Scientific letter
Tsukamurella paurometabola peritonitis in a patient on automated peritoneal dialysis
Peritonitis por Tsukamurella paurometabola en un paciente en diálisis peritoneal automatizada
Rashad Ismayilova,
, Zeynep Cansu Duranb, Gulsen Hazirolanc, Ahmet Çagkan Inkayab
Corresponding author
a Hacettepe University Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey
b Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
c Hacettepe University Faculty of Medicine, Department of Medical Microbiology, Ankara, Turkey
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Although the risk factors and the route of transmission are not certain, different clinical manifestations such as ocular and cutaneous infections, meningitis, tenosynovitis, prosthetic joint infections, respiratory tract infections, catheter-related bloodstream infections, and peritonitis are reported in the literature.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 67-year-old male patient with type 2 diabetes mellitus and chronic kidney disease admitted with complaints of abdominal pain and vomiting. The patient was on automated peritoneal dialysis for 8 years. There was not any redness, discharge, and tenderness around the peritoneal catheter insertion site. Laboratory investigation revealed white blood cell count of (WBC) 9.7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL (4.3–10.3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL), neutrophil count 8.53<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL (2.1–6.1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL), erythrocyte sedimentation rate (ESR) 20<span class="elsevierStyleHsp" style=""></span>mm/h, C-reactive protein (CRP) 1.21<span class="elsevierStyleHsp" style=""></span>mg/dL (0–0.8<span class="elsevierStyleHsp" style=""></span>mg/dL), and procalcitonin 0.20<span class="elsevierStyleHsp" style=""></span>ng/mL (0–0.1<span class="elsevierStyleHsp" style=""></span>ng/mL). Abdominal computed tomography revealed diffuse contrast enhancement compatible with peritonitis. Thereafter, intravenous ampicillin/sulbactam (SAM), 1000/500<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleSup">BID</span> was commenced empirically. Peritoneal fluid cell count was 4400/mm<span class="elsevierStyleSup">3</span> with 87.1% of neutrophils. The peripheral blood cultures signaled growth in aerobic bottles of the Bactec FX system (BD, USA) after 34<span class="elsevierStyleHsp" style=""></span>h of incubation. Gram staining from blood culture tubes showed straight, non-branching, Gram-positive rods. The specimens from the bottles were plated onto 5% sheep blood/eosin methylene blue agar (BD) and chocolate agar. On the other hand, peritoneal fluid culture taken from the peritoneal catheter was performed by inoculating sample into 5% sheep blood/eosin methylene blue agar (BD), chocolate agar, and fluid thioglycolate medium. The mediums were incubated at 35<span class="elsevierStyleHsp" style=""></span>°C in 5% CO<span class="elsevierStyleInf">2</span>. After 24<span class="elsevierStyleHsp" style=""></span>h, white, rough, dry, and non-hemolytic colonies were observed. Gram staining from peritoneal fluid culture showed non-branching, Gram-positive rods, too. The colonies were found to be catalase positive and oxidase negative. Matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) system (Bruker, Germany) was used for identification (MBT 7854 MSP Library). The peritoneal fluid isolate identified as <span class="elsevierStyleItalic">Tsukamurella paurometabola</span> with a Bruker score of 2.1 by Bruker Biotyper indicated confident species level identification. The blood culture isolates identified as <span class="elsevierStyleItalic">Tsukamurella</span> spp. with a Bruker score of 1.9 by Bruker Biotyper indicated confident genus level identification. Gentamicin 0.6<span class="elsevierStyleHsp" style=""></span>mg/kg intravenously was added on treatment day 3. Peritoneal fluid pleocytosis decreased to 100/mm<span class="elsevierStyleSup">3</span> (22% neutrophil) on treatment day 6. Follow-up peritoneal fluid and blood cultures remained sterile. Gentamicin was discontinued on day 21. As patients’ complaints did not improve, peritoneal dialysis catheter was removed surgically and the patient was put-on routine hemodialysis program on day 35. Peritoneal biopsy sample collected during catheter removal showed fibrotic changes and no sign of any other infection. Intravenous SAM switched to oral amoxicillin/clavulanate on the 37th day of treatment and continued for an additional 14 days. Complaints of patients improved totally after catheter removal.</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Tsukamurella</span> spp. have many common features with <span class="elsevierStyleItalic">Rhodococcus, Corynebacterium, Nocardia</span>, and <span class="elsevierStyleItalic">Mycobacterium</span>, which may lead to misidentification. In addition to this, the differentiation of <span class="elsevierStyleItalic">Tsukamurella</span> bacteria at the species level is quite complicated and difficult by conventional methods. At present, the identification of bacteria up to the genus level can be accomplished with 16S rRNA sequencing, but PCR sequencing is still expensive and time-consuming. In contrast, MALDI-TOF MS is a rapid and cost-effective method. This method allows adding MSPs of bacterial species not included in the database to improve its performance. In a study using an expanded database, 98.3% of <span class="elsevierStyleItalic">Tsukamurella</span> isolates were correctly identified at the species level with a score of ≥2.0.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Currently, the genus is composed of 17 validly identified species.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> MALDI-TOF MS can be used for routine species identification of <span class="elsevierStyleItalic">Tsukamurella</span> in clinical microbiology laboratories after optimization of the database by adding reference MSPs of all known <span class="elsevierStyleItalic">Tsukamurella</span> species.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Tsukamurella</span> spp. are opportunistic pathogens and often cause catheter-induced infections. Previously, cases of peritonitis have been reported in patients receiving continuous ambulatory peritoneal dialysis.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> However, there is insufficient information about the clinical course and treatment duration. To our knowledge, the case we presented is the first case of <span class="elsevierStyleItalic">Tsukamurella</span> peritonitis that received automated peritoneal dialysis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Consequently, <span class="elsevierStyleItalic">Tsukamurella</span> species are very rare in humans, as well as the presence of catheters and poor hygiene may pose a risk.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of <span class="elsevierStyleItalic">Tsukamurella</span> species in human infections: first literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Safaei" 1 => "M. Fatahi-Bafghi" 2 => "O. Pouresmaeil" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.nmni.2017.10.002" "Revista" => array:6 [ "tituloSerie" => "New Microbes New Infect" "fecha" => "2018" "volumen" => "22" "paginaInicial" => "6" "paginaFinal" => "12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29556401" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MALDI-TOF MS for identification of <span class="elsevierStyleItalic">Tsukamurella</span> species: <span class="elsevierStyleItalic">Tsukamurella tyrosinosolvens</span> as the predominant species associated with ocular infections article" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.L.L. Teng" 1 => "Y. Tang" 2 => "S.S.Y. Wong" 3 => "J.Y.H. Fong" 4 => "Z. Zhao" 5 => "C.P. Wong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Emerg Microbes Infect" "fecha" => "2018" "volumen" => "7" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "List of Prokaryotic names with Standing in Nomenclature (LPSN) moves to the DSMZ" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.C. Parte" 1 => "J. Sardà Carbasse" 2 => "J.P. Meier-Kolthoff" 3 => "L.C. Reimer" 4 => "M. Göker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Int J Syst Evol Microbiol" "fecha" => "2020" "paginaInicial" => "0" "paginaFinal" => "5" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tsukamurella peritonitis associated with continuous ambulatory peritoneal dialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.J. Shaer" 1 => "C.A. Gadegbeku" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Clin Nephrol" "fecha" => "2001" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of <span class="elsevierStyleItalic">Tsukamurella tyrosinosolvens</span> peritonitis associated with continuous ambulatory peritoneal dialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.-C. Park" 1 => "J.-S. Hong" 2 => "J.-G. Seo" 3 => "W.-K. Chung" 4 => "Y.-H. Seo" 5 => "H.-H. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Korean J Med" "fecha" => "2009" "volumen" => "76" "paginaInicial" => "225" "paginaFinal" => "228" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/0213005X/0000003900000008/v1_202110050758/S0213005X20303281/v1_202110050758/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/0000003900000008/v1_202110050758/S0213005X20303281/v1_202110050758/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X20303281?idApp=UINPBA00004N" ]
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