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Lactococcus garvieae septicemia with liver abscess in an immunosuppressed patient

2000; Elsevier BV; Volume: 109; Issue: 6 Linguagem: Inglês

10.1016/s0002-9343(00)00534-9

1555-7162

Au Mofredj, Daoud Baraka, J.F. Cadranel, Patrice Lemaître, G. Kloeti, Jean Loup Dumont,

Aquaculture disease management and microbiota

Lactococcus garvieae was first isolated from cases of bovine mastitis, and it may also infect several species of fish (1Collins M.D. Farrow J.A.E. Philips B.A. Kandler O. Streptococcus garvieae sp.nov. and Streptococcus plantarum sp. nov. J Gen Microbiol. 1983; 129: 3427-3431PubMed Google Scholar, 2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar, 3Eldar A. Goria M. Ghittino C. et al.Biodiversity of Lactococcus garvieae strains isolated from fish in Europe, Asia, and Australia.Appl Environ Microbiol. 1999; 65: 1005-1008PubMed Google Scholar). Infection in humans is rare (4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar, 5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 6Elliott J.A. Collins M.D. Pigott N.E. Facklam R.R. Differentiation of Lactococcus lactis and Lactococcus garvieae from humans by comparison of whole-cell protein patterns.J Clin Microbiol. 1991; 29: 2731-2734PubMed Google Scholar).A 68-year-old woman was admitted to our intensive care unit with gastrointestinal bleeding. Two months before admission, a cholangiocarcinoma involving the intrahepatic branches of the biliary tract had been discovered. A Teflon biliary prosthesis was placed in each of the branches, and treatment with prednisone was begun. No recent history of infection or contact with fish or animals was reported.On admission, the patient had no abdominal pain, fever, or chills. Physical examination showed a cachectic, pale, and icteric woman. Her temperature was 37.1°C. Other clinical findings were normal. Laboratory studies showed a hemoglobin level of 6.6 g/dL, a hematocrit of 26%, a white blood cell count of 28,900/μL with 86.6% neutrophils, a total bilirubin level of 121 μM, an aspartate aminotransferase level of 181 IU/L, and a lactate dehydrogenase level of 694 IU/L. Gastrointestinal endoscopy revealed active bleeding in the second portion of the duodenum, which suggested hemobilia.The patient received a blood transfusion, and treatment with omeprazole was begun. A retrograde cholangiography showed obstruction of the two prostheses and an intrahepatic cavity (4 cm in diameter) that communicated with the left intrahepatic branch of the biliary tract, suggesting abscess. Three blood cultures obtained at admission grew streptococci. The prostheses were removed and treatment with amoxicillin (1 g three times daily), netilmicin (250 mg daily), and metronidazole (500 mg three times daily) was begun. The organism was identified as L. garvieae using a rapid system for identification of streptococci and related organisms (rapid ID 32 STREP; bioMérieux sa, Marcy-l’Etoile, France), which consists of 32 biochemical reactions that are read after an incubation period of 4 hours. The organism was susceptible to amoxicillin, tetracycline, erythromycin, vancomycin, and teicoplanin. The patient died on the 12th hospital day from a massive gastrointestinal hemorrhage.There have been only a few reports of human infection with lactococci (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 7Mannion P.T. Rothburn M.M. Diagnosis of bacterial endocarditis caused by Streptococcus lactis and assisted by immunoblotting of serum antibodies.J Infect. 1990; 21: 317-326Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 8Wood H.F. Jacobs K. McCarty M. Streptococcus lactis isolated from a patient with subacute bacterial endocarditis.Am J Med. 1985; 18: 345-347Abstract Full Text PDF Scopus (31) Google Scholar). However, because it is difficult for many microbiology laboratories to distinguish between lactococci and enterococci (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar), human infections may be underdiagnosed. In addition, the published biochemical and antigenic characteristics of L. garvieae do not differentiate this pathogen from L. lactis(2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar). A specific polymerase chain reaction assay or antibiotic susceptibility tests may help distinguish the two pathogens (2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar, 4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar, 5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). Indeed, L. garvieae seems to be more resistant to clindamycin than is L. lactis(2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar, 4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar).Although L. garvieae could not be cultured from the infected bile in our patient, we believe that it was the causal agent of the liver abscess, and this collection was the primary source of bacteremia.Prior reports have identified approximately 15 strains from clinical specimens, most of which were cultured from blood (4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar, 6Elliott J.A. Collins M.D. Pigott N.E. Facklam R.R. Differentiation of Lactococcus lactis and Lactococcus garvieae from humans by comparison of whole-cell protein patterns.J Clin Microbiol. 1991; 29: 2731-2734PubMed Google Scholar). In 3 cases, the pathogen involved prosthetic valves (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). The significance of the other isolates was less clear (6Elliott J.A. Collins M.D. Pigott N.E. Facklam R.R. Differentiation of Lactococcus lactis and Lactococcus garvieae from humans by comparison of whole-cell protein patterns.J Clin Microbiol. 1991; 29: 2731-2734PubMed Google Scholar). In 1998, a case of septicemia and native valve endocarditis was reported (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). As in our case, the patient was immunosuppressed, suggesting the possible invasiveness of this pathogen in these patients. Physicians should be aware of the possible severity of the disease and institute prompt antibiotic treatment, particularly in immunosuppressed patients. Lactococcus garvieae was first isolated from cases of bovine mastitis, and it may also infect several species of fish (1Collins M.D. Farrow J.A.E. Philips B.A. Kandler O. Streptococcus garvieae sp.nov. and Streptococcus plantarum sp. nov. J Gen Microbiol. 1983; 129: 3427-3431PubMed Google Scholar, 2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar, 3Eldar A. Goria M. Ghittino C. et al.Biodiversity of Lactococcus garvieae strains isolated from fish in Europe, Asia, and Australia.Appl Environ Microbiol. 1999; 65: 1005-1008PubMed Google Scholar). Infection in humans is rare (4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar, 5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 6Elliott J.A. Collins M.D. Pigott N.E. Facklam R.R. Differentiation of Lactococcus lactis and Lactococcus garvieae from humans by comparison of whole-cell protein patterns.J Clin Microbiol. 1991; 29: 2731-2734PubMed Google Scholar). A 68-year-old woman was admitted to our intensive care unit with gastrointestinal bleeding. Two months before admission, a cholangiocarcinoma involving the intrahepatic branches of the biliary tract had been discovered. A Teflon biliary prosthesis was placed in each of the branches, and treatment with prednisone was begun. No recent history of infection or contact with fish or animals was reported. On admission, the patient had no abdominal pain, fever, or chills. Physical examination showed a cachectic, pale, and icteric woman. Her temperature was 37.1°C. Other clinical findings were normal. Laboratory studies showed a hemoglobin level of 6.6 g/dL, a hematocrit of 26%, a white blood cell count of 28,900/μL with 86.6% neutrophils, a total bilirubin level of 121 μM, an aspartate aminotransferase level of 181 IU/L, and a lactate dehydrogenase level of 694 IU/L. Gastrointestinal endoscopy revealed active bleeding in the second portion of the duodenum, which suggested hemobilia. The patient received a blood transfusion, and treatment with omeprazole was begun. A retrograde cholangiography showed obstruction of the two prostheses and an intrahepatic cavity (4 cm in diameter) that communicated with the left intrahepatic branch of the biliary tract, suggesting abscess. Three blood cultures obtained at admission grew streptococci. The prostheses were removed and treatment with amoxicillin (1 g three times daily), netilmicin (250 mg daily), and metronidazole (500 mg three times daily) was begun. The organism was identified as L. garvieae using a rapid system for identification of streptococci and related organisms (rapid ID 32 STREP; bioMérieux sa, Marcy-l’Etoile, France), which consists of 32 biochemical reactions that are read after an incubation period of 4 hours. The organism was susceptible to amoxicillin, tetracycline, erythromycin, vancomycin, and teicoplanin. The patient died on the 12th hospital day from a massive gastrointestinal hemorrhage. There have been only a few reports of human infection with lactococci (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 7Mannion P.T. Rothburn M.M. Diagnosis of bacterial endocarditis caused by Streptococcus lactis and assisted by immunoblotting of serum antibodies.J Infect. 1990; 21: 317-326Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 8Wood H.F. Jacobs K. McCarty M. Streptococcus lactis isolated from a patient with subacute bacterial endocarditis.Am J Med. 1985; 18: 345-347Abstract Full Text PDF Scopus (31) Google Scholar). However, because it is difficult for many microbiology laboratories to distinguish between lactococci and enterococci (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar), human infections may be underdiagnosed. In addition, the published biochemical and antigenic characteristics of L. garvieae do not differentiate this pathogen from L. lactis(2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar). A specific polymerase chain reaction assay or antibiotic susceptibility tests may help distinguish the two pathogens (2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar, 4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar, 5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). Indeed, L. garvieae seems to be more resistant to clindamycin than is L. lactis(2Zlotkin A. Eldar A. Ghittino C. Bercovier H. Identification of Lactococcus garvieae by PCR.J Clin Microbiol. 1998; 36: 983-985PubMed Google Scholar, 4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar). Although L. garvieae could not be cultured from the infected bile in our patient, we believe that it was the causal agent of the liver abscess, and this collection was the primary source of bacteremia. Prior reports have identified approximately 15 strains from clinical specimens, most of which were cultured from blood (4Elliott J.A. Facklam R.R. Antimicrobial susceptibilities of Lactococcus lactis and Lactococcus garvieae and a proposed method to discriminate between them.J Clin Microbiol. 1996; 34: 1296-1298PubMed Google Scholar, 6Elliott J.A. Collins M.D. Pigott N.E. Facklam R.R. Differentiation of Lactococcus lactis and Lactococcus garvieae from humans by comparison of whole-cell protein patterns.J Clin Microbiol. 1991; 29: 2731-2734PubMed Google Scholar). In 3 cases, the pathogen involved prosthetic valves (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). The significance of the other isolates was less clear (6Elliott J.A. Collins M.D. Pigott N.E. Facklam R.R. Differentiation of Lactococcus lactis and Lactococcus garvieae from humans by comparison of whole-cell protein patterns.J Clin Microbiol. 1991; 29: 2731-2734PubMed Google Scholar). In 1998, a case of septicemia and native valve endocarditis was reported (5Fefer J.J. Ratzan K.R. Sharp S.E. Saiz E. Lactococcus garvieae endocarditis report of case and review of the literature.Diagn Microbiol Infect Dis. 1998; 32: 127-130Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar). As in our case, the patient was immunosuppressed, suggesting the possible invasiveness of this pathogen in these patients. Physicians should be aware of the possible severity of the disease and institute prompt antibiotic treatment, particularly in immunosuppressed patients.