J. Clin. Microbiol.-2008-Lagacé-Wiens-804-6

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Published Ahead of Print 5 December 2007.10.1128/JCM.01545-07.

2008, 46(2):804. DOI:J. Clin. Microbiol.Tamara Burdz, Deborah Wiebe and Kathryn BernardPhilippe R. S. Lagac-Wiens, Betty Ng, Aleisha Reimer,

Characterization of the IsolatePreviously Healthy Man: Case Report and

Bacteremia in aGardnerella vaginalis

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JOURNAL OF CLINICAL MICROBIOLOGY , Feb. 2008, p. 804806 Vol. 46, No. 20095-1137/08/$08.00 0 doi:10.1128/JCM.01545-07Copyright 2008, American Society for Microbiology. All Rights Reserved.

CASE REPORTS

Gardnerella vaginalis Bacteremia in a Previously Healthy Man: CaseReport and Characterization of the IsolatePhilippe R. S. Lagace-Wiens, 1 Betty Ng,2 Aleisha Reimer, 2 Tamara Burdz, 2

Deborah Wiebe, 2 and Kathryn Bernard 1,2 * Department of Medical Microbiology and Infectious Diseases, Faculty of Medicine, University of Manitoba, Winnipeg, Canada, 1 and

Department of Special Bacteriology, Division of Emerging Pathogens, National Microbiology Laboratory, Winnipeg, Canada 2

Received 2 August 2007/Returned for modication 30 September 2007/Accepted 16 November 2007

Gardnerella vaginalis in women causes vaginitis or infections in other sites, such as the urinary tract, but isan infrequent cause of bacteremia. Bacteremia in men is very rare and is typically associated with immuno-compromised states. Here we describe G. vaginalis bacteremia in a previously healthy man with renal calculiand urosepsis.

CASE REPORT

A 41-year-old male roofer with no prior medical problemspresented with sudden onset of left ank pain. The pain wascolicky in nature and not accompanied by fever, chills, urgency,or dysuria. A physical examination at the time of presentation was unremarkable. A computed tomography scan of the abdo-men revealed a 6.5-mm kidney stone in the midpole of thekidney and a 3-mm calculus at the left vesicoureteric junction.Obstructive uropathy and perinephric stranding were noted.Urine biochemistry revealed slight hemoglobinuria. The pa-

tient underwent ureteroscopy the following day, and as noinfection was thought to be present, no antibiotics were given.The distal ureteric calculus was not seen and was assumed tohave passed spontaneously. Follow-up imaging demonstratedonly the larger proximal stone. The patient was dischargedfrom the hospital, but he returned 2 days later with worse ankpain. The computed tomography scan was repeated, and itdemonstrated a 4-mm stone in the proximal left ureter, withsmall fragments remaining in the midpole of the kidney. Ad-ditional investigations revealed a leukocyte count of 16.0 109

cells/liter (normal range, 4 109 to 11 109 cells/liter) with apredominance of neutrophils (absolute count, 12.6 109 cells/ liter; normal count, 2 109 to 5 109 cells/liter). Creatinine was elevated at 148 mol/liter (normal range, 70 to 110 mol/ liter). The patient was readmitted for a repeat ureteroscopy.Prior to this procedure, the patient was febrile, with a temper-ature of 39.1C and rigors. He appeared well otherwise, and hisphysical examination, including blood pressure, was unremark-able. Ciprooxacin (400 mg intravenously every 12 h) wasempirically started for presumed urosepsis. The patients com-plete blood count was normal, and cultures of urine and blood

(two sets, with 20 ml from one site for anaerobe and aerobiccultures and 10 ml from a second site for an aerobic bottle) were taken prior to initiation of antimicrobial therapy. Thequantitative urine culture revealed 6.5 107 CFU/liter of aciprooxacin-sensitive strain of Escherichia coli . On the fthday of incubation, the aerobic blood culture from the rst set was agged positive by the automated BacT/Alert system. A subculture of the second blood culture set revealed the sameorganism. The hospital laboratory was unable to achieve adenitive identication of the blood culture isolate, so theisolate was sent to a reference center.

The patient underwent a repeat ureteroscopy with litho-tripsy and an extraction of the proximal stone. A ureteric stent was inserted, and it was removed the following week. Thepatient was treated with a 10-day course of oral ciprooxacinand had no recurrences or sequelae.

An initial Gram stain of the blood culture revealed pleo-morphic, gram-negative coccobacilli. The blood culture isolate was plated on in-house-prepared 5% sheep blood agar (baseagar from Oxoid Ltd., Ottawa, Ontario, Canada; sheep bloodfrom Quad Five, Ryegate, MT) and chocolate agar (Oxoid) in5% CO 2 -MacConkey agar (Oxoid) for aerobic incubation, andbrucella agar with vitamin K (Oxoid) for anaerobic incubation. After 48 h of incubation, small gray colonies were observed onthe chocolate agar, with poor growth of gray, nonhemolyticcolonies found on the sheep blood agar. Gram staining revealed similar gram-negative coccobacilli. Catalase and rapidoxidase tests were negative, so the isolate was referred to theCanadian National Microbiology Laboratory (NML) as a sus-pected isolate of Francisella tularensis . Rapid molecular testingindicated that the isolate was not F. tularensis , and furthertesting was undertaken, with the strain being assigned NML Special Bacteriology identier no. 060420. A repeat Gramstaining suggested that the organism was gram-positive orgram-variable short rods. The colonies were pinpoint (after 2days) to small ( 1 mm) and translucent (after 4 days), with nohemolysis observed after growth on 5% sheep blood agar. The

* Corresponding author. Mailing address: National Microbiology Lab-oratory, 1015 Arlington Street, Winnipeg, Manitoba R3E 3R2, Canada.Phone: (204) 789-2135. Fax: (204) 784-7509. E-mail: [email protected].

Published ahead of print on 5 December 2007.

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isolate did have a narrow zone of beta-hemolysis after 4 dayson vaginalis agar, which contains human red blood cells (PML Microbiologicals, Mississauga, Ontario, Canada). The isolategrew well at 37C in 5% CO2 under strictly anaerobic condi-tions, but no growth was observed in air at 25C, 37C, or 42C.Biochemical testing using carbohydrate (CHO) tube sugars,metabolic products of fermentation, cellular fatty acid (CFA)composition analysis, and 16S rRNA gene sequencing was per-formed as previously described (3, 4). Acid was observed inCHO sugars containing galactose, glucose, glycogen, maltose,sucrose, and xylose. The strain produced lipase and was neg-ative for fermentation of fructose, glycerol, lactose, mannitol,mannose, rafnose, ribose, salicin, and trehalose. Tests for theutilization or hydrolysis of citrate, esculin, and urea, nitratereduction, the presence of indole, staining with methyl red, andgelatin and lecithinase production, as well as the Voges-Proskauer test, were all negative. An API Strep strip used asdescribed by the manufacturer (bioMerieux, Montreal, Que-bec, Canada) generated a code of 2050001, which correspondsto a 99.8% condence value of identication of Gardnerella vaginalis, including the utilization of starch. These reactionsare consistent with the identication of G. vaginalis (6). Themajor metabolic product was acetic acid. The CFA composi-tion was consistent with those observed for G. vaginalis strainsreferred to the NML as well as for the type strain ATCC 14018, with CFAs C14:0 , C16:0 , 18:1 9c, and C18:0 predominating(3, 13).

Sequence analysis of a 1,463-bp segment of the 16S rRNA genes of the organism demonstrated 99.2% identity with G. vaginalis ATCC 14018T (GenBank accession no. M58744) andclustering within GenBanks 16S sequences for G. vaginalisonly.

Antimicrobial susceptibilities were determined by broth mi-crodilution using Sensititre GPN3F panels and cation-adjustedMueller-Hinton broth with lysed horse blood (2 to 5% [vol/ vol]) by Trek Diagnostics Inc. (Nova Century Scientic Inc.,Burlington, Ontario, Canada), by using the manufacturers in-structions and following CLSI guidelines for Streptococcus spp.other than S. pneumoniae (8). The MICs (in g/ml) observed were 0.25 for erythromycin, 0.12 for quinupristin-dalfopris-tin, 1.0 for vancomycin, 0.5 for ampicillin, 0.5 for rifampin,

0.12 for clindamycin, 0.5 for daptomycin, 2.0 for tetracy-cline, 1.0 for levooxacin, 0.5 for linezolid, 0.5 for penicillin,

2.0 for gentamicin, 1.0 for ciprooxacin, 1/19 for tri-methoprim-sulfamethoxazole, 8.0 for ceftriaxone, and 1.0for gatioxacin, consistent with previous ndings (6).

Gardnerella vaginalis is typically associated with bacterial vaginosis (6). It has also been reported as a pathogen in womenfollowing delivery or pelvic surgery, potentially leading to thepreterm rupture of membranes, chorioamnionitis, and post-partum fever and to bacteremia in neonates (1, 11, 14). How-ever, in one study, 7 to 11% of men had G. vaginalis as part of their urogenital or anorectal ora, leading to the possibility of urinary tract colonization and infection (9). In the presentstudy, the patient had a sexual partner but the status regardingcolonization or infection by this agent was not known. G. vaginalis bacteremia has rarely been described for men and

usually in men with identiable risk factors, including immu-nosuppression, anatomical genitourinary abnormalities, andalcoholism (2, 5, 10, 12, 15). Here we present the rst pub-lished case of G. vaginalis bacteremia in a previously healthyman with urolithiasis. Although the patients urine culturegrew a potential uropathogen, it was present in 108 CFU/literand was not identied in any of the blood cultures obtained,despite the patient not receiving antimicrobials at the time of culture. Furthermore, due to the lack of on-site microbiologyfacilities, 15 h elapsed from the time of specimen collection toits arrival at the microbiology laboratory, and for part of thatperiod, refrigeration for storage of the urine was not available.Therefore, the isolation of E. coli from the urine specimen mayhave represented the overgrowth of a contaminant. Lastly,since two sets and three bottles of blood cultures were positivefor G. vaginalis , but none were positive for E. coli, it is unlikelythat E. coli played a role in his urosepsis.

The treatment of G. vaginalis infections outside the femalegenital tract has not been studied. Previous case reports havedocumented successful therapy with -lactams, tetracyclines,cephalosporins, clindamycin, chloramphenicol, and metronida-zole alone or in combination (2, 5, 10, 12, 15). Cases of severesepsis have been treated with combination therapy (5, 12, 15).In our case, the removal of the stone and a short course of ciprooxacin therapy were curative.

Virulence factors of G. vaginalis are not well characterized.The bacterium produces a hemolysin and a sialidase which playa role in the evasion of mucosal immunity and result in localtissue damage (7). Teichoic acid in the cell wall may produce asystemic inammatory response after invasion, but the factorsthat allow the organism to cause systemic infection are notknown. However, a recent report of G. vaginalis bacteremia with multifocal abscess formation in an alcoholic patient who

was otherwise immunocompetent suggests that the organismhas some capacity to evade the immune response (5).In conclusion, we report the rst case of urolithiasis compli-

cated by G. vaginalis bacteremia in an otherwise well malepatient. The patient was successfully treated with stone extrac-tion and a short course of ciprooxacin without adverse se-quelae. This case illustrates that G. vaginalis may be an occa-sional cause of signicant systemic disease in both men and women and that the original smear, being read as a gram-negative coccobacillus, caused some delay in the diagnosis andcorrect identication of the pathogen.

Nucleotide sequence accession number. A nearly full 16Ssequence for the isolate studied here has been deposited underGenBank accession no. EF194095.

REFERENCES

1. Agostini, A., M. Beerli, F. Franchi, F. Bretelle, and B. Blanc. 2003. Gard- nerella vaginalis bacteremia after vaginal myomectomy. Eur. J. Obstet.Gynecol. Reprod. Biol. 108: 229.

2. Bastida Vila, M. T., P. Lopez Onrubia, J. Rovira Lledos, J. A. MartinezMartinez, and M. Exposito Aguilera. 1997. Gardnerella vaginalis bacteremiain an adult male. Eur. J. Clin. Microbiol. Infect. Dis. 16: 400401.

3. Bernard, K. A., M. Bellefeuille, and E. P. Ewan. 1991. Cellular fatty acidcomposition as an adjunct to the identication of asporogenous, aerobicgram-positive rods. J. Clin. Microbiol. 29: 8389.

4. Bernard, K. A., C. Munro, D. Wiebe, and E. Ongsansoy. 2002. Characteris-tics of rare or recently described Corynebacterium species recovered fromhuman clinical material in Canada. J. Clin. Microbiol. 40: 43754381.

5. Calvert, L. D., M. Collins, and J. R. Bateman. 2005. Multiple abscessescaused by Gardnerella vaginalis in an immunocompetent man. J. Infect.51:E27E29.

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6. Catlin, B. W. 1992. Gardnerella vaginalis : characteristics, clinical consider-ations, and controversies. Clin. Microbiol. Rev. 5:213237.

7. Cauci, S., S. Driussi, R. Monte, P. Lanzafame, E. Pitzus, and F. Quadrifo-glio. 1998. Immunoglobulin A response against Gardnerella vaginalis hemo-lysin and sialidase activity in bacterial vaginosis. Am. J. Obstet. Gynecol.178: 511515.

8. Clinical and Laboratory Standards Institute. 2006. Methods for dilution anti-microbial susceptibility tests for bacteria that grow aerobically. Approved stan-dard M7-A7, 7th ed. Clinical and Laboratory Standards Institute, Wayne, PA.

9. Dawson, S. G., C. A. Ison, G. Csonka, and C. S. Easmon. 1982. Male carriageof Gardnerella vaginalis . Br. J. Vener. Dis. 58: 243245.10. Denoyel, G. A., E. B. Drouet, H. P. De Montclos, A. Schanen, and S. Michel.

1990. Gardnerella vaginalis bacteremia in a man with prostatic adenoma.J. Infect. Dis. 161: 367368.

11. Florez, C., B. Muchada, M. C. Nogales, A. Aller, and E. Martin. 1994.Bacteremia due to Gardnerella vaginalis : report of two cases. Clin. Infect.Dis. 18: 125.

12. Legrand, J. C., A. Alewaeters, L. Leenaerts, P. Gilbert, M. Labbe, and Y.Glupczynski. 1989. Gardnerella vaginalis bacteremia from pulmonary abscessin a male alcohol abuser. J. Clin. Microbiol. 27: 11321134.

13. ODonnell, A. G., D. E. Minnikin, M. Goodfellow, and P. Piot. 1984. Fattyacid, polar lipid and wall amino acid composition of Gardnerella vaginalis . Arch. Microbiol. 138: 6871.

14. Reimer, L. G., and L. B. Reller. 1984. Gardnerella vaginalis bacteremia: areview of thirty cases. Obstet. Gynecol. 64: 170172.

15. Wilson, J. A., and A. J. Barratt. 1986. An unusual case of Gardnerella vaginalis septicaemia. Br. Med. J. 293: 309.

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