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An unusual case of Corynebacterium striatum endocarditis and a review of the literature

2008; Elsevier BV; Volume: 12; Issue: 6 Linguagem: Inglês

10.1016/j.ijid.2007.12.010

1878-3511

Yaqoob Bhat, Abhijit M. Bal, Stuart Rochow, Ian M. Gould,

Bacterial Identification and Susceptibility Testing

An 83-year-old man was admitted with a 3-day history of fever and joint pain (mostly knee and shoulder). Over the previous three weeks he had been treated in the community with ciprofloxacin for a presumed recurrent urinary tract infection. He was known to have metastatic prostate cancer and had developed secondary hyperfibrinolysis syndrome with an intracerebral bleed from which he had made a good recovery. On examination, he was afebrile. His pulse rate was 85 per minute and his blood pressure was 98/60 mmHg. An ejection systolic murmur was heard. His knees and shoulders were tender and hot to the touch. Respiratory and abdominal examinations were normal. Neurological examination revealed increased tone in the muscles. Polymyalgia rheumatica, polyarthritis, rheumatoid arthritis, and metastatic effects of prostate cancer were considered in the differential diagnosis. Laboratory studies revealed elevated urea and creatinine (12.5 mmol/l and 148 μmol/l, respectively), high alkaline phosphatase (351 U/l), and a markedly elevated C-reactive protein (CRP) (565 mg/l). He had a mild leukocytosis (11.4 × 109/l) and a raised erythrocyte sedimentation rate (74 mm/h). Tests for rheumatoid factor and anti-neutrophil cytoplasmic antibody were negative. A chest roentgenogram showed clear lung fields, but extensive bony sclerosis was noted consistent with bony metastases. Four separate sets of blood cultures taken at different times grew Corynebacterium striatum. In the absence of definitive laboratory guidelines for determining the antibiotic susceptibility of diphtheroids, we established the minimum inhibitory concentrations (MIC) for penicillin, gentamicin, and vancomycin. These values were 1.5 mg/l, 0.032 mg/l, and 0.5 mg/l, respectively. A transthoracic echocardiogram revealed a mobile oscillating mass at the tip of the mitral valve leaflet. A diagnosis of infective endocarditis (IE) was made and therapy with vancomycin and rifampin was instituted. As the patient showed no signs of improvement despite 5 days of treatment, therapy was switched to intravenous benzyl penicillin in combination with gentamicin in doses prescribed for IE. Combination therapy was used because the MIC of penicillin was considered to be on the higher side. Penicillin and gentamicin combination is known to be synergistic in the treatment of diphtheroid endocarditis irrespective of the MIC of penicillin provided the strains are gentamicin-susceptible.1Murray B.E. Karchmer A.W. Moellering Jr., R.C. Diphtheroid prosthetic valve endocarditis. A study of clinical features and infecting organisms.Am J Med. 1980; 69: 838-848Abstract Full Text PDF PubMed Scopus (71) Google Scholar However, the patient remained febrile on this combination although his CRP and total leukocyte count continued to fall. An abdominal CT scan in the third week of admission was reported as normal. A repeat echocardiogram at this stage failed to show any vegetation. Six sets of blood cultures (two while on vancomycin and four on penicillin) taken on different days after the initiation of treatment did not grow any pathogens. As there was a temporal relationship between the administration of penicillin and the fever spikes, β-lactam induced fever was considered and combination therapy was discontinued following which the patient defervesced. However, since the therapy for endocarditis was thought to be incomplete at this point, treatment was switched to intravenous daptomycin 6 mg/kg once daily. The MIC of daptomycin for this strain was found to be 0.064 mg/l. He remained apyrexial and his inflammatory markers continued to improve while on daptomycin. An additional blood culture set taken 7 days after daptomycin was started did not grow any bacteria. Daptomycin was given for a total of 17 days following which the patient was discharged. Although he appeared to recover from endocarditis based on his clinical status, repeat echocardiogram findings, and negative microbiology, he died of myocardial infarction 2 weeks following discharge. Emboli to the coronary arteries can complicate the course of IE but this is unlikely to have complicated the present case because of the long interval between the repeat negative echocardiogram and the occurrence of myocardial infarction. A literature search in Medline revealed only 15 reports of C. striatum endocarditis (Table 1).2Stoddart B. Sandoe J.A. Denton M. Corynebacterium striatum endocarditis masquerading as connective tissue disorders.Rheumatology (Oxford). 2005; 44: 557-558Crossref PubMed Scopus (12) Google Scholar, 3Shah M. Murillo J.L. Successful treatment of Corynebacterium striatum endocarditis with daptomycin plus rifampin.Ann Pharmacother. 2005; 39: 1741-1744Crossref PubMed Scopus (37) Google Scholar, 4Markowitz S.M. Coudron P.E. Native valve endocarditis caused by an organism resembling Corynebacterium striatum.J Clin Microbiol. 1990; 28: 8-10PubMed Google Scholar, 5Rufael D.W. Cohn S.E. Native valve endocarditis due to Corynebacterium striatum: case report and review.Clin Infect Dis. 1994; 19: 1054-1061Crossref PubMed Scopus (62) Google Scholar, 6Melero-Bascones M. Munoz P. Rodriguez-Creixems M. Bouza E. Corynebacterium striatum: an undescribed agent of pacemaker-related endocarditis.Clin Infect Dis. 1996; 22: 576-577Crossref PubMed Scopus (33) Google Scholar, 7Tattevin P. Cremieux A.C. Muller-Serieys C. Carbon C. Native valve endocarditis due to Corynebacterium striatum: first reported case of medical treatment alone.Clin Infect Dis. 1996; 23: 1330-1331Crossref PubMed Scopus (23) Google Scholar, 8Juurlink D.N. Borczyk A. Simor A.E. Native valve endocarditis due to Corynebacterium striatum.Eur J Clin Microbiol Infect Dis. 1996; 15: 963-965Crossref PubMed Scopus (17) Google Scholar, 9de Arriba J.J. Blanch J.J. Mateos F. Martinez-Alfaro E. Solera J. Corynebacterium striatum first reported case of prosthetic valve endocarditis.J Infect. 2002; 44: 193Abstract Full Text PDF PubMed Scopus (25) Google Scholar, 10Houghton T. Kaye G.C. Meigh R.E. An unusual case of infective endocarditis.Postgrad Med J. 2002; 78: 290-291Crossref PubMed Scopus (23) Google Scholar, 11Kocazeybek B. Ozder A. Kucukoglu S. Kucukates E. Yuksel H. Olga R. Report of a case with polymicrobial endocarditis related to multiresistant strains.Chemotherapy. 2002; 48: 316-319Crossref PubMed Scopus (18) Google Scholar, 12Mashavi M. Soifer E. Harpaz D. Beigel Y. First report of prosthetic mitral valve endocarditis due to Corynebacterium striatum: successful medical treatment. Case report and literature review.J Infect. 2006; 52: e139-e141Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 13Tibrewala A.V. Woods C.J. Pyrgos V.J. Ruiz M.E. Native valve endocarditis caused by C. striatum.Scand J Infect Dis. 2006; 38: 805-807Crossref PubMed Scopus (6) Google Scholar, 14Elshibly S. Xu J. Millar B.C. Armstrong C. Moore J.E. Molecular diagnosis of native mitral valve endocarditis due to Corynebacterium striatum.Br J Biomed Sci. 2006; 63: 181-184PubMed Google Scholar, 15Belmares J. Detterline S. Pak J.B. Parada J.P. Corynebacterium endocarditis species-specific risk factors and outcomes.BMC Infect Dis. 2007; 7: 4Crossref PubMed Scopus (82) Google Scholar In our patient, multiple joint pain coupled with a history of prostate cancer pointed towards a primary rheumatologic condition or the effects of metastasis of the primary carcinoma. Prostate cancer is prone to metastasize in long bones. Repeated isolation of C. striatum in blood cultures and the subsequent echocardiogram finding clinched the diagnosis of IE.Table 1Summarizing previously reported cases of Corynebacterium striatum endocarditisReferenceAgeSexAssociated illnessValveInterventionOutcome4Markowitz S.M. Coudron P.E. Native valve endocarditis caused by an organism resembling Corynebacterium striatum.J Clin Microbiol. 1990; 28: 8-10PubMed Google Scholar76MNoneAorticMedicalDied5Rufael D.W. Cohn S.E. Native valve endocarditis due to Corynebacterium striatum: case report and review.Clin Infect Dis. 1994; 19: 1054-1061Crossref PubMed Scopus (62) Google Scholar54MHypertensionAorticMedical and surgicalSurvived6Melero-Bascones M. Munoz P. Rodriguez-Creixems M. Bouza E. Corynebacterium striatum: an undescribed agent of pacemaker-related endocarditis.Clin Infect Dis. 1996; 22: 576-577Crossref PubMed Scopus (33) Google Scholar73MPacemakerTricuspidMedical and surgicalSurvived7Tattevin P. Cremieux A.C. Muller-Serieys C. Carbon C. Native valve endocarditis due to Corynebacterium striatum: first reported case of medical treatment alone.Clin Infect Dis. 1996; 23: 1330-1331Crossref PubMed Scopus (23) Google Scholar24MVentricular shuntPulmonaryMedicalSurvived8Juurlink D.N. Borczyk A. Simor A.E. Native valve endocarditis due to Corynebacterium striatum.Eur J Clin Microbiol Infect Dis. 1996; 15: 963-965Crossref PubMed Scopus (17) Google Scholar68MHypertensionMitralMedicalSurvived9de Arriba J.J. Blanch J.J. Mateos F. Martinez-Alfaro E. Solera J. Corynebacterium striatum first reported case of prosthetic valve endocarditis.J Infect. 2002; 44: 193Abstract Full Text PDF PubMed Scopus (25) Google Scholar72FProsthetic valveAorticMedicalDied10Houghton T. Kaye G.C. Meigh R.E. An unusual case of infective endocarditis.Postgrad Med J. 2002; 78: 290-291Crossref PubMed Scopus (23) Google Scholar62FProsthetic valveAorticMedicalSurvived11Kocazeybek B. Ozder A. Kucukoglu S. Kucukates E. Yuksel H. Olga R. Report of a case with polymicrobial endocarditis related to multiresistant strains.Chemotherapy. 2002; 48: 316-319Crossref PubMed Scopus (18) Google Scholar50MMycotic aneurysmAorticMedical and surgicalSurvived2Stoddart B. Sandoe J.A. Denton M. Corynebacterium striatum endocarditis masquerading as connective tissue disorders.Rheumatology (Oxford). 2005; 44: 557-558Crossref PubMed Scopus (12) Google Scholar61FRheumatic feverMitralMedicalSurvived2Stoddart B. Sandoe J.A. Denton M. Corynebacterium striatum endocarditis masquerading as connective tissue disorders.Rheumatology (Oxford). 2005; 44: 557-558Crossref PubMed Scopus (12) Google Scholar72FProsthetic valveMitralMedicalSurvived3Shah M. Murillo J.L. Successful treatment of Corynebacterium striatum endocarditis with daptomycin plus rifampin.Ann Pharmacother. 2005; 39: 1741-1744Crossref PubMed Scopus (37) Google Scholar46FHemodialysisTricuspidMedicalSurvived12Mashavi M. Soifer E. Harpaz D. Beigel Y. First report of prosthetic mitral valve endocarditis due to Corynebacterium striatum: successful medical treatment. Case report and literature review.J Infect. 2006; 52: e139-e141Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar68MProsthetic valveMitralMedicalSurvived13Tibrewala A.V. Woods C.J. Pyrgos V.J. Ruiz M.E. Native valve endocarditis caused by C. striatum.Scand J Infect Dis. 2006; 38: 805-807Crossref PubMed Scopus (6) Google Scholar69FEndometrial cancerMitralMedical and surgicalSurvived14Elshibly S. Xu J. Millar B.C. Armstrong C. Moore J.E. Molecular diagnosis of native mitral valve endocarditis due to Corynebacterium striatum.Br J Biomed Sci. 2006; 63: 181-184PubMed Google Scholar77FNoneMitralMedicalSurvived15Belmares J. Detterline S. Pak J.B. Parada J.P. Corynebacterium endocarditis species-specific risk factors and outcomes.BMC Infect Dis. 2007; 7: 4Crossref PubMed Scopus (82) Google Scholar62MHypertensionAorticMedical and surgicalSurvived Open table in a new tab IE is associated with immune complexes. Deposition of the antigen–antibody complexes can give rise to joint manifestations or vasculitis. Stoddart and colleagues reported two cases of endocarditis due to C. striatum that presented with symptoms suggestive of vasculitis and systemic sclerosis.2Stoddart B. Sandoe J.A. Denton M. Corynebacterium striatum endocarditis masquerading as connective tissue disorders.Rheumatology (Oxford). 2005; 44: 557-558Crossref PubMed Scopus (12) Google Scholar It is possible that because diphtheroids are often dismissed as contaminants even when isolated from sterile sites, the diagnosis is delayed, thereby allowing a full-blown immunological process to manifest in the absence of antibiotic treatment. By reducing the number of organisms, antibiotics cause a fall in the number of immune complexes.16Bayer A.S. Theofilopoulos A.N. Dixon F.J. Guze L.B. Circulating immune complexes in experimental streptococcal endocarditis: a monitor of therapeutic efficacy.J Infect Dis. 1979; 139: 1-8Crossref PubMed Scopus (15) Google Scholar Early and specific intervention in IE due to more common causes may often prevent the onset of severe immunologic manifestations. Penicillin and vancomycin have been used for the treatment of diphtheroid endocarditis, but neither was found to be suitable in our patient. Daptomycin is a rapidly bactericidal lipopeptide antibiotic that is currently licensed in the UK for severe skin and soft tissue infections and has recently been licensed in the USA for endocarditis. A recent study found daptomycin to be useful for right-sided IE caused by Staphylococcus aureus.17Fowler Jr., V.G. Boucher H.W. Corey G.R. Abrutyn E. Karchmer A.W. Rupp M.E. et al.Daptomycin versus standard therapy for bacteremia and endocarditis caused by Staphylococcus aureus.N Engl J Med. 2006; 355: 653-665Crossref PubMed Scopus (1243) Google Scholar Its long half-life allows once-daily administration. The combination of daptomycin and rifampin has been used in one previously reported case of C. striatum endocarditis.3Shah M. Murillo J.L. Successful treatment of Corynebacterium striatum endocarditis with daptomycin plus rifampin.Ann Pharmacother. 2005; 39: 1741-1744Crossref PubMed Scopus (37) Google Scholar Our patient seemed to respond to daptomycin monotherapy and completed a total course of 5 weeks of treatment that included vancomycin, penicillin, and daptomycin. In summary, patients presenting with features suggestive of a rheumatologic condition should be thoroughly reviewed before blood culture isolates are dismissed as contaminants. In recalcitrant cases of diphtheroid endocarditis, daptomycin may be a useful alternative for patients who fail to respond to standard therapy. There is also an urgent need to establish antibiotic susceptibility guidelines for diphtheroids that would help infectious diseases specialists to choose the most appropriate antibiotics. This paper was presented in part at the Scottish Microbiology Association meeting, Dunblane, November 11, 2006. Conflict of interest: No conflict of interest to declare.