JEADV
LETTER TO THE EDITOR
Pantoea agglomerans – an underestimated pathogenic agent in penetrating trauma involving vegetative material Editor A 71-year-old woman presented with a subcutaneous node on the lower arm, increasing for 3 months. She reported neither a trauma nor an abroad visit during the past 2 years. The history included tuberculosis when she was 25. Clinically, on the ulnar side of the right lower arm was a 6 9 7 cm-sized, subcutaneous, hardly moveable, coarse pressure-sensitive node with no epidermal involvement. There was pale erythema of the skin above the pseudotumor with blurred outline and moderate hyperthermia (Fig. 1a). Besides a moderate CRP-elevation of 10.3 mg/l all other routine laboratory parameters were within normal ranges. Magnetic resonance imaging revealed a subcutaneous and muscle oedema without signs of osseous involvement (Fig. 1b). Differential diagnostics included benign and malignant tumours, as well as abscessing or granulomatous inflammations. Therapeutically, we decided on surgical exploration of the node. The tumour was found intraoperatively to be subfascial (Fig. 1c). After the muscle fascia was opened, semisolid yellowish pus was exuded and also a black, slightly branched foreign body about
1 cm in length (Fig. 1d). The granulomatous tissue was excised and the wound partially closed. In addition, we applied intravenous antibiotic therapy, initially calculated and later based on a resistogram, with cefuroxim and metronidazol. Restitutio ad integrum followed quickly. Although investigated several times, the patient could not remember any penetrating trauma at any time in the past. Histopathological examination showed the foreign body as a cell-rich piece of a plant with a pronounced bacterial mat in the outer portions (Fig. 2). Extensive purulent granulation was seen in the surrounding tissue. The lower arm fascia was also infiltrated with inflammatory cells. In all preparations, plasma cells, neutrophilic granulocytes and macrophages were found repeatedly. There was no evidence of fungal elements or cells with malignancy criteria. Only Pantoea agglomerans was cultured from the swab material collected intraoperatively. The culture for proof of tuberculosis bacteria, ubiquitous mycobacteria and yeasts were negative. Based on these findings, we diagnosed a localized pyomyositis caused by a wooden splinter contaminated with Pantoea agglomerans. Pantoea agglomerans is a gram-negative, facultatively anaerobic, yellow-pigmented rod-shaped bacterium belonging to the family of Enterobacteriaceae. The primary habitat of this bacterium is the environment, where it is usually found as epiphyte and endophyte in association with plants, fruits and vegetables. Additionally, it is isolated in the faeces of humans and animals and in the soil.1 As an
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(b)
(c)
(d)
Figure 1 Pale erythema of the skin above the pseudotumor (a) and MRI-scan of the right lower arm with subcutaneous and muscle oedema (b). After the muscle fascia was opened (c), semisolid yellowish pus and also a black, slightly branched foreign body about 1 cm in length (d) was exuded.
JEADV 2015
© 2015 European Academy of Dermatology and Venereology
Letter to the Editor
2
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(b)
infection have been reported in connection with contaminated parenteral nutrient products, infusions, catheters or blood products.1 In addition to its importance in human medicine, Pantoea agglomerans is of great interest for agriculture.5 Certain strains produce a number of potent antimicrobial substances. Because of this, they are used commercially in the USA, Canada and New Zealand as biopesticides against fire blight in apple and pear trees. In Europe, this use is not possible, since the bacterium is rated biosafety level 2 due to its opportunistic, human-pathogenetic properties. Thus, in the future, increased attention and documentation of cases of Pantoea agglomerans-caused illness is required in Europe to maintain the most objective rating of biosafety possible, independent of socio-economic interests, so that a pathogen which has hardly been noticed and which only seems to have low virulence cannot spread unconditionally.
Funding sources No funding source was engaged to write the manuscript or submit it for publication. ,2 W. Ch. Marsch,1 V. Stadie1 F. Friedling,1,* A.S. Kekule 1
Department of Dermatology and Venereology Halle (Saale), University Hospital Halle (Saale) of the Martin Luther University Halle Wittenberg, Ernst-Grube-Straße 40, Halle (Saale), Germany, 2Martin Luther University Halle-Wittenberg, Institute for Medical Microbiology, Magdeburger Straße 6, Halle (Saale), Germany *Correspondence: F. Friedling. E-mail: [email protected]
References Figure 2 Histopathological examination of the foreign body showed a cell-rich piece of a plant with a pronounced bacterial mat in the outer portions (a), HE 409. (b) presents a higher magnification of the square detail shown in (a), HE 4009. (ep, epidermis; ca, cambium; pi, pith).
opportunistic pathogen with low virulence, infections are uncommon in healthy individuals, typically following penetrating trauma by vegetation.2,3 As described in our case, the low virulence may lead to a delayed manifest infection after a long latency phase. Consequently, penetrating plant parts should be carefully located and surgically removed to prevent high-risk complications. In addition to localized infections immuno-suppressed patients and neonates may also develop primary bacteriemias and systemic infections.4 Outbreaks of nosocomial
JEADV 2015
1 Cruz AT, Cazacu AC, Allen CH. Pantoea agglomerans, a plant pathogen causing human disease. J Clin Microbiol 2007; 45: 1989–1992. 2 Vaiman M, Lazarovich T, Lotan G. Pantoea agglomerans as an indicator of a foreign body of plant origin in cases of wound infection. J Wound Care 2013; 22: 182, 184–185. 3 Jain S, Bohra I, Mahajan R, Jain S, Chugh TD. Pantoea agglomerans infection behaving like a tumor after plant thorn injury: an unusual presentation. Indian J Pathol Microbiol 2012; 55: 386–388. 4 Rave O, Assous MV, Hashkes PJ, Lebel E, Hadas-Halpern I, Megged O. Pantoea agglomerans foreign body-induced septic arthritis. Pediatr Infect Dis J 2012; 31: 1311–1312. 5 V€ olksch B, Thon S, Jacobsen ID, Gube M. Polyphasic study of plant- and clinic-associated Pantoea agglomerans strains reveals indistinguishable virulence potential. Infect Genet Evol 2009; 9: 1381–1391. DOI: 10.1111/jdv.13081
© 2015 European Academy of Dermatology and Venereology
LETTER TO THE EDITOR
Pantoea agglomerans – an underestimated pathogenic agent in penetrating trauma involving vegetative material Editor A 71-year-old woman presented with a subcutaneous node on the lower arm, increasing for 3 months. She reported neither a trauma nor an abroad visit during the past 2 years. The history included tuberculosis when she was 25. Clinically, on the ulnar side of the right lower arm was a 6 9 7 cm-sized, subcutaneous, hardly moveable, coarse pressure-sensitive node with no epidermal involvement. There was pale erythema of the skin above the pseudotumor with blurred outline and moderate hyperthermia (Fig. 1a). Besides a moderate CRP-elevation of 10.3 mg/l all other routine laboratory parameters were within normal ranges. Magnetic resonance imaging revealed a subcutaneous and muscle oedema without signs of osseous involvement (Fig. 1b). Differential diagnostics included benign and malignant tumours, as well as abscessing or granulomatous inflammations. Therapeutically, we decided on surgical exploration of the node. The tumour was found intraoperatively to be subfascial (Fig. 1c). After the muscle fascia was opened, semisolid yellowish pus was exuded and also a black, slightly branched foreign body about
1 cm in length (Fig. 1d). The granulomatous tissue was excised and the wound partially closed. In addition, we applied intravenous antibiotic therapy, initially calculated and later based on a resistogram, with cefuroxim and metronidazol. Restitutio ad integrum followed quickly. Although investigated several times, the patient could not remember any penetrating trauma at any time in the past. Histopathological examination showed the foreign body as a cell-rich piece of a plant with a pronounced bacterial mat in the outer portions (Fig. 2). Extensive purulent granulation was seen in the surrounding tissue. The lower arm fascia was also infiltrated with inflammatory cells. In all preparations, plasma cells, neutrophilic granulocytes and macrophages were found repeatedly. There was no evidence of fungal elements or cells with malignancy criteria. Only Pantoea agglomerans was cultured from the swab material collected intraoperatively. The culture for proof of tuberculosis bacteria, ubiquitous mycobacteria and yeasts were negative. Based on these findings, we diagnosed a localized pyomyositis caused by a wooden splinter contaminated with Pantoea agglomerans. Pantoea agglomerans is a gram-negative, facultatively anaerobic, yellow-pigmented rod-shaped bacterium belonging to the family of Enterobacteriaceae. The primary habitat of this bacterium is the environment, where it is usually found as epiphyte and endophyte in association with plants, fruits and vegetables. Additionally, it is isolated in the faeces of humans and animals and in the soil.1 As an
(a)
(b)
(c)
(d)
Figure 1 Pale erythema of the skin above the pseudotumor (a) and MRI-scan of the right lower arm with subcutaneous and muscle oedema (b). After the muscle fascia was opened (c), semisolid yellowish pus and also a black, slightly branched foreign body about 1 cm in length (d) was exuded.
JEADV 2015
© 2015 European Academy of Dermatology and Venereology
Letter to the Editor
2
(a)
(b)
infection have been reported in connection with contaminated parenteral nutrient products, infusions, catheters or blood products.1 In addition to its importance in human medicine, Pantoea agglomerans is of great interest for agriculture.5 Certain strains produce a number of potent antimicrobial substances. Because of this, they are used commercially in the USA, Canada and New Zealand as biopesticides against fire blight in apple and pear trees. In Europe, this use is not possible, since the bacterium is rated biosafety level 2 due to its opportunistic, human-pathogenetic properties. Thus, in the future, increased attention and documentation of cases of Pantoea agglomerans-caused illness is required in Europe to maintain the most objective rating of biosafety possible, independent of socio-economic interests, so that a pathogen which has hardly been noticed and which only seems to have low virulence cannot spread unconditionally.
Funding sources No funding source was engaged to write the manuscript or submit it for publication. ,2 W. Ch. Marsch,1 V. Stadie1 F. Friedling,1,* A.S. Kekule 1
Department of Dermatology and Venereology Halle (Saale), University Hospital Halle (Saale) of the Martin Luther University Halle Wittenberg, Ernst-Grube-Straße 40, Halle (Saale), Germany, 2Martin Luther University Halle-Wittenberg, Institute for Medical Microbiology, Magdeburger Straße 6, Halle (Saale), Germany *Correspondence: F. Friedling. E-mail: [email protected]
References Figure 2 Histopathological examination of the foreign body showed a cell-rich piece of a plant with a pronounced bacterial mat in the outer portions (a), HE 409. (b) presents a higher magnification of the square detail shown in (a), HE 4009. (ep, epidermis; ca, cambium; pi, pith).
opportunistic pathogen with low virulence, infections are uncommon in healthy individuals, typically following penetrating trauma by vegetation.2,3 As described in our case, the low virulence may lead to a delayed manifest infection after a long latency phase. Consequently, penetrating plant parts should be carefully located and surgically removed to prevent high-risk complications. In addition to localized infections immuno-suppressed patients and neonates may also develop primary bacteriemias and systemic infections.4 Outbreaks of nosocomial
JEADV 2015
1 Cruz AT, Cazacu AC, Allen CH. Pantoea agglomerans, a plant pathogen causing human disease. J Clin Microbiol 2007; 45: 1989–1992. 2 Vaiman M, Lazarovich T, Lotan G. Pantoea agglomerans as an indicator of a foreign body of plant origin in cases of wound infection. J Wound Care 2013; 22: 182, 184–185. 3 Jain S, Bohra I, Mahajan R, Jain S, Chugh TD. Pantoea agglomerans infection behaving like a tumor after plant thorn injury: an unusual presentation. Indian J Pathol Microbiol 2012; 55: 386–388. 4 Rave O, Assous MV, Hashkes PJ, Lebel E, Hadas-Halpern I, Megged O. Pantoea agglomerans foreign body-induced septic arthritis. Pediatr Infect Dis J 2012; 31: 1311–1312. 5 V€ olksch B, Thon S, Jacobsen ID, Gube M. Polyphasic study of plant- and clinic-associated Pantoea agglomerans strains reveals indistinguishable virulence potential. Infect Genet Evol 2009; 9: 1381–1391. DOI: 10.1111/jdv.13081
© 2015 European Academy of Dermatology and Venereology
