Streptococcus sinensis has been described as a causative organism for infective endocarditis in 3 Chinese patients from Hong Kong. We describe a closely related strain in an Italian patient with chronic rheumatic heart disease. The case illustrates that S. sinensis is a worldwide emerging pathogen

Bolivar, Ignacio

Djordjevic, Marina

Garzoni, Christian

Ninet, Béatrice

Nobre, Vandack

Rohner, Peter

Schrenzel, Jacques

Uçkay, Ilker

Emerging Infectious Diseases

English

PubMed

Bern Open Repository and Information System (BORIS)

DISPATCHES1250 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 8, August 2007Streptococcus sinensis Endocarditis outside Hong KongIlker Uçkay,* Peter Rohner,* Ignacio Bolivar,† Béatrice Ninet,* Marina Djordjevic,* Vandack Nobre,* Christian Garzoni,* and Jacques Schrenzel*Streptococcus sinensis has been described as a caus-ative organism for infective endocarditis in 3 Chinese pa-tients from Hong Kong. We describe a closely related strain in an Italian patient with chronic rheumatic heart disease. The case illustrates that S. sinensis is a worldwide emerg-ing pathogen.Among the hundreds of bacteria that are pathogenic for humans, some are reposted only once and remain a rarity, while others are considered as emerging pathogens after several cases have been published. In 2002, Woo et al. from Hong Kong Special Administrative Region, People’s Republic of China, reported a new pathogen isolated from a 42-year-old Chinese woman with mitral regurgitation due to chronic rheumatic heart disease and infective endocardi-tis (HKU4) (1). Its 16S rRNA sequence (2) showed a new streptococcal species, subsequently named Streptococcus sinensis in honor of China; the sequencing showed that it was closely related to Streptococcus gordonii (96.4% ho-mology) and to Streptococcus intermedius (96.3%) (1). Phenotypically, the species most closely resembled S. in-termedius; some evidence suggests that S. sinensis could be the common ancestor of S. anginosus and S. mitis (3). In 2004, the same group published a retrospective analysis of 302 bacteremia cases caused by S. viridans in Hong Kong, including 2 other cases of endocarditis caused by S. sinen-sis with Lancefi eld group F (4). We describe another case of an infective endocarditis (or infection in general) due to S. sinensis outside Hong Kong.The CaseIn December 1998, a 57-year-old Italian man with a severe mitral insuffi ciency of rheumatic origin underwent a nonbleeding dental procedure without antimicrobial prophylaxis. One month later, he was hospitalized at the University Hospitals of Geneva with fever (38°C–39°C), rigors, and weight loss of 4 kg in 3 weeks. There was no history of prior endocarditis, drug abuse, traumatism, or concomitant disease. At admission he was hemodynami-cally compensated and without fever. Over the cardiac apex, a grade 5/6 proto-mesosystolic murmur was audible. Transesophageal echocardiography showed vegetation on the mitral valve without abscesses. An ophthalmologic ex-amination showed an embolus near the right macula. The urinary sediment exhibited microhematuria. In all blood-culture bottles, a gram-positive Streptococcus sp. was grown. Thus, infective endocarditis was diagnosed by the presence of 2 major and 3 minor criteria according to modi-fi ed Duke criteria (5).An antimicrobial drug treatment with intravenous (i.v.) penicillin G 6 × 4 million U/day and gentamicin 3 × 1 mg/kg/day for 3 weeks was initiated. After an excellent clinical course and normalization of infl ammation markers, treat-ment was switched to i.v. ceftriaxone 1 × 2 g/day for anoth-er 3 weeks to enable outpatient therapy (6). No secondary abscesses occurred. Several infected teeth were extracted during treatment. Because of the severity of the preexist-ing mitral regurgitation, an elective replacement with a mechanical prosthesis was performed in March 1999. The patient was considered cured. Three years later he died of cerebral hematoma attributed to oral anticoagulation. Autopsy did not show any sequelae of former infection.All 6 blood-culture bottles (3 BACTEC aerobic plus/F and 3 BACTEC anaerobic lytic/F; Becton Dickinson, Sparks, MD, USA.) were positive with gram-positive cocci in chains. The isolate grew as transparent α-hemolytic col-onies (0.5- to 1-mm diameter) on sheep blood Columbia agar after an incubation of 24 h at 35°C in 4% CO2-enriched atmosphere. The biochemical identifi cation system API 20 Strep (bioMérieux, Lyon, France) was used to attempt the identifi cation. The numerical profi le was 4241450, indi-cating S. sanguinis (95% similarity). Agglutination with Lancefi eld antisera (Streptokit, bioMérieux) was nega-tive for groups A, B, C, D, F, and G. Antimicrobial MICs were determined with Etest (AB Biodisk, Solna, Sweden). Results were interpreted according the available Clinical Laboratory Standard Institute (CLSI, formerly NCCLS) criteria (7) (Table).The genetic sequence of the 16S rRNA was determined by a capillary sequence analyzer (ABI 3130 XL DNA An-alyzer, Applied Biosystems (Foster City, CA, USA) and compared with the nucleotide sequences in GenBank. Of >1,000 bp in the 16S rRNA sequence, only 2 differed from the previously published S. sinensis HKU4 (AF432856) (1), a sequence identical to that of HKU5 (AF432855) and HKU6 (AF432857) (4). Results were positive for identify-ing the superoxid dismutase (sodA) (primer from reference 8) and RNA polymerase β-subunit (rpoB) (9) housekeep-ing gene sequences. Concerning sodA, for >404 bp there was 97.3% homology with the positive S. sinensis strain *University Hospitals of Geneva, Geneva, Switzerland; and †Insti-tut für Angewandte Immunologie, Zuchwil, Switzerland source: https://doi.org/10.7892/boris.25686 | downloaded: 8.5.2016Streptococcus sinensis Endocarditis outside Hong Kong Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 8, August 2007 1251 AY386220 (9) and only 2 bp differences in >286 bp (99.3% homology) with the S. sinensis strain EF451825. Concern-ing rpoB, 485 bp were identical over 516 nt sequences (94% homology) of the S. sinensis strain AF199923 (9).ConclusionsWe report a case outside Hong Kong of infective en-docarditis caused by a strain of S. sinensis. Information on this novel pathogen has been published for 3 Chinese pa-tients (2–4). Ours is the fourth published case worldwide. Because the original S. sinensis (1) is most closely related to our strain, we believe that our isolate belongs to that spe-cies. The close relationship of the sequence of our strain to the referential sodA and rpoB gene sequences also identi-fi es our Geneva strain as S. sinensis. We have submitted the sodA and rpoB sequencing results to GenBank (accession nos. EF585234 and EF591041, respectively).A 16S rRNA sequence with only 3 base differences from HKU4 had been detected by a German group in the aortic valve of another patient (GenBank accession no. AY049738, unpub. data), and other sequences have been reported by a French group (EF371928, unpub. data) and a British group (AY386220, unpub. data). We do not know more about these cases. Our Geneva strain differed only in 2 nt bases from the HKU4 strain (on positions 43 and 48) and only in 1 base (position 66) from the German sequence, whereas it is identical with the French sequence. This might suggest the emergence of a European strain of S. sinensis. From a clinical point of view, all reported patients (1,4) had an underlying chronic rheumatic heart disease of the mitral valve as the major risk factor. Only l patient had a preceding tooth extraction (4), like our patient with teeth abscesses. No other infections besides endocarditis caused by S. sinensis have been described thus far in humans or in animals. All previously reported patients were successfully treated by i.v. penicillin G or ampicillin for 4 weeks (com-bined therapy with gentamicin during the fi rst 2 weeks) without necessity for surgical intervention. In light of other streptococcal endocarditic recommendations (10,11) and reported experiences with S. sinensis (4), our 6 weeks of antimicrobial drug treatment was probably excessive. The elective mitral valve replacement was indicated because of the severity of the preexisting regurgitation.In conclusion, our case outside Hong Kong confi rms that S. sinensis causes endocarditis throughout the world. Like other viridans streptococci, S. sinensis might be part of the human oral fl ora. The real number of cases is prob-ably underestimated because commercial kits misidentify S. sinensis as S. intermedius or S. anginosus (1). With ad-equate sequencing technology, further reports may indicate the real prevalence of this emerging pathogen.AcknowledgmentsWe are indebted to Nouria Azam for the microbiologic anal-yses and to our colleges in the Central Laboratory of Bacteriology of the University Hospitals of Geneva for their help.Dr Uçkay works in the Infection Control Program of the University Hospitals of Geneva. His research interests are infec-tion control and clinical infectious diseases, especially bone and prosthesis infections.References  1.  Woo PCY, Tam DMW, Leung KW, Lau SKP, Teng JLL, Wong MKM, et al. Streptococcus sinensis sp. nov., a novel species iso-lated from a patient with infective endocarditis. J Clin Microbiol. 2002;40:805–10.  2.  Olsen GJ, Woese CR. Ribosomal RNA: a key to phylogeny. FASEB J. 1993;7:113–23.  3.  Woo PCY, Teng JLL, Lau SKP, Yuen KY. Clinical, phenotypic, and genotypic evidence for Streptococcus sinensis as the common ances-tor of anginosus and mitis groups of streptococci. Med Hypotheses. 2006;66:345–51.  4.  Woo PCY, Teng JLL, Leung KW, Lau SKP, Tse H, Wong BHL, et al. Streptococcus sinensis may react with Lancefi eld group F antiserum. J Med Microbiol. 2004;53:1083–8.  5.  Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG Jr, Ryan T, et al. Proposed modifi cations to the Duke criteria for the diagnosis of in-fective endocarditis. Clin Infect Dis. 2000;30:633–8.  6.  Francioli P, Etienne J, Hoigne R, Thys JP, Gerber A. Treatment of streptococcal endocarditis with a single daily dose of ceftriaxone sodium for 4 weeks. Effi cacy and outpatient treatment feasibility. JAMA. 1992;267:264–7.  7.  National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing. Informational sup-plement M100–S9. Wayne (PA): the Committee; 1999.  8.  Poyart C, Quesne G, Boumaila C, Trieu-Cuot P. Rapid and accurate species-level identifi cation of coagulase-negative staphylococci by using the sodA gene as a target. J Clin Microbiol. 2001;39:4296–301.  9.  Hoshino T, Fujiwara T, Kilian M. Use of phylogenetic and pheno-typic analyses to identify nonhemolytic streptococci isolated from patients. J Clin Microbiol. 2005;43:6073–85.Table. Susceptibility of Streptococcus sinensis–related strain from University Hospitals of Geneva Antimicrobial agent MIC (mg/L) Interpretation Penicillin 0.064 SusceptibleCeftriaxone 0.19 SusceptibleImipenem 0.064 SusceptibleGentamicin 3 Intermediate resistantLevofloxacin 1 SusceptibleClindamycin 0.094 SusceptibleErythromycin 0.047 SusceptibleRifampicin 0.032 SusceptibleCotrimoxazole 1 SusceptibleTetracycline 0.125 SusceptibleTigecycline 0.064 SusceptibleLinezolid 0.5 SusceptibleVancomycin 1 SusceptibleTeicoplanin 0.25 SusceptibleDISPATCHES1252 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 8, August 200710.  Wilson WR, Karchmer AW, Dajani AS, Taubert KA, Bayer A, Kaye D, et al. Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci, and HACEK mi-croorganisms. American Heart Association. JAMA. 1995;274: 1706–13.11.  Francioli P. Antibiotic treatment of streptococcal and enterococcal endocarditis: an overview. Eur Heart J. 1995;16:75–9.Address for correspondence: Ilker Uçkay, Division of Infectious Diseases, University Hospitals of Geneva, 24, rue Micheli-du-Crest, 1211 Geneva 14, Switzerland; email: ilker.uckay@hcuge.chUse of trade names is for identifi cation only and does not imply endorsement by the Public Health Service or by the U.S. Department of Health and Human Services.

Streptococcus sinensis endocarditis outside Hong Kong

Ilker Uçkay

Peter Rohner

Ignacio Bolivar

Béatrice Ninet

Marina Djordjevic

Vandack Nobre

Christian Garzoni

Jacques Schrenzel

Directory of Open Access Journals

Streptococcus sinensis Endocarditis outside Hong Kong

and genotypic evidence for Streptococcus sinensis as the common ancestor of anginosus and mitis groups of streptococci. Med Hypotheses.

Proposed modiﬁ cations to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis.

Rapid and accurate species-level identiﬁ cation of coagulase-negative staphylococci by using the sodA gene as a target.

Ribosomal RNA: a key to phylogeny.

Standards. Performance standards for antimicrobial susceptibility testing. Informational supplement M100–S9. Wayne (PA): the Committee;

Streptococcus sinensis may react with Lanceﬁ eld group F antiserum.

Streptococcus sinensis sp. nov., a novel species isolated from a patient with infective endocarditis.

Treatment of streptococcal endocarditis with a single daily dose of ceftriaxone sodium for 4 weeks. Efﬁ cacy and outpatient treatment feasibility.

Use of phylogenetic and phenotypic analyses to identify nonhemolytic streptococci isolated from patients.

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Streptococcus sinensis Endocarditis outside Hong Kong

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