Annals of Clinical & Laboratory Science 38:401-404 (2008)
© 2008 Association of Clinical Scientists
Staphylococcus gallinarum Bacteremia in a Patient with Chronic Hepatitis B Virus Infection
Daojun Yu1,
Yueming Chen1,
Yunfeng Pan2,
Haijing Li3,
Melinda A. McCormac4 and
Yi-Wei Tang3,4
1 Departments of Clinical Laboratories and 2 Internal Medicine, Hangzhou First People’s Hospital, Hangzhou, China; 3 Departments of Medicine and 4 Pathology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Address correspondence to Daojun Yu, M.D., Department of Clinical Laboratories, Hangzhou First People’s Hospital, Hangzhou, China; tel 86 571 8706 5701; fax 86 571 8791 4773; e-mail yudaojun98{at}163.com; and Yi-Wei Tang, M.D., Ph.D., Molecular Infectious Disease Laboratory, Vanderbilt University Hospital, 4605 TVC, Nashville, TN 37232-5310, USA; tel 615 322 2035; fax 615 343 8420; e-mail yiwei.tang{at}vanderbilt.edu.
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Abstract
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An unusual staphylococcal isolate was recovered from blood cultures in a patient with chronic hepatitis B virus infection, who presented with low grade fever accompanied by increased upper abdominal pain, nausea and weakness. The isolate was identified as Staphylococcus gallinarum based on biochemical characteristics and 16S rRNA gene sequence analyses.
Keywords: Staphylococcus gallinarum, bacteremia, 16S rRNA
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Case Report
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A 51-yr-old woman with chronic hepatitis B virus (HBV) infection presented with low-grade fever, increased upper abdominal pain, nausea, and weakness. The patient is a retired textile worker with a 10-yr history of hepatitis B, who often had contact with living domestic birds in the market. She had a laparoscopic gallbladder resection 4 mo previously and had fully recovered, with no pain, fever, chills, shortness of breath, or chest tightness until this visit.
Her body temperature was 38.1°C; pulse, 92/ min; respirations, 22/min; and blood pressure, 122/91 mmHg. She had neither chills, vomiting, shortness of breath, nor diarrhea. Her abdominal pain was paroxysmal, but not intense. Her serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma glutamyl transpeptidase (GGT) activities were 558, 299, and 287 U/L, respectively. The HBV plasma viral load was 2.35x103/ml (DaAn Gene Co, Guangzhou, China). Two blood samples were drawn from 2 separate venipuncture sites for culture (aerobic bottles only) on a BacT/Alert 60/120 blood culture system (bioMerieux, Marcy-l’Etoile, France) prior to antibiotic administration. The patient was hospitalized and treated po with ceftazidime (3 g, twice daily), isepamicin (200 mg/day), diammonium glycyrrhizinate (150 mg/day), and ginkgo leaf extract (25 ml, twice daily). Additional blood samples for culture were drawn 24 and 48 hr after admission.
A coagulase-negative Staphylococcus (CoNS) was isolated from the first 2 blood culture bottles and the subsequent 2 bottles were negative. The patient became afebrile (36.3–36.9°C) at 18 hr after hospitalization, and ceftazidime and isepamicin were discontinued 3 days later. The patient’s liver function tests improved after 10 days (ALT, 18; AST, 20; and GGT, 121 U/L) and her HBV viral load diminished to <1,000 copies/ml. Diammonium glycyrrhizinate and ginkgo leaf extract were discontinued on the tenth hospitalization day, when her abdominal pain had disappeared and the patient was discharged from the hospital without any medications.
The CoNS isolate was further identified with 2 prototype strains (S. aureus, ATCC 25922 and S. gallinarum, ATCC 35539) included as controls. The isolate on sheep blood agar after 12 hr incubation presented dull white, dry, large, flat colonies with ragged edges; the colonies turned yellow upon further incubation (Fig. 1
). Biochemical characteristics were determined by manual methods and with API STAPH (bioMerieux Vitek) and VITEK 60/VITEK-II (bioMerieux Vitek) automated analysis systems, according to the manufacturer’s instructions [1,2]. Both isolates had identical biochemical reactions and antimicrobial susceptibility profiles; they were gram-positive cocci, non-hemolytic, spot coagulase positive, tube coagulase negative, catalase positive, and oxidase negative. They were not identified by the VITEK 60 and API STAPH systems, but were identified as Staphylococcus gallinarum by the VITEK-II. In vitro antimicrobial susceptibility testing for a panel of antibiotics was determined by a disc diffusion method in accordance with a Clinical and Laboratory Standards Institute (CLSI) standard for CoNS [3]. The two isolates were resistant to penicillin and oxacillin, intermediate to rifampin, and sensitive to amoxicillin-clavulanate, cefazolin, clindamycin, erythromycin, gentamicin, levofloxacin, minocycline, trimethoprim/sulfamethoxazole, and vancomycin.
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Fig. 1. Colony morphology on sheep blood agar plate. The isolate presented dull white, dry, large, flat colonies with ragged edges after 12 hr incubation (right top panel) and became light yellow after 20 hr incubation (left panel) and dark yellow-pigmented after 44 hr incubation (right bottom panel).
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Nucleic acids were extracted from a pure colony by a heat and lysis method [4]. Partial nucleic acid sequences of bacterial 16S rRNA gene were determined as previously described [5]. The first 500 base-pair 16S rRNA gene sequences were identical to previously published S. gallinarum sequences (GenBank accession number AY688059
[GenBank]
) [6] (Fig. 2). Primers were designed to amplify five S. aureus genes related to virulence (ie, coagulase, enterotoxin, leukocidin, staphylokinase and lipase), and the isolate was negative for all 5 genes. On the basis of the biochemical reactions and 16S rRNA gene sequence analyses, the new isolate was identified as Staphylococcus gallinarum.
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Fig. 2. Neighbor-joining analysis of nucleic acid sequences of 16S rRNA gene from the unusual isolate with homology to previously published gene sequences of related Staphylococcus species. Phylogenetic analysis was mainly based on partial 16S rRNA gene sequences [6]. S. auricularis (AY688030
[GenBank]
), S. aureus (AY688032
[GenBank]
), S. capitis (AY688037
[GenBank]
), S. carnosus (AY688041
[GenBank]
), S. cohnii (AY688045
[GenBank]
), S. condimenti (AY688048
[GenBank]
), S. epidermidis (AY688051
[GenBank]
), S. equorum (AY688054
[GenBank]
), S. gallinarum (AY688059
[GenBank]
), S. haemolyticus (AY688060
[GenBank]
), S. hominis (AY688063
[GenBank]
), S. intermedius (AY688067
[GenBank]
), S. kloosii (AY688071
[GenBank]
), S. lugdunensis (AY688074
[GenBank]
), S. nepalensis (AY688080
[GenBank]
), S. pettenkoferi (AY688083
[GenBank]
), S. saprophyticus (AY688089
[GenBank]
), S. schleiferi (AY688091
[GenBank]
), S. sciuri (AY688095
[GenBank]
), S. simulans (AY688099
[GenBank]
), S. succinus (AY688102
[GenBank]
), S. warneri (AY688105
[GenBank]
), and S. xylosus (AY688107
[GenBank]
), respectively. The scale indicates relative phylogenetic distance
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Discussion
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Staphylococcus species are commonly isolated from blood cultures. Coagulase-negative Staphylococci (CoNS) such as S. epidermidis are common members of the normal flora of skin and recognized as frequent contaminants in blood cultures. However, the incidence of infections caused by CoNS has increased throughout the world. Staphylococcus lugdunensis has emerged as an important pathogen since its initial description in 1988 [7]. Clinical manifestations of infections with these organisms include abscesses, meningitis, ventriculoperitoneal shunt infection, spondylodiscitis, prosthetic joint infection, catheter-related bacteremia, and endocarditis [8,9]. Some other CoNS species have been identified as important pathogens causing diseases in humans and animals [10–16]. We report a case of bloodstream infection caused by Staphylococcus gallinarum in a patient with chronic hepatitis B virus infection.
S. gallinarum was first described in 1983 [17] as a coagulase-negative Staphylococcus that was isolated initially from domestic birds and subsequently isolated from skin and respiratory tract of animals such as goat, sheep, camel, pig, and cattle [10]. The infection rate and morbidity of S. gallinarum is comparatively low and its effects on humans are limited [10,11,13]. There was one report that S. gallinarum was isolated from the wound site of a patient in Nigeria [12]. We believe ours to be the first description of S. gallinarum blood isolate from a human. Our patient is a retired textile worker who is often in contact with living domestic birds in the market, where she may have been exposed and infected by S. gallinarum through skin direct contact. Although five Staphylococcus virulence-related genes were not detected in our isolate, the clinical relevance and portal of entry of S. gallinarum merit further investigation.
We determined biochemical characteristics and 16S rRNA gene sequences of the human blood isolate of S. gallinarum. The GenBank accession number for the partial 16S rRNA gene of this isolate is EU046490. The API STAPH and VITEK 60 automated microbiology analytical systems failed to identify this isolate, but the VITEK-II system provided correct identification.
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Acknowledgements
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The authors thank Shao-Yong Yu for technical assistance and San-Hua Fang and Charles Stratton, who critically reviewed the manuscript.
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Abstract
Case Report
