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10. Rubin SJ. Klebsiella marker systems. Infect Control Hosp Epideniiol 1985; 6: 59-63. 11. Ayling-Smith B, Pitt TL. The state of the art in typing Klebsiella spp. J Hosp Infect 1990; 16: 287-95. 12. National Committee for Clinical Laboratory Standards. Methods for dilution antlmicrobial susceptibility tests for bacteria that grow aerobically, 3rd edn. Approved Standard M7-A3. Villanova, PA: NCCLS, 1993. 13. Olsen JE. An improved method for rapid isolation of plasmid DNA from wild-type Gram-negative bacteria for plasmid restriction profile analysis. Lett Appl Microbiol 1990; 10: 209-12
14. Akopyanz N, Bukanov NO, Westblom TU, Kresovich S, Berg DE. DNA diversity among clinical isolates of Helicobacter pylori detected by PCR-based RAPD fingerprinting. Nucleic Acids Res 1992; 20: 513742. 15. Smith CL, Cantor CR. Purification, specific fragmentation and separation of large DNA molecules. Methods Enzyinol 1987; 155: 449-67. 16. Wang CC, Chu ML, H o L, Hwang RC. Analysis of plasmid pattern in paediatric intensive care unit outbreaks of nosocomial infection due to Enterobacter cloacae. J Hosp Infect 1991; 19: 3330.
Pneumonia due to Stomatococcus muciluginosus in an AIDS patient: case report and literature review Clin Microbiol Infect 1999; 5: 112-1 14
Olivier Lumbotte*, Thiervy Debord *, Charles Soler‘ arid R e d Rozit* *Service d e Maladies Infectieuses et Tropicales, H6pital d ’ h s t r u c t i o n des Armkes Bkgin, 69 avenue de Paris 94163 Saint Mandk Cedex, France; ’Service de Biologie Mkdicale, H6pital d ’ h t r u c t i o n des Armkes Percy, Clamart, France *Tel: +33 43 98 50 21 Fax: f 3 3 43 98 52 79
E-mail:
Accepted 11 July 1998
Stomatococctrr mtrcilaginorrrs is a normal inhabitant of the mouth, throat and upper respiratory tract. It is a Granipositive coccus closely related to the genus Rothia [l]. Since the first case in 1978, its involvement has been reported in an increasing spectrum of infections, exclusively among immunocompromised patients. We report a case of pneumonia in an AIDS patient and review the 69 published cases of infection due to this pathogen. A 43-year-old man was admitted for subacute dyspnea. He was a heavy smoker. A positive serology for HIV had been discovered in 1989. He had genital tuberculosis in 1990, pneumocystis pneumonia in 1995 (with cutaneous allergy to co-trimoxazole), and cerebral toxoplasmosis in June 1996. His medications were pentamidine aerosol, pyrimethamine, clindamycin, indinavir, stavudine, and lamivudine. In December 1996, the patient began to complain of mild dyspnea, which became worse in the first days of 1997, accompanied by a productive cough. The patient was admitted in January. O n examination, he was polypneic (respiration rate: 40/min) with orthopnea, audible bronchospasm with bilateral symmetric sibilants,
ronchi, and some crackles in the two bases. His temperature was 37.2OC, his pulse was 100/min, and his blood pressure was 130/70 mmHg. The chest X-ray showed a sequellar reticular pattern in the middle lobe. The arterial blood partial pressure of oxygen was 70 mmHg, the carbon dioxide level was 30.5 mmHg, p H 7.4, and the bicarbonate level was 21 mmol/L. The white cell count was 6300/mm3, the neutrophil count was -1200/mm3, the CD4’ lymphocyte count was 5O/mm3 (6%), the platelet count was 210 OOO/mm3, and the hemoglobin level was 13.3 g/dL. The C-reactive protein level was 212 mg/L. The other laboratory values were normal. O n admission, pneumocystis pneumonia due to prophylaxis failure was suspected. Intravenous trimethoprim-sulfamethoxazole and rnethylprednisolone were started with aerosolized salbutamol. As the patient’s condition did not improve, a fibrobronchoscopic examination was performed on the fourth day. It showed purulent secretions from the entire bronchial tract. The bronchoalveolar lavage showed 8.1 x lo6 cells/mL with 85% neutrophils, no acid-fast bacilli, no pneumocystis, and negative immunofluorescence for Legionella. Gram-stained smears
Concise Communications
Table 1 Infections due to conditions 14-14] Nunibcr of cases
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Stornatococrus muciluLqinorris: clinical
Fatal outcome
presrntation. main underlying diseases and predisposing
Underlying disease Leukemia
HMT Solid tumors
Bactereiniac
40
17
5
9
Meningitis Endocarditis
8 7
3
3
1
Pneumonias
7 7
miscellaneous^' Total
60
..
1
21
1 10
?
1
11
Prcdisposing conditions Others
Neutropenia
CV C
Mucitis
Others
24
23 Catheterrelated 7 6
11
IVIIU 2 Dental surgery 2
AIDS 2 Diabetes 2
7
Heart valvular abnormalities 4 Valvular prosthesir 4 AIDS1 Dialysis 2
1 -J
IVDU 4
4
4
1 36
1
31
2 15
BMT, bone marrow transplantation; CVC, central venous catheter; IVDU, intravenous drug user. Two chronic anibulatory peritoneal dialysis peritonits, empyema, cellulitis around a Broviac catheter, nosocomial endophthalinitis. osteoniyrliti,, cholangitis. The last two cases occurred without imniunodepresion 19.101.
showed numerous Gram-positive cocci in clumps. After bronchoscopic examination, trimethoprimsulfamethoxazole was enipirically replaced by amoxycillin plus clavulanic acid (3g/day). The patient’s condition improved quickly in 1 days. S. mucilaginosns grew in pure culture (lo5 CFU/mL) in the endotracheal aspirates and in the bronchoalveolar lavage. It was characterized by strong adherence to the agar and was catalase negative. A high production of slime was observed. The antibiograrn (disk diffusion method) showed resistance to niacrolides and quinolones, and sensitivity to aiiiinoglycosides, rifampicin, fosfomycin, and glycopeptides. The penicillin MIC was 8 mg/L and that of trimethoprim-sulfaniethoxazole was > 8 mg/L. All the specimens of blood cultures were negative for mycobacteria. Cryptococcal antigenemia results were negative and so were the results of the search for cytomegalovirus. The serologic tests for chlamydiae, Alycoplasrna, Lgiorzrlla, rickettsiae, influenza virus, parainfluenza virus, syncytial respiratory virus and adenovirus were negative. The clinical spectrum of S. nimcilaggirzosus infections is expanding. Sixty-nine cases (Table 1) have been recorded with 31 in children. Fifty-eight per cent are bacteremias. Almost all cases occur in conjunction with a severe underlying disease as shown in Table 1, mainly leukemia, bone marrow transplantation, and solid cancers. Three main predisposing conditions are found: neutropenia due to drug toxicity (defined as less than 1000/nin13 neutrophils), central venous catheter, and riiucosal ulcerations. These predisposing factors are a consequence of the properties of Stotnatococci~s. Since this organism belongs to the oral flora, oral ulcerations are a portal of entry, especially if neutropenia develops. This is
in agreement with previous studies which recorded an increasing incidence of Gram-positive cocci in bacteremias among hematologic patients treated with aplastic cheniotherapies 121. The strong adhesive qualities of Stomatococcus [3] may predispose its engraftrnent on defective heart valves or prostheses. O n e hypothesis for the origin of Stornatococcus in endocarditis is the tendency of drug users to lick the needle, so as not to lose any drug, or to stick theniselves in the mouth. Four S. rnncilagiriosus infections have been reported in AIDS patients: two bacteremias [4,5] and two pneumonias [5,6]. We report a third case of pneumonia. In the three cases of pneumonia in AIDS patients, Stomatococcus was isolated from the lungs (bronchoalveolar lavage). In imniunocompromised patients, with impaired bronchial immunity, Stomatococcus, found in bronchial secretions [3], can easily invade the parenchyma. Moreover, AIDS patients often have oral ulcerations. In all AIDS patients, CD1+ lymphocyte counts were lower than 100/mni3. Although rare, Stomatococccus has become an opportunistic pathogen in HIV-positive and other immunocompromised patients. P-Lactaiiis were used in 43 of the reported cases and vancomycin in 35 cases. Strains with diminished susceptibility to penicillin (from 0.35 to 1 mg/L) have sometimes been isolated 171. Moreover, the strains isolated in AIDS patients who had previously received co-trimoxazole as prophylaxis for pneumocystis have diminished susceptibility to this antibiotic, although Stomatococcus is usually sensitive [1,6]. Initial antibiotic therapy with glycopeptides is the most rational choice, but therapy should be switched to p-lactams if results of in vitro testing reveal a sensitive organism.
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Acknowledgment
We are indebted to Mrs Freund for assistance in the preparation of the manuscript. References I. Stackebrandt E, Koch C, Gvozdiak 0, Schumann P. Taxonomic dissection of the genus Alicrococcus: Kocuriu gen. nov., Nesterenkonia gen. nov., kytococcus gen. nov., Dermacoccns gen. nov., and Microcuccus Cohn 1872 gen. emend. Int J Syst Bacteriol 1995; 45(4): 682-92. 2. Richard P, Amador Del Valle G, Moreau P, et al. Viridans sti-eptococcal bacteraemia in patients with neutropenia. Lancet 1995; 345: 1607-9. S . Bergan T, Kocur M. Stonfatococcus mucilaginosus gen. nov., sp. nov., ep. rev., a member of the family Micrococcaceae. Int J Syst Bacteriol 1981; 32(3):37+7. 4. Ascher UP, Zbick C, White C, Fischer GW. Infections due to Stonlatococcus mucifaginosus: 10 cases and review. Rev Infect Dis 1991; 13: 1048-52. 5. Patey 0,Malkin JE, Coutaux A, et al. AIDS-related Stonlatococcus mncilaginosus infection. Lancet 1991; 338: 631-2. 6 Cunniffe JG, Mallia C, Alcock PA. Stomatococcus mucilaginosus lower respiratory tract infection in a patient with AIDS. J Infect 1994; 29 : 327-30.
7. McWhinney PHM, Kibbler CC, Gillespie SH, et al. Stomatococcus muriiaginosus:an emerging pathogen in neutropenic patients. Clin Infect Dis 1992; 14: 641-6. 8. Henwick S, Koehler M, Patrick CC. Complications ofbacteremia due to Stomatococcus mtrciluginostrs in neutroprnic children. Clin Infect Dis 1993; 17: 667-71. 9. Nielsen H . Vertebral osteomyelitis with Stomatococcus mucilaginosus. Eur J Clin Microbiol Infect Dis 1994; 13: 775-6. 10. Harjola VP, Valtonen M, Sivoneii A. Association of Stomafococcus mucilaginosus with cholangitis. Eur J Clin Microbiol Infect Dis 1994; 13: 606-8. 11 Tan R, White V, Servais G, Bryce EA. Postoperative endophthalmitis caused by Stomatococcus muciluginostrr. Clin Infect Dis 1994; 18: 492-3. 12 Andstrom E, Bygdenian S, Ahlen S, Heimdal A, Nystrom €3. Stomatococcus mucilaginosus septicemia in two bone marrow transplanted patients. Scand J Infect Dis 1994; 26: 209-14. 13 Ben Salah H, Crockaert F, Levy J, Ferster A, Devalck C, Sariban E. Meningite iStomatococcus mucilaginosus chez un enfaant immunodeprinie. Arch Pediatr 1994; 1: 813-15. 14 Park MK, Khan J, Stock F, Lucey DR. Successful treatment of Stomatococcus mucilaginosns meningitis with intravenous vancomycin and intravenous cefiriaxone. Clin Infect Dis 1997; 24: 278.
The ability of the Dry Spot Staphytect Plus test, in comparison with other tests, to identify Stuphylococcus species, in particular S. uureus Clin Microbial Itrfect 1999; 5 : 114-1 16
Clirista Czrtiy, Birgit Pasemanti atid WoEfgatig Witte" Robert Koch Institute, Wernigerode Branch, Burgstrane 37, G-38855 Wernigerode, Germany *Tel: +49 39 43 679 246 Fax: +49 39 43 679 207 E-mail:
[email protected] Revised version accepted 19 July 1998
Coagulase-negative staphylococci differ phenotypically from Staphylococcus aureus by lacking the ability to form some extracellular products and cell wall-associated proteins [l]. In routine clinical microbiology the coagulase test-tube reaction has been used as the main species characteristic of S. auretcs [l], as has DNase formation in food microbiology [2]. Although less sensitive and less specific than coagulase formation [3], the demonstration of clumping factor is often used in routine clinical microbiology. The clumping factor of S. uureus is a cell wall-associated protein which reacts with fibrinogen monomers, thus leading to aggregation of S. arireiis cells [4]. The recent emergence of epidemic methicillin-resistant S. aureus (MRSA) lacking this capability [5] has rendered tests based only on the
demonstration of protein agglutination unreliable [6]. Therefore, recently developed test kits have included the use of antibodies against cell wall-associated macromolecules, and IgG specific for S.arireus protein A [7]. This communication reports on the sensitivity and specificity of the Dry Spot Staphytect Plus test (Oxoid, Basingstoke, UK) and three other agglutination tests for speciating staphylococcal species, especially S. aureus including methicillin-resistant isolates. For methicillin-sensitive S. aureus (MSSA, tz= 130), strains belonging to the major clonal group of this species as deduced from genomic D N A fragment patterns [8] were tested. For MRSA (n=8O), five isolates from each of six MRSA epidemics with an inter-regional dissemination in Germany [9] were
