The Journal of Laryngology and Otology November 1992, Vol. 106, pp. 1000-1001
Acute peritonsillar abscess caused by Arcanobacterium haemolyticum M. BARNHAM, M.D., R R . C P A T H . , R. A. BRADWELL, F.R.C.S. (Harrogate)
Abstract A patient is reported with a peritonsillar abscess yielding Arcanobacterium haemolyticum. This appears to be only the fifth such case described in the medical literature and the first from Europe. The organism has been reported as an occasional cause of tonsillopharyngitis with rash, resembling infection with Streptococcus pyogenes but often unresponsive to penicillin therapy. A. haemolyticum easily passes unrecognized in bacteriological cultures as a result of its slow growth, coryneform appearance in the Gram's stain and weak haemolytic activity on conventional laboratory media.
Case report A 19-year-old unemployed girl had been in good health except for recurrent sore throats in the last two years. She was admitted to hospital in February 1992 with a five-day history of increasingly sore throat despite treatment by her General Practitioner with oral paracetamol and penicillin V 250 mg four times a day for the previous four days. On the day before admission she developed dysphagia for solid foods, trismus and dyspnoea. On admission she had a fever of 38°C, pulse rate 100 and respiratory rate 80 per minute, and examination of the oropharynx showed a painful right peritonsillar swelling. There was no rash. Peripheral blood showed a negative Paul Bunnel test, haemoglobin 12.0 g/dl and a white blood cell count of 8.7 x 109/l with 80 per cent neutrophils. Aspiration of the peritonsillar abscess yielded 8 ml of brown pus and she was treated with intravenous penicillin 500 mg four times a day and metronidazole 400 mg three times a day for two days, followed by continuation of this regime orally for four days. On receipt of the bacteriological results treatment was changed to oral erythromycin 250 mg four times a day for a further 10 days and the patient made a steady recovery. She still however, complained of a moderately sore throat two weeks after the aspiration. A Gram-stained film of the aspirated pus showed many leucocytes and clusters of branching gram-positive rods (Fig. 1). Aerobic culture on 6 per cent horse blood agar yielded a pure growth of a gram-positive rod identified by the API CORYNE system (bioMerieux UK, Basingstoke, Hants) as Arcanobacterium haemolyticum, API code number 2730360; colonies were small at 18 h but by 48 h measured up to 1.5 mm diameter with a characteristic central dark dot and they showed a very small surrounding zone of beta-haemolysis. The organism was susceptible to penicillin, tetracycline and erythromycin but resistant to gentamicin by standard disc diffusion tests; it showed no Lancefield grouping reaction with reagents A-G (Streptex: Wellcome Diagnostics, Dartford).
Waagner, 1991); the organism has also been found in various septic lesions of the skin and occasional reports of systemic infection include isolation from brain abscess, meningitis, endocarditis and osteomyelitis (Waagner, 1991). A. haemolyticum seems, in particular, to be associated with a syndrome of tonsillo-pharyngitis in teenagers and young adults, featuring cervical lymphadenopathy and a desquamating scarlatiniform rash on the extremities in one-third to one-half of reported cases. This condition mimicks upper respiratory tract infection with Streptococcus pyogenes but bacteriological studies suggest that it is some two- to eight-fold less common (Banck and Nyman, 1986; Brenwald et al., 1990). A few reports have been published of severe local infection of the throat with A. haemolyticum, including two patients with membranous tonsillo-pharyngitis resembling diphtheria and warranting treatment with specific antisera on clinical grounds \
.y • i
Discussion The isolation of A. haemolyticum from the throat of patients with tonsillo-pharyngitis has been reported in several studies since it was first described in this condition in 1946 (Wickremesinghe, 1981; Banck and Nyman, 1986; Selander and Ljungh, 1986; Miller et al., 1986; Brenwald et al., 1990;
I Fig. 1 Clusters of branching gram-positive rods of A. haemolyticum with leucocytes in peritonsillar pus (Gram's stain xl500).
Accepted for publication: 23 May 1992. 1000
1001
CLINICAL RECORDS
(Green and LaPeter, 1981; Kovatch £>/a/., 1983); in a report from Sri Lanka both A. haemolyticum and Corynebacterium diphtheriae were isolated from several patients with clinical infections of the throat (Wickremesinghe, 1981). Kovatch et al. (1983) reported the first case of peritonsillar abscess yielding A. haemolyticum in a patient from Pittsburgh, Pennsylvania and the following year Miller and Brancato (1984) reported three further cases from Seattle, Washington. These patients showed similarities in clinical presentation and course of disease to the present case, including ages ranging from 14 to 21 years, prior unsuccessful treatment with penicillin in at least two instances, unilateral abscess in three of the four patients, no rash, and a satisfactory final result after drainage in all cases. The occurrence of serious local infection with this organism in the throat adds weight to the view that it is a genuine pathogen at that site. Despite in vitro susceptibility to penicillin, many strains of A. haemolyticum have been shown to be tolerant to the drug and clinical and bacteriological treatment failures commonly occur (Waagner, 1991). Unsuspected infection with A. haemolyticum may explain some penicillin treatment failures in patients with recurring tonsillopharyngitis of suspected streptococcal aetiology. Cultures of A. haemolyticum are usually susceptible to erythromycin and this appears to be the drug of choice. Previously classified in the genus Corynebacterium, A. haemolyticum was assigned to its present taxonomic position in 1982 (Collins et al., 1982). In a number of laboratory tests it resembles the haemolytic gram-positive rod Actinomyces pyogenes but the latter species has rarely been reported from infections of the throat (Barnham, 1988) and may be distinguished by, amongst other tests, a positive reaction with the streptococcal Lancefield group G antiserum (Lammler and Blobel, 1988). Few laboratories recognize A. haemolyticum in routine cultures from the throat or other superficial sites on account of its slow growth and its coryneform appearance resembling the normal body flora. The organism shows enhanced haemolysis, which may be helpful in identification, when cultured on agar incorporating blood from humans or rabbits rather than on the more commonly available horse or sheep blood; a selective medium for the isolation of A. haemolyticum from human specimens has recently been reported (Brenwald et al., 1990). Infection in the throat with this organism appears to be fairly common, particularly in teenagers and young adults (Brenwald et al., 1990); in view of its poor response to commonly used antibiotics and the possibility of serious local and systemic compli-
cations we recommend that laboratories consider testing for it routinely in throat cultures. References Banck, B., Nyman, M. (1986) Tonsillitis and rash associated with Corynebacterium haemolyticum. Journal of Infectious Diseases, 154: 1037-1040. Barnham, M. (1988) Actinomycespyogenes bacteraemia in a patient with carcinoma of the colon. Journal of Infection, 17: 231-234. Brenwald, N. P., Teare, E. L., Mountfort, L. K., Tettmar, R. E. (1990) Selective medium for isolating Arcanobacterium haemolyticum. Journal of Clinical Pathology, 43: 610. Collins, M. D., Jones, D., Schofield, G. M. (1982) Rectification of Corynebacterium haemolyticum in the genus Arcanobacterium gen. nov. as Arcanobacterium haemolyticum nom. rev., comb, nov. Journal of General Microbiology, 128: 1279-1281. Green, S. L., LaPeter, K. S. (1981) Pseudodiphtheritic membranous pharyngitis caused by Corynebacterium hemolyticum. Journal of American Medical Association, 245: 2330-2331. Kovatch, A. L., Schuit, K. E., Michaels, R. H. (1983) Corynebacterium hemolyticum peritonsillar abscess mimicking diphtheria. Journal of American Medical Association, 249: 1757-1758. Lammler, C, Blobel, H. (1988) Comparative studies on Actinomyces pyogenes and Arcanobacterium haemolyticum. Medical Microbiology and Immunology, Y11: 109-114. Miller, R. A., Brancato, F. (1984) Peritonsillar abscess associated with Corynebacterium hemolyticum. Western Journal of Medicine, 140:449-451. Miller, R. A., Brancato, R, Holmes, K. K. (1986) Corynebacterium hemolyticum as a cause of pharyngitis and scarlatiniform rash in young adults. Annals of Internal Medicine, 105: 867-872. Selander, B., Ljungh, A. (1986) Corynebacterium haemolyticum as a cause of nonstreptococcal pharyngitis. Journal of Infectious Diseases, 154: 1041. Waagner, D. C. (1991) Arcanobacterium haemolyticum: biology of the organism and diseases in man. Pediatric Infectious Disease Journal, 10: 933-939. Wickremesinghe, R. S. B. (1981) Corynebacterium haemolyticum infections in Sri Lanka. Journal of Hygiene (Cambridge), 87: 271-276. Address for correspondence: Dr M. Barnham, Department of Microbiology, Harrogate General Hospital, Harrogate, North Yorkshire HG2 7ND.
Key words: Arcanobacterium haemolyticum; Abscess, peritonsillar
Acute peritonsillar abscess caused by Arcanobacterium haemolyticum M. BARNHAM, M.D., R R . C P A T H . , R. A. BRADWELL, F.R.C.S. (Harrogate)
Abstract A patient is reported with a peritonsillar abscess yielding Arcanobacterium haemolyticum. This appears to be only the fifth such case described in the medical literature and the first from Europe. The organism has been reported as an occasional cause of tonsillopharyngitis with rash, resembling infection with Streptococcus pyogenes but often unresponsive to penicillin therapy. A. haemolyticum easily passes unrecognized in bacteriological cultures as a result of its slow growth, coryneform appearance in the Gram's stain and weak haemolytic activity on conventional laboratory media.
Case report A 19-year-old unemployed girl had been in good health except for recurrent sore throats in the last two years. She was admitted to hospital in February 1992 with a five-day history of increasingly sore throat despite treatment by her General Practitioner with oral paracetamol and penicillin V 250 mg four times a day for the previous four days. On the day before admission she developed dysphagia for solid foods, trismus and dyspnoea. On admission she had a fever of 38°C, pulse rate 100 and respiratory rate 80 per minute, and examination of the oropharynx showed a painful right peritonsillar swelling. There was no rash. Peripheral blood showed a negative Paul Bunnel test, haemoglobin 12.0 g/dl and a white blood cell count of 8.7 x 109/l with 80 per cent neutrophils. Aspiration of the peritonsillar abscess yielded 8 ml of brown pus and she was treated with intravenous penicillin 500 mg four times a day and metronidazole 400 mg three times a day for two days, followed by continuation of this regime orally for four days. On receipt of the bacteriological results treatment was changed to oral erythromycin 250 mg four times a day for a further 10 days and the patient made a steady recovery. She still however, complained of a moderately sore throat two weeks after the aspiration. A Gram-stained film of the aspirated pus showed many leucocytes and clusters of branching gram-positive rods (Fig. 1). Aerobic culture on 6 per cent horse blood agar yielded a pure growth of a gram-positive rod identified by the API CORYNE system (bioMerieux UK, Basingstoke, Hants) as Arcanobacterium haemolyticum, API code number 2730360; colonies were small at 18 h but by 48 h measured up to 1.5 mm diameter with a characteristic central dark dot and they showed a very small surrounding zone of beta-haemolysis. The organism was susceptible to penicillin, tetracycline and erythromycin but resistant to gentamicin by standard disc diffusion tests; it showed no Lancefield grouping reaction with reagents A-G (Streptex: Wellcome Diagnostics, Dartford).
Waagner, 1991); the organism has also been found in various septic lesions of the skin and occasional reports of systemic infection include isolation from brain abscess, meningitis, endocarditis and osteomyelitis (Waagner, 1991). A. haemolyticum seems, in particular, to be associated with a syndrome of tonsillo-pharyngitis in teenagers and young adults, featuring cervical lymphadenopathy and a desquamating scarlatiniform rash on the extremities in one-third to one-half of reported cases. This condition mimicks upper respiratory tract infection with Streptococcus pyogenes but bacteriological studies suggest that it is some two- to eight-fold less common (Banck and Nyman, 1986; Brenwald et al., 1990). A few reports have been published of severe local infection of the throat with A. haemolyticum, including two patients with membranous tonsillo-pharyngitis resembling diphtheria and warranting treatment with specific antisera on clinical grounds \
.y • i
Discussion The isolation of A. haemolyticum from the throat of patients with tonsillo-pharyngitis has been reported in several studies since it was first described in this condition in 1946 (Wickremesinghe, 1981; Banck and Nyman, 1986; Selander and Ljungh, 1986; Miller et al., 1986; Brenwald et al., 1990;
I Fig. 1 Clusters of branching gram-positive rods of A. haemolyticum with leucocytes in peritonsillar pus (Gram's stain xl500).
Accepted for publication: 23 May 1992. 1000
1001
CLINICAL RECORDS
(Green and LaPeter, 1981; Kovatch £>/a/., 1983); in a report from Sri Lanka both A. haemolyticum and Corynebacterium diphtheriae were isolated from several patients with clinical infections of the throat (Wickremesinghe, 1981). Kovatch et al. (1983) reported the first case of peritonsillar abscess yielding A. haemolyticum in a patient from Pittsburgh, Pennsylvania and the following year Miller and Brancato (1984) reported three further cases from Seattle, Washington. These patients showed similarities in clinical presentation and course of disease to the present case, including ages ranging from 14 to 21 years, prior unsuccessful treatment with penicillin in at least two instances, unilateral abscess in three of the four patients, no rash, and a satisfactory final result after drainage in all cases. The occurrence of serious local infection with this organism in the throat adds weight to the view that it is a genuine pathogen at that site. Despite in vitro susceptibility to penicillin, many strains of A. haemolyticum have been shown to be tolerant to the drug and clinical and bacteriological treatment failures commonly occur (Waagner, 1991). Unsuspected infection with A. haemolyticum may explain some penicillin treatment failures in patients with recurring tonsillopharyngitis of suspected streptococcal aetiology. Cultures of A. haemolyticum are usually susceptible to erythromycin and this appears to be the drug of choice. Previously classified in the genus Corynebacterium, A. haemolyticum was assigned to its present taxonomic position in 1982 (Collins et al., 1982). In a number of laboratory tests it resembles the haemolytic gram-positive rod Actinomyces pyogenes but the latter species has rarely been reported from infections of the throat (Barnham, 1988) and may be distinguished by, amongst other tests, a positive reaction with the streptococcal Lancefield group G antiserum (Lammler and Blobel, 1988). Few laboratories recognize A. haemolyticum in routine cultures from the throat or other superficial sites on account of its slow growth and its coryneform appearance resembling the normal body flora. The organism shows enhanced haemolysis, which may be helpful in identification, when cultured on agar incorporating blood from humans or rabbits rather than on the more commonly available horse or sheep blood; a selective medium for the isolation of A. haemolyticum from human specimens has recently been reported (Brenwald et al., 1990). Infection in the throat with this organism appears to be fairly common, particularly in teenagers and young adults (Brenwald et al., 1990); in view of its poor response to commonly used antibiotics and the possibility of serious local and systemic compli-
cations we recommend that laboratories consider testing for it routinely in throat cultures. References Banck, B., Nyman, M. (1986) Tonsillitis and rash associated with Corynebacterium haemolyticum. Journal of Infectious Diseases, 154: 1037-1040. Barnham, M. (1988) Actinomycespyogenes bacteraemia in a patient with carcinoma of the colon. Journal of Infection, 17: 231-234. Brenwald, N. P., Teare, E. L., Mountfort, L. K., Tettmar, R. E. (1990) Selective medium for isolating Arcanobacterium haemolyticum. Journal of Clinical Pathology, 43: 610. Collins, M. D., Jones, D., Schofield, G. M. (1982) Rectification of Corynebacterium haemolyticum in the genus Arcanobacterium gen. nov. as Arcanobacterium haemolyticum nom. rev., comb, nov. Journal of General Microbiology, 128: 1279-1281. Green, S. L., LaPeter, K. S. (1981) Pseudodiphtheritic membranous pharyngitis caused by Corynebacterium hemolyticum. Journal of American Medical Association, 245: 2330-2331. Kovatch, A. L., Schuit, K. E., Michaels, R. H. (1983) Corynebacterium hemolyticum peritonsillar abscess mimicking diphtheria. Journal of American Medical Association, 249: 1757-1758. Lammler, C, Blobel, H. (1988) Comparative studies on Actinomyces pyogenes and Arcanobacterium haemolyticum. Medical Microbiology and Immunology, Y11: 109-114. Miller, R. A., Brancato, F. (1984) Peritonsillar abscess associated with Corynebacterium hemolyticum. Western Journal of Medicine, 140:449-451. Miller, R. A., Brancato, R, Holmes, K. K. (1986) Corynebacterium hemolyticum as a cause of pharyngitis and scarlatiniform rash in young adults. Annals of Internal Medicine, 105: 867-872. Selander, B., Ljungh, A. (1986) Corynebacterium haemolyticum as a cause of nonstreptococcal pharyngitis. Journal of Infectious Diseases, 154: 1041. Waagner, D. C. (1991) Arcanobacterium haemolyticum: biology of the organism and diseases in man. Pediatric Infectious Disease Journal, 10: 933-939. Wickremesinghe, R. S. B. (1981) Corynebacterium haemolyticum infections in Sri Lanka. Journal of Hygiene (Cambridge), 87: 271-276. Address for correspondence: Dr M. Barnham, Department of Microbiology, Harrogate General Hospital, Harrogate, North Yorkshire HG2 7ND.
Key words: Arcanobacterium haemolyticum; Abscess, peritonsillar
