Soft tissue infection due to catalase-negative Staphylococcus lugdunensis: First case reported in Europe

Falces-Romero, Iker; Jiménez-Rodríguez, Sonia; Rico-Nieto, Alicia

doi:10.1016/j.medcli.2019.06.013

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Coagulase-negative staphylococci infections predominantly present as abscesses and paronychia. They are most common in elderly or immunosuppressed patients.<a class="elsevierStyleCrossRef" href="#bib0030">1</a>The bibliographic search was performed using the PubMed database with the following keywords“soft tissue”, “infection”, “Staphylococcusaureus”, “Staphylococcuslugdunensis”, “mutation”, “catalase negative”. Years covered by the search: 2005–2018.We report a case of soft tissue infection due to catalase-negative Staphylococcus lugdunensis in our tertiary-care hospital. A 46-year-old female was admitted to the Emergency Room with an infection in the fourth finger of the right hand after an accidental wound with a fishbone 3 months before. She had received empirical treatment with amoxicillin/clavulanic acid and clindamycin together with several surgical cleanings without clinical improvement. At the Emergency Room, a tissue sample was obtained and sent to the Microbiology Department. The sample was cultured in conventional media and standard conditions and S. lugdunensis was isolated. According to EUCAST criteria, the strain was resistant only to penicillin due to production of a betalactamase. One week later, the patient was admitted to Plastic Surgery Unit for a new debridement and intravenous antibiotherapy with cefazolin (2g/8h). A new tissue sample was obtained and S. lugdunensis was isolated again. Magnetic resonance imaging (MRI) and radiography were performed to rule out osteomyelitis and osteolytic lesions, respectively. After 7 days of treatment, she presented clinical improvement and was discharged with oral levofloxacin (750mg/24h) to complete the treatment for 2 weeks.In the first sample, after 24h of incubation, a pure culture of a non-haemolytic, white and flat colonies grew. Gram stain revealed gram-positive cocci but catalase test was negative on analysis with 3% H2O2. MALDI-TOF mass spectrometry (Bruker Daltonics GmbH, Bremen, Germany) identified the microorganism as S. lugdunensis (Score: >2), in agreement with the biochemical identification (99.9% probability) performed in the broth microdilution panel where the antibiotic susceptibility was tested (MicroScan Pos Combo Panel Type 37 – Beckman Coulter, Brea, CA). The same catalase-negative S. lugdunensis was obtained in the second sample. The catalase gene was amplified by PCR using primers Sl-F1 (5′-GAAGCATTAGTCTTGAAAGGAGC-3′), Sl-R1 (5′-TGGGTATTCACCATGATACC-3′), Sl-F2 (5′-CGATGAAGAAGCGGCAGATGTGA-3′) and R2 (5′-CAAGGATGCAATATCTTCTAG-3′) and sequenced using the same four primers and Sl-F3 (5′-CCATTCCCAACAGATGGTG-3′) and Sl-R3 (5′-ATGCATACGGCGTTCTGG-3′). The sequence was deposited in Genbank accession number: MK416184 and it was compared with other sequences deposited in the same database. A G→A mutation in position 1427 was found that would produce a change from Glycine to Glutamic Acid at position 476 (G476E).Staphylococcus lugdunensis is a coagulase-negative Staphylococcus (CNS), which is part of the normal skin microbiota. However, in terms of its pathogenicity and virulence it is more similar to Staphylococcus aureus than to CNS, causing serious infections such as infective endocarditis, bloodstream infections, catheter-related infections, bone and joint infections, meningitis or brain abscesses.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> Production of catalase is considered to be a virulence determinant in pathogenic staphylococci like S. aureus, because it confers the bacteria the ability to better resist intra- and extra-cellular killing by hydrogen peroxide. Strains which do not produce catalase are thought to be less virulent. Catalase activity assay is a classical test for identification of gram-positive cocci belonging to the genus Staphylococcus. Only two Staphylococcus species, S. aureus subsp. anaerobius and S. saccharolyticus, are known not to produce catalase. Catalase-negative Staphylococcus aureus strains with mutations in the katA gene have been reported<a class="elsevierStyleCrossRef" href="#bib0040">3</a> but, to our knowledge, only one case of molecular characterization of catalase-negative Staphylococcus lugdunensis has been reported in a patient with a chronic suppurative otitis media in China.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> The mutation found in our strain has not been previously reported in other strains of catalase-negative Staphylococcus spp. Some reports of catalase-negative S.aureus<a class="elsevierStyleCrossRefs" href="#bib0040">3,5</a> have discussed the clinical relevance of these strains because there is some evidence that catalase is not an absolute requirement for pathogenicity. In our case, catalase did not seem to be relevant for pathogenicity because the patient had an aggressive deep soft tissue infection which required intravenous antibiotherapy and surgical debridement.Although the frequency of catalase negative mutants is low, we should be aware that the interpretation of catalase activity assays may be misled by atypical isolates. This underlines the value of performing an adequate identification by either, MALDI-TOF mass spectrometry or classical microbiological methods." 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