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Diagnosis at first sight
Catheter-related bacteremia of rare etiology
Bacteriemia asociada a catéter de etiología infrecuente
Ramón Vela-Fernández
Corresponding author
, Inmaculada Guerrero-Lozano, Manuel Rodriguez-Iglesias, Fátima Galán-Sánchez
Servicio de Microbiología Clínica, Complejo Hospitalario Universitario Puerta del Mar-San Carlos, Cádiz, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case description</span><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 68-year-old male with a medical history of diabetes mellitus type 2&#44; arterial hypertension&#44; severe obstructive sleep apnea and ischemic cerebrovascular disease who was admitted to our hospital for elective cardiac surgery&#44; due to multivessel coronary artery disease after a non-ST-elevation myocardial infarction&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">During the first day of hospitalization the patient had two episodes of fever above 38<span class="elsevierStyleHsp" style=""></span>&#176;C with shivering and petechial lesions in lower limbs&#46; He denied headache&#44; seizure&#44; caught&#44; chest or abdominal pain&#46; The patient could not recall any contact with animals recently&#46; Only C reactive protein &#40;85&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#44; fibrinogen &#40;544<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; and procalcitonin &#40;0&#46;4<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#41; were slightly elevated&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Catheter-related phlebitis&#44; in the right hand&#44; was observed&#46; To rule out catheter-related bacteremia&#44; four samples of 10<span class="elsevierStyleHsp" style=""></span>mL of blood obtained from the peripheral venous catheter and venopunction were placed into 2 pair of blood culture bottles &#40;BD Bactec&#174; Plus Aerobic&#47;F and Plus Anaerobic&#47;F&#41; and were processed in the BD Bactec&#174; Fx System &#40;BD Diagnostics&#41;&#46; Additionally&#44; the peripheral catheter was removed&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After 30 and 35<span class="elsevierStyleHsp" style=""></span>h of incubation&#44; the two aerobic bottles from the catheter and venopunction flagged positive&#44; respectively&#46; Gram stain revealed Gram-positive bacilli &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; that changed to Gram-positive coccobacilli and cocci after 24 and 72<span class="elsevierStyleHsp" style=""></span>h of incubation in solid media &#40;5&#8211;7&#37; CO<span class="elsevierStyleInf">2</span> atmosphere at 37<span class="elsevierStyleHsp" style=""></span>&#176;C in BD BBL&#8482; Chocolate II Agar&#41;&#46; In this agar&#44; round&#44; small &#40;&#60;2<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; smooth&#44; semitransparent&#44; mucoid&#44; coalescing&#44; and shiny colonies were observed&#44; which became larger and salmon-pink in color with age but not before 4 days of incubation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis and evolution</span><p id="par0025" class="elsevierStylePara elsevierViewall">Identification using MALDI-TOF &#40;Bruker&#174; Daltonics GmbH&#41; directly from the blood culture &#40;triton-formic acid-ethanol extraction&#41; yielded <span class="elsevierStyleItalic">Rhodococcus hoagii</span> as the first proposed identification with a low score of 1&#46;30&#44; and repetition from colonies after 24<span class="elsevierStyleHsp" style=""></span>h of incubation did not produce any result&#46; Based on Gram stain morphology&#44; bacilli in liquid media&#44; coccobacilli and cocci after 24 and 72<span class="elsevierStyleHsp" style=""></span>h of incubation in solid media&#44; respectively &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2B and 3B</a>&#41;&#44; and colonies appearance &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2A and 3A</a>&#41;&#44; a presumptive diagnosis of <span class="elsevierStyleItalic">Rhodococcus</span> spp&#46; was provided&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">A third set of blood cultures&#44; obtained 6 days after removal of the catheter&#44; achieved the growth of the same microorganism after 5 days of incubation&#46; In this case&#44; a definitive diagnosis was possible with a higher score &#40;1&#46;82&#41; using MALDI-TOF from colonies&#46; During hospital admission serial transthoracic echocardiographies were negative for endocarditis&#46; Surgery was performed one day before this third set flagged positive&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Further species identification was confirmed by the partial sequencing of the 16S ribosomal RNA gene&#46; The purified amplicons were sequenced and the result obtained was compared using BLAST&#44; demonstrating 99&#37; similarity to <span class="elsevierStyleItalic">R&#46; hoagii</span>&#46; The antimicrobial susceptibility testing was determined by MIC test strips &#40;Liofilchem&#44; Inc&#46;&#44; Italy&#41; and the results were interpreted according to PK-PD breakpoints defined by EUCAST &#40;<a href="http://www.eucast.org/">www&#46;eucast&#46;org</a>&#41; as follows&#58; imipenem &#40;MIC 2<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; susceptible&#41;&#44; levofloxacin &#40;MIC 0&#46;75<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; susceptible increased exposure&#41;&#44; and linezolid &#40;MIC 3<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; resistant&#41;&#46; After the identification&#44; antibiotic therapy with ciprofloxacin 500<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h was added for 7 days before surgery and 14 days after surgery&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rhodococcus</span> spp&#46; is a pleomorphic Gram-positive coccobacillus&#44; varying the percentage of presentation of the coccoid or bacillary form according to the conditions of growth and the phase in which it is&#46; This zoonosis-producing microorganism causes several diseases like granulomatous pneumonia and lung abscess in foals less than six months old&#46; It sporadically infects other mammals including cats&#44; dogs and pigs&#44; in which produces submandibular adenitis&#44; and is being increasingly reported as a cause of infection in immunocompromised humans&#46; Because diphtheroids are regarded as part of normal respiratory microbiota&#44; the importance of <span class="elsevierStyleItalic">R&#46; hoagii</span> as a pulmonary pathogen may not be fully appreciated and its prevalence may be underestimated&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In humans&#44; <span class="elsevierStyleItalic">R&#46; hoagii</span> is the main representative species related to pathological processes&#46; It is an intracellular pathogen that infects macrophages and polymorphonuclear cells&#44; especially in patients with alterations of the cellular immunity&#44; immunosuppressive treatment&#44; hematological neoplasm and&#44; in general&#44; any type of immunodeficiency<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> causing respiratory infection&#44; skin infection&#44; abscesses&#44; peritonitis&#44; and bacteremia&#46; Infection is possible&#44; although rare&#44; in immunocompetent persons&#44; with different clinical presentations like respiratory disease and cerebellar abscess&#46; In a systematic review including 531 infections caused by <span class="elsevierStyleItalic">R&#46; hoagii</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> no bacteremia related to peripheral venous catheter infections was described&#46; Despite this&#44; catheter-related bacteremia by <span class="elsevierStyleItalic">R&#46; hoagii&#44;</span> although rare&#44; should be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In terms of treatment&#44; it is important to emphasize that the condition of intracellular pathogen gives <span class="elsevierStyleItalic">R&#46; hoagii</span> some special characteristics such as the need for prolonged treatments with combined antibiotic regimens&#44; especially in immunocompromised patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is important to recognize the characteristic appearance of these microorganism colonies and its variable morphology in the Gram stain in order to make an adequate early diagnosis&#44; since it may not be adequately identified by MALDI-TOF because the cell wall of <span class="elsevierStyleItalic">R&#46; hoagii</span> stops the complete uptake of energy when fired upon by the laser&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> A Ziehl-Neelsen stain &#40;preferably staining modification that decolorizes slides with 0&#46;5&#8211;1&#37; sulfuric acid solution&#41; and biochemical tests as positive catalase and negative oxidase could be helpful in the presence of a low MALDI-TOF score&#46; Its identity can be confirmed by species-specific and cholesterol oxidase &#40;<span class="elsevierStyleItalic">choE</span>&#41; PCR using genomic DNA as template&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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ISSN: 2529993X
Original language: English
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