Pleural effusion due to corynebacterium propinquum
PLEURAL EFFUSION DUE TO CORYNEBACTERIUM PROPINQUUM IN A PATIENT WITH SQUAMOUS CELL CARCINOMA Corynebacterium propinquum (C. propinquum) is part of
admission, he looked pale, cachectic, and had finger
the normal oropharyngeal flora. Originally called CDC clubbing. His temperature was 38°C. Chest auscultation coryneform ANF-3 (absolute nonfermenter), it was Riegel
revealed right basal crepitation, and he also had tenderness
et al. in 1993 who proposed the name C. propinquum.1 On
in the right hypochondrium. Blood investigation showed a
gram stain, it shows corynebacterial forms after 24 hours’
leukocyte count of 21.70 x 109/L with 91% neutrophils,
incubation on sheep blood agar. Colonies appear whitish,
hemoglobin of 8.4 g/L and ESR of 113 mm/hour. Chest x-
nonhemolytic and 1-2 mm in diameter with a matted ray showed right pleural effusion. Blood culture was taken, surface. C. propinquum is nonlipophilic, catalase positive,
and 400 mL of pus was aspirated from the pleural effusion,
reduces nitrate and hydrolyzes tyrosine, but does not which showed a leukocyte count of >200,000/mm3, with hydrolyze urea or esculin, and also does not ferment sugars.
100% polymorphs, and red blood cells of 160/mm3. Gram
CAMP test for the organism is usually negative.2 Clinical
stain showed gram-positive coryneform-like bacilli. Ziehl-
infections by C. propinquum are rare. There has only been
Neelsen staining for acid-fast bacilli was negative.
one previously reported case of native valve endocarditis
The patient was started on ceftriaxone 2 g intravenously
due to Corynebacterium ANF-3, in 1994,3 but there have
per day and 500 mg metronidazole 8 hourly. On day four,
been no reports of this organism as a causative agent of
ultrasound of the liver and lung revealed thick wall pleural
lower respiratory tract infection in the English and non-
effusion and a collection in the liver, with a possible
English literature over the last 20 years. In this report, we
diagnosis of liver abscess. Brain CT scan showed two-ring
describe a case of pleural effusion which grew C.
lesions, which could either have been brain abscess or
propinquum in a patient with squamous cell carcinoma of
metastasis. An intercostal chest tube was inserted for the
the lung. The organism was multiresistant to penicillin, empyema, and drained 250-300 mL of serosanguineous cefuroxime, gentamicin, erythromycin, clindamycin, fluid/day. The pus from both liver and from pleural effusion rifampicin and vancomycin, but sensitive to ceftriaxone, were negative by routine culture and also for ciprofloxacin, imipenem, tetracycline, and
Mycobacterium tuberculosis. The patient was continued on
sulfamethoxazole-trimethoprim. To our knowledge, this is
ceftriaxone and metronidazole for four weeks. During this
the second reported case of clinically significant C.
period the patient’s condition was stabilized and the chest
tube was subsequently removed, as there was no more fluid
coming out. At a further evaluation of the patient’s
Case Report
condition, a liver biopsy was done under CT guide, and
histopathology result confirmed a squamous cell carcinoma
A 70-year-old Saudi male was admitted to King Khalid
of possible lung origin, with metastasis to the liver and
University Hospital, Riyadh, in August 2000, with brain. After consultation with the oncology team, a decision complaints of cough, shortness of breath, right-sided chest
was made to put the patient on palliative treatment, as this
and abdominal pain of one year’s duration. The patient had
type of carcinoma is usually resistant to chemotherapy. The
a history of fever, weight loss, hemoptysis and cough, for
patient died after 46 days of admission.
which he had been seen at different clinics with no
The pleural fluid was cultured on sheep blood and
definitive diagnosis made. He had no history of previous
McConkey agar plates and incubated for 24-48 hours
admission to hospital or treatment with antibiotics. On aerobically and anaerobically for the blood agar and only
aerobically for 24 hours for the McConkey agar.
Antimicrobial susceptibility was tested by Stoke’s method
From the Department of Pathology/Microbiology, King Khalid University
and E-test (AB Biodisk, Solna, Sweden) on Mueller Hinton
agar with 5% sheep blood (Mueller Hinton II, Becton
Address reprint requests and correspondence to Dr. Babay: Dickinson, USA). A heavy pure growth of tiny colonies
Department of Pathology/Microbiology (32), King Khalid University Hospital, P.O. Box 2925, Riyadh 11461, Saudi Arabia.
appeared on the sheep blood agar after 24 hours incubation
Accepted for publication 16 September 2001. Received 26 February
in air which, after a further 24 hours incubation, grew
colonies which were ∼1 mm in diameter, convex, whitish
Annals of Saudi Medicine, Vol 21, Nos 5-6, 2001
TABLE 1. MIC results for C. propinquum.
sensitive to most antibiotics and vancomycin.3 Due to the
lack of established standards for coryneform bacteria and a
referral sensitivity strain, it is recommended to report MIC
results without interpretative criteria.7 Our MIC was
compared with MIC of the isolate from the case of
endocarditis and those of C. pseudodiphtheriticum.2,3 Both
were sensitive to many antibiotics, including β-lactam
antibiotics, aminoglycosides and vancomycin. Multiple
antimicrobial resistance has also been reported in C. jeikeium, C. urealyticum, C. xerosis, C. minutissimum,
CDC coryneform group G and C. amycolatum.7-9 However,
these bacteria were in all cases susceptible to vancomycin,
the recommended drug for infections caused by these
Infections due to nonenterococcal vancomycin-resistant
nonpigmented and nonhemolytic. Gram stain showed gram-
gram-positive bacteria are thought to be associated with a
positive club shaped and arranged as coryneform bacteria.
mortality rate of 5%-20%, which is similar to infections due
The organism was not acid or partially acid fast. There was
to susceptible staphylococci or streptococci.10,11
no growth on the McConkey and the anaerobic agar plates.
Although there was no history of previous hospital
The isolate was catalase positive, reduced nitrate, and did
admission or treatment with broad-spectrum antibiotic or
not hydrolyze urea. Identification was made by the API vancomycin in our patient, and because the isolate from the Coryne System (Bio-Merieux SA, France), suggesting the
case of native valve endocarditis due to C. propinquum was
coryne group ANF. These include positive reaction to sensitive to vancomycin, the origin of vancomycin pyrazinamidase, negative tests for alkaline phosphatase and
resistance in our isolate is difficult to explain, but we would
pyrrolidonyl arylamidase. Negative tests were also given like to speculate that its source was probably the upper
for sugar fermentation, β-glucuronidase, β-glactosidase, α-
In conclusion, as with other emerging coryneform
glucosidase, N-acetyl-β-glucosaminidase, gelatin
bacteria, full identification of the isolates, especially when
hydrolysis and esculin. The organism showed similar they appear on original plate as pure or predominant,
susceptibility pattern by both disk diffusion and E-test
should be performed.2 In diagnostic laboratories,
methods. It was susceptible to ceftriaxone, imipenem, identification can simply be achieved by biochemical test
ciprofloxacin, tetracycline and sulfomethoxazole-
and API Coryne system.2,9 Due to the unpredictable
trimethoprim. Table 1 shows the minimum inhibitory susceptibility to antibiotics, susceptibility testing should be
concentration (MIC) test results for the antimicrobial agents
performed on all antibiotics including vancomycin.7
Treatment of vancomycin-resistant infections can be by the
third-generation cephalosporins, ciprofloxacin or
Discussion
imipenem.12 Stringent infection control precautions and
prudent use of broad-spectrum antibiotics and vancomycin
Nondiphtherial coryneform bacteria with pathogenic are essential for the prevention or spread of vancomycin
potential are being increasingly isolated from patients who
are immunocompromised or implanted with prostheses.4
The clinical significance of C. propinquum in our patient was based on positive direct gram stain with strong
Acknowledgements
leukocyte reaction and heavy pure isolation from a sterile
We would like to thank Dr. Kingsley Twum-Danso for
site.2 Rapidly growing Mycobacterium, Rhodoccus spp. or
his valuable comments and for revising the manuscript.
Nocardia spp. were among the differential identification of
the organism. Identification was made by a combination of morphological characteristics of gram stain, negative acid-
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