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Journal of Clinical Microbiology, March 1999, p. 769-771, Vol. 37, No. 3
0095-1137/99/$04.00+0
Copyright © 1999, American Society for Microbiology. All rights reserved.
Isolation of Abiotrophia adiacens from a
Brain Abscess Which Developed in a Patient after Neurosurgery
C.
Biermann,1,*
G.
Fries,2
P.
Jehnichen,1
S.
Bhakdi,1 and
M.
Husmann1
Institut für Medizinische Mikrobiologie
und Hygiene,1 and
Neurochirurgische
Klinik und Poliklinik,2 Johannes Gutenberg
Universität Mainz, 55101 Mainz, Germany
Received 30 September 1998/Returned for modification 5 November
1998/Accepted 16 November 1998
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ABSTRACT |
We report the case of a patient who developed a large brain abscess
after neurosurgery. Cerebrospinal fluid from the abscess drainage
yielded Abiotrophia adiacens-specific PCR products and microorganisms that were identified by conventional microbiological methods and by 16S ribosomal DNA analysis as Abiotrophia
adiacens, which was formerly classified as a member of
nutritionally variant streptococci.
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TEXT |
The genus Abiotrophia
comprises fastidious gram-positive bacteria (4), previously
referred to as nutritionally variant streptococci (NVS). These
organisms grow as satellite colonies around other bacteria or on
complex media supplemented with L-cysteine or pyridoxal
hydrochloride. NVS are part of the normal oral, intestinal, and genital
flora and were first isolated from patients with endocarditis and
otitis media (3). Reportedly, NVS cause 5% of the cases of
streptococcal endocarditis (6). Isolations have also been made from patients with otitis externa, wound infections, pancreatic abscess, and conjunctivitis (8). We report the isolation of Abiotrophia adiacens from the cerebrospinal fluid (CSF) of a
patient who developed a brain abscess after neurosurgery.
Case report.
A 46-year-old woman was admitted to the
Department of Neurosurgery, University Hospital Mainz, because of
persisting headache, nausea, and vomiting for 3 weeks. Her past medical
history revealed two neurosurgical operations: excision of an
astrocytoma, WHO grade II-III, in 1994 and removal of a tumor
recurrence in March 1998, 2 months prior to this admission. On
admission, the patient appeared ill and displayed low-grade neck
stiffness. She was afebrile, and nothing abnormal was detected at the
former site of operation. The patient had a leukocyte count of
17.4 × 109/liter and an elevated C-reactive protein
level (6 mg/dl). A computerized tomography (CT) of the brain revealed a
large cystic mass with perifocal edema at the former tumor resection
site (Fig. 1). On clinical examination,
the patient did not display symptoms of sinusitis, dental infections,
or other conditions predisposing for the development of a brain
abscess. The patient received high-dose steroids and underwent a
craniotomy. Purulent material was aspirated following incision of the
dura mater. A large brain abscess that could be completely excised was
found at the former tumor resection site. The lateral wall of the right
ventricle was resected, and a cerebrospinal fluid (CSF) drainage was
established. Histopathological examination of the abscess material
revealed pus and central necrosis surrounded by a capsule consisting of
connective tissue, indicative of a chronic inflammatory reaction.
Following removal of the abscess, the patient was treated with
ceftriaxone (1 g per day) and gentamicin (240 mg per day) for 10 days.
The C-reactive protein level and leukocyte count returned to normal
values during therapy. Clinical recovery was achieved, and the patient
was discharged after 15 days.
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FIG. 1.
Results from a gadolinium-enhanced CT scan demonstrating
a cystic mass with perifocal edema in the right frontal temporoparietal
hemisphere.
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Two swabs were taken from the aspirated pus for microbiological
analysis. Microscopic examination of Gram-stained smears revealed
polymorphonuclear neutrophils (PMN) but no bacteria. Cultures
of this
material on blood agar cross-streaked with
Staphylococcus aureus, on cysteine-lactose-electrolyte-deficient (CLED) agar,
and on Schaedler agar as well as thioglycolate broth remained
sterile.
A possible explanation for the sterile cultures could
be that the swabs
were not taken from the active margin of the
lesion and did not contain
sufficient amounts of bacteria for
culture. Possibly fastiduous
bacteria did not get enough support
for growth during transport. A
sample of the purulent abscess
aspirate would have been the superior
material for microbiological
examination.
At 36 h after the neurosurgical procedure, CSF drained from the
operation site was taken for microbiological analysis. Many
PMN and
pleomorphic gram-variable coccobacilli were visible on
the Gram-stained
smear, most of them located within granulocytes
(Fig.
2). CSF cultures were performed on blood
agar plates (aerobic
and anaerobic culture conditions) and on brain
heart infusion
broth. After 24 h, growth of a few alpha-hemolytic
colonies was
detected only on blood agar plates cross-streaked with
S. aureus.
The bacteria could not be cultivated on chocolate
agar. The pathogen
was identified by sequencing of amplified 16S
ribosomal DNA (rDNA)
fragments as described previously (
9).
Sequencing of amplification
products obtained directly from the CSF
yielded identical results.
Similarity searches using the BLAST program
(
1) were performed
with test sequences of various lengths up
to 530 bp. For unambiguous
species identification, a signature sequence
of 50 bases (corresponding
to positions 145 through 194 of the
Abiotrophia adiacens gene
[accession no.
dbj/D50450/ABAGIFUA]) was sufficient. All four
of the
highest-scoring homologous sequences were derived from
various
Abiotrophia species isolates, with
A. adiacens
showing
the highest alignment score.
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FIG. 2.
Direct smear of CSF drained from the operation site
showing PMN and intracellular pleomorphic gram-variable coccobacilli.
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Results of conventional microbiological tests were in accordance with
the 16S rDNA-based identification of our isolate. As
described for
Abiotrophia species, 0.001% pyridoxal hydrochloride
or
0.01% cysteine was required for growth on blood agar plates
(
8). Neither chocolate agar, thioglycolate broth, brain
heart
infusion broth, nor anaerobic culture supported growth of the
present isolate. Conflicting reports have been published (
8)
on the usefulness of these culture conditions for growth of NVS.
These
discrepant results are probably due to inconsistent levels
of required
nutrients in different formulations of the same medium
or variability
in the levels of nutrients required by individual
NVS strains. Further
biochemical characterization was performed
by using the API 20 Strep
System with modifications as described
by Bouvet et al. (
2).
As shown in Table
1, the isolated strain
exhibited the enzyme pattern characteristic of
A. adiacens
(
7,
8).
Central nervous system infections due to
Abiotrophia or NVS
have never been reported to our knowledge. One reason could be
that
these organisms are easily overlooked because of their nutritional
requirements. Perhaps NVS can cause cerebral infections only under
special conditions. In the present case, it remains unclear whether
the
infection was acquired from an endogenous or exogenous source.
The
patient did not display clinical signs of an additional focus
of
infection. The histological findings of a chronic inflammation
suggest
that this abscess had developed over a long period. It
is possible that
the bacteria had entered the brain during the
neurosurgical procedure
performed 2 months previously. Alternatively,
a transient bacteremia
could have resulted in colonization of
the tumor resection site. A CT
scan done after the craniotomy
in March had revealed intracranial
hemorrhage. As in two other
cases (
5,
10) of brain abscesses
due to a commensal bacterium
(
Mycoplasma hominis), hematoma
formation might have been an important
prerequisite for the development
of this central nervous system
infection with
Abiotrophia
adiacens.
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ACKNOWLEDGMENTS |
We thank the members of our routine laboratory for skillful work,
Bernhard Jahn for helpful discussions, and P. Stoeter for kindly
providing the CT scans.
This work was supported by grant 836-386261/190 of the "Stiftung
Rheinland-Pfalz für Innovation" awarded to M. Husmann and S. Bhakdi.
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FOOTNOTES |
*
Corresponding author. Mailing address: Institut
für Med. Mikrobiologie und Hygiene, Hochhaus am Augustusplatz,
55101 Mainz, Germany. Phone: 06131-172865. Fax: 06131-392359. E-mail:
Biermann{at}goofy.zdv.uni-mainz.de.
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Journal of Clinical Microbiology, March 1999, p. 769-771, Vol. 37, No. 3
0095-1137/99/$04.00+0
Copyright © 1999, American Society for Microbiology. All rights reserved.
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