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CORRESPONDENCE
Year : 2012  |  Volume : 30  |  Issue : 4  |  Page : 489-491
 

Catheter-related bacteremia due to M. chelonae in an immunocompromised patient: An emerging nosocomial pathogen


1 Department of Microbiology, BLK Super Speciality Hospital, New Delhi, India
2 Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Department of Medical Oncology, BLK Super Speciality Hospital, New Delhi, India

Date of Submission19-Feb-2012
Date of Acceptance09-Aug-2012
Date of Web Publication24-Nov-2012

Correspondence Address:
S Jain
Department of Microbiology, BLK Super Speciality Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.103792

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How to cite this article:
Jain S, Singh S, Sankar M M, Saha R, Rangaraju R R, Chugh T D. Catheter-related bacteremia due to M. chelonae in an immunocompromised patient: An emerging nosocomial pathogen. Indian J Med Microbiol 2012;30:489-91

How to cite this URL:
Jain S, Singh S, Sankar M M, Saha R, Rangaraju R R, Chugh T D. Catheter-related bacteremia due to M. chelonae in an immunocompromised patient: An emerging nosocomial pathogen. Indian J Med Microbiol [serial online] 2012 [cited 2019 Sep 18];30:489-91. Available from: http://www.ijmm.org/text.asp?2012/30/4/489/103792


Dear Editor,

Rapidly growing mycobacteria (RGM) have emerged as important pathogens in catheter-related infections, especially in immunocompromised hosts with malignancies and long-term indwelling catheters. [1] The incidence of NTM (non-tuberculous mycobacteria) infection has been increasing with the growing population of patients with therapeutic interventions, induced immunocompromised status. Recently, Redelman-Sidi and Sepkowitz reviewed 36 studies in world-wide literature reporting 151 cancer patients with RGM bacteremia wherein central venous catheter (CVC) was present in 97% patients and M. mucogenicum was the predominant species. [2] The data on incidence of clinically significant NTM infections from India are scarce as these are frequently underdiagnosed in countries endemic for TB due to nonspecific clinical manifestations, unfamiliarity of clinicians and inadequacy of laboratory services. [3] Only two reports of RGM bacteremia are available from India - a report of four RGM bacteremia cases due to M. chelonae and M. fortuitum from a tertiary care centre in South India; and a case of M. abscessus bacteremia secondary to non-healing sternal osteomyelitis from North India. [4],[5] The NTM isolation rate from India has been reported to range from 0.5% to 8.6%. [4],[6]

We report a case of catheter-related bacteremia due to M. chelonae in a 55-year-old woman with recurrent ovarian carcinoma undergoing aggressive chemotherapy via a totally implanted central venous device (TID) (Port-a-Cath) inserted 3 months back. She presented with complaints of high grade fever and chills. The catheter exit site appeared normal with no evident source for her fever. Her total leucocyte count was 2.4×10 3 /ml, platelet count was 77×10 3 /ml. Her urine and blood sample from peripheral vein were sterile on culture. Blood culture vial (BACTEC 9120, BD, NJ, USA) with blood from port catheter signalled positive after 13.2 hours and gram stained smear from the vial showed gram positive bacilli in clusters. Ziehl-Neelsen staining was performed which was positive for acid fast bacilli. On subcultures, white to pale coloured, 2-3 mm in diameter, smooth colonies on blood agar [Figure 1] and small, pink colonies on MacConkey agar were obtained after 72 h of incubation. The isolate was identified as M. chelonae based on following results : l0 ack of pigmentation, negative nitrate reduction, positive tellurite test, growth on MacConkey agar and multiplex PCR. The PCR comprised of genus-specific primer targeting hsp65 gene, Mycobacterium tuberculosis complex-specific primer targeting esat 6 and Mycobacterium avium complex-specific primer pairs targeting 16S-23S Internal Transcribed Spacer sequences. Only hsp65 gene was amplified while the genes for M. tuberculosis complex and M. avium complex were not detected. Primers for the amplification of a 1030 bp 16 s rRNA gene target were used as described elsewhere. [7] The sequence and orientation of these primers were as follows 16 s rRNA 285, 5' gag agt ttg atc ctg gct cag 3'; and primer 16 s rRNA 264, 5' tgc aca aca ggc cac aag gga 3'. Antimicrobial susceptibility performed by Kirby-Bauer disk diffusion method showed sensitivity to amikacin, erythromycin, linezolid, imipenem and levofloxacin and resistance to doxycycline. Oral levofloxacin and linezolid therapy was initiated, however, fever continued although catheter insertion site did not suggest any signs of infection. Her repeat blood culture from catheter was positive for gram positive and acid fast bacilli while peripheral blood culture was sterile. Her white cell counts further lowered to 0.7×10 3 /ml, and platelets, 26×10 3 /ml. Antibiotic lock therapy with amikacin was attempted to salvage the catheter but fever persisted even after two weeks of therapy; therefore, implanted catheter was surgically excised after sending blood from both sites along with catheter tip for culture. This time, both catheter and peripheral blood vials flagged positive and the catheter tip showing gram positive and acid fast bacilli. Intravenous amikacin and oral clarithromycin were administered after removal of catheter; however, fever continued despite a week of therapy. After switching over to cefoperazone-sulbactum, she defervesced within 48 hours and blood counts increased to 3.7×10 3 /ml. The patient remained afebrile with sterile blood cultures on follow up visits for 4 months.
Figure 1: Blood agar showing growth of Mycobacterium chelonae

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Considering the persistent colonization of port catheter (as it was positive for M. chelonae on three different occasions before being positive in peripheral blood) and to prevent the possible impending risk of bacteremia, antibiotic lock therapy was initiated to eradicate the organism from the port catheter. M. fortuitum and M. chelonae may colonize and readily form biofilms on catheter wall making it extremely difficult to eradicate and contributing to their resistance to antimicrobial agents. Our patient subsequently did develop M. chelonae bacteremia probably due to combined effect of host's immunocompromised condition and unrelenting colonization of catheter in situ which was continuous source of infection. Therefore, catheter removal is necessary in immunocompromised patients for successful control of therapy even in the absence of any signs of infection at the exit site.

Because of differences in susceptibilities among species and even within species, rapid identification and subsequent susceptibility testing are essential for selection of appropriate antibiotic agent(s). Amikacin by far shows the highest efficacy to M. chelonae. [4] Despite in vitro sensitivity to amikacin and clarithromycin, our patient failed to exhibit clinical response to the therapy after the infected catheter was also removed. Therapeutic regimen therefore needs to be tailored based on combination of susceptibility results, immunological status of host, clinical response and microbiological clearance of the previously positive site.

In conclusion, clinicians need to be aware of the significance of NTM infections in immunocompromised patients and in the event of fever and/or redness or oozing at catheter exit site, blood cultures can enhance detection of such infections. NTM infections are also underreported in the laboratory since many times gram positive bacilli may be dismissed as diphtheroids and not processed further for identification.

 
 ~ References Top

1.Swanson DS. Central venous catheter-related infections due to nontuberculous mycobacterium species. Pediatr Infect Dis J 1998;17:1163-4.  Back to cited text no. 1
    
2.Redelman-Sidi G, Sepkowitz KA. Rapidly growing mycobacteria infection in patients with cancer. Clin Infect Dis 2010;51:422-34.   Back to cited text no. 2
[PUBMED]    
3.Jani MN, Rodrigues CS, Mehta AP. The neglected and often ignored : N0 ontuberculous mycobacteria. J Global Infect Dis 2011;3:94.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Jesudason MV, Gladstone P. Non-tuberculous mycobacteria isolated from clinical specimens at a tertiary care hospital in South India. Indian J Med Microbiol 2005;23:172-5.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Sarma S, Sharma S, Baweja UK, Mehta Y. Mycobacterium abscessus bacteremia in an immunocompetent patient following a coronary artery bypass graft. J Cardiovasc Dis Res 2011;2:80-2.   Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.Set R, Rokade S, Agrawal S, Shastri J. Antimicrobial susceptibility testing of rapidly growing mycobacteria by microdilution-experience of a tertiary care centre. Indian J Med Microbiol 2010;28:48-50.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Springer B, Stockman L, Teschner K, Roberts GD, Böttger EC. Two-laboratory collaborative study on identification of mycobacteria: Molecular versus phenotypic methods. J Clin Microbiol 1996;34:296-303.  Back to cited text no. 7
    


    Figures

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