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Tsukamurella tyrosinosolvens intravascular catheter related

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					European Review for Medical and Pharmacological Sciences                          2011; 15: 1343-1346

Tsukamurella tyrosinosolvens intravascular
catheter-related bacteremia in a haematology
patient: a case report
                                .
R. KARUNAKARAN, H.A. HALIM*, K.P NG, Y.A. HANIFAH, E. CHIN*,
 .L.
F JAAFAR, S. ABUBAKAR

Department of Medical Microbiology, and *Department of Medicine, Faculty of Medicine, University of
Malaya, 50603 Kuala Lumpur (Malaysia)




   Abstract. – Tsukamurella spp. are a rare              spp. (previously known as Gordona spp.) and the
but important cause of intravascular catheter-           rapid growing Mycobacterium spp.1,3. It is impor-
related bacteremia in immunocompromised pa-              tant to correctly identify these organisms, as
tients. The organism is an aerobic, Gram-posi-           treatment guidelines are available for Nocardia
tive, weakly acid-fast bacillus that is difficult to
differentiate using standard laboratory methods          spp., Rhodococcus equi and some of the rapid-
from other aerobic actinomycetales such as No-           growing Mycobacterium spp., while treatment
cardia spp., Rhododoccus spp., Gordonia spp.,            guidelines for infection with Gordonia spp. and
and the rapid growing Mycobacterium spp. We              Tsukamurella spp. are presently insufficient and
report a case of Tsukamurella tyrosinosolvens            management of these infections are guided main-
catheter-related bacteremia in a 51-year-old             ly by case reports and reviews in the literature.
haematology patient who responded to treat-
ment with imipenem and subsequent line re-
                                                            We describe here a case of bacteremia with
moval. 16srRNA sequencing allowed for the                Tsukamurella tyrosinosolvens in a 51-year-old
prompt identification of this organism.                  haematology patient.

Key Words:                                               Case Report
                                                            A 51-year-old lady with acute myeloid
  Tsukamurella tyrosinosolvens, Catheter-related,
Bacteremia.                                              leukemia was admitted for chemotherapy. Two
                                                         days later a peripherally inserted central venous
                                                         catheter (PICC) was inserted. Granulocyte stimu-
                                                         lating factor (GCSF rescue) was given on com-
                                                         pletion of chemotherapy. On day 13 post
                                                         chemotherapy, she became febrile. Physical ex-
                  Introduction                           amination and chest X-ray were unremarkable.
                                                         Blood cultures were taken from the periphery
   Tsukamurella spp. are a rare but important            and through the central line, after which she was
cause of serious infection in immunocompro-              given intravenous cefepime 2 g (8 hourly) and
mised patients, especially those with indwelling         gentamicin 240 mg daily. Blood counts on day
intravascular catheters1-3. Other reported infec-        14 post chemotherapy revealed she was neu-
tions include bacteremia in haemodialysis pa-            tropenic and the neutropenia persisted until day
tients with catheters4,5, lung infection6, meningi-      23 post chemotherapy. As she was still febrile on
tis in a leukemic patient7, subcutaneous abscesses       day 18 post chemotherapy, repeat blood cultures
and necrotizing tenosynovitis8, conjunctivitis9,         were taken from a peripheral vein and via the
and others.                                              PICC, and antibiotic therapy was switched to
   The organism is an aerobic, Gram-positive,            imipenem 500 mg (6 hourly). She responded
weakly acid-fast bacillus that is difficult to differ-   within 12 hours with deferverscence of fever.
entiate using standard laboratory methods from           Gram positive, partially acid-fast bacilli were
some of the other aerobic actinomycetales such           isolated from blood cultures taken from a periph-
as Nocardia spp., Rhododoccus spp., Gordonia             eral vein and via the PICC catheter on day 13

Corresponding Author: Rina Karunakaran, MD; e-mail: rina@ummc.edu.my, rina_k@um.edu.my              1343
                                        .                            .L.
         R. Karunakaran, H.A. Halim, K.P Ng, Y.A. Hanifah, E. Chin, F Jaafar, S. AbuBakar


and day 18 respectively. The microbiology labo-        and the colour was yellow on blood and choco-
ratory informed that the partially acid-fast bacilli   late agar, and pale pink on Mac Conkey agar
were possibly a Rhodococcus spp., Nocardia             without crystal violet. The organism was a strict
spp., Gordona spp. or a rapid growing Mycobac-         aerobe, catalase positive and weakly acid-fast.
terium spp. After six days of intravenous imipen-      The API Coryne (BioMérieux sa, Marcy l’Etoile,
em, she remained well, and pending full identifi-      Craponne, France) profile was 2150004, which
cation of these rods, the patient was discharged       identified with low discrimination as Rhodococ-
and planned for review in the clinic a week later.     cus spp. (82.9%) followed by Aureobacterium
   When seen at the review, she was well apart         spp./Corynebacterium acquaticum (12.2%). The
from pus discharge from the PICC insertion site.       possibility of genus Gordona or Dietza or Nocar-
A swab was taken for culture from this site. She       dia was also mentioned.
was given oral cloxacillin and sent home. A               There are no interpretation criteria for disk dif-
week later, at the second review (by which time        fusion sensitivity testing of Gram positive rods
the identification of the Gram-positive rods from      using the Clinical and Laboratory Standards In-
the earlier blood cultures were known to be            stitute (CLSI) disk diffusion method. Based on
Tsukamurella tyrosinosolvens by 16s sequenc-           the criteria available for Staphylococci10, the or-
ing) the patient was still found to have pus dis-      ganism appeared sensitive to imipenem, van-
charge from the PICC site and in addition, had         comycin, cefepime and trimethoprim-sul-
tenderness at the insertion site. The earlier swab     famethoxazole and resistant to piperacillin/
from the PICC site had grown coagulase negative        tazobactam (however, when repeated at a later
Staphylococcus which was methicillin resistant.        date, was found to be sensitive to it). The mini-
Another pus swab and blood drawn via the PICC          mum inhibitory concentration by E test (AB
line were taken for culture. The line was then re-     Biodisk, Solna, Sweden) performed later was
moved. Another weeks’ course of oral cloxacillin       0.19 µg/ml for imipenem and 1.0 µg/ml for ce-
was given empirically. At the third review a week      fepime. As the API identification of the organism
later, the patient was found to be well with no        was not conclusive, molecular identification by
pus discharge or abscess at the previous PICC in-      PCR amplification and sequencing of the 16S
sertion site. The blood culture taken via the line     rRNA gene was performed as previously de-
at the second review had grown Bacillus spp., but      scribed11. The resulting sequences were aligned
clinically the patient did not appear septicaemic,     and assembled into contig using SequencherTM
and it was not thought to be clinically relevant.      ver 4.9 (Gene Codes Corporation, Ann Arbor,
The pus swab grew a mixture of coagulase nega-         MI, USA). The complete 16s rRNA consensus
tive Staphylococcus which was methicillin resis-       sequence containing 1385 nucleotides was com-
tant and also “diphtheroids”. The PICC line tip        pared with those available in the GenBank Data
grew >15 CFU (colony forming units) (using the         System. A 99% sequence similarity to Tsuka-
Maki roll technique) of partially acid-fast Gram-      murella tyrosinosolvens (Gen Bank Accession
positive rods again, identified as T. tyrosinosol-     Number: AY254699) was obtained.
vens based on its identical characteristics to the
earlier isolates from the blood cultures. The pa-
tient was well and no further antibiotics were
given.                                                                    Discussion
Microbiology Investigations                              Tsukamura and Mizuno first described Gor-
   Blood culture from a peripheral vein taken on       dona aurantiaca from sputum of patients with
day 13 post chemotherapy and from the PICC             chronic pulmonary disease in 197112. This or-
line on Day 18 post chemotherapy grew Gram-            ganism was later also known as Rhodococcus
positive bacilli from the BD BACTECTM Plus             aurantiacus3,13 until 1988, when Collins et al14
Aerobic/F Medium bottles (Becton, Dickinson            found 99% sequence homology of the organism
Diagnostic Inc, Sparks, MD, USA). It grew after        with Corynebacterium paurometabolum (which
overnight incubation when subcultured onto             had earlier been described by Steinhaus in
blood agar, chocolate agar and Mac Conkey agar.        1941)15, and proposed reclassifying and merg-
Gram stain of the colonies revealed non-branch-        ing these organisms, naming it Tsukamurella
ing rods. After 48 hours, the colonies were larger     paurometabolum (now known as Tsukamurella
and distinctly dry with a wrinkled appearance,         paurometabola) 14,3 . This organism has been

1344
                               Tsukamurella tyrosinosolvens, bacteremia


found in soil, sludge and arthropods3,16. Various     murella tyrosinosolvens. It is important to docu-
species have been described in the genus Tsuka-       ment infection with this organism as it is rarely
murella2, and intravascular catheter-related in-      encountered. It also underlines the importance of
fections have been previously reported among          correctly identifying partially acid-fast Gram-
the infections caused by Tsukamurella tyrosino-       positive rods as management of their respective
solvens2,3,5.                                         infections is different. 16srRNA sequencing
   In the present case, the initial tests by API      proved a useful tool in the identification of this
Coryne could not ascertain the identity of the or-    organism.
ganism. The possibility of it being a Rhodococ-
cus spp. was doubtful as the Gram stain did not
reveal cocco-bacilli, nor was there any                                –
                                                      –––––––––––––––––––
rod/coccus cyclic variation which may be seen in      Acknowledgements
some Rhodococcus spp.1 “Unlike Nocardia spp.1,            The 16srRNA gene sequencing was funded by a Uni-
this organism did not have a branching appear-            versity of Malaya F vote grant (FS243/2008B).
ance on Gram stain”. Elshibly et al2, also report-
ed an API identification profile of 2150004 (sim-
ilar to ours) for an isolate subsequently con-
firmed as Tsukamurella tyrosinosolvens. Tsuka-
murella cells are described as long rods that frag-                      References
ment and grow independently1. They do not form
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           R. Karunakaran, H.A. Halim, K.P Ng, Y.A. Hanifah, E. Chin, F Jaafar, S. AbuBakar


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