We report for the first time from Jordan and probably Arab countries a very rare case of Comamonas testosteroni causing blood stream infection in a Sudanese patient with renal failure on hemodialysis whom was waiting for a living-related renal transplant. He was successfully treated with cefepime and had his transplant ten days into his treatment. Post-transplant he did well and was discharged home

Abu Rumoh MD, Saleh

Al Ramahi M.D, Jamal Wadi

BSc, NaheelHalloub

W. Khali, Basmah

International Medical Publisher Journals (iMedPub)

THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS© Under License of Creative Commons Attribution 3.0 License 12013Vol. 3 No. 4:5doi: 10.3823/742iMedPub Journalshttp://journals.imedpub.comThis article is available from: www.iajaa.orgCase ReportComamonas testosteroni Blood Stream Infection in A Patient with End-stage Renal Failure on Hemodialysis 1  Jordan Hospital and Jordan Hospital Medical Center, Amman, Jordan2  The Specialty Hospital , Department of Internal Medicine3  Laboratory Department, Amman, JordanCorresponding author: Dr. Jamal Wadi Al Ramahi MDjamalwadimd@yahoo.comJamal Wadi  Al Ramahi MD1, Saleh Abu Rumoh MD2, NaheelHalloub BSc3, Basmah W. Khalil MD2AbstractWe report for the first time in Jordan and probably Arab countries a very rare case of Comamonas testosteroni causing blood stream infec-tion in a Sudanese patient with renal failure on hemodialysis whom was waiting for a living-related renal transplant. He was successfully treated with cefepime and had his transplant ten days into his treat-ment. Post-transplant he did well and was discharged home.Keywords: Comamonas testosteroni, Renal failure, kidney transplant, cefepime, blood stream infectionIntroductionComamonas testosterone (formerly Pseudomonas testosteroni) is a ubiquitous aerobic gram-negative bacillus, motile, glucose non-fermen-ter, do not form spores. It is found in soil, plants, water saprophytes, and also may be found in humidifier reservoir water, even isolated from dromedary rumen fluid (1). Although it is frequently considered a commensal, it is a potential human pathogen. Attention was drawn to Comamonas testosteroni since1987 when reports were accumulating on human infections at different sites, such as cellulitis (2), peritonitis especially with a perforated appendix (3), bloodstream infection (4,5), infective endocarditis (6), purulent meningitis, (7) postoperative en-dophthalmitis (8) and hemodialysis catheter-related bacteremia (9). It THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS2013Vol. 3 No. 4:5doi: 10.3823/742This article is available from: www.iajaa.org2may express a putative protein that exhibits similar-ity to Pasteurella multocida (10). Furthermore, some strains of Comamonas testosteroni acquired plasmid mediated blaNDM1, hampering treatment options in the event this bacterium causes human infec-tions (11). An interesting finding is that a related species i.e. Comamonas acidovorans isolated from water pond in South Jordan was found to have an antifungal activity against filamentous fungi and yeasts (12).The CaseA 47 year old male patient from Sudan, he suffered from end-stage renal disease and maintained on hemodialysis for the last three months through a subclavian central venous catheter before he pre-sented to us. He presented to outpatient clinic for assessment as a kidney transplant candidate. He had been having chills during dialysis session, but no documented fever. Two sets of blood cultures including aerobic and anaerobic bottles grew Co-mamonas testosteroni. Patient hemodialysis cath-eter (PermaCath) was removed and replaced with a temporary central venous hemodialysis catheter. He was treated with parenteral cefepime (one gram daily for 14 days). Day 4 on treatment, blood cul-ture was sterile. The patients was transplanted from a living-related Kidney donor, meanwhile he was on cefepime without complications. He was main-tained on oral cyclosporine 200mg twice daily, My-cophenolate mofetil 360mg twice daily by mouth and prednisone 30mg by mouth twice daily. Also, he was started on oral INH 300mg once daily.Culture and Identification of Comamonas testosteroniPatients’ Blood samples were inoculated into blood culture bottles (BD BACTEC Aerobic/F, Shannon , Ireland ). One droplet of the positive growth blood culture was inoculate into BD BACTEC 9120 Blood culture system (Becton, Dickinson and company Franklin Lakes, NJ, USA) was placed on sheep blood agar, chocolate blood agar and Maconkey agar plates (Oxoid Diagnostic Company Ltd, Bas-ingstoke, Hampshire, England) and pricked by ster-ile needle. Chocolate-agar plates were incubated in micro-aerophilic conditions prepared by a candle jar at 37C0. Sheep blood agar plates and MacConkey agar plates were aerobically incubated at 37C0 for 24-48 hours. Gram-negative bacterial colonies ap-peared on blood, chocolate, and MacConkey agar after 24 hours of incubation. Gram staining was performed for both single colonies and patient’s blood sample showed gram-negative bacilli. The isolate was catalase negative and oxidase positive. The complementary identical tests were performed using biochemical test (Vitek 2 system, Biomerieux, France, Europe).Antimicrobials susceptibility tests were performed based on Kirby-Bauer disk-diffusion method on Mueller-Hinton agar plates, antibiotic disk (OXOID Company,England), double-checked by MIC method using Vitek II system (Biomerieux, France, Europe). Finally, this strain was identified as Comamonas testosterone with high certainty. The isolated or-ganism was sensitive to cefepime, ciprofloxacin, co-trimoxzole, levofloxacin, ofloxacin, polymyxin B and tigecycline, and was resistant to amikacin, gentami-cin, Imipenem, meropenem, and pipracillin/tazobac-tam with intermediate sensitivity for ceftazidime.DiscussionComamonas testosterone has been reported infre-quently as a cause of different infections. It was given this name due to its characteristic of utilizing carbon from the metabolism of testosterone (13). Main points worth consideration is that most in-fections took place in community, rarely occurring THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS2013Vol. 3 No. 4:5doi: 10.3823/742© Under License of Creative Commons Attribution 3.0 License 3in nosocomial setting (8), and that most reported patients have somehow immune suppression such as malignancy (4), on hemodialysis patients, (9) al-coholic patient, patient with hepatitis B infection with liver cirrhosis and hepatocellular carcinoma (2), and cholesteatoma (7). This patient has end-stage renal disease, possibly got the infection while he is under outpatient medical care on hemodialysis i.e. healthcare-associated infection, like few previously reported cases.Comamonas testosteroni treatment is reported mostly utilizing cephalosporins including cefepime, cefoxitine, ceftazidime, ciprofloxacin, imipenem, meropenem and ampicillin once susceptible (4). One case of meningitis was reported to have had failed on ceftriaxone treatment though was in vitro sus-ceptible, the patient was switched to meropenem with response (7).This case report was treated with parenteral ce-fepime one gram daily with success, adjusted for renal failure before and after kidney transplantation. He was successfully transplanted with a kidney from a living-related donor and was discharged home on immunosuppressive therapy in good health condi-tion. Conflict of interestnon for all authors.THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS2013Vol. 3 No. 4:5doi: 10.3823/742This article is available from: www.iajaa.org4References  1. Bouraoui H, Vendramin E, Squartini A, Haddi, ML. Taxonomical analysis of the suspended bacterial fraction in the dromedary rumen fluid. African J Biotech 2011, 30 ;10(76):17640-17644 2. Tsaob SM, Liue KS, Chenc TY, Wang YL, Teng YH, Tsuia TL, Lee YT.Comamonas testosteroni infection in Taiwan: Reported two cases and literature review. Journal of Microbiology, Immunol Infect 2011; 44(1):67–71 3. Barbaro JD, Mackowiak A P, Barth SS, Southern PM Jr. Pseudomonas testosteroni Infections: Eighteen Recent Cases and a Review of the Literature. Clin Infect Dis 1987; 9 (1): 124-129.  4. Farshad S, Norouzi F, Aminshahidi M, Heidari B, AbdolvahabAlborzi. Two cases of bacteremia due to an unusual pathogen, Comamonas testosteroni in Iran and a review literature. J Infect Dev Ctries 2012; 6(6):521-525 5. Gul M, Ciragil P, Bulbuloglu E, Aral M, Alkis S, Ezberci F. Comamonas testosteroni bacteremia in a patient with perforated acute appendicitis. Acta Microbiol Immunol Hung 2007 ; 54(3):317-321 6. Coopera RG, Staples DE, Iczkowski AK, Clancy JC. Comamonas (Pseudomonas) testosteroni endocarditis. Cardiovasc Pathol 2005 ;14(3):145–149 7. 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Antifungal activity of Comamonas acidovorans isolated from water pond in south Jordan. Afr J Biotechnol 2007 ; 6(19): 2216-2219 13. Horinouchi M, Yamamoto T, Taguchi K, Arai H, Kudo T . Meta-cleavage enzyme gene tesB is necessary for testosterone degradation in Comamonas testosteroni TA441. Microbiology 2001; 147: 3367-3375Where Doctors exchange clinical experiences,  review their cases and share clinical knowledge.  You can also access lots of medical publications for free. Join Now! http://medicalia.org/Comment on this article:The Journal is an open access peer-reviewed journal that publishes scientific papers about all aspects of antimicrobials. The journal will publish original research articles, reviews, brief reports and case reports dealing with basic and clinical antibacterial agents, antiviral, antiprotozoals, antituberculuous, antifungal and antihelminthes agents.All manuscripts must be prepared in English, and are subject to a rigorous and fair peer-review process. 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Comamonas testosteroni Blood Stream Infection in A Patient with End-stage Renal Failure on Hemodialysis

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Comamonas testosteroni Blood Stream Infection in A Patient with End-stage Renal Failure on Hemodialysis

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