Jean, Sophonie

Lainhart, William

Yarbrough, Melanie Y

English

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Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2019The Brief Case: Erysipelothrix bacteremia andendocarditis in a 59-year-oldimmunocompromised male on chronic high-dosesteroidsSophonie JeanWashington University School of Medicine in St. LouisWilliam LainhartUniversity of ArizonaMelanie Y. YarbroughWashington University School of Medicine in St. LouisFollow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationJean, Sophonie; Lainhart, William; and Yarbrough, Melanie Y., ,"The Brief Case: Erysipelothrix bacteremia and endocarditis in a59-year-old immunocompromised male on chronic high-dose steroids." Journal of Clinical Microbiology.57,. e02031-18. (2019).https://digitalcommons.wustl.edu/open_access_pubs/7859The Brief Case: Erysipelothrix Bacteremia and Endocarditis in a59-Year-Old Immunocompromised Male on Chronic High-DoseSteroidsSophonie Jean,a William Lainhart,b Melanie L. YarbroughaaDepartment of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri, USAbDepartment of Pathology, University of Arizona, Tucson, Arizona, USAKEYWORDS Erysipelothrix, endocarditis, vancomycin resistanceCASEA 59-year-old male with a past medical history of rheumatoid arthritis for which hewas on high-dose prednisone (20 mg daily) for more than 3 years, chronicobstructive pulmonary disease, chronic lower back pain, lower extremity neuropathy,gout, and hypertension presented to the emergency department (ED) with a 2-dayhistory of increasing shortness of breath and subjective fever. The patient had a familyhistory signiﬁcant for heart disease but denied any personal history of coronary arteryor valvular heart disease. The patient also noted an ulceration on his right great toewith drainage for 1 to 2 months. Upon arrival in the ED, the patient was tachycardic(heart rate, 100 to 149 bpm) and febrile to 39.4°C with normal respiration (bloodoxygen saturation [SpO2], 94%). Initial laboratory studies were signiﬁcant for elevatedwhite blood cells at 18,600 cells/mm3 (reference, 3,800 to 9,000), 91.4% neutrophils,lactate at 5.9 mmol/liter (reference, 0.5 to 2.2), and N-terminal pro-b-type natriureticpeptide (NT-pro-BNP) of 151 (reference, 52 to 125 pg/ml). On physical examination, a1-cm ulcer was noted on his great right toe that was associated with erythema but fromwhich no sinus tract or signiﬁcant purulence was noted. Chest, abdomen, and pelviscomputed tomography with contrast revealed minor bronchiolar densities in the rightupper lobe, likely representing early pulmonary bronchiolitis. Two sets of blood cultureswere obtained, and the patient was started on intravenous (i.v.) levoﬂoxacin and i.v.metronidazole. Twelve hours into incubation, the aerobic and anaerobic bottles (Ver-saTrek, TREK Diagnostic Systems, Cleveland, OH) of both sets of blood cultures signaledpositive, and short Gram-positive bacilli with rounded ends were observed on Gramstain (Fig. 1A and B), prompting initiation of empirical treatment with i.v. vancomycin,cefepime, and metronidazole. Within 1 day, pinpoint, alpha-hemolytic colonies grew on5% sheep blood and chocolate agars incubated at 37°C in 5% CO2 and brucella bloodagars incubated anaerobically (Fig. 1C). The isolate was identiﬁed as Erysipelothrixrhusiopathiae with scores of 2.26 and 2.14 using the research use only (RUO) BDAL v7database of the Bruker biotyper matrix-assisted laser desorption ionization–time ofﬂight mass spectrometry (MALDI-TOF MS; Billerica, MA), indicating a high-conﬁdencespecies-level identiﬁcation (scores, 2.0). Additional biochemical testing demonstratedthat the isolate was catalase negative, resistant to vancomycin (30 g; BD, Sparks, MD),and produced hydrogen sulﬁde when incubated on triple sugar iron (TSI) Agar (Remel,Lenexa, KS), consistent with Erysipelothrix rhusiopathiae (Fig. 1D and E).Following report of the E. rhusiopathiae result, the patient’s antimicrobial therapywas switched to i.v. penicillin G and a transesophageal echocardiogram (TEE) wasperformed. A 0.9- by 0.5-cm vegetation was seen on the posterior mitral leaﬂetconsistent with endocarditis. No signiﬁcant valve destruction was found, precludingCitation Jean S, Lainhart W, Yarbrough ML.2019. The Brief Case: Erysipelothrix bacteremiaand endocarditis in a 59-year-oldimmunocompromised male on chronic high-dose steroids. J Clin Microbiol 57:e02031-18.https://doi.org/10.1128/JCM.02031-18.Editor Alexander J. McAdam, BostonChildren's HospitalCopyright © 2019 American Society forMicrobiology. All Rights Reserved.Address correspondence to Melanie L.Yarbrough, myarbro@wustl.edu.For answers to the self-assessment questions andtake-home points, see https://doi.org/10.1128/JCM.02032-18 in this issue.PublishedTHE BRIEF CASEcrossmJune 2019 Volume 57 Issue 6 e02031-18 jcm.asm.org 1Journal of Clinical Microbiology24 May 2019 on June 20, 2019 by guesthttp://jcm.asm.org/Downloaded from surgical intervention, but mild mitral regurgitation was noted. The open wound on thepatient’s right great toe was thought to be the source of infection, as the patientreported frequently walking barefoot at home and has pet cats and dogs. Drainageﬂuid from the ulcer was submitted for aerobic culture. Gram stain of the primaryspecimen demonstrated no inﬂammatory cells or organisms seen, and the culture grewrare mixed Gram-positive organisms. X-ray and magnetic resonance imaging of theright foot revealed soft tissue swelling and no evidence of osteomyelitis. The patientremained clinically asymptomatic and was discharged with 6 weeks of i.v. penicillin G.At 4 weeks postdischarge, the patient was readmitted with low-grade fevers and leftupper extremity swelling consistent with deep vein thrombosis secondary to theperipherally inserted central catheter line. Posttreatment blood cultures remainednegative, and follow-up TEE ﬁndings were unchanged compared with those of previousstudies. The patient completed the remaining week of antimicrobial therapy with i.v.ceftriaxone and recovered with no further complications.DISCUSSIONErysipelothrix rhusiopathiae is a facultative anaerobic non-spore-forming Gram-positive bacillus. First isolated by Koch in 1880, E. rhusiopathiae was identiﬁed as thecausative agent of swine erysipelas and later recovered from a human patient withlocalized infection in 1909 (1). E. rhusiopathiae is widely distributed but is mostfrequently associated with pigs and can also be found in the digestive tracts of variousFIG 1 Phenotypic and biochemical features of Erysipelothrix rhusiopathiae. (A) Gram stain of positiveblood culture broth demonstrating Gram-positive bacilli. (B) Inset of image (A) highlighting Gram-positive bacilli appearing at times Gram negative (arrows). (C) Small, alpha-hemolytic colonies of E.rhusiopathiae growing on 5% sheep blood agar after 3 days of incubation. (D) Growth of E. rhusiopathiaeisolate abuts 30-g vancomycin disk demonstrating vancomycin resistance. (E) Hydrogen sulﬁde pro-duction is noted by formation of black precipitate when a triple sugar iron (TSI) Agar slant is inoculatedwith E. rhusiopathiae.The Brief Case Journal of Clinical MicrobiologyJune 2019 Volume 57 Issue 6 e02031-18 jcm.asm.org 2 on June 20, 2019 by guesthttp://jcm.asm.org/Downloaded from animals, including ﬁsh, sheep, and cattle, as well as dogs and cats. Two additionalspecies in the genus, namely Erysipelothrix tonsillarum and Erysipelothrix inopinata, havebeen recovered from the tonsils of healthy pigs and cattle and the environment.Although a rare cause of human infection, E. rhusiopathiae enters the environmentwhen shed in the urine or feces of infected animals and are transmitted to humans fromdirect contact through cuts, abrasions, and injuries.E. rhusiopathiae is largely a zoonotic pathogen that can cause disease in a variety ofanimals. In pigs, E. rhusiopathiae can cause an acute infection characterized by septi-cemia and diffuse erythema resulting in sudden death. Subacute and chronic infectionspresenting as cutaneous lesions or local arthritis and endocarditis can also occur. Inother animals, including sheep, cattle, and birds, E. rhusiopathiae can cause skin lesionsand arthritis and can result in death (2).Human Erysipelothrix sp. infection is rare and is usually due to exposure to infectedanimals, such as ﬁsh or swine. As such, individuals with occupational exposures toanimals or animal products, such as veterinarians, abattoir workers, and ﬁsherman, areat greatest risk for infection (3). Infections can manifest in one of the following threeforms: (i) a localized cutaneous lesion or erysipeloid, (ii) a generalized cutaneous form,and (iii) a septicemic form which is often associated with infectious endocarditis. In thelocalized cutaneous form, the erysipeloid develops 2 to 4 days postexposure, andinfection is typically limited to the ﬁngers or hand. Surface swabs are not useful forisolation of E. rhusiopathiae from cutaneous lesions since the organisms reside deep inthe subdermal layer. Rather, biopsy specimens are optimal for isolation of the organism.In bloodstream infections, E. rhusiopathiae can be recovered from standard bloodcultures and is strongly associated with endocarditis. E. rhusiopathiae endocarditisoccurs in patients with underlying heart conditions and animal exposure and can havemortality approaching 40% (1). Although as many as 90% of E. rhusiopathiae blood-stream infections are associated with endocarditis, newer reports suggest endocarditisdue to systemic E. rhusiopathiae infection is rare (4). In the absence of occupationalexposures, risk factors for invasive Erysipelothrix rhusiopathiae infection include immu-nocompromising conditions, such as chronic kidney disease, diabetes mellitus, andtreatment with high-dose steroids (as was the case with this patient). In patients withE. rhusiopathiae endocarditis, excessive alcohol use, in addition to underlying heartconditions, has also been identiﬁed as a signiﬁcant risk factor (1, 4).Identiﬁcation of Erysipelothrix species can present some diagnostic challenges. Theorganism can have an uneven Gram stain appearance and may even appear Gramnegative at times, similar to this case (Fig. 1A and B). Colonies are pinpoint andalpha-hemolytic on routine medium, as shown in Fig. 1C, and the short Gram-positiverods can resemble streptococci and enterococci. Similar to enterococci, E. rhusiopathiaeis also positive for pyrrolidonyl aminopeptidase (PYR) activity, which may contribute tomisidentiﬁcation. Erysipelothrix species can be differentiated from enterococci by theability to produce hydrogen sulﬁde (H2S) on TSI Agar (Fig. 1E). Biochemical testing andGram stain appearance may readily distinguish Erysipelothrix sp. isolates from othernon-spore-forming Gram-positive bacilli, including Corynebacterium spp., Listeria mono-cytogenes, and Lactobacillus spp. (Table 1). Positive catalase reactions differentiateCorynebacterium spp. and Listeria spp. from Erysipelothrix spp., which are negative formost rapid biochemical tests, including catalase, oxidase, indole, methyl red, Voges-Proskauer, and hydrolysis of esculin or urea (5). Lactobacillus species are catalase-negative long, slender Gram-positive bacilli that can be vancomycin resistant and arealso associated with bloodstream infection and endocarditis. However, Lactobacillusspecies are negative for H2S production on TSI Agar. Another unique characteristic ofE. rhusiopathiae is the “bottle-brush” or “pipe cleaner” appearance of growth in agelatin stab. Further biochemical testing is necessary for species-level differentiation ofE. rhusiopathiae from E. tonsillarum, which ferments sucrose and is positive for alkalinephosphatase (5).Automated identiﬁcation systems, including Vitek2 (bioMérieux, Durham, NC) andBD Phoenix (BD Diagnostics, Sparks, MD), as well as the API Coryne and Strep systemsThe Brief Case Journal of Clinical MicrobiologyJune 2019 Volume 57 Issue 6 e02031-18 jcm.asm.org 3 on June 20, 2019 by guesthttp://jcm.asm.org/Downloaded from (bioMérieux, Durham, NC), can reliably identify E. rhusiopathiae. MALDI-TOF massspectrometry can also identify E. rhusiopathiae. FDA-cleared databases for both Brukerbiotyper CA and Vitek MS systems do not include Erysipelothrix species. However, theBruker biotyper RUO database includes mass spectral proﬁles (MSP) for both E. rhusio-pathiae and E. tonsillarum, while the Vitek MS KnowledgeBase RUO library only includesE. rhusiopathiae. While 16S rRNA sequencing has been used to identify Erysipelothrixspecies, the99% sequence identity of the 16S rRNA gene between some Erysipelothrixspecies may preclude use of this method for species-level identiﬁcation (2).Erysipelothrix spp. are intrinsically resistant to vancomycin; thus, prompt and accu-rate identiﬁcation is critical to ensure effective antibiotic therapy. Ampicillin andpenicillin are the treatment of choice for both localized and systemic Erysipelothrixinfections, as resistance to these agents has not been described. Other beta-lactams,including extended-spectrum cephalosporins and carbapenems, have comparable invitro activity against Erysipelothrix isolates. In penicillin-allergic patients, erythromycin,clindamycin, and ﬂuoroquinolones can be considered. Although susceptibility testing isusually unnecessary, testing may be warranted for penicillin-allergic patients, as resis-tance to clindamycin and erythromycin has been noted. Antimicrobial susceptibilitytesting guidelines and interpretive breakpoints for Erysipelothrix rhusiopathiae arepublished in the M45 document from Clinical and Laboratory Standards Institute (CLSI)(6). Treatment with aminoglycosides and sulfonamides is not recommended, as Erysip-elothrix isolates are frequently resistant to these agents.In summary, we present a case of Erysipelothrix rhusiopathiae bloodstream infectionand endocarditis in a patient on chronic steroids due to rheumatoid arthritis. Thisisolate was identiﬁed using MALDI-TOF MS and conﬁrmed with biochemical testing.Rapid and accurate identiﬁcation of this isolate facilitated prompt initiation of appro-priate antimicrobial therapy, which contributed to successful treatment and recovery ofthe patient.SELF-ASSESSMENT QUESTIONS1. Which of the following exposures is associated with the highest risk of Erysip-elothrix rhusiopathiae exposure and subsequent infection?a. Sustaining a cut while working in an abattoirb. Consuming unpasteurized dairy productsc. Hunting game in a wooded aread. Harvesting crops on a farm2. Erysipelothrix spp. exhibit which of the following phenotypes on biochemicaltests, differentiating them from other aerobic, non-spore-forming Gram-positivebacilli?TABLE 1 Biochemical characteristics differentiating Erysipelothrix rhusiopathiae from select non-spore-forming Gram-positive bacilliaCharacteristic Erysipelothrix spp. Lactobacillus spp. Listeria spp. Corynebacterium spp.Gram stain Short bacilli, rounded ends;occurs singly, short chainsor long ﬁlamentsLong and slender bacilli;occurs singly orin chainsShort, regular bacilli;occurs singly orshort chainsPleomorphic coccobacilliSizeWidth (m) 0.2–0.5 0.5–1 0.4–0.5 0.3–0.6Length (m) 0.8–2.5 2–10 0.5–2 1.5–8Hemolysis  /None  NoneCatalase    Esculin hydrolysis    bH2S on TSI    Motility    Notable intrinsic resistance Vancomycin Vancomycinc Cephalosporins Nonea, positive; , negative.bRare Corynebacterium species are positive for esculin hydrolysis.cSome Lactobacillus species are intrinsically vancomycin resistant, including Lactobacillus rhamnosus and Lactobacillus casei/L. paracasei, among others.The Brief Case Journal of Clinical MicrobiologyJune 2019 Volume 57 Issue 6 e02031-18 jcm.asm.org 4 on June 20, 2019 by guesthttp://jcm.asm.org/Downloaded from a. Catalase (), beta-hemolytic, H2S on triple sugar iron (TSI) Agar ()b. Catalase (), motility (), H2S on TSI Agar ()c. Catalase (), alpha-hemolytic, H2S on TSI Agar ()d. Catalase (), motility (), H2S on TSI Agar ()3. Which of the following is the treatment of choice for Erysipelothrix rhusiopathiae?a. Penicillinb. Vancomycinc. Clindamycind. GentamicinREFERENCES1. Gorby GL, James E, Peacock J. 1988. Erysipelothrix rhusiopathiaeendocarditis: microbiologic, epidemiologic, and clinical features of anoccupational disease. Rev Infect Dis 10:317–325. https://doi.org/10.1093/clinids/10.2.317.2. Wang Q, Chang BJ, Riley TV. 2010. Erysipelothrix rhusiopathiae. Vet Micro-biol 140:405–417. https://doi.org/10.1016/j.vetmic.2009.08.012.3. Reboli AC, Farrar WE. 1989. Erysipelothrix rhusiopathiae: an occupationalpathogen. Clin Microbiol Rev 2:354–359. https://doi.org/10.1128/CMR.2.4.354.4. Tan EM, Marcelin JR, Adeel N, Lewis RJ, Enzler MJ, Tosh PK. 2017. Erysip-elothrix rhusiopathiae bloodstream infection—a 22-year experience atMayo Clinic, Minnesota. Zoonoses Public Health 64:e65–e72. https://doi.org/10.1111/zph.12348.5. Wellinghausen N. 2015. Listeria and Erysipelothrix, p 462–473. In Jor-gensen JH, Pfaller MA, Carroll KC, Funke G, Landry ML, Richter SS, War-nock DW (ed), Manual of clinical microbiology, 11th ed, vol 1. ASM Press,Washington, DC.6. Clinical and Laboratory Standards Institute. 2016. Methods for antimicro-bial dilution and disk susceptibility testing of infrequently isolated orfastidious bacteria. CLSI document M45-ED3. Clinical Laboratory Stan-dards Institute, Wayne, PA.The Brief Case Journal of Clinical MicrobiologyJune 2019 Volume 57 Issue 6 e02031-18 jcm.asm.org 5 on June 20, 2019 by guesthttp://jcm.asm.org/Downloaded from 

The Brief Case: Erysipelothrix bacteremia and endocarditis in a 59-year-old immunocompromised male on chronic high-dose steroids

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The Brief Case: Erysipelothrix bacteremia and endocarditis in a 59-year-old immunocompromised male on chronic high-dose steroids

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