Dec 31, 2011 - nary valve vegetation and did not reveal vegetation on the catheter. The MICs and MBCs of amoxicillin, ceftriaxone, and netilmicin were 1 and ...
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4. Kuberski T, Papadimitriou J, Phillips P. Ultrastructure of Calymmatobacterium granulomatis in lesions of granuloma inguinale. J Infect Dis 1980; 142:744-9. 5. Rake G. The antigenic relationships of Donovania granulomatis (Anderson) and the significance of this organism in granuloma inguinale. American Journal of Syphilis, Gonorrhea and Venereal Diseases 1948;32: 150-8. 6. Maddocks I, Anders EM, Dennis E. Donovanosis in Papau New Guinea. Br J Vener Dis 1976;52:190-6.
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7. Van der Ley P, Bekkers A, Van Meersbergen J, Tommassen J. A comparative study on the phoE genes of three enterobacterial species. Eur J Biochem 1987; 164:469-75. 8. Chapel T, Brown WJ, Jeffries C, Stewart JA. The microbiological flora of penile ulcerations. J Infect Dis 1978; 137:50-6. 9. Wasserheit J. Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex TransmDis 1992;19:61-77. 10. O'Farrell N. Global eradication of donovanosis: an opportunity for limiting the spread ofHIV-l infection. Genitourin Med 1995;71:27-31.
Native Valve Endocarditis Due to Corynebacterium striatum: First Reported Case of Medical Treatment Alone B
The first case of native valve endocarditis due to Corynebacterium striatum required a combination of medical and surgical treatments for cure [1]. We describe the first patient with native valve endocarditis due to e. striatum who received only medical treatment. A 24-year-old man was admitted to the hospital because of a persistent unexplained fever. His medical history was remarkable for congenital hydrocephalus that led to complete paraplegia and required an ventriculoatrial shunt at the age of2 months. The shunt catheter was replaced when he was 16 years old because the distal extremity had migrated into the pulmonary artery. He had had an isolated fever 7 weeks before the current admission. Providencia stuartii, e. striatum, and Escherichia coli were successively isolated from cultures of urine. The patient received therapy with ceftriaxone and cefixime for 1 week each; his fever resolved with therapy, but it returned as soon as the antibiotics were discontinued. A chest radiograph obtained 8 days before admission revealed a localized alveolar infiltrate in the lower lobe of the left lung. On admission, the alveolar infiltrate was not apparent. e. striatum was isolated in three sets of blood cultures. A transthoracic echocardiogram revealed a 10-mm vegetation on the pulmonary valve that was close to the distal extremity ofthe ventriculoatrial shunt catheter and that was fluttering in the pulmonary artery. A trans esophageal echo cardiogram confirmed the pulmonary valve vegetation and did not reveal vegetation on the catheter. The MICs and MBCs of amoxicillin, ceftriaxone, and netilmicin were 1 and 128 j.£g/mL, 8 and 64 j.£g/mL, and 0.D3 and 0.D3 j.£g/mL, respectively. The MICs of vancomycin and teicoplanin were 0.25 j.£g/mL and 0.25 j.£g/mL, respectively, and the MBCs of these drugs were 2 j.£g/mL and 0.25 j.£g/mL, respectively. The patient's initial treatment included amoxicillin and netilmicin. Therapy with netilmicin was discontinued after 2 weeks. A sacral bedsore, which was considered the portal of entry of e. striatum, was treated surgically. Six weeks after the treatment was started, while the patient was still receiving iv amoxicillin, he developed a sudden fever, chills,
Reprints or correspondence: Dr. Anne-Claude Cremieux, Hopital BichatClaude Bernard, 46 Rue Henri-Huchard, 75877 Paris Cedex 18, France. Clinical Infectious Diseases 1996;23:1330-1 © 1996 by The University of Chicago. All rights reserved. 1058-4838/96/2306-0050$02.00
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Figure 1. The effect of antibiotics alone or in combination on the Corynebacterium striatum strain isolated from a patient with native valve endocarditis as determined on the basis of bactericidal kinetics. .. = control; • = amoxicillin (1 mg/L); 0 = teicoplanin (0.25 mgl L); ~ = netilmicin (0.06 mg/L); e = teicoplanin (0.25 mgIL) + netilrnicin (0.06 mg/L); 0 = amoxicillin (1 mgIL) + teicoplanin (0.25 mg/L); L. = amoxicillin (1 mg/L) + netilmicin (0.06 mgIL). The plots for ~, e, and L. are superimposed.
thoracic pain, and dyspnea. A localized alveolar infiltrate in the lower segment of the right lung was noted on a chest radiograph. Three sets of blood cultures remained sterile. A transthoracic echocardiogram showed that the size of the vegetation had not changed despite 7 weeks of therapy. Antibiotic treatment was then changed, in accordance with in vitro synergy studies (figure 1), to include amoxicillin, netilmicin, and iv teicoplanin. An endovascular procedure was attempted in order to remove the catheter in the pulmonary artery, but this procedure was unsuccessful. However, medical treatment led to improvement in the patient's condition as the size of the vegetation decreased (seen on an echo cardiogram). After 4 weeks of therapy with amoxicillin, netilmicin, and teicoplanin, the patient was discharged from the hospital and continued to received therapy with oral amoxicillin for 2 more weeks. Antibiotic treatment was then discontinued; three sets of blood cultures performed 1 month later remained sterile. No fever was noted at a follow-up visit 10 months later. Twenty months after the initial episode, the patient was readmitted to our hospital because of fever. Clinical examination was unremarkable, and findings on a chest radiograph were normal. A
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Brief Reports
transesophageal echocardiogram did not reveal any vegetations. Three sets of routine blood cultures yielded the strain that was initially isolated (c. striatum). This episode of bacteremia was interpreted as being due to the persistence of organisms on the ventriculoatrial shunt catheter. As surgery was not performed, the patient was discharged from the hospital with instructions to continue his long-term oral antibiotic therapy. Cases of endocarditis due to Corynebacterium other than C. diphtheriae were recently reviewed [I, 2]. Most patients were treated with penicillin or ampicillin alone or in combination with gentamicin, with the exception of patients with endocarditis due to Corynebacterium group IK, which required treatment with a glycopeptide alone or with a glycopeptide combined with gentamicin [I]. Few cases of C. striatum infections have been reported [3], and only one case of native valve endocarditis due to C. striatum has been well documented [I]. Most of the isolated strains of C. striatum appear to be susceptible to a wide variety of antibiotics, including penicillin G, vancomycin, gentamicin, rifampin, and ciprofioxacin. In one case [3], a strain that was resistant to penicillin G and ciprofioxacin was responsible for central venous catheter-related infection during bone marrow transplantation. The patient was cured after the catheter was removed and amikacin and vancomycin were administered. Another strain that was resistant to many agents (i.e., rifampin, ciprofioxacin, and erythromycin) was responsible for a fatal pulmonary infection in a young man who was recovering from a cerebral hemorrhage in an intensive care unit [4]. Few synergy tests have been performed with C. striatum. The fractional inhibitory and fractional bactericidal indexes, which were determined for the strain responsible for endocarditis [1], showed slight synergy between ampicillin and gentamicin. There was no evidence of synergy with the combination of vancomycin and gentamicin. In vitro time-kill curves have been shown to be predictive of therapeutic results in experimental endocarditis [5]. Time-kill curves plotted for the strain isolated from our patient (figure 1) showed that the most rapid killing occurred with netil-
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micin alone. The addition of amoxicillin or teicoplanin or both did not increase the rate of killing obtained with netilmicin. This finding is consistent with findings of the few time-kill studies performed with corynebacteria other than C. diphtheriae isolated from patients with endocarditis [6, 7]. More information is needed concerning medical treatment of C. striatum infections since few cases of these infections have been reported. Nevertheless, the findings in our case suggest that a combination regimen that includes an arninoglycoside could help control this difficult-to-treat infection. Pierre Tattevin, Anne-Claude CnlIDieux, Claudette MuUer-Serieys, and Claude Carbon Service de Medecine Interne and Service de Microhiologie, Hopital Bichat-Claude Bernard, Paris, France References 1. Rufael DW, Cohn SE. Native valve endocarditis due to Corynebacterium striatum: case report and review. Clin Infect Dis 1994; 19:1054-61. 2. Petit PLC, Bok JW, Thompson J, Buiting AGM, Coyle MB. Native-valve endocarditis due to CDC coryneform group ANF-3: report of a case and review of corynebacterial endocarditis. Clin Infect Dis 1994; 19:897901. 3. Watkins DA, Chahine A, Creger RJ, Jacobs MR, Lazarus HM. Corynebacterium striatum: a diphtheroid with pathogenic potential. Clin Infect Dis 1991; 17:21-5. 4. Martinez-Martinez L, Suarez AI, del Carmen Ortega M, Rodriguez-Jimimez R. Fatal pulmonary infection caused by Corynebacterium striatum [letter]. Clin Infect Dis 1994; 19:806-7. 5. Cremieux AC, Carbon C. Pharmacokinetic and pharmacodynamic requirements for antibiotic therapy of experimental endocarditis. Antimicrob Agents Chemother 1992; 36:2069-74. 6. Malanoski GJ, Parker R, Eliopoulos GM. Antimicrobial susceptibilities of a Corynebacterium CDC group n strain isolated from a patient with endocarditis. Antimicrob Agents Chemother 1992;36:1329-31. 7. Morris A, Guild I. Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains. Rev Infect Dis 1991; 13:887-92.
