Species Corynebacterium Important Meningitis: Case Report and … · 2017. 4. 14. · 1246 Corynebacterium striatum Meningitis: Case Report and Review of an Increasingly Important

1246

Corynebacterium striatum Meningitis: Case Report and Review of an Increasingly Important Corynebacterium Species

K. Weiss, A. C. Labbe, and M. Laverdiere From the Department of Microbiology and Infectious Diseases, H6pital Maisonneuve-Rosemont, University of Montreal, Montreal,

Quebec, Canada

For a long time, corynebacteria were considered simple cutaneous contaminants with little poten­tial pathogenicity. Corynebacterium striatum is a known saprophytic cutaneous bacterium; however, in the last decade, this organism has been increasingly recognized as a pathogen. It has been mostly implicated in respiratory tract and blood infections. To our knowledge, we report the first case of meningitis due to C. striatum. Treatment with intravenous vancomycin resulted in therapeutic success. We also thoroughly review all previously reported cases of C. striatum infection. Identifica­tion of Corynebacterium species can be difficult because of rapid taxonomic changes, and susceptibil­ity testing for these microorganisms is not yet standardized. However, because of their growing clinical importance, data on these bacteria are accumulating.

Corynebacterium species are part of the normal skin flora; these microorganisms are also found in the environment or in animals [1]. For a long time, they were considered simple cutaneous contaminants with little or no potential pathogenic­ity. However, during the last decade, Corynebacteriumjeikeium and Corynebacterium urealyticum have been implicated in in­fectious processes, especially catheter-related infections and urinary tract infections [2]. These species are characterized by their multiresistant susceptibility profile, which makes them unique among Corynebacterium species. The taxonomy of Cor­ynebacterium species is rapidly changing and is still not com­pletely established. Numerous Corynebacterium species have been recently reclassified as members of the coryneform group, and taxonomic modifications are still being made [1].

Corynebacterium striatum has not been considered a poten­tially pathogenic microorganism until recently. When this or­ganism was found in clinical specimens, it was often discarded as a contaminant. Its taxonomic classification is not yet very clear. Several case reports of C. striatum infection have been published; however, most of these cases were blood infections [3-8] or respiratory tract infections [9-12]. To our knowledge, we report the first proven case of meningitis caused by C. striatum. Moreover, we review the previously reported cases of infection due to this increasingly important emerging patho­genic species of Corynebacterium.

Case Report

A 23-year-old man with no underlying medical problem presented to the emergency department of our hospital on 29

Received 2 May 1996; revised 24 June 1996. Reprints or correspondence: Dr. K. Weiss, Hopita1 Maisonneuv~-Rosemont,

5415 L'Assomption, Montreal, Quebec, Canada HIT 2M4.

Clinical Infectious Diseases 1996; 23:1246-8 © 1996 by The University of Chicago. All rights reserved. 1058--4838/96/2306-0023$02.00

November 1995 complaining of headache, nausea, vomiting, and photophobia. In May 1995, the patient had had a major motorcycle accident in which he sustained a fracture of the right humerus that was complicated by avulsion of nerve roots from C-6 to T -1. He subsequently had pseudomeningocele and paralysis ofthe right arm; he underwent extensive nerve recon­structive surgery on 16 November 1995. A drain was left in place at that time, and a persistent leak was present. The pa­tient's condition following his surgery was favorable, and he was discharged on 20 November 1995. A few days later, he started complaining of an increasingly painful headache that was occasionally accompanied by chills.

At the time of admission, the patient was alert and well oriented and had a severe headache; his oral temperature was 38.5°C, and his vital signs were normal. Neurological examina­tion showed a stiff neck and right arm paralysis. Physical exam­ination was otherwise unremarkable, and there was no infection at the surgical site. However, there was a leak of cloudy fluid through a cutaneous fistula, which was likely in communication with the CSF; the drain was immediately removed.

Laboratory tests of blood taken at admission showed a WBC count of 21.3 X 109/L with 94% polymorphonuclear leuko­cytes. A lumbar puncture yielded cloudy CSF; analysis of CSF revealed a decreased glucose concentration of 1.5 mmollL (nor­mal value, 2.8-3.9 mmollL), an increased protein concentra­tion of 4.35 gIL (normal value, 0.15-0.4 giL), and an elevated WBC count of 1131 ilL (92% neutrophils). Gram staining of CSF demonstrated the presence of coccobacillary gram­positive bacteria. Intravenous ceftriaxone (1 g every 12 hours) and intravenous vancomycin (1 g every 12 hours) were immedi­ately administered to the patient. Two cultures of blood taken before the start of antibiotic therapy remained negative.

After a 24-hour incubation period, culture of a CSF specimen subsequently yielded pure growth of a gram-positive rod. The microorganism had a beige appearance, was catalase-positive, reduced nitrate, and was nonmotile. After 48 hours, the colo­ny's diameter was about 2-3 mm, and it had a creamy texture.

cm 1996;23 (December) Corynebacterium striatum Meningitis 1247

Table 1. Summary of data on reported cases of Corynebacterium striatum infection.

Year of publication Patient's Predisposing [reference] age (y)/sex Disease condition(s) Therapy Outcome

1980 [9] 791M Pneumonia Chronic lymphocytic Carbenicillin Died leukemia

1986 [10]* 221M Empyema Multiple trauma ND Alive 1989 [3]t 641F Septicemia Endometrial Ampicillin, gentamicin Alive

carcinoma, recent chemotherapy

1990 [4] 761M Endocarditis None Ampicillin, gentamicin Died 1991 [16] 801F Keratitis Diabetes, glaucoma Cefazolin, tobramycin Alive 1993 [5] 191M Blood infection Lymphoma, BMT Vancomycin, amikacin Alive 1993 [5] 461F Catheter site Myelodysplasia, BMT Vancomycin, Alive

infection tobramycin, mezlocillin

1993 [5] 3lIF Uterus Pregnant (28 w) Ampicillinlsulbactam Alive infection

1993 [11] 691M COPD COPD Amoxicillin Alive exacerbation

1994 [12] 271M Pneumonia Alcoholism Vancomycin Died 1994 [6] 261M Bacteremia AIDS, IV drug user Teicoplanin Alive

1994 [7] 541M Aortic valve Right elbow abrasion Ampicillin, Alive

endocarditis vancomycin, valve replacement

1995 [15] 531M CAPD Chronic renal failure Vancomycin, Alive

peritonitis ceftazidime

1996 [8] 731M Endocarditis Pacemaker Vancomycin Alive

1996 [PRJ 231M Meningitis CSF-skin fistula Vancomycin Alive

NOTE. BMT = bone marrow transplant; CAPD = continuous ambulatory peritoneal dialysis; COPD = chronic obstructive pulmonary disease; ND = not done; PR = present report.

* C. striatum was a possible cause. t The strain's identification was controversial.

The bacterium was subsequently identified as C. striatum by using the API-Coryne system (bioMerieux, Marcy I 'Etoile, France); the identification was categorized as good (identifica­tion code, 3100105; % id = 97.1; T index = 1). The strain's identification was confirmed by the Quebec Provincial Labora­tory (Ste. Anne de Bellevue, Quebec, Canada) by means of conventional methods. Susceptibility testing was performed by a broth microdilution technique with cation-adjusted Mueller­Hinton broth supplemented with 4.5% lysed horse blood agar and 6.6% rabbit serum. Plates were incubated under aerobic conditions for 48 hours [l3]. With use of the criteria of the National Committee for Clinical Laboratory Standards [14], the bacterium was found to be susceptible to vancomycin (MIC, ~0.125 mglL) and erythromycin (MIC, ~0.016 mglL) and intermediately susceptile to penicillin (MIC, 0.25 mg/L).

Ceftriaxone therapy was discontinued after 24 hours, whereas vancomycin therapy was continued for a total of 10 days. After 48 hours of treatment, we noted a marked improve­ment in the patient's condition; he became afebrile, and his headache almost completely disappeared. In the meantime, the leak progressively stopped, and it completely ceased on 9 De­cember 1995. A culture of leaking fluid obtained 5 days after admission yielded no bacterial growth. A control lumbar punc-

ture was not done, and the CSF level of vancomycin was not measured. On 12 December 1995, the patient was discharged in excellent condition; there were no new neurological se­quelae, and he was not receiving any antibiotic therapy. At a I-month follow-up at the outpatient clinic, he was perfectly well.

Discussion

For a long time, C. striatum was considered a saprophytic bacterium colonizing the anterior nares and skin; it seemed to be isolated more often from sites on the upper part of the body. However, during the last few years, several cases of definite infection caused by this microorganism have been reported. The first case report describing this bacterium as a pathogenic microorganism was published in 1980 [9]. This case involved pulmonary infection in an immunocompromised host. Infec­tions in the other reports almost always were associated with underlying medical problems. Most cases of C. striatum infec­tion occurred in either immunocompromised patients or pa­tients whose skin barrier integrity was broken. C. striatum was mainly recovered from either blood (six cases) or respiratory

1248 Weiss, Labbe, and Laverdiere CID 1996;23 (December)

tract specimens (four cases). A total of 15 cases, including ours, have been reported (table 1).

Previous reports have not implicated C. striatum in CNS infection, and this case confirms that this bacterium has the potential to cause meningitis. The fact that there was direct communication between the skin and the CSF through a cathe­ter left in place following the initial surgery could explain the pathogenesis of this particular infection. This bacterium has also caused chronic peritonitis associated with ambulatory peri­toneal dialysis [15] as well as keratitis [16].

C. striatum is a Corynebacterium species that can be difficult to identify in certain circumstances, and sometimes it can be confused with Corynebacterium xerosis. These two bacteria can be differentiated by maltose utilization [1]. However, C. xerosis seems to be much more resistant to erythromycin [13, 17, 18]. Colonies of C. striatum are white, tan, or yellowish and grow well on sheep blood agar, and individual cells are rather large compared with the other Corynebacterium species. The bacterium is named after the stripes often observed during gram staining.

Susceptibility testing for Corynebacterium species is still a controversial issue for which there are no clear recommenda­tions or guidelines [13, 17, 18]. We used the criteria for Strepto­coccus for interpreting susceptibility to penicillin, because in a previous study [13] we found that to avoid major errors these criteria are more appropriate than those for Listeria (the only gram-positive rod for which susceptibility criteria are avail­able).

Our patient was successfully treated with vancomycin, but this antibiotic penetrates the CSF poorly when there is no inflammation. However, vancomycin can reach an acceptable level when there is inflammation of the meninges. There are some controversial data regarding inflammation and diffusion of vancomycin in the CSF. Some investigators [19] found that 18% of the initial dose could penetrate the CSF in cases of meningitis, while other investigators found an unacceptably high level of therapeutic failure in cases of meningitis due to penicillin-resistant pneumococci [20]. G1ycopeptides (vanco­mycin or teicop1anin) were prescribed in most of the cases, but therapeutic success was also achieved with ampicillin. MICs of penicillin for C. striatum often range from 0.25 to 1 mg/L, whereas all strains are susceptible to vancomycin [13, 17].

C. striatum is being increasingly described as a pathogenic Corynebacterium species, and its presence in clinical speci­mens should not always be overlooked, especially in samples from patients with underlying medical conditions. Moreover, until definitive results of susceptibility testing are available, vancomycin is the recommended treatment for severe infec­tions due to Corynebacterium species [17, 18].

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