Previous Article | Next Article 
Journal of Clinical Microbiology, June 2000, p. 2450-2452, Vol. 38, No. 6
0095-1137/00/$04.00+0
Copyright © 2000, American Society for Microbiology. All rights reserved.
Recurrent Bacteremic Peritonitis Caused by Enterococcus
cecorum in a Patient with Liver Cirrhosis
Po-Ren
Hsueh,1,2
Lee-Jene
Teng,1,3
Yu-Chi
Chen,1
Pan-Chyr
Yang,2
Shen-Wu
Ho,3 and
Kwen-Tay
Luh1,2,*
Departments of Laboratory
Medicine1 and Internal
Medicine,2 National Taiwan University Hospital,
and School of Medical Technology, National Taiwan
University College of Medicine,3 Taipei, Taiwan
Received 29 November 1999/Returned for modification 18 February
2000/Accepted 6 March 2000
 |
ABSTRACT |
Enterococcus cecorum (formerly Streptococcus
cecorum), originally isolated from poultry intestines, has rarely
been encountered in human diseases. A 60-year-old man with liver
cirrhosis and hepatocellular carcinoma developed peritonitis on the
seventh day of his hospitalization. Cultures of one blood sample and
one ascites fluid sample obtained on that day both grew E. cecorum. The patient received intravenous cefoxitin therapy and
initially responded well. Unfortunately, another episode of peritonitis associated with septic shock developed 24 days after the start of
treatment, and culture of one blood specimen yielded the same organism.
The isolates were identified by the conventional biochemical tests, the
API Rapid ID 32 Strep system, and the API ZYM system (both systems from
bioMerieux, Marcy L'Etoile, France) and were further confirmed by
cellular fatty acid chromatography and 16S rRNA gene partial
sequencing. The identical biotype, antibiotype, and random amplified
polymorphic DNA pattern of the three isolates documented the long-term
persistence of this organism in the patient. To the best of our
knowledge, this is the first clinical description of recurrent
bacteremic peritonitis caused by E. cecorum.
| |
CASE REPORT |
A 60-year-old man was admitted to the hospital on
1 December 1998 because of black-colored stool, oliguria, jaundice, and disorientation of 1 week's duration. The patient had had hepatitis B
virus-related liver cirrhosis diagnosed 20 years earlier. During his
hospitalization, bleeding of esophageal and gastric varices, decompensated liver cirrhosis with ascites, and hepatic encephalopathy were diagnosed. He received supportive treatment, and his general condition improved. However, fever and abdominal pain developed on 19 December 1998. The patient was treated with intravenous cefoxitin (2 g
every 8 h) under the suspicion of spontaneous bacterial peritonitis. Examinations of the ascites fluid specimen revealed a
white blood cell count of 4,000/mm3 with 85% neutrophils.
Bacterial cultures of one blood sample in BACTEC 6A aerobic culture
bottles (Becton Dickinson, Sparks, Md.) and one ascites fluid (turbid)
specimen collected on 19 December both yielded Enterococcus
species (isolates A and B) after 2 days of incubation. The fever
subsided and the abdominal pain resolved 2 days after the initiation of
treatment. The two Enterococcus isolates were susceptible to
penicillin (MICs, 0.094 µg/ml) as determined by the Etest (AB
BIODISK, Solna, Sweden). The patient received cefoxitin treatment for a
total of 14 days.
Unfortunately, fever, abdominal pain with shifting dullness, increasing
abdominal girth, and tarry stool were noticed on 10 January 1999. One
set of blood cultures (grown in BACTEC 6A aerobic bottles) revealed the
same Enterococcus species; however, an ascites fluid culture
was negative for the organism. The patient received intravenous
ceftizoxime (2 g every 12 h) therapy. The patient's clinical
condition deteriorated and was complicated by acute renal failure,
jaundice, and intractable shock. Though the antibiotics were
shifted to vancomycin (1 g per day) and meropenem (500 mg per
day) because of the intractable septic shock, the patient died on the
53rd hospital day.
Microbiology.
The three isolates grew well on Trypticase soy
agar supplemented with 5% sheep blood (BBL Microbiology Systems,
Cockeysville, Md.) in 5% CO2 and in ambient air at
35°C. They were catalase-negative and gram-positive cocci. The
isolates formed smooth, gray, and convex colonies with slight
-hemolysis on Trypticase soy agar supplemented with 5% sheep blood.
These isolates did not grow on agar containing 5% NaCl and were unable
to grow on bile esculin agar (BBL Microbiology Systems) in ambient air
or 5% CO2 within 2 days, but scanty growth on both agar
plates was identified after 3 to 5 days of incubation. Group D antigen
reactions (Oxoid, Unipath Limited, Basingstoke, Hampshire,
England) of the three isolates were negative. They did not
hydrolyze pyrrolidony-
-naphthylamide but were able to
hydrolyze leucine--naphthylamide. Further phenotypic identification of these three isolates to the species level was done
using the API Rapid ID 32 Strep system (bioMerieux, Marcy L'Etoile,
France), and the API ZYM (bioMerieux Vitek, Inc.). Enterococcus cecorum ATCC 43198 was used as a control strain in this study.
The reaction profiles generated by the API Rapid ID 32 Strep system
(27176707110) and the API ZYM system for the three isolates and the
control strain were identical. The following characteristics suggested
our three isolates belonged to group IV E. cecorum: they had
positive reactions for sorbitol, raffinose, sucrose, -glucuronidase,
and alkaline phosphatase and negative reactions for mannitol, sorbose,
arginine, and arabinose (7).
Cellular fatty acid analysis of the isolates was performed as
previously described (
10). Six major cellular fatty acids
were found: octadecenoic acid (18:1), hexadecanoic acid (16:0),
tetradecanoic acid (14:0), hexadecenoic acid (16:1),
cis-9,12-octadecadienoic
acid (18:2), and octadecanoic acid
(18:0). The four isolates had
identical cellular fatty acid profiles
(Fig.
1).
View larger version (12K):
[in this window]
[in a new window]
|
FIG. 1.
Gas chromatogram of cellular fatty acid methyl esters of
E. cecorum. The designations of the fatty acid peaks refer
to the number of carbon atoms (number before the colon) and the number
of double bonds (number after the colon) (Microbial Identification
System; Microbial ID Inc., Newark, Del.).
|
|
Further identification of the isolates to species level was performed
by 16S rRNA gene partial sequencing using a pair of
universal primers,
DG74 and RW01, as described previously (
8).
The
amplification products were sequenced after being cloned into
plasmids
using a TA cloning kit. Following thermal cycling of
the sequencing
reactions with fluorescent dye-labeled primers
or terminators, the
nucleotide sequence was determined by an autosequencer
(Perkin-Elmer,
Applied Biosystem Division, Foster City, Calif.).
A BLAST search was
performed to compare the sequence of the clinical
isolate with those in
the GenBank and Ribosomal Database Project
databases. The closest match
observed was with
E. cecorum.
MICs of the 11 antimicrobial agents for the three isolates (isolates A,
B, and C) and the control strain (isolate D) of
E. cecorum were determined by the agar dilution method using
unsupplemented
Mueller-Hinton agar (BBL Microbiology Systems) as
described by
the National Committee for Clinical Laboratory
Standards (
11).
Staphylococcus aureus ATCC 29213 and
Enterococcus faecalis ATCC
29212 were used as
control strains in each set of the tests. The
three isolates recovered
from the patient were susceptible to
all the antimicrobial agents
tested and had identical antibiotypes,
which were different from that
of the control strain (Table
1).
The
-lactamase activities, determined by means of a chromogenic
cephalosporin assay (cefinase disk; BBL Microbiology Systems),
of the
three isolates were negative.
Random amplified polymorphic DNA (RAPD) patterns generated by
arbitrarily primed PCR (APPCR) were obtained, and the results
were
interpreted as previously described (
10). Two
oligonucleotide
primers, M13 (5'-GAGGGTGGCGGTTCT-3') and
ERIC1 (5'-GTGAATCCCCAGGAGCTTACAT-3'),
were used. The three
isolates recovered from the patient had identical
RAPD patterns, which
were different from those of the control
strain (Fig.
2).
View larger version (86K):
[in this window]
[in a new window]
|
FIG. 2.
RAPD patterns of the four isolates of E. cecorum generated by APPCR using two primers, ERIC1 and M13.
Lanes: M, molecular size marker; A to C, E. cecorum isolates
from the patient; D, E. cecorum ATCC 43198.
|
|
Enterococcus cecorum was first isolated from chicken
intestines and was formerly described as
Streptococcus
cecorum by Devriese
et al. in 1983 (
6). Since then,
this species has been identified
as part of the intestinal microflora
of many animal hosts, not
limited to poultry (
4-7). The
first human infection was reported
in a malnourished adult patient with
severe septicemia in 1997
(
9). We describe a patient with
liver cirrhosis and hepatocellular
carcinoma who had recurrent
bacteremic peritonitis due to this
organism.
Three important points were demonstrated in the present study. First,
this is the first clinical description of primary peritonitis
and
bacteremia due to
E. cecorum. Second, the phenotypic and
chemotaxonomic
traits of our
E. cecorum isolates (delayed
growth on both 5% NaCl
agar and bile esculin agar, negative
pyrrolidony-
-naphthylamide
reaction, devoid of demonstrable group D
antigen, and absence
of a cellular fatty acid,
C
19:0cyc11,12) were unique to those
displayed by more
frequently isolated enterococcal species (
1,
7,
9). Third,
using the biotyping, antibiotyping, and molecular
typing methods,
we documented that this organism can persist over
the long
term in the bloodstream or peritoneum and cause recurrent
infection.
The portal of entry of this organism and the cause for recurrent
infection in our patient were obscure. Greub et al. suggested
that
E. cecorum could colonize in the cutaneous lesions of a
person
who might have acquired the organism from domestic animals and
then reach the bloodstream, possibly via placement of an intravenous
catheter (
9). Whether our patient had previous
exposure to
any poultry or domestic animals before admission was not
known.
This organism has never been reported to inhabit the human
gastrointestinal
tract or skin (
7,
9). In our patient, the
seeding of this
organism into the peritoneum might have been secondary
to catheter-related
bacteremia or could have occurred via diseased
intestinal mucosa
where the organism had already been existing.
However, stool cultures
for the recovery of
E. cecorum were
not performed and cultures
of the removed catheter could not yield the
organism. The use
of cefoxitin, a well-known suboptimal agent for
treating severe
enterococcal infection (
11), during the
first bacteremic episode
might partly have contributed to the
recurrence of the
bacteremia.
Our
E. cecorum isolates had biochemical reactions, including
those in the API Rapid ID 32 Strep and API ZYM systems, identical
with
those of the isolate recovered by Greub et al. and also identical
with
that of the control strain (
9). In addition to the
biochemical
identification test, sodium dodecyl sulfate-polyacrylamide
gel
electrophoresis analysis of whole-cell proteins and reverse
transcriptase
sequencing of 16S rRNA are useful for accurate
identification
of
E. cecorum (
9,
12). The
commercially available enterococcal
nucleic acid probe (AccuProbe;
Gen-Probe, San Diego, Calif.) for
culture confirmation was reported to
be 100% accurate in identifying
Enterococcus species, but a
negative reaction of the assay was
documented in
E. cecorum
isolates (
2,
7,
9). Although
not valuable for species
identification, pulsed-field gel electrophoresis
has been superior for
the interpretation of interstrain relationships
(
3).
However, as described in our previous study (
10), RAPD
patterns generated by APPCR also appeared to be useful for strain
discrimination. The present report further demonstrates that cellular
fatty acid analysis is also a useful tool for the identification
of
E. cecorum.
In conclusion, this report described a case of
E. cecorum
peritonitis and bacteremia in a patient with liver cirrhosis and
emphasized the recurrent nature of this organism in human diseases.
To
accurately recognize this organism, clinical microbiologists
should be
alert to the unusual phenotypic traits of this enterococcal
species.
| |
FOOTNOTES |
*
Corresponding author. Mailing address: Department of
Laboratory Medicine, National Taiwan University Hospital, No. 7 Chung-Shan South Rd., Taipei, Taiwan. Phone: 886-2-23562149. Fax:
886-2-23224263. E-mail: luhkt{at}ha.mc.ntu.edu.tw.
| |
REFERENCES |
| 1.
|
Bosley, S. G.,
P. L. Wallace,
C. W. Moss,
A. G. Steigerwalt,
D. J. Brenner,
J. M. Swenson,
G. A. Hebert, and R. R. Facklam.
1990.
Phenotypic characterization, cellular fatty acid composition, and DNA relatedness of aerococci and comparison to related genera.
J. Clin. Microbiol.
28:416-421[Abstract/Free Full Text].
|
| 2.
|
Daly, J. A.,
N. L. Clifton,
K. C. Seskin, and W. M. Gooch, III.
1991.
Use of rapid, nonradioactive DNA probes in culture confirmation tests to detect Streptococcus agalactiae, Haemophilus influenzae, and Enterococcus spp. from pediatric patients with significant infections.
J. Clin. Microbiol.
29:80-82[Abstract/Free Full Text].
|
| 3.
|
Descheemaker, P.,
C. Lammens,
B. Pot,
P. Vandamme, and H. Goosens.
1997.
Evaluation of arbitrarily primed PCR analysis and pulsed-field gel electrophoresis of large DNA fragments for the identification of enterococci important in human medicine.
Int. J. Syst. Bacteriol.
47:555-561[Abstract/Free Full Text].
|
| 4.
|
Devriese, L. A.,
J. Hommez,
B. Pot, and F. Haesebrouck.
1994.
Identification and composition of the streptococcal and enterococcal flora of tonsils, intestines and faeces of pigs.
J. Appl. Bacteriol.
77:31-36[Medline].
|
| 5.
|
Devriese, L. A.,
K. Ceyssens, and F. Haesebrouck.
1991.
Characteristics of Enterococcus cecorum strains from the intestines of different animal sources.
Lett. Appl. Microbiol.
12:137-139.
|
| 6.
|
Devriese, L. A.,
G. N. Dutta,
J. A. E. Farrow,
A. van de Kerckhove, and B. A. Phillips.
1983.
Streptococcus cecorum, a new species isolated from chickens.
Int. J. Syst. Bacteriol.
33:772-776[Abstract/Free Full Text].
|
| 7.
|
Facklam, R. R.,
D. F. Sahm, and L. M. Teixeira.
1999.
Enterococcus, p. 297-305.
In
P. R. Murray, E. J. Baron, M. A. Pfaller, F. C. Tenover, and R. H. Yolken (ed.), Manual of clinical microbiology, 7th ed. American Society for Microbiology, Washington, D.C.
|
| 8.
|
Greisen, K.,
M. Loeffelholz,
A. Purohit, and D. Leong.
1994.
PCR primers and probes for the 16S rRNA gene of most species of pathogenic bacteria, including bacteria found in cerebrospinal fluid.
J. Clin. Microbiol.
32:335-351[Abstract/Free Full Text].
|
| 9.
|
Greub, G.,
L. A. Devriese,
B. Pot,
J. Dominguez, and J. Bille.
1997.
Enterococcus cecorum septicemia in a malnourished adult patient.
Eur. J. Clin. Microbiol. Infect. Dis.
16:594-598[CrossRef][Medline].
|
| 10.
|
Hsueh, P. R.,
L. J. Teng,
H. J. Pan,
Y. C. Chen,
L. H. Wang,
S. H. Chang,
S. W. Ho, and K. T. Luh.
1999.
Emergence of vancomycin-resistant enterococci at a university hospital in Taiwan: persistence of multiple species and multiple clones.
Infect. Control Hosp. Epidemiol.
20:828-833[CrossRef][Medline].
|
| 11.
|
National Committee for Clinical Laboratory Standards.
1999.
Performance standard for antimicrobial susceptibility testing. Ninth informational supplement. NCCLS document M100-S9.
National Committee for Clinical Laboratory Standards, Wayne, Pa.
|
| 12.
|
Williams, A. M.,
J. A. E. Farrow, and M. D. Collins.
1989.
Reverse transcriptase sequencing of 16S ribosomal RNA from Streptococcus cecorum.
Lett. Appl. Microbiol.
8:185-189.
|
Journal of Clinical Microbiology, June 2000, p. 2450-2452, Vol. 38, No. 6
0095-1137/00/$04.00+0
Copyright © 2000, American Society for Microbiology. All rights reserved.
This article has been cited by other articles:
-
Chung, H.-C., Teng, L.-J., Hsueh, P.-R.
(2007). Liver abscess due to Neisseria sicca after repeated transcatheter arterial embolization. J Med Microbiol
56: 1561-1562
[Abstract]
[Full Text]
-
Tsai, J.-C., Hsueh, P.-R., Lin, H.-M., Chang, H.-J., Ho, S.-W., Teng, L.-J.
(2005). Identification of Clinically Relevant Enterococcus Species by Direct Sequencing of groES and Spacer Region. J. Clin. Microbiol.
43: 235-241
[Abstract]
[Full Text]
-
Chiang, W.-C., Tsai, J.-C., Chen, S.-Y., Hsu, C.-Y., Wu, C.-T., Teng, L.-J., Hsueh, P.-R.
(2004). Mycotic Aneurysm Caused by Streptococcus constellatus subsp. constellatus. J. Clin. Microbiol.
42: 1826-1828
[Abstract]
[Full Text]
-
Woo, P. C. Y., Tam, D. M. W., Lau, S. K. P., Fung, A. M. Y., Yuen, K.-Y.
(2004). Enterococcus cecorum Empyema Thoracis Successfully Treated with Cefotaxime. J. Clin. Microbiol.
42: 919-922
[Abstract]
[Full Text]
-
De Baere, T., Claeys, G., Verschraegen, G., Devriese, L. A., Baele, M., Van Vlem, B., Vanholder, R., Dequidt, C., Vaneechoutte, M.
(2000). Continuous Ambulatory Peritoneal Dialysis Peritonitis due to Enterococcus cecorum. J. Clin. Microbiol.
38: 3511-3512
[Abstract]
[Full Text]
Top
Abstract
Case Report
