Scientific letter
Streptobacillus moniliformis bacteraemia: A case report
Bacteriemia por Streptobacillus moniliformis: a propósito de un caso
a Servicio de Microbiología, Hospital Univeristario de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Spain
b Servicio de Medicina Interna, Hospital Univeristario “Lucus Augusti”, Lugo, Spain
c Servicio de Enfermedades Infecciosas, Hospital Univeristario de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Spain
d CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
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array:4 [ 0 => array:3 [ "nombre" => "Dàmaris" "apellidos" => "Berbel" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 1 => array:3 [ "nombre" => "Eva" "apellidos" => "Romay" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Oscar" "apellidos" => "Murillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "Carmen" "apellidos" => "Ardanuy" "email" => array:1 [ 0 => "c.ardanuy@bellvitgehospital.cat" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Univeristario de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Univeristario “Lucus Augusti”, Lugo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Enfermedades Infecciosas, Hospital Univeristario de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Bacteriemia por <span class="elsevierStyleItalic">Streptobacillus moniliformis</span>: a propósito de un caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Streptobacillus moniliformis</span> is a fastidious, pleomorphic, Gram-negative rod that is part of rodents’ upper respiratory tract microbiota. <span class="elsevierStyleItalic">S. moniliformis</span> as well as <span class="elsevierStyleItalic">Spirillium minus</span> cause “rat-bite fever” (RBF) disease.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Here we report a case of bacteraemia and possible infectious endocarditis due to <span class="elsevierStyleItalic">S. moniliformis</span>. A 31-year-old man was admitted to the emergency department after a two-week history of fever and unspecific cutaneous lesions in some fingers and feet. He had little dotted lesions in both hands located only on the fingers but not on the palms. There were also other unspecific lesions on the sole of the feet. Blood samples were collected to perform further serologic studies. Considering that the patient general condition was good, he was discharged under paracetamol therapy and he was referred to the infectious diseases outpatient department. One week later, the patient returned to the hospital because of persistent fever as well as the appearance of arthralgia and additional skin lesions. After examining the patient, one and two millimetre-sized petechial and purpuric lesions were found on both hands (fingers and palms) and feet (the right toe and the left heel). Some of them were slightly bigger and similar to Osler's nodes. Neither cellulitis nor oedema was observed. Empiric therapy was started with intravenous (IV) ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h due to infectious endocarditis suspicion.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The initial peripheral blood analysis (obtained one week before) and the new analysis results demonstrated normocytic anaemia, thrombocytosis, C-reactive protein value of 15<span class="elsevierStyleHsp" style=""></span>mg/L, erythrocyte sedimentation rate of 40<span class="elsevierStyleHsp" style=""></span>mm/h and normal values of rheumatoid factor, and serologic studies were negative (HIV, hepatitis, toxoplasma and <span class="elsevierStyleItalic">Treponema pallidum</span> serologies). Histopathological studies of skin lesions found small thrombi causing occlusive vasculopathy. Neither the ophtalmoscopic exam nor the transthoracic echocardiogram revealed any abnormalities.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Gram stain of the blood cultures (positive after 20<span class="elsevierStyleHsp" style=""></span>h incubation) showed thin and long Gram-negative bacilli. Microorganism identification directly from blood culture using MALDI-TOF mass spectrometry was not achieved. After a 72-h incubation under capnophilic atmosphere, small and greyish colonies grew on sheep blood agar subculture. Those colonies were identified using MALDI-TOF analysis as <span class="elsevierStyleItalic">S. moniliformis</span> with a 1.95 score. Identification by 16S rRNA PCR and sequencing yield a 709<span class="elsevierStyleHsp" style=""></span>bp amplified fragment that shared 99% identity with <span class="elsevierStyleItalic">S. moniliformis</span> ATCC49940 (acc. num. KP657489.1). Susceptibility testing was performed by the gradient diffusion (Etest) and disk-diffusion methods on sheep blood agar plates. The isolate was susceptible to penicillin (MIC: 0.03<span class="elsevierStyleHsp" style=""></span>mg/L), cefotaxime (MIC: 0.012<span class="elsevierStyleHsp" style=""></span>mg/L), imipenem (MIC: 0.012<span class="elsevierStyleHsp" style=""></span>mg/L), tetracycline (MIC: 0.38<span class="elsevierStyleHsp" style=""></span>mg/L) and ciprofloxacin (MIC 0.19<span class="elsevierStyleHsp" style=""></span>mg/L) and was resistant to aminoglycosides (MICs: tobramycin 8<span class="elsevierStyleHsp" style=""></span>mg/L, amikacin 32<span class="elsevierStyleHsp" style=""></span>mg/L and gentamycin 4<span class="elsevierStyleHsp" style=""></span>mg/L), colistin (MIC: 32<span class="elsevierStyleHsp" style=""></span>mg/L) and co-trimoxazole (MIC: >32<span class="elsevierStyleHsp" style=""></span>mg/L), in agreement with previous reports.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Since penicillin-resistance in <span class="elsevierStyleItalic">S. moniloformis</span> is extremely rare, the recommended treatment is penicillin.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2,5</span></a> In our case, the empirical treatment with IV ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g/day was prolonged for four weeks due to its proved clinical efficacy against <span class="elsevierStyleItalic">S. moniliformis</span>, and the patient cured.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4,5</span></a> Without proper treatment, the mortality associated to this disease is approximately 10%.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3,4</span></a> In this case the patient could have presented a typical RBF onset (fever, polyarthralgias and polymorphic cutaneous lesions in both hands and feet<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3–5</span></a>); however, it was also difficult to distinguish between RBF and possible endocarditis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Indeed, positive results of 2 separate blood cultures with <span class="elsevierStyleItalic">S. moniliformis</span> (a microorganism with the ability to cause infective endocarditis) as major criteria, and the presence of fever, vascular (determined by histopathology) and immunological phenomena (Osler nodes-like) as minor criteria, posed concerns for the existence of possible infective endocarditis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">After knowing the blood culture results, the patient was asked about animal contact. He explained he had four dogs, two cats and two domestic rats, but he did not remember being bitten recently. Rats and other rodents are the main reservoir of <span class="elsevierStyleItalic">S. moniliformis</span> and its bite is directly related with RBF. Moreover, It can also be transmitted by contact with its saliva, excrements or through other colonized pets.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3,4</span></a> No history of animal bites, which is the case of our patient, have also been reported by nearly 30% of the patients.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,5</span></a> Although, the incidence of RBF in Spain is unknown, several cases have been reported (three cases of bacteraemia and other cases of arthritis, abscesses and wound infection) after rodents’ bite.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Overall, this case emphasizes the need for a high clinical suspicion and a well-addressed anamnesis, which was indeed performed inaccurately here, in order to diagnose this infectious disease.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. moniliformis</span> is a fastidious bacillus that requires microaerobic atmosphere (5–10% CO<span class="elsevierStyleInf">2</span>), long incubation period (2–7 days) and culture media with blood for its growth. In blood cultures it is inhibited by the presence of sodium polyanethol sulfonate (used as an anticoagulant in some blood cultures) but it is not affected by the presence of resins in the media.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–5</span></a> The incorporation of MALDI-TOF analysis in clinical Microbiology departments has reduced the time needed for optimal bacterial identification in such a fastidious microorganism.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> If there is a high clinical suspicion of RBF and difficulties in culturing samples, diagnosis carried out by 16S rRNA PCR analysis can be done.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3,5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, infections caused by <span class="elsevierStyleItalic">S. moniliformis</span> in Spain are rare; ours is the fourth case of bacteraemia reported. History of rodent contact and high clinical suspicion are essential in order to adapt laboratory protocols and to improve microbiological diagnosis and patient outcome.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rat bite fever and <span class="elsevierStyleItalic">Streptobacillus moniliformis</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.P. 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Del Zotti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehv319" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2015" "volumen" => "36" "paginaInicial" => "3075" "paginaFinal" => "3128" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26320109" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack428024" "titulo" => "Acknowledgements" "texto" => "<p id="par0045" class="elsevierStylePara elsevierViewall">We thank all the staff of the Microbiology and Infectious Diseases Departments who with their daily work contributed to the improvement of the patient's care.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/0213005X/0000003700000008/v1_201909271629/S0213005X18302374/v1_201909271629/en/main.assets" "Apartado" => array:4 [ "identificador" => "8590" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/0213005X/0000003700000008/v1_201909271629/S0213005X18302374/v1_201909271629/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X18302374?idApp=UINPBA00004N" ]
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| 2024 November | 10 | 2 | 12 |
| 2024 October | 65 | 8 | 73 |
| 2024 September | 66 | 11 | 77 |
| 2024 August | 55 | 8 | 63 |
| 2024 July | 51 | 9 | 60 |
| 2024 June | 35 | 26 | 61 |
| 2024 May | 46 | 16 | 62 |
| 2024 April | 30 | 30 | 60 |
| 2024 March | 55 | 29 | 84 |
| 2024 February | 45 | 10 | 55 |
| 2024 January | 58 | 9 | 67 |
| 2023 December | 61 | 15 | 76 |
| 2023 November | 71 | 43 | 114 |
| 2023 October | 96 | 33 | 129 |
| 2023 September | 36 | 13 | 49 |
| 2023 August | 50 | 2 | 52 |
| 2023 July | 72 | 81 | 153 |
| 2023 June | 85 | 33 | 118 |
| 2023 May | 123 | 11 | 134 |
| 2023 April | 81 | 3 | 84 |
| 2023 March | 85 | 8 | 93 |
| 2023 February | 100 | 38 | 138 |
| 2023 January | 56 | 10 | 66 |
| 2022 December | 75 | 15 | 90 |
| 2022 November | 70 | 31 | 101 |
| 2022 October | 60 | 24 | 84 |
| 2022 September | 99 | 31 | 130 |
| 2022 August | 66 | 10 | 76 |
| 2022 July | 54 | 9 | 63 |
| 2022 June | 36 | 23 | 59 |
| 2022 May | 88 | 23 | 111 |
| 2022 April | 44 | 18 | 62 |
| 2022 March | 89 | 11 | 100 |
| 2022 February | 58 | 15 | 73 |
| 2022 January | 117 | 15 | 132 |
| 2021 December | 45 | 18 | 63 |
| 2021 November | 52 | 26 | 78 |
| 2021 October | 78 | 18 | 96 |
| 2021 September | 62 | 21 | 83 |
| 2021 August | 66 | 24 | 90 |
| 2021 July | 53 | 17 | 70 |
| 2021 June | 53 | 14 | 67 |
| 2021 May | 160 | 24 | 184 |
| 2021 April | 195 | 27 | 222 |
| 2021 March | 323 | 16 | 339 |
| 2021 February | 69 | 21 | 90 |
| 2021 January | 68 | 8 | 76 |
| 2020 December | 45 | 18 | 63 |
| 2020 November | 22 | 13 | 35 |
| 2020 October | 36 | 9 | 45 |
| 2020 September | 42 | 14 | 56 |
| 2020 August | 43 | 12 | 55 |
| 2020 July | 45 | 12 | 57 |
| 2020 June | 26 | 9 | 35 |
| 2020 May | 30 | 15 | 45 |
| 2020 April | 41 | 19 | 60 |
| 2020 March | 1 | 2 | 3 |
| 2020 February | 1 | 2 | 3 |
| 2020 January | 1 | 1 | 2 |
| 2019 December | 4 | 13 | 17 |
| 2019 November | 9 | 4 | 13 |
| 2019 October | 41 | 18 | 59 |
| 2019 September | 27 | 6 | 33 |
| 2019 January | 0 | 2 | 2 |
| 2018 November | 0 | 2 | 2 |
Show all
