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CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 6  |  Page : 547-549  

A case of non-healing ulcer by Corynebacterium striatum


Department of Microbiology and Dermatology, Tertiary Care Hospital, Pune, Maharashtra, India

Date of Submission20-Dec-2018
Date of Acceptance09-Feb-2019
Date of Web Publication17-Oct-2019

Correspondence Address:
Kanwaljit Kaur
Tertiary Care Hospital, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_257_18

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  Abstract 


Corynebacterium diphtheriae is well known to cause pathogenicity in humans as well as animals but other species of genus Corynebacterium are considered Diphtheroids and disregarded as commensals. But these good bacteria can become bad whenever immunosuppression takes place. Few authors have reported a negative experience by not giving them due importance. Corynebacterium striatum is one such diphtheroid which was isolated in our institute from a case of non-healing ulcer. The timely isolation and appropriate antibiotic led to complete recovery of the individual.

Keywords: Corynebacterium striatum, cutaneous diphtheria, skin nodules, skin ulceration


How to cite this article:
Kaur K, Sengupta P, Vashisht D, Pandit P. A case of non-healing ulcer by Corynebacterium striatum. Med J DY Patil Vidyapeeth 2019;12:547-9

How to cite this URL:
Kaur K, Sengupta P, Vashisht D, Pandit P. A case of non-healing ulcer by Corynebacterium striatum. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Nov 17];12:547-9. Available from: http://www.mjdrdypv.org/text.asp?2019/12/6/547/269430




  Introduction Top


Corynebacterium spp. other than diphtheriae are considered as commensals. However, with the advent of newer diagnostic technologies, identification of many bacterial species in the clinical samples has opened doors for pathogenic mechanisms for these organisms. Corynebacterium striatum is such one organism which has gained importance due to its isolation in many clinical samples. C. striatum has been known to cause endocarditis,[1] infections of the skin, wound, respiratory system, and central lines in both immunocompetent and immunocompromised patients.


  Case Report Top


A 29-year-old male patient, known case of HIV on antiretroviral therapy and disseminated tuberculosis on antitubercular therapy, presented with complaints of nonhealing, painless ulcer over the right supraclavicular region of 6-week duration.

Patient initially presented in August 2016 with fever, weight loss, and chronic cough for 4 weeks. During evaluation, he was found to be HIV positive. He had multiple enlarged cervical and axillary lymph nodes. The biopsy from a cervical lymph node was reported as granulomatous lymphadenitis with multiple acid-fast bacilli (AFB). However, sputum for AFB was negative. Contrast-enhanced computed tomography chest and abdomen showed multiple enlarged axillary and retroperitoneal lymphadenopathies along with hepatomegaly. CD4 count was 111 cells/ml. He was started on antitubercular therapy (ATT) with Isoniazid, Rifampicin, Pyrazinamide, Ethambutol (HRZE) initially for disseminated TB, followed 1 month later by ART (tenofovir, lamivudine, and efavirenz). He responded well in the form of weight gain, gradually decreasing lymphadenopathy, and increasing CD4 count to 594 cells/μl over 1 year.

Even after strict compliance to ATT, there was an increase in the size of right supraclavicular lymph node. Repeat lymph node biopsy was suggestive of granulomatous lymphadenitis. Line probe assay for MTB PCR was positive with sensitivity to rifampicin and isoniazid. Sputum for AFB was negative. HIV-1 viral load was <34 copies/ml. He was continued on HRZE and TLE.

The lymph node biopsy site showed little tendency to heal over the next 6 weeks. At presentation, there was well-defined ulcer with undermined edges in medial one-third of the right supraclavicular region with associated erythema and edema in the surrounding area. Ulcer was fixed to underlying structures and did not bleed on touch [Figure 1]. Pus swab culture from biopsy site was sent to microbiology laboratory for processing which showed growth of Corynebacterium spp. sensitive to linezolid. He was started on capsule linezolid 600 mg BD with near-complete healing of ulcer over the next 3 weeks.
Figure 1: Nonhealing ulcer

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Microbiological analysis

Pus swab and scrapings from the ulcer site were subjected to Gram staining and aerobic culture on blood agar and MacConkey agar. Gram-stained smears showed few pus cells and Gram-positive bacilli in Chinese letter pattern. After 24 h of incubation at 37°C, a single type of colony appeared on blood agar, which was 2–3 mm in size, moist, grayish white, and opaque with no hemolysis [Figure 2]. Gram-stained smear from the cultured colonies also exhibited Gram-positive bacilli in Chinese letter pattern [Figure 3]. The catalase test was positive. To rule out the possibility of nontuberculous mycobacteria, Zeihl–Neelson staining was also done which showed nonacid-fast bacilli. A presumptive diagnosis of Corynebacterium spp. was made. The growth so obtained was subjected to culture on Loeffler serum slope and Albert staining showed metachromatic granules and culture on Hoyle's medium showed black-colored colonies due to the conversion of tellurite to tellurium [Figure 2]. Repeat pus swab culture also showed similar growth. Hence, microbiological report of growth of Corynebacterium spp. was given to the clinician. The antibiotic sensitivity was put up by Kirby–Bauer method, and the isolate was found to be sensitive to linezolid, vancomycin, and teicoplanin.
Figure 2: Growth on blood agar and Hoyle's medium

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Figure 3: Chinese letter pattern on Gram staining

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For further confirmation of identity, the isolate was subjected to 16S rRNA sequencing by Sanger's method. The identification report was generated by EzBioCloud database, and confidence in identification was based on 700 bp sequence of the isolate with database, which showed 99.9% similarity with C. striatum. FASTA sequence of the same has been submitted to GenBank vide Accession number MH973198.


  Discussion Top


C. striatum is being recognized as an emerging multidrug-resistant pathogen. There is evolving interest in its pathogenicity as it has been reported in many of the case reports and hospital outbreaks as opportunistic pathogen in long-term hospitalized patients.[2] Masuda et al.[3] have also reported that C. striatum should not be disregarded just as a commensal but should be considered a potential pathogen because of its association with life-threatening complications.

C. striatum has been reported to be isolated from many specimens, namely, wound swab, tracheal aspirate, left ventricular assist devices, and blood. As it is a skin commensal, it can cause de novo cutaneous infection or can invade the preexisting skin lesions. McMullen et al.[1] have also found that this organism has specific predilection for skin and wound specimens. They have also found that majority of positive blood culture isolates are from peripheral sites rather than central lines, suggesting that it can cause endovascular device-associated infections. Bhat et al.[4] have reported an unusual presentation by this organism as a causative agent for infective endocarditis and isolated in repeated blood cultures. Souza et al.[5] have found an increased association of this organism in tracheal aspirate specimens owing to biofilm production.

As reported in many studies, C. striatum is a multidrug-resistant strain with resistance to penicillin, ciprofloxacin, cephalosporins, tetracycline, and clindamycin. Our isolate was also sensitive to only linezolid, vancomycin, and teicoplanin.


  Conclusion Top


C. striatum is an emerging multidrug-resistant pathogen and should be given due importance, especially in immunocompromised patients.[6] The early institution of appropriate antibiotic is a must to prevent life-threatening complications, including bacteremia. Besides, the hospital infection control practices and antibiotic stewardship programs must include this potential nosocomial pathogen because of multidrug resistance and intrahospital dissemination.[7]

Acknowledgment

The authors would like to acknowledge the National center for cell science (NCCS), Pune, especially Dr. Abhay Bajaj for helping in sequencing of the isolate. The authors would also like to appreciate and acknowledge the microbiology staff Mr. R K Verma and Mr. NM Poojar for their hard work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
McMullen AR, Anderson N, Wallace MA, Shupe A, Burnham CA. When good bugs go bad: Epidemiology and antimicrobial resistance profiles of Corynebacterium striatum, an emerging multidrug-resistant, opportunistic pathogen. Antimicrob Agents Chemother 2017;61. pii: e01111-17.  Back to cited text no. 1
    
2.
Verroken A, Bauraing C, Deplano A, Bogaerts P, Huang D, Wauters G, et al. Epidemiological investigation of a nosocomial outbreak of multidrug-resistant Corynebacterium striatum at one Belgian university hospital. Clin Microbiol Infect 2014;20:44-50.  Back to cited text no. 2
    
3.
Masuda H, Nakamura T, Mouri N, Sawa Y. Aortic valve replacement for quadricuspid valve: A lesson learnt from a negative experience. Interact Cardiovasc Thorac Surg 2014;19:334-5.  Back to cited text no. 3
    
4.
Bhat Y, Bal AM, Rochow S, Gould IM. An unusual case of Corynebacterium striatum endocarditis and a review of the literature. Int J Infect Dis 2008;12:672-4.  Back to cited text no. 4
    
5.
Souza CD, Faria YV, Sant'Anna Lde O, Viana VG, Seabra SH, Souza MC, et al. Biofilm production by multiresistant Corynebacterium striatum associated with nosocomial outbreak. Mem Inst Oswaldo Cruz 2015;110:242-8.  Back to cited text no. 5
    
6.
Bottone EJ, Fabbri M, Ashraf A. Corynebacterium striatum: Chronic infection of a cutaneous ulcer in a patient with AIDS. Rev Infect 2010;1:104-9.  Back to cited text no. 6
    
7.
Suh JW, Ju Y, Lee CK, Sohn JW, Kim MJ, Yoon YK, et al. Molecular epidemiology and clinical significance of Corynebacterium striatum isolated from clinical specimens. Infect Drug Resist 2019;12:161-71.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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