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Journal of Clinical Microbiology, June 1999, p. 2068-2070, Vol. 37, No. 6
0095-1137/99/$04.00+0
Copyright © 1999, American Society for Microbiology. All rights reserved.
Two Cases of Chromobacterium violaceum
Infection after Injury in a Subtropical Region
J.
Lee,1,*
J. S.
Kim,1
C. H.
Nahm,1
J. W.
Choi,1
J.
Kim,1
S. H.
Pai,1
K. H.
Moon,2
K.
Lee,3 and
Y.
Chong3
Departments of Clinical
Pathology1 and Orthopedic
Surgery,2 College of Medicine, Inha
University, Inchon, and Department of Clinical Pathology,
College of Medicine, Yonsei University, Seoul,3
Korea
Received 16 October 1998/Returned for modification 26 December
1998/Accepted 5 March 1999
 |
ABSTRACT |
Chromobacterium violaceum is a gram-negative rod and is
isolated from soil and water in tropical and subtropical regions. The species have pigmented and nonpigmented colony types. Infections caused by nonpigmented strains are rare. We report on two cases of
infection caused by both pigmented and nonpigmented strains of C. violaceum. Two 24-year-old Korea Airline stewardesses were admitted to Inha University Hospital, Inchon, South Korea, on 9 August
1997, 3 days after an airplane accident in Guam. Both had multiple
lacerations on exposed parts of their bodies. There was swelling,
tenderness, and pus discharge. The wounds contained many small
fragments of stones and weeds. A pigmented strain was isolated from the
left hand and a nonpigmented strain was isolated from the left knee of
one patient. For the other patient only a nonpigmented strain
was isolated from a foot wound. The nonpigmented colonies from the
left-knee and the left-foot wounds did not produce any pigment
even after an extended period of incubation. The biochemical characteristics were the same for each strain except for oxidase and
indole reactions. The pigmented strain was oxidase negative and
indole positive, whereas the nonpigmented strains were oxidase positive and indole negative. The patients were successfully
treated by debridement and with appropriate antibiotics.
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TEXT |
Chromobacterium violaceum
is a gram-negative rod which is found in the soil and water of tropical
and subtropical areas (8-10, 15, 18). Both pigmented and
nonpigmented strains exist, although the nonpigmented strains are rare.
Although infections caused by C. violaceum are rare
among mammals, Woley et al. reported on a case of C. violaceum infection in buffaloes in 1905 (11), and the
first human infection caused by the organism was reported in Malaysia
in 1927 (17).
We recently had an opportunity to see two patients with
C. violaceum infections. One patient was infected with
both pigmented and nonpigmented strains, and the other patient
was infected with only a nonpigmented strain. These are the first
two cases of C. violaceum infection reported in Korea.
Two 24-year-old Korean Airline stewardesses who received multiple
lacerations and abrasions at the time of a jetliner crash were
transferred from Guam to Inha University Hospital in Inchon, South
Korea, 3 days after the accident. They received emergency treatment
while at a hospital in Guam. At the time of admission to our hospital
the laboratory results for both patients were not remarkable. The
colonies that grew from a sample from the left-hand wound from patient
1 were deep purple, round, and slightly raised on blood agar and
MacConkey agar plates. A sample taken from the left-knee wound
from the same patient was cultured and grew nonpigmented colonies on
both blood agar and MacConkey agar plates, showing beta-hemolysis on the blood agar plate. Both showed gram-negative rods on Gram-stained smears. A bacterial culture of a sample taken from the left-foot wound
of patient 2 grew beta-hemolytic, colorless colonies on a blood agar
plate and colorless colonies on a MacConkey agar plate in 10 days. All
of these isolates were identified as C. violaceum by
conventional biochemical reactions (with published reactions
[21]) and with the API 20 NE system (Table
1). Antibiotic susceptibility tests were
performed by the disk diffusion method, and these results are presented
in Table 2. Empiric treatment with
cefpiramide and pefloxacin was started before identification and
susceptibility testing of the isolates. Antimicrobial
susceptibility testing showed that all of the isolates were
susceptible to ciprofloxacin; therefore, we considered that they should
be susceptible to pefloxacin as well. One of the isolates was
resistant to cefotaxime, but the empirically selected regimen was
continued for 10 days because the wound was showing signs of
healing. Later, the wounds were closed surgically. The patients
improved after 10 days of treatments, with complete healing.
Although the infectivity of C. violaceum is low, there
have been reports of human infections resulting in septicemia and skin, pulmonary, and liver abscesses in Vietnam, Taiwan, Malaysia, the United
States, Australia, and Senegal, among other places (2, 4, 7, 12,
13, 19, 20). In the majority of patients with C. violaceum infection, the skin is the port of entry for organisms
found in contaminated soil and water. It is even possible to be
infected via the oral route (14). C. violaceum can be an opportunistic pathogen and may cause diseases
in immunocompromised individuals. The case fatality rate may be as high
as 57%, according to a report from the United States. Macher et al.
(11) reported on 12 cases of C. violaceum
infection in patients with chronic granulomatous disease, and 7 of
these patients died between 7 days and 15 months after initial
infection. Because the culture of a specimen from the left hand of the
first patient grew pigmented C. violaceum along with
Serratia marcescens, the pathogenic role of
C. violaceum in this infection is not clear. However,
the only organism isolated from the lesions of the left knee of patient 1 and the left foot of patient 2 was nonpigmented C. violaceum, suggesting that C. violaceum was the
causative agent of these infections. About 9% of C. violaceum strains are reported to be nonpigmented. Although there
has been debate regarding the pathogenicities of nonpigmented
strains, it has been shown that in rats the infectivities of both
pigmented and nonpigmented strains of C. violaceum are comparable (16).
Samples from our patients grew both pigmented and nonpigmented strains
of C. violaceum. The pigmented strain developed a faint violet color after 1 day of incubation on a blood agar plate, and the
color became deeper in subsequent days. The nonpigmented strain did not
develop pigment even after a week of incubation. Most C. violaceum isolates produce oxidase and catalase but are negative
for Voges-Proskauer reaction and esculin. At times it may be difficult
to perform the oxidase test due to pigmentation. Therefore, we used
both fresh aerobically grown colonies with mild pigmentation and
anaerobically grown colonies without pigmentation when we performed the
oxidase test, as recommended by Silvendra et al. (15). About
21% of C. violaceum isolates are reported to be indole
positive (3, 5, 15). In contrast to previously reported
findings that most nonpigmented strains of C. violaceum are indole positive, our pigmented strain was indole positive and our
nonpigmented strains were indole negative.
Oxidase-negative nonpigmented strains of C. violaceum
may be difficult to differentiate from Haemophilus
aphrophilus or Pasteurella. However, the C. violaceum isolates were differentiated by their ability to grow on
a salmonella-shigella agar plate and by their arginine dihydrolase activity.
Oxidase-positive, nonpigmented strains may be confused with
Vibrio or Aeromonas (11, 15). These
may be differentiated by their ability to grow in a nutrient broth with
0% NaCl, their fermentation of D-glucose, mannitol, and
maltose, and their lysine decarboxylase and ornithine decarboxylase activities.
C. violaceum is usually susceptible to aminoglycosides,
chloramphenicol, and tetracycline but is resistant to penicillins and
cephalosporins (1, 6, 15). Some C. violaceum
strains have been reported to be resistant to the broad-spectrum
cephalosporins (1). At their last visits, 6 months after the
accident, both patients were free of infection.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Department of
Clinical Pathology, Inha University Hospital, 7-206, 3-Ga,
Shinheung-Dong, Jung-Gu, Inchon, 400-103, Korea. Phone: 82-32-890-2502. Fax: 82-32-890-2529. E-mail: Lee4{at}netsgo.com.
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Journal of Clinical Microbiology, June 1999, p. 2068-2070, Vol. 37, No. 6
0095-1137/99/$04.00+0
Copyright © 1999, American Society for Microbiology. All rights reserved.
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