Kayoko Sugita

Fungemia due to Rhodotorula mucilaginosa after allogeneic hematopoietic stem cell transplantation

T. Mori, Y. Nakamura, J. Kato, K. Sugita, M. Murata, K. Kamei, S. Okamoto. Fungemia due to Rhodotorula mucilaginosa after allogeneic hematopoietic stem cell transplantation.
Transpl Infect Dis 2011. All rights reserved

Leuconostoc septicemia in a neutropenic patient with acute myelogenous leukemia relapsed after allogeneic peripheral blood stem cell transplantation

To the Editor Leuconostoc species are not part of the usual human £ora, and are commonly found in dairy products, legumes and vegetables, wine, and pickling products, and more rarely in human vaginal and stool samples (1^3). Infection such as septicemia due to Leuconostoc species has been infrequently reported even in immunocompromised hosts (4^7). We report a patient with acute myelogenous leukemia (AML) who developed Leuconostoc septicemia after allogeneic peripheral blood stem cell transplantation (PBSCT). A 34 -year-oldwomanwith AMLunderwent PBSCTfrom her human leukocyte antigen (HLA) 2 loci-mismatched mother for the graft rejection of her ¢rst cord blood transplantation. Although the neutrophil engraftment was achieved on day 15 after transplant, her leukemia relapsed concurrently with the development of graft-versus-host disease (GVHD). Low-dose intravenous cytarabine for relapsed AML and high-dose glucocorticoid for GVHD were initiated. Although gastrointestinal problems often seenwith GVHDwere not observed, she had been managed with intravenous nutrient using a central venous catheter. After she had been treated with teicoplanin intermittently for about 4 months because of frequent febrile neutropenia without documentation of any speci¢c pathogens, she developed a high-grade fever in the complete absence of neutrophils. Blood culture yielded gram-positive cocci, and teicoplanin was immediately restarted. However, the isolate was identi¢ed as a Leuconostoc species, which was determined to be resistant to teicoplanin and vancomycin with minimum inhibitory concentration (MIC) above 256 mg/mL by E-test. The MICs of other agents for the isolate were 1.0 mg/mL for penicillin G, 2 mg/mL for ampicillin, 8 mg/mL for imipenem, 0.5 mg/mL for gentamicin, 4 mg/mL for levo£oxacin, and 4 mg/mL for linezolid. Ampicillin in combination with gentamicin was initiated, based on the results of susceptibility tests. After this combination therapy was initiated, the pathogenwas no longer isolated from the blood. The patient later died due to pulmonary fungal infection, and autopsy was not performed. Leuconostoc species are gram-positive facultative, anaerobic cocci that grow in pairs and chains, and can thus be morphologically mistaken for streptococci (1^3). Only a few reviews on infection due to Leuconostoc species have been published since its ¢rst identi¢cation as a causative pathogen in 1985 (1, 2, 8). The most prominent feature of Leuconostoc species is their natural resistance to glycopepr 2009 Wiley Periodicals, Inc.

High rate of inducible clindamycin resistance in Staphylococcus aureus isolates – A multicenter study in Tokyo, Japan

The resistance of Staphylococcus aureus (S. aureus) to antibiotics is an increasing problem. Clindamycin has been used as empiric therapy for the rising incidence of community-acquired methicillin-resistant S. aureus (MRSA). As such, the local rate of inducible resistance against clindamycin is an important consideration. This multicenter study was conducted to identify the incidence of inducible clindamycin resistance of S. aureus isolates in Tokyo, the most populous city in Japan. A total of 2408 adult and pediatric samples were collected from a university hospital and two pediatric hospitals between January 2011 and December 2011. Among the 2341 samples analyzed, the incidence of inducible clindamycin resistance in erythromycin-resistant and clindamycin-susceptible/intermediate isolates was found to be 91% (n = 585), a figure much higher compared to most reports from other countries. In conclusion, we found a very high rate of inducible clindamycin resistance in macrolide-resistant S. aureus isolates in our geographic area.

Disseminated mycobacterium marinum infection with a destructive nasal lesion mimicking extranodal NK/T cell lymphoma: A case report

AbstractMycobacterium marinum is a ubiquitous waterborne organism that mainly causes skin infection in immunocompetent patients, and its disseminated infection is rare. Extranodal NK/T cell lymphoma, nasal type (ENKL) usually localizes at the nasal and/or paranasal area, but occasionally disseminates into the skin/soft tissue and gastrointestinal tract. Compromised immunity is a risk factor for developing nontuberculous mycobacterial (NTM) infection and malignant lymphoma, and the 2 diseases may share similar clinical presentation; however, only a few reports have described NTM infection mimicking malignant lymphoma.A 43-year-old Japanese man presented to our hospital complaining of multiple progressive skin nodules and purulent nasal discharge for 3 weeks. He was diagnosed with Crohn disease with refractory enteropathic arthritis and has been treated with anti-tumor necrosis factor alpha agents for 25 years. Fiberoptic nasal examination revealed septal perforation with hemorrhagic mucus and purulent rhinorrhea. Histological examination of the nasal septum revealed the infiltration of atypical medium-to-large-sized cells with erosion. The cells were positive for cytoplasmic CD3, granzyme B, and Epstein–Barr virus-encoded small RNA. Histological examination of the skin nodules and auricle also showed infiltration of atypical lymphocytes. The patient was tentatively diagnosed with ENKL, and chemotherapy was considered. However, the skin lesions decreased in size after discontinuation of immunosuppressive agents and minocycline administration. Two weeks later, nasal septum and lavage fluid and left leg skin cultures were positive for M marinum, and minocycline was discontinued. The skin and the nasal lesions improved after 2 months.To the best of our knowledge, this is the first case of disseminated M marinum infection with a destructive nasal lesion mimicking ENKL. The differentiation between M marinum infection and ENKL is clinically important because misdirected treatment leads to a poor prognosis. NTM infections including M marinum should be considered in differential diagnosis of ENKL. Bacterial cultures, pathological analysis, and close monitoring are required for the differentiation of ENKL and disseminated M marinum infection; both are serious diseases and early diagnostic distinction between them and immediate appropriate treatment will improve the patients prognosis.

Central line-associated bacteremia caused by Rhizobium radiobacter after allogeneic bone marrow transplantation.

To the Editor The genus Rhizobium (formerlyAgrobacterium) is well recognized by plant microbiologists as a phytopathogenic pathogen, and human diseases associated with this pathogen have been considered uncommon (1). However, Rhizobium radiobacter has become recognized as one of the rare organisms causing human diseases, mostly in immunocompromised patients, since the ¢rst case of prosthetic valve endocarditis due to R. radiobacter was reported (2). We experienced a case in which Hickman catheter-associated bacteremia by R. radiobacter developed after allogeneic bone marrow transplantation (BMT). A 59 -year-old man with chemotherapy-refractory adult T-cell leukemia/lymphoma (ATLL) underwent BMT from a human leukocyte antigen-matched unrelated donor. A central line (Hickman catheter) was placed through a subcutaneous tunnel 3 weeks before BMT. Neutrophil engraftment was achieved on day 15 post transplant, but ATLL relapsed around day 30 post transplant. Anti-neoplastic agents, such as vincristine, vindesine, etoposide, and carboplatin, were administered repeatedly to control the activity of ATLL. On day 93 post transplant, with no evidence of neutropenia (granulocyte 4.0 10/L), the patient developed high-grade fever, and tazobactam/piperacillin and amikacin were empirically initiated. Blood cultures obtained from both the Hickman catheter and a peripheral vein yielded a gram-negative rod that was identi¢ed as R. radiobacter. No pain, swelling, or exudates at the catheter insertion site or subcutaneous tunnel were observed. An in vitro susceptibility test revealed that the isolate was susceptible to cefepime, cefotaxime, meropenem, amikacin, cipro£oxacin, and tazobactam/piperacillin, but resistant to piperacillin, ceftazidime, and aztreonam. A commercially available kit using ce¢nase discs (Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA) showed that the isolate was positive for b-lactamase. Although the fever was relieved after tazobactam/piperacillin and amikacin were initiated, blood cultures obtained from the catheter continued to yield the pathogen, while peripheral blood ber 2009 John Wiley & Sons A/S

Helicobacter cinaedi bacteremia with cellulitis after ABO-incompatible living-donor liver transplantation: Case report

Helicobacter cinaedi (H. cinaedi), a Gram-negative spiral-shaped bacterium, is an enterohepatic non-Helicobacter pylori Helicobacter species. We report the first case of H. cinaedi bacteremia with cellulitis after liver transplantation. A 48-year-old male, who had been a dog breeder for 15 years, underwent ABO-incompatible living-donor liver transplantation for hepatitis C virus-induced decompensated cirrhosis using an anti-hepatitis B core antibody-positive graft. The patient was preoperatively administered rituximab and underwent plasma exchange twice to overcome blood type incompatibility. After discharge, he had been doing well with immunosuppression therapy comprising cyclosporine, mycophenolate mofetil, and steroid according to the ABO-incompatible protocol of our institution. However, 7 mo after transplantation, he was admitted to our hospital with a diagnosis of recurrent cellulitis on the left lower extremity, and H. cinaedi was detected by both blood culture and polymerase chain reaction analysis. Antibiotics improved his symptoms, and he was discharged at day 30 after admission. Clinicians should be more aware of H. cinaedi in immunocompromised patients, such as ABO-incompatible transplant recipients.

Central line-associated bacteremia caused by drug-resistant Staphylococcus caprae after chemotherapy for acute myelogenous leukemia

Coagulase-negative staphylococci (CNS), including Staphylococcus epidermidis (S. epidermidis), have been recognized as a cause of nosocomial infections, mostly infection at sites of indwelling devices. The species that most frequently cause infection in humans is S. epidermidis. However, other species of CNS are increasingly recognized as causative pathogens of infection. S. caprae was originally isolated from goat’s milk, and has been considered to be infrequently detected in human clinical samples. There have been only a limited number of cases of infection due to S. caprae, most of which were associated with infection at sites of indwelling devices (i.e. orthopedic prostheses) [1–3]. To the best of our knowledge, only a few cases of bacteremia due to S. caprae have been reported [4–7]. We experienced a case of central line-associated bacteremia caused by S. caprae during a neutropenic period after anti-cancer chemotherapy for acute myeloid leukemia. A 46-year-old woman with acute myeloid leukemia received combination chemotherapy consisting of cytarabine (100 mg/m for 5 days) and idarubicin (12 mg/m for 2 days) via a central line that had been placed in the right jugular vein 1 day before initiating chemotherapy. For prophylaxis against bacterial and fungal infection, oral ciprofloxacin (600 mg/day) and itraconazole (200 mg/day) were simultaneously started. Sixteen days after initiating chemotherapy, when the neutrophil count was less than 0.1 9 10/L, the patient developed a high-grade fever. Although cefepime was initiated, she remained febrile. A series of blood cultures yielded Gram-positive cocci, which were later identified as S. caprae. ID 32 STAPH system (SYSMEX bioMérieux Co, Tokyo, Japan) was used for identification. The patient had neither contact with goats nor had she visited a farm. An echocardiogram revealed no findings of endocarditis. The isolate was only susceptible to vancomycin and linezolid, and resistant to oxacillin, penicillin G, ampicillin, cefazolin, cefepime, meropenem, imipenem, amikacin, ciprofloxacin, and clarithromycin. The isolate was positive for penicillin-binding protein (PBP)-20 and b-lactamase. In spite of the intravenous administration of vancomycin, blood cultures continued to yield S. caprae. Then, the central line was removed, and blood cultures became negative. After the cessation of 2week vancomycin therapy, bacteremia did not recur, and the patient recovered without sequelae. Because of the limited number of cases of infection due to S. caprae, the clinical course of infection and microbiological characteristics, including its susceptibility to antibiotic, remain to be fully elucidated. Besides indwelling device-associated bone or joint infection, S. caprae has also been reported as a causative pathogen of bacteremia, endocarditis, urinary tract infection, meningitis, and otitis externa [7–9]. As in the present case, previously reported cases of bacteremia due to S. caprae have been associated with intravascular catheters, especially in non-neonatal patients [7]. Thus, we think that S. caprae should be recognized as an emerging pathogen of intravascular catheterrelated bacteremia as well as other species of CNS. J. Kato T. Mori (&) Y. Ono A. Yamane T. Shimizu S. Okamoto Division of Hematology, Department of Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan e-mail: tmori@sc.itc.keio.ac.jp

Sinusitis caused by Exserohilum rostratum after cord blood transplantation for myelodysplastic syndrome: A case report and literature review

Invasive fungal disease is a serious infectious complication of allogeneic hematopoietic stem cell transplantation (HSCT). Exserohilum rostratum is a species causing phaeohyphomycosis, which rarely causes invasive disease in humans. We treated a case of sinusitis caused by E. rostratum after cord blood transplantation (CBT). A 60‐year‐old man with myelodysplastic syndrome, who had a medical history of an operation to correct deviation of the nasal septum, developed sinusitis caused by E. rostratum under prolonged profound neutropenia after a second CBT because of the graft rejection of the first transplantation. Liposomal amphotericin B improved the sinusitis. A literature review revealed nine reported cases of sinusitis caused by E. rostratum, including our case. Although five cases had severe neutropenia at onset (HSCT recipients, n = 2; aplastic anemia, n = 3), the remaining four had no preexisting immunosuppressive conditions. However, three of the four patients had preexisting nasal diseases with or without a history of surgery, as in our case. Excluding our case, the outcome was fatal in five neutropenic patients, whereas the four patients without neutropenia recovered. Although sinusitis caused by E. rostratum is rare, E. rostratum should be recognized as a possible pathogen causing sinusitis in highly immunosuppressed patients such as HSCT recipients. Preexisting nasal disease and/or nasal surgery could be risks for this infection.

Bacteremia due to Rothia mucilaginosa after chemotherapy for myeloid malignancies

The number of reported cases of bacteremia due to Rothia mucilaginosa (R. mucilaginosa), a component of the normal flora of human gastrointestinal tract mucosa, is limited. We encountered three cases of bacteremia due to R. mucilaginosa during neutropenia after chemotherapy for myeloid malignancies. Although all three patients were successfully treated with antimicrobial agents, one patient developed disseminated lesions in the lungs and soft tissue. The portal of R. mucilaginosa bacteremia is reportedly mucositis or dental disorders; however, no such complications were identified in our patients. Even in the absence of a preexisting portal, R. mucilaginosa should be recognized as a potential causative pathogen of bacteremia during neutropenic periods. Accumulations of cases and isolates are required to further elucidate the risk factors for developing R. mucilaginosa bacteremia, its clinical course, and the optimal antimicrobial treatment.

The first case report of acute cholangitis and bacteremia due to Neisseria subflava

We herein report a case of acute cholangitis and bacteremia caused by a commensal Neisseria species, Neisseria subflava, in an 82-year-old man with cholangiocarcinoma. Emergency endoscopic nasobiliary drainage and cefoperazone/sulbactam therapy were effective. Gram negative coccobacilli were isolated from both blood and bile cultures on 5% sheep blood agar. The isolate was identified as N. subflava biovar perflava by mass spectrometry, a sequence analysis of the 16S rRNA, and biochemical testing. Although biliary infections due to commensal Neisseria are extremely rare, this case demonstrates the possibility of its occurrence in patients undergoing bile duct treatment.