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Journal of Clinical Microbiology, February 2000, p. 929-930, Vol. 38, No. 2
Diagnostica Medical
Laboratory,1 Hirslanden
Hospital,2 and Department of Medical
Microbiology, University of Zurich,3 Zurich,
Switzerland
Received 2 August 1999/Accepted 8 November 1999
We present the case of a 77-year-old woman who developed an
Actinomyces naeslundii infection of a hip prosthesis. The
isolate grew well aerobically with 5% CO2. Possible
diagnostic problems may arise in the microbiological laboratory because
aerobic growth is not sufficiently accounted for in some of the
traditional identification schemes and commercial test kits. Therefore,
besides presenting an unusual pathogen in this setting, this report
focuses on possible diagnostic problems in the microbiological laboratory.
We report a case of an
Actinomyces naeslundii infection of a hip prosthesis in a
77-year-old woman. In 1992, the patient underwent a total arthroplasty
of the right hip. Due to loosening of the prosthesis, a replacement was
necessary in November 1998. Perioperatively, three 1.5-g doses of
cefuroxime were given parenterally, every 12 h, with the first
dose given 1 h prior to surgery. Initially, a considerable
response with good mobilization was achieved. Early in April 1999, severe motion-dependent pain was observed. There were no signs of
infection, and an X ray of the hip joint was judged normal. On April
17, the patient had to be hospitalized due to progressive pain. The
C-reactive protein level in the patient was 123 mg/liter (normal,
<10.0 mg/liter), and the leukocyte count was 10,100/mm3
(normal, 4,000 to 10,000/mm3). Puncture yielded a purulent
fluid. In a Gram stain, many leukocytes but no microorganisms could be
seen. After 2 days of incubation at 37°C, a few tiny colonies grew on
sheep blood agar incubated aerobically with 5% CO2 as well
as anaerobically; these bacteria were eventually identified as A. naeslundii. When antimicrobial susceptibilities were known,
therapy with amoxicillin with clavulanic acid was replaced with
cefuroxime plus rifampin on April 29 (16). The clinical
response was good, laboratory parameters returned to normal, and,
subsequently, therapy was stopped on June 8. On June 22, the C-reactive
protein level had reached 11 mg/liter. At the present time, the
clinical course has been excellent, and therefore, the hip has not been
punctured again.
A. naeslundii infection is known in classical settings
of actinomycosis in the head and the abdomen (2). The
infection of a hip prosthesis presented here is unique. According to a
Medline search, A. naeslundii has not been described as an
infectious agent in infections of prostheses. However, a serious case
of osteomyelitis with A. naeslundii after a foot injury has
been reported (14). Two reports of Actinomyces
israelii being the causative agent in late hip infection with
possible hematogenous spread have been published (11, 13).
Since the infection in the patient reported herein occurred only 6 months after hip surgery, a hematogenous spread from the patient's own
bacterial flora could be postulated (10). Dental work on a
molar tooth was performed early in 1999. Routine
antibiotic prophylaxis is not recommended for such procedures
(1).
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Copyright © 2000, American Society for Microbiology. All rights reserved.
Infection of a Hip Prosthesis by
Actinomyces naeslundii
ABSTRACT
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Abstract
Case Report
References
CASE REPORT
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Abstract
Case Report
References
TABLE 1.
Microbiological characteristics of the A. naeslundii strain isolated from our patient
The bacterial isolate was identified by conventional methods (15) combined with gas-liquid chromatography of volatile and nonvolatile fatty acids from prereduced, anaerobically sterilized chopped-meat broth containing carbohydrates (9). MICs were determined by the E-test procedure (AB Biodisk, Solna, Sweden) with an inoculum corresponding to McFarland standard 0.5 on Mueller-Hinton agar with 5% sheep blood incubated at 37°C in 5% CO2 for 24 h (8). The results are summarized in Table 1.
Today, many laboratories rely on commercial identification kits rather
than traditional media. Therefore, the following kits were challenged
with our A. naeslundii isolate: RapID ANA II, RapID CB Plus
(both from Remel, Lenexa, Kans.), API 20A, and API CORYNE 2.0 (both
from BioMérieux, La-Balme-les-Grottes, France). Enzymatic
activities were further determined by the API ZYM kit (BioMérieux). The results are presented in Table
2. The RapID ANA II and API 20A anaerobe
identification kits performed well, with the exception of the negative
test for urea degradation in the RapID ANA II. Enzymatic activity in
the API ZYM kit corresponded to the data published by Brander and
Jousimies-Somer (3). Problems were encountered with the API
CORYNE, version 2.0, which was in fact used in a first attempt because
the strain grew as well in 5% CO2 as it did in an
anaerobic atmosphere. Subsequent testing in RapID CB Plus, the only
commercial alternative to API CORYNE for aerobically growing
gram-positive rods, resulted in an excellent identification. For
differentiation of A. naeslundii from A. israelii, urease production is a critical test; it could be
detected only after 48 h of incubation in the API 20A kit, after
4 h in the RapID CB Plus kit, and after 3 days in Chistensen's
medium.
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Problems of correct recognition of many Actinomyces spp. are posed by their ability to grow aerobically to some extent and by the fact that aerobic growth is not taken into account in some of the traditional identification schemes used in clinical laboratories (5) nor in commercial identification kits (6, 7). As early as 1977, in the VPI Anaerobe Laboratory Manual (9), some strains of A. israelii, A. naeslundii, and Actinomyces viscosus were described as being able to grow as well aerobically with CO2 as anaerobically. This was also pointed out by Schaal in the 1986 Bergey's Manual of Systematic Bacteriology (12). Therefore, these Actinomyces spp. should be included in tables and commercial systems used for the identification of aerobically isolated gram-positive rods. They are dealt with, for example, in the identification scheme of von Graevenitz and Funke (15). In the 1999 edition of the Manual of Clinical Microbiology (4), there is an introductory algorithm that may be helpful in avoiding erroneous identifications.
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ADDENDUM IN PROOF |
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A crude antigen of the A. naeslundii isolate from the patient was prepared as described previously (R. Zbinden, A. Hany, R. Lüthy, D. Conen, and I. Heiner, APMIS 106:547-552, 1998) and was used to determine the serological response by complement fixation. A serum sample collected on 31 August 1999 revealed a titer of 1:80 that sustains an immunological reaction against the causative A. naeslundii.
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FOOTNOTES |
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* Corresponding author. Mailing address: Labor Diagnostica, Dufourstrasse 90, CH-8034 Zürich, Switzerland. Phone: 41-1-383 89 50. Fax: 41-1-383 83 47. E-mail: jwust{at}unilabs.ch.
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REFERENCES |
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Abstract
Case Report
References
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Journal of Clinical Microbiology, February 2000, p. 929-930, Vol. 38, No. 2
0095-1137/00/$04.00+0
Copyright © 2000, American Society for Microbiology. All rights reserved.
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