Scientific letter
A case of bacteremia by Streptococcus pseudopneumoniae
Un caso de bacteriemia por Streptococcus pseudopneumoniae
Ana Verónica Halperina,b,
, Marta Pérez-Abeledoc, Cristina Galeanob,d, Juan Carlos Sanzc,e
Corresponding author
a Microbiology Department, Ramón y Cajal Hospital, Madrid, Spain
b Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
c Clinical Microbiology Unit, Public Health Regional Laboratory of the Community of Madrid, Directorate General of Public Health, Regional Ministry of Health of Madrid, Madrid, Spain
d Infectious Diseases Department, Ramón y Cajal Hospital, Madrid , Spain
e CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
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He was diagnosed with benign prostate hyperplasia and he was treated with photovaporization. Few hours after the procedure he presented with septic shock. Treatment with antibiotics (meropenem, linezolid and daptomycin) and vasoactive drugs was initiated with significant improvement after 72<span class="elsevierStyleHsp" style=""></span>h. <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> was tentatively identified in one of two blood cultures. Urine antigen of <span class="elsevierStyleItalic">S. pneumoniae</span> (BinaxNOW, Abbott) and HIV serology were negative. There were no signs of lung consolidation in the chest radiography.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The presumptive identification of <span class="elsevierStyleItalic">S. pneumoniae</span> in the microbiology laboratory was performed by optochin disc diffusion test incubated in CO<span class="elsevierStyleInf">2</span> and in ambient air (susceptible in both atmospheres), and mass spectrometry (MALDI-TOF, Bruker). Susceptibility testing was performed with disc diffusion according to EUCAST (v13.1) (<a href="http://www.eucast.org/">www.eucast.org</a>). The isolate was susceptible to cefotaxime, clindamycin and vancomycin, and susceptible with increased exposure to penicillin and levofloxacin. Treatment was deescalated to ceftriaxone with good clinical progress.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As part of a surveillance programme at the Madrid Autonomous Community, all isolates of <span class="elsevierStyleItalic">S. pneumoniae</span> are analyzed at the Regional Public Health Laboratory for characterization. These results showed that this particular isolate was non typable, and soluble in bile. The capsular polysaccharide biosynthesis A <span class="elsevierStyleItalic">(cpsA)</span> and autolysin <span class="elsevierStyleItalic">(lytA)</span> genes were not detected, while the amplification of the pneumolysin gene <span class="elsevierStyleItalic">(ply)</span> was positive. Given this variety in our findings, whole genome sequencing (WGS) was performed with MinION (Oxford Nanopore) leading to identification of <span class="elsevierStyleItalic">Streptococcus pseudopneumoniae</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">S. pseudopneumoniae</span> is a bacterial species closely related to <span class="elsevierStyleItalic">S. pneumoniae</span>, first identified in 2004 as part of the <span class="elsevierStyleItalic">Streptococcus mitis</span> group.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is considered an opportunistic pathogen associated with septicaemia and meningitis,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> particularly in patients with haematologic disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Phenotypic characteristics can provide some clues for its identification, but these may not be definitive, as they can overlap with other streptococcal species. <span class="elsevierStyleItalic">S. pseudopneumoniae</span> colonies have a similar appearance to <span class="elsevierStyleItalic">S. pneumoniae</span> in blood agar plates with alpha-hemolytic activity, but unlike the latter, <span class="elsevierStyleItalic">S. pseudopneumoniae</span> lacks capsule, is often resistant to optochin (inhibition zones <14<span class="elsevierStyleHsp" style=""></span>mm) when incubated with CO<span class="elsevierStyleInf">2</span> but susceptible to optochin (inhibition zones >14<span class="elsevierStyleHsp" style=""></span>mm) when incubated in ambient atmosphere, and not soluble in bile.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,4</span></a> However, there are exceptions and a variable proportion of <span class="elsevierStyleItalic">S. pneumoniae</span> strains do not have a specific agglutination in the Quellung reaction due to lack of capsule (non-typeable), can be optochin resistant and bile insoluble.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> Additionally, a proportion of <span class="elsevierStyleItalic">S. pseudopneumoniae</span> has also been reported as optochin susceptible when incubated in CO<span class="elsevierStyleInf">2</span> (16.4%), or bile soluble (36.1%)<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> like in our case, although this does not represent the majority of the isolates. Moreover, commercial tests (such as antigen detection or DNA hybridization probes), might not easily discriminate between both species.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">lytA</span> and the <span class="elsevierStyleItalic">cpsA</span> genes are harbored by <span class="elsevierStyleItalic">S. pneumoniae</span> (although the latter may be absent in non-typeable strains), however none of these genes are present in <span class="elsevierStyleItalic">S. pseudopneumoniae</span>, hence being useful for discrimination between both species.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,8</span></a> Nevertheless, there are some rare <span class="elsevierStyleItalic">S. pneumoniae</span> strains that show some molecular peculiarities of the <span class="elsevierStyleItalic">lytA</span> gene that confer an atypical bile insoluble phenotype.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In contrast to the <span class="elsevierStyleItalic">lytA</span> and the <span class="elsevierStyleItalic">cpsA</span> genes absent in <span class="elsevierStyleItalic">S. pseudopneumoniae</span>, some isolates can carry the <span class="elsevierStyleItalic">ply</span> gene.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Our isolate was non-typeable, optochin susceptible when incubated both in CO<span class="elsevierStyleInf">2</span> and in ambient air, and bile soluble. The PCR was positive for <span class="elsevierStyleItalic">ply</span>, while negative for <span class="elsevierStyleItalic">lytA</span>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Resistance rates are often higher in <span class="elsevierStyleItalic">S. pseudopneumoniae</span>, particularly for penicillin (60.7%) and erythromycin (42.6%),<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> therefore the correct identification could affect empiric treatment.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In our patient, who presented with an invasive disease (bacteraemia), the urinary tract seemed the most likely focus, although urine culture was sterile. Nevertheless, routine culture media used for urine are not suitable for <span class="elsevierStyleItalic">Streptococcus</span> spp. and culture in enriched media was not performed. To our knowledge, no cases of urinary tract infection caused by <span class="elsevierStyleItalic">S. pseudopneumoniae</span> have been described previously.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, it is important to note that relying solely on phenotypic characteristics for the identification of <span class="elsevierStyleItalic">S. pseudopneumoniae</span> can be inconclusive and may lead to misidentification. Molecular methods, such as WGS, might be needed for accurate identification.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accuracy of phenotypic and genotypic testing for identification of <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> and description of <span class="elsevierStyleItalic">Streptococcus pseudopneumoniae</span> sp. nov" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.C. Arbique" 1 => "C. Poyart" 2 => "P. 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