Pleural effusion due to corynebacterium propinquum

PLEURAL EFFUSION DUE TO CORYNEBACTERIUM PROPINQUUM
IN A PATIENT WITH SQUAMOUS CELL CARCINOMA

Corynebacterium propinquum (C. propinquum) is part of
admission, he looked pale, cachectic, and had finger the normal oropharyngeal flora. Originally called CDC clubbing. His temperature was 38°C. Chest auscultation coryneform ANF-3 (absolute nonfermenter), it was Riegel revealed right basal crepitation, and he also had tenderness et al. in 1993 who proposed the name C. propinquum.1 On in the right hypochondrium. Blood investigation showed a gram stain, it shows corynebacterial forms after 24 hours’ leukocyte count of 21.70 x 109/L with 91% neutrophils, incubation on sheep blood agar. Colonies appear whitish, hemoglobin of 8.4 g/L and ESR of 113 mm/hour. Chest x- nonhemolytic and 1-2 mm in diameter with a matted ray showed right pleural effusion. Blood culture was taken, surface. C. propinquum is nonlipophilic, catalase positive, and 400 mL of pus was aspirated from the pleural effusion, reduces nitrate and hydrolyzes tyrosine, but does not which showed a leukocyte count of >200,000/mm3, with hydrolyze urea or esculin, and also does not ferment sugars. 100% polymorphs, and red blood cells of 160/mm3. Gram CAMP test for the organism is usually negative.2 Clinical stain showed gram-positive coryneform-like bacilli. Ziehl- infections by C. propinquum are rare. There has only been Neelsen staining for acid-fast bacilli was negative. one previously reported case of native valve endocarditis The patient was started on ceftriaxone 2 g intravenously due to Corynebacterium ANF-3, in 1994,3 but there have per day and 500 mg metronidazole 8 hourly. On day four, been no reports of this organism as a causative agent of ultrasound of the liver and lung revealed thick wall pleural lower respiratory tract infection in the English and non- effusion and a collection in the liver, with a possible English literature over the last 20 years. In this report, we diagnosis of liver abscess. Brain CT scan showed two-ring describe a case of pleural effusion which grew C. lesions, which could either have been brain abscess or propinquum in a patient with squamous cell carcinoma of metastasis. An intercostal chest tube was inserted for the the lung. The organism was multiresistant to penicillin, empyema, and drained 250-300 mL of serosanguineous cefuroxime, gentamicin, erythromycin, clindamycin, fluid/day. The pus from both liver and from pleural effusion rifampicin and vancomycin, but sensitive to ceftriaxone, were negative by routine culture and also for ciprofloxacin, imipenem, tetracycline, and Mycobacterium tuberculosis. The patient was continued on sulfamethoxazole-trimethoprim. To our knowledge, this is ceftriaxone and metronidazole for four weeks. During this the second reported case of clinically significant C. period the patient’s condition was stabilized and the chest tube was subsequently removed, as there was no more fluid coming out. At a further evaluation of the patient’s Case Report
condition, a liver biopsy was done under CT guide, and histopathology result confirmed a squamous cell carcinoma A 70-year-old Saudi male was admitted to King Khalid of possible lung origin, with metastasis to the liver and University Hospital, Riyadh, in August 2000, with brain. After consultation with the oncology team, a decision complaints of cough, shortness of breath, right-sided chest was made to put the patient on palliative treatment, as this and abdominal pain of one year’s duration. The patient had type of carcinoma is usually resistant to chemotherapy. The a history of fever, weight loss, hemoptysis and cough, for patient died after 46 days of admission. which he had been seen at different clinics with no The pleural fluid was cultured on sheep blood and definitive diagnosis made. He had no history of previous McConkey agar plates and incubated for 24-48 hours admission to hospital or treatment with antibiotics. On aerobically and anaerobically for the blood agar and only aerobically for 24 hours for the McConkey agar. Antimicrobial susceptibility was tested by Stoke’s method From the Department of Pathology/Microbiology, King Khalid University and E-test (AB Biodisk, Solna, Sweden) on Mueller Hinton agar with 5% sheep blood (Mueller Hinton II, Becton Address reprint requests and correspondence to Dr. Babay: Dickinson, USA). A heavy pure growth of tiny colonies Department of Pathology/Microbiology (32), King Khalid University Hospital, P.O. Box 2925, Riyadh 11461, Saudi Arabia. appeared on the sheep blood agar after 24 hours incubation Accepted for publication 16 September 2001. Received 26 February in air which, after a further 24 hours incubation, grew colonies which were ∼1 mm in diameter, convex, whitish Annals of Saudi Medicine, Vol 21, Nos 5-6, 2001 TABLE 1. MIC results for C. propinquum. sensitive to most antibiotics and vancomycin.3 Due to the lack of established standards for coryneform bacteria and a referral sensitivity strain, it is recommended to report MIC results without interpretative criteria.7 Our MIC was compared with MIC of the isolate from the case of endocarditis and those of C. pseudodiphtheriticum.2,3 Both were sensitive to many antibiotics, including β-lactam antibiotics, aminoglycosides and vancomycin. Multiple antimicrobial resistance has also been reported in C. jeikeium, C. urealyticum, C. xerosis, C. minutissimum, CDC coryneform group G and C. amycolatum.7-9 However, these bacteria were in all cases susceptible to vancomycin, the recommended drug for infections caused by these Infections due to nonenterococcal vancomycin-resistant nonpigmented and nonhemolytic. Gram stain showed gram- gram-positive bacteria are thought to be associated with a positive club shaped and arranged as coryneform bacteria. mortality rate of 5%-20%, which is similar to infections due The organism was not acid or partially acid fast. There was to susceptible staphylococci or streptococci.10,11 no growth on the McConkey and the anaerobic agar plates. Although there was no history of previous hospital The isolate was catalase positive, reduced nitrate, and did admission or treatment with broad-spectrum antibiotic or not hydrolyze urea. Identification was made by the API vancomycin in our patient, and because the isolate from the Coryne System (Bio-Merieux SA, France), suggesting the case of native valve endocarditis due to C. propinquum was coryne group ANF. These include positive reaction to sensitive to vancomycin, the origin of vancomycin pyrazinamidase, negative tests for alkaline phosphatase and resistance in our isolate is difficult to explain, but we would pyrrolidonyl arylamidase. Negative tests were also given like to speculate that its source was probably the upper for sugar fermentation, β-glucuronidase, β-glactosidase, α- In conclusion, as with other emerging coryneform glucosidase, N-acetyl-β-glucosaminidase, gelatin bacteria, full identification of the isolates, especially when hydrolysis and esculin. The organism showed similar they appear on original plate as pure or predominant, susceptibility pattern by both disk diffusion and E-test should be performed.2 In diagnostic laboratories, methods. It was susceptible to ceftriaxone, imipenem, identification can simply be achieved by biochemical test ciprofloxacin, tetracycline and sulfomethoxazole- and API Coryne system.2,9 Due to the unpredictable trimethoprim. Table 1 shows the minimum inhibitory susceptibility to antibiotics, susceptibility testing should be concentration (MIC) test results for the antimicrobial agents performed on all antibiotics including vancomycin.7 Treatment of vancomycin-resistant infections can be by the third-generation cephalosporins, ciprofloxacin or Discussion
imipenem.12 Stringent infection control precautions and prudent use of broad-spectrum antibiotics and vancomycin Nondiphtherial coryneform bacteria with pathogenic are essential for the prevention or spread of vancomycin potential are being increasingly isolated from patients who are immunocompromised or implanted with prostheses.4 The clinical significance of C. propinquum in our patient was based on positive direct gram stain with strong Acknowledgements
leukocyte reaction and heavy pure isolation from a sterile We would like to thank Dr. Kingsley Twum-Danso for site.2 Rapidly growing Mycobacterium, Rhodoccus spp. or his valuable comments and for revising the manuscript. Nocardia spp. were among the differential identification of the organism. Identification was made by a combination of morphological characteristics of gram stain, negative acid- References
fast and partial acid-fast staining of the isolate, biochemical Riegel P, De Briel D, Prevost G, Jehl F, Monteil H. Proposal of reaction and API Coryne System. The API Coryne System Corynebacterium propinquum sp. for Corynebacterium group ANF-3 is a reliable and improved system for the identification of strains. FEMS Microbiol 1993;113:229-34. Funke G, Von Graevenitz A, Clarridge JE III, Bernard KA. Clinical C. propinquum is distinguished from a phylogenetically microbiology of coryneform bacteria. Clin Microbiol Rev 1997;10: 125-59. related C. pseudodiphtheriticum, which is urease positive, Petit PLC, Bok JW, Thompson J, Buiting AGM, Coyle MB. Native- and from the CDC group ANF-1, which is negative for valve endocarditis due to CDC Coryneform group ANF-3: report of a nitrate reduction.2,7 C. propinquum (CDC group ANF-3), case and review of corynebacterial endocarditis. Clin Infect Dis previously isolated from native valve endocarditis, was Annals of Saudi Medicine, Vol 21, Nos 5-6, 2001 4. Sewell DL, Coyle MB, Funke G. Prosthetic valve endocarditis patterns of some recently established coryneform bacteria. caused by Corynebacterium afermentans subsp. lipophilum (CDC Antimicrob Agents Chemother 1996;40:2874-8. coryneform group ANF-1). J Clin Microbiol 1995;33:759-61. 10. Krcmery V Jr, Spanik S, Trupl J. First report of vancomycin-resistant Martinez-Martinez L, Suarez AI, Winstanley J, Ortega MC, Bernard Streptococcus mitis bacteremia in a patient with acute leukemia after K. Phenotypic characteristics of 31 strains of Corynebacterium prophylaxis with quinolones and during treatment with vancomycin. striatum isolated from clinical samples. J Clin Microbiol 1995;33: 11. Krcmery V Jr, Trupl J, Drgona L, Lacka J, Kukuekova E, Oravcova Freney J, Duperron MT, Courtier C, Hansen W, Allard F, Boeufgras E. Nosocomial bacteremia due to vancomycin-resistant JM, et al. Evaluation of API Coryne in comparison with conventional Staphylococcus epidermidis in four patients with cancer, neutropenia methods for identifying coryneform bacteria. J Clin Microbiol 1991; and previous treatment with vancomycin. Eur J Clin Microbiol Infect 7. Martinez-Martinez L. Clinical significance of newly recognized 12. Barnass S, Holland K, Tabaqchali S. Vancomycin-resistant coryneform bacteria. Rev Med Microbiol 1998;9:55-68. Corynebacterium species causing prosthetic valve endocarditis Soriano F, Zapardiel J, Nietro E. Antimicrobial susceptibilities of successfully treated with imipenem and ciprofloxacin. J Infect 1991; Corynebacterium species and other nonspore-forming gram-positive bacilli to 18 antimicrobial agents. Antimicrob Agents Chemother 13. Krcmery V Jr, Sefton A. Vancomycin resistance in gram-positive bacteria other than Enterococcus spp. Intern J Antimicrob Agents unke G, Punter V, Von Graevenitz A. Antimicrobial susceptibility Annals of Saudi Medicine, Vol 21, Nos 5-6, 2001

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