950
Letters
Oerskovia xanthineolytica and Methicillin-Resistant Staphylococcus aureus in a Patient with Cirrhosis and Variceal Hemorrhage Oerskovia spp. are yellow-pigmented, gram-positive, non-acid-fast organisms with extensively branched filaments which usually fragment into small motile rods (1). These microorganisms were first isolated from soil and described by Orskov in 1938 as motile Nocardia. The organisms have been described as opportunistic pathogens in humans (2-4). They have been reported to be the causative agent in a case of catheter-related bacteremia in a child with acute myeloblastic leukemia (5) and the causative agent in a case of peritonitis, which resolved following removal of a peritoneal catheter (6). Oerskovia spp. have also been described as the etiologic agent in cases of meningitis (7), endocarditis (3) and endophthalmitis (8), This report describes a 40-year-old man with a history of alcoholism and biopsy-confirmed micronodular cirrhosis who was admitted to Temple University Hospital with hematemesis. He bled from esophageal varices and received sclerotherapy. During his hospital stay he developed methicillin-resistant Staphylococcus aureus bacteremia, which was complicated by Oerskovia xanthineolytica bacteremia.
Physical examination on admission revealed an agitated male with hematemesis. The blood pressure was 6010 mm Hg and the heart rate 120/min; the patient was afebrile, the hemoglobin level was 8.8 g/dl, the platelet count 80,000/~1 and the leukocyte count 6,000/lal with an unremarkable differential. The creatinine level was 2.2 mg/dl. The prothrombin time was 18.5 see, the total bilirubin level 1.5 mg/dl and the albumin level 3.2 g/dl; the aspartate transaminase and alanine transaminase levels were moderately elevated but the alkaline phosphatase was normal. A chest radiograph showed no abnormalities. The patient developed progressive respiratory distress and was intubated. During emergency endoscopic esophagogastroscopy on the clay of admission large actively bleeding esophageal varices were injected with tetradecyl sulfate, intravenous pitressin (0.4 ~g/min) and ranitidine were begun, and the gastrointestinal bleeding was eventually controlled. On the second hospital day, the patient developed fever and a new right lower lobe infiltrate. Ceftriaxone and clindamycin were administered. Vancomycin was added when methicillin-resistant Staphylococcus aureus was cultured from blood (2 of 2 bottles, aerobic and
Vol. 11. No. 10
anaerobic) obtained on the second hospital day. The patient remained febrile, ceftriaxone was discontinued and gentamicin begun. One blood culture (1 of 2 bottles, aerobic) on the sixth hospital day revealed gram-positive bacilli and grew a corynebacterium-like organism which was not group JK. The organism was sensitive to vancomycin and subsequently identified as Oerskovia xanthineolytica. The patient became more alert and his temperature returned to 100 °F (37.8 °C). His further hospitalization was characterized by respiratory failure, recurrent gastrointestinal bleeding and Escherichia coli sepsis, but he ultimately improved and was discharged 37 days after admission. The gram-positive bacillus isolated from this patient's blood appeared initially to be similar to a corynebacterium, not JK. Routine disk diffusion susceptibility tests (9) to determine antibiotic susceptibility demonstrated the following: susceptibility to ampicillin, cephalothin, penicillin, tetracycline, trimethoprim/sulfamethoxazole and vancomycin; resistance to gentamicin, clindamycin, nafcillin and erythromycin. Biochemical tests were performed and on this basis (Table 1) the organism was identified as Oerskovia xanthineolytica (4). Very few case reports describe human Oerskovia infections. To our knowledge, the patient reported in this case represents the first documented case of Oerskovia xanthineolytica bacteremia. Reference laboratories, however, have identified eight Oerskovia xanthineolytica isolates that are thought to originally have had a blood source (4). Case histories were unavailable for all eight isolates. Previous reports have described the organism as an opportunistic pathogen, but its precise role in human infections is yet to be elucidated. This report describes a patient with a history of alcoholism and micronodular cirrhosis who presented with gastrointestinal bleeding requiring emergency endoscopy. He suffered a bacteremic episode with methicillin-resistant Staphylococcus aureus (MRSA), which was followed very closely by a bacteremic episode with Oerskovia xanthineolytica. The patient was given vancomycin very early in the hospital course, and the methicillin-resistant Staphylococcus aureus isolated from the blood was susceptible to vancomycin. Interestingly, the patient had been receiving vancomycin for four days before a blood culture taken on the sixth hospital day revealed grampositive bacilli (susceptible to vancomycin), which were identified as Oerskovia xan-
Vol. 11, 1992
951
Table 1: Comparison of 26 isolates of Oerskovia xanthineolytica reported in the literature a n d the Temple University Hospital ( T U H ) isolate. Characteristic
Substrate hyphae on heart infusion agar Motility Yellow growth pigment Gelatinase U r e a hydrolysis Acid from: Glucose Xylose Mannitol Lactose Sucrose Maltose Decomposition of: Casein Xanthine Hypoxanthine Adenine Tyrosine
Reported isolates a (n = 26)
TU.H isolate
+ + (3) b + + +
+(rare) + + +
+ +
+ +
+ (7) ~ + +
+ +
+ + + -
+ + + -
a Reference no. 4 bThree isolates did not show this reaction. e Seven isolates did not show this reaction.
thineolytica. Seven sets of blood cultures obtained during the week following isolation of Oerskovia xanthineolytica were negative except for one aerobic bottle which contained coagulase-negative Staphylococcus.
References
One cannot rule out that the Oerskovia was a contaminant, however it would have been a highly unusual contaminant. Oerskovia have been isolated from soil samples in the USA and Europe. However, an association with soil was not apparent with this patient. Prosthetic devices, which have been described as being a significant persistent focus of this microorganism, were also not a factor in this patient.
2. Cruickshank JG, Gawler AH, Shaldon G: Oerskovia
A.L. Truant 1,2,3,4. V. Satishchandran4 R. Eisenstaedt 2 R Richman2 M.M. McNeil 5
6. Ribs JD, McNeil MM, Brown JM, Yu VL: Oerskovia xanthineolytica implicated in peritonitis associated
1 Department of Microbiology and Immunolog); 2Department of Medicine, 3Department of Pathology, and 4Clinical Laboratories, Temple University, Hospital and School of Medicine, 3401 North Broad St., Philadelphia, Pennsylvania 19140, USA. s Mycotic Diseases Branch, Division of Bacterial and Mycotic Diseases, Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333, USA.
1. Erikson D: Factors promoting cell division in a "soft" mycelial type of Nocardia: Noeardia turbata n. sp. Journal of General Microbiology 1954, 11: 198-208. species: rare opportunistic pathogens. Journal of Medical Microbiology 1979, 12: 513-515.
3. Relier LB, Maddoux GL, Eckman MR, Pappas G: Bacterial endocarditis caused by Oerskovia turbata. Annals of Internal Medicine 1975, 83: 664---666.
4. Sottnek FO, Brown JM, Weaver RE, Carroll GF: Recognition o[ Oerskovia species in the clinical laboratory: characterization of 35 isolates. International Journal of Systematic Bacteriology 1977, 27" 263270. 5. Le Prowse C, McNeil MM, McCarty JM: Catheterrelated bacteremia caused by Oerskovia turbata. Journal of Clinical Microbiology 1989, 27: 571-572. with peritoneal dialysis: case report and review of Oerskovia infections in humans. Journal of Clinical Microbiology 1990, 28: 1934-1937. 7. Kailath E J, Goldstein E, Wagner FH: Case report: meningitis caused by Oerskovia xanthineolytica. American Journal of Medical Science 1988, 295: 216217.
8. Hussain Z, Gonder JR, Lannigan R, Stoakes L: Endophthalmitis due to Oerskovia xanthineolytica. Canadian Journal of Ophthalmology 1987, 22: 234-236.
9. National Committee For Clinical Laboratory Standards: Performance standards for antimicrobial disk susceptibility tests, 4th edition. Tentative standard. MS-T4 NCCLS. Villanova, PA, 1988.
Letters
Oerskovia xanthineolytica and Methicillin-Resistant Staphylococcus aureus in a Patient with Cirrhosis and Variceal Hemorrhage Oerskovia spp. are yellow-pigmented, gram-positive, non-acid-fast organisms with extensively branched filaments which usually fragment into small motile rods (1). These microorganisms were first isolated from soil and described by Orskov in 1938 as motile Nocardia. The organisms have been described as opportunistic pathogens in humans (2-4). They have been reported to be the causative agent in a case of catheter-related bacteremia in a child with acute myeloblastic leukemia (5) and the causative agent in a case of peritonitis, which resolved following removal of a peritoneal catheter (6). Oerskovia spp. have also been described as the etiologic agent in cases of meningitis (7), endocarditis (3) and endophthalmitis (8), This report describes a 40-year-old man with a history of alcoholism and biopsy-confirmed micronodular cirrhosis who was admitted to Temple University Hospital with hematemesis. He bled from esophageal varices and received sclerotherapy. During his hospital stay he developed methicillin-resistant Staphylococcus aureus bacteremia, which was complicated by Oerskovia xanthineolytica bacteremia.
Physical examination on admission revealed an agitated male with hematemesis. The blood pressure was 6010 mm Hg and the heart rate 120/min; the patient was afebrile, the hemoglobin level was 8.8 g/dl, the platelet count 80,000/~1 and the leukocyte count 6,000/lal with an unremarkable differential. The creatinine level was 2.2 mg/dl. The prothrombin time was 18.5 see, the total bilirubin level 1.5 mg/dl and the albumin level 3.2 g/dl; the aspartate transaminase and alanine transaminase levels were moderately elevated but the alkaline phosphatase was normal. A chest radiograph showed no abnormalities. The patient developed progressive respiratory distress and was intubated. During emergency endoscopic esophagogastroscopy on the clay of admission large actively bleeding esophageal varices were injected with tetradecyl sulfate, intravenous pitressin (0.4 ~g/min) and ranitidine were begun, and the gastrointestinal bleeding was eventually controlled. On the second hospital day, the patient developed fever and a new right lower lobe infiltrate. Ceftriaxone and clindamycin were administered. Vancomycin was added when methicillin-resistant Staphylococcus aureus was cultured from blood (2 of 2 bottles, aerobic and
Vol. 11. No. 10
anaerobic) obtained on the second hospital day. The patient remained febrile, ceftriaxone was discontinued and gentamicin begun. One blood culture (1 of 2 bottles, aerobic) on the sixth hospital day revealed gram-positive bacilli and grew a corynebacterium-like organism which was not group JK. The organism was sensitive to vancomycin and subsequently identified as Oerskovia xanthineolytica. The patient became more alert and his temperature returned to 100 °F (37.8 °C). His further hospitalization was characterized by respiratory failure, recurrent gastrointestinal bleeding and Escherichia coli sepsis, but he ultimately improved and was discharged 37 days after admission. The gram-positive bacillus isolated from this patient's blood appeared initially to be similar to a corynebacterium, not JK. Routine disk diffusion susceptibility tests (9) to determine antibiotic susceptibility demonstrated the following: susceptibility to ampicillin, cephalothin, penicillin, tetracycline, trimethoprim/sulfamethoxazole and vancomycin; resistance to gentamicin, clindamycin, nafcillin and erythromycin. Biochemical tests were performed and on this basis (Table 1) the organism was identified as Oerskovia xanthineolytica (4). Very few case reports describe human Oerskovia infections. To our knowledge, the patient reported in this case represents the first documented case of Oerskovia xanthineolytica bacteremia. Reference laboratories, however, have identified eight Oerskovia xanthineolytica isolates that are thought to originally have had a blood source (4). Case histories were unavailable for all eight isolates. Previous reports have described the organism as an opportunistic pathogen, but its precise role in human infections is yet to be elucidated. This report describes a patient with a history of alcoholism and micronodular cirrhosis who presented with gastrointestinal bleeding requiring emergency endoscopy. He suffered a bacteremic episode with methicillin-resistant Staphylococcus aureus (MRSA), which was followed very closely by a bacteremic episode with Oerskovia xanthineolytica. The patient was given vancomycin very early in the hospital course, and the methicillin-resistant Staphylococcus aureus isolated from the blood was susceptible to vancomycin. Interestingly, the patient had been receiving vancomycin for four days before a blood culture taken on the sixth hospital day revealed grampositive bacilli (susceptible to vancomycin), which were identified as Oerskovia xan-
Vol. 11, 1992
951
Table 1: Comparison of 26 isolates of Oerskovia xanthineolytica reported in the literature a n d the Temple University Hospital ( T U H ) isolate. Characteristic
Substrate hyphae on heart infusion agar Motility Yellow growth pigment Gelatinase U r e a hydrolysis Acid from: Glucose Xylose Mannitol Lactose Sucrose Maltose Decomposition of: Casein Xanthine Hypoxanthine Adenine Tyrosine
Reported isolates a (n = 26)
TU.H isolate
+ + (3) b + + +
+(rare) + + +
+ +
+ +
+ (7) ~ + +
+ +
+ + + -
+ + + -
a Reference no. 4 bThree isolates did not show this reaction. e Seven isolates did not show this reaction.
thineolytica. Seven sets of blood cultures obtained during the week following isolation of Oerskovia xanthineolytica were negative except for one aerobic bottle which contained coagulase-negative Staphylococcus.
References
One cannot rule out that the Oerskovia was a contaminant, however it would have been a highly unusual contaminant. Oerskovia have been isolated from soil samples in the USA and Europe. However, an association with soil was not apparent with this patient. Prosthetic devices, which have been described as being a significant persistent focus of this microorganism, were also not a factor in this patient.
2. Cruickshank JG, Gawler AH, Shaldon G: Oerskovia
A.L. Truant 1,2,3,4. V. Satishchandran4 R. Eisenstaedt 2 R Richman2 M.M. McNeil 5
6. Ribs JD, McNeil MM, Brown JM, Yu VL: Oerskovia xanthineolytica implicated in peritonitis associated
1 Department of Microbiology and Immunolog); 2Department of Medicine, 3Department of Pathology, and 4Clinical Laboratories, Temple University, Hospital and School of Medicine, 3401 North Broad St., Philadelphia, Pennsylvania 19140, USA. s Mycotic Diseases Branch, Division of Bacterial and Mycotic Diseases, Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333, USA.
1. Erikson D: Factors promoting cell division in a "soft" mycelial type of Nocardia: Noeardia turbata n. sp. Journal of General Microbiology 1954, 11: 198-208. species: rare opportunistic pathogens. Journal of Medical Microbiology 1979, 12: 513-515.
3. Relier LB, Maddoux GL, Eckman MR, Pappas G: Bacterial endocarditis caused by Oerskovia turbata. Annals of Internal Medicine 1975, 83: 664---666.
4. Sottnek FO, Brown JM, Weaver RE, Carroll GF: Recognition o[ Oerskovia species in the clinical laboratory: characterization of 35 isolates. International Journal of Systematic Bacteriology 1977, 27" 263270. 5. Le Prowse C, McNeil MM, McCarty JM: Catheterrelated bacteremia caused by Oerskovia turbata. Journal of Clinical Microbiology 1989, 27: 571-572. with peritoneal dialysis: case report and review of Oerskovia infections in humans. Journal of Clinical Microbiology 1990, 28: 1934-1937. 7. Kailath E J, Goldstein E, Wagner FH: Case report: meningitis caused by Oerskovia xanthineolytica. American Journal of Medical Science 1988, 295: 216217.
8. Hussain Z, Gonder JR, Lannigan R, Stoakes L: Endophthalmitis due to Oerskovia xanthineolytica. Canadian Journal of Ophthalmology 1987, 22: 234-236.
9. National Committee For Clinical Laboratory Standards: Performance standards for antimicrobial disk susceptibility tests, 4th edition. Tentative standard. MS-T4 NCCLS. Villanova, PA, 1988.
