, Kokura Memorial Hospital. References 1) Bilos ZJ, Kucharchuk A, et al: Ei’＇kenella corrodens in human bites. Clin Orthop 134: 320-324, 1978. 2) Brooks GF, 0’Donoghue JM, et al: Eikenella corrodens, a recently recognized pathogen: infections in medical-surgical patients and in association with methylphenidate abuse. Medicine 53: 325-342, 1974. 3) Carruthers MM and Sommers HM: Eikenella corrodens osteomyelitis. Ann Intern Med 79: 900, 1973. 4) Dorff GF, Jackson LJ, et al: Infections with Ei"kenella corrodens. a newly recognized pathogen. Ann Intern Med 80: 305-309, 1974. 5) Eiken M: Studies on an anaerobic, rod-shaped, Gram-negative microorganism: Bacteroi"des corrodens n sp. Acta Pathol Microbiol Scand 43: 404-416, 1958. 6) Geraci JE, Hermans PE, et al: Ei"kenella corrodens endocarditis. Report of cure in two cases. Mayo Clin Proc 49: 950-953, 1974. 7) Goldstein EJC, Barones MF, et al: Ei"kenella corrodens in hand infections. J Hand Surg 8: 563-567, 1983. 8) Goldstein EJC, Kirby BD, et al: Isolation of Eikenella corrodens from pulmonary infections. Am Rev Respir Dis 119: 55-58, 1979. 9) Goldstein EJC, Miller TA, et al: Infections following clenched-fist injury: A new perspective. J Hand Surg 3: 455-457, 1978. 10) Henriksen SD: Studies in gram-negative anaerobes. I. Gram-negative anaerobic rods with spreading colonies. Acta Pathol Microbiol Scand 25: 368-375, 1948. 11) Henriksen SD: Corroding bacteria from the respiratory tract. 2. Bacteroides corrodens. Acta Patl叫Microbiol Scand 75: 91-96, 1969. 12) Holm P: Studies on the etiology of human actinomycc;:isis. I. The 、thermicrobes" and their importance. Acta Pathol Microbiol Scand 27: 736 751, 1950. 13) Jackson FL, Goodman YE, et al: Taxonomic status of facultative and strictly anaerobic ～orroding bacilli”that have been classified as Bacteroides corrodens. J Med Microbiol 4: 171-184, 1971. 14) Jackson FL and Goodman YE: Transfer of the facultatively anaerobic organism Bacteroi"des corrodens Eiken to a new genus, Ei"kenella. Int J Syst Bacteriol 22: 73ー7,1972. 15) Jackson FL and Goodman YE: Bacteroi"des ureolyti"cus, a new species to accomodat巴strainspreviously identi五edas“Bacteroides corrodens, anaerobic”. Int J Syst Bacteriol 28: 197-200, 1978. 16) Johnson SM and Pankey GA: Eikenella corrodens osteomyelitis, arthritis, and cellulitis of the hand. South Med J 69: 535-539, 1976. 806 日外宝第53巻第6号（昭和59年11月）17) Kaplan JM, McCracken GH, et al: Infections in children caused by HB group of bacteria. J Pediatr 82: 398-403, 1973. 18) King EO and Tatum HW: Actinobacillus actinomycetemcomitans and Hemophilusψhr op Ml us. J Infect Dis 111: 85-94, 1962. 19) Marsden HB and Hyde WA: Isolation of Bacteroides corrodens from infections in children. T Clin Path 24: 117-119, 1971. 20) McDonald I: Eikenella corrodens infection of the hand. Hand 11: 224-227, 1979. 21) Polin K and Shulman ST: Eikenella corrodens osteomyelitis. Pediatrics 70: 462-463, 1982. 22) Riley PS, Tatum HW, et al: Identity of HB-1 of King and Eikenella corrodens (Eiken) Jackson and Goodman. Int J Syst Bacteriol 23: 75-76, 1973. 23) Sawatari K, Mochida C, et al: Bacteriological study on Eikenella corrodens isolated from pulmonary punctured fluid of lung abscess. Clin Pathol 25: 597-602, 1977 (in Japanese). 24) Yamashita M, Fujita S, et al: Clinical and bacteriological studies on Eikenella corrodens isolated from clinical materials. Clin Pathol 29: 511-516, 1981 (in Japanese). 和文抄録Eikenella corrodensを起炎菌とする手の化膿性臆鞘炎・骨髄炎の 1例社会保険小倉記念病院整形外科清水克時，粟屋梧老，松田文秀，宮本敏広，脇田重明同検査診断科細菌部光武洋子，永山真紀，見増洋子，白川和代Eikenella corrodens による骨関節感染症としては本 小梓菌で，人の口腔内などに常在菌として存在する．邦第1例と恩われる症例を報告した． 感染症の起炎菌として注目されたのが比較的最近であ症例は46歳男性で，庭石の聞に右手環指をはさまれ るととと，培養に若干の手技を要するため，本菌によ受傷，直後に同僚が創を口に当て吸ったのち放置して る感染症の報告は多くはないが，欧米においては，人いた．疹痛と腫脹が強く，排膿がみられたため第6日 の授創による骨関節感染症の報告がいくつかあり，本に受診した．抗生剤投与と副子固定により症状は軽快 菌に対する認識が高まるにつれ，症例数は増加していしたが，排膿が続き， 5固にわたって Eikenellacor- る．本菌は hemin加チョコレート寒天培地で C02存rodensが分離された．また同時に a-streptococcusが 在下iとよく成育し，寒天表面上から凹んだ，特徴的な分離され，混合感染が疑われた.x線上骨吸収像が現 形状のコロニーを作ること，および生化学的性状によれたので，受傷5週自に，屈筋腿腿鞘切開と中節骨の り同定される．抗生剤感受性は良好であるが，一般菌デプリドマンを行った．創は開放のまま治癒させ，術 と感受性が乙となるため，正確な菌の同定と感受性検後16カ月の現在，手の機能は良好で，炎症の再発もな 査が必要である・同時に適切な整形外科的処置が重要である．Eikenella corrodensは，微好気性，グラム陰性の

Eikenella corrodensを起炎菌とする手の化膿性腱鞘炎・骨髄炎の1例

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Eikenella corrodensを起炎菌とする手の化膿性腱鞘炎・骨髄炎の1例

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