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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
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  Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 38  |  Issue : 3  |  Page : 496-499
 

Burkholderia vietnamiensis causing a non-lactational breast abscess in a non-cystic fibrosis patient in Tamil Nadu, India


1 Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India
2 Division of Infectious Diseases, Nitte University Center for Science Education and Research, Nitte (Deemed to be University), Deralakatte, Mangaluru, Karnataka, India
3 Department of Breast Surgery, Madras Medical Mission, Chennai, Tamil Nadu, India

Date of Submission20-Jul-2020
Date of Decision26-Jul-2020
Date of Acceptance14-Aug-2020
Date of Web Publication4-Nov-2020

Correspondence Address:
Dr. Vijaya Kumar Deekshit
Nitte University Center for Science Education and Research, Nitte (Deemed to be University), Kotekar Beeri Road, Paneer Campus, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_20_329

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 ~ Abstract 


Burkholderia cepacia complex is a Gram-negative opportunistic pathogen usually found in people with an immunocompromised condition such as cystic fibrosis (CF). In a tropical country like India, this organism has been associated with a number of hospital-acquired infections including sepsis. We present here a report of a case of Burkholderia vietnamiensis causing a non-lactational breast abscess in a non-CF patient. The pathogen was identified as B. cepacia using Vitek system and matrix-assisted laser desorption ionisation–time of flight. This was confirmed by polymerase chain reaction (PCR) using recA genus-specific gene and sequencing of the PCR amplicons. recA-restriction fragment length polymorphism and recA gene sequencing revealed that the isolate is B. vietnamiensis. This is the first description of B. vietnamiensis isolated from a clinical case from India.


Keywords: Burkholderia vietnamiensis, diagnosis, recA-restriction fragment length polymorphism, wound infection


How to cite this article:
Rohit A, Rani M S, Anand N S, Chellappa C, Mohanapriya P, Karunasagar I, Karunasagar I, Deekshit VK. Burkholderia vietnamiensis causing a non-lactational breast abscess in a non-cystic fibrosis patient in Tamil Nadu, India. Indian J Med Microbiol 2020;38:496-9

How to cite this URL:
Rohit A, Rani M S, Anand N S, Chellappa C, Mohanapriya P, Karunasagar I, Karunasagar I, Deekshit VK. Burkholderia vietnamiensis causing a non-lactational breast abscess in a non-cystic fibrosis patient in Tamil Nadu, India. Indian J Med Microbiol [serial online] 2020 [cited 2020 Nov 24];38:496-9. Available from: https://www.ijmm.org/text.asp?2020/38/3/496/299835





 ~ Introduction Top


Burkholderia cepacia complex (Bcc) is a group of Gram-negative pathogens capable of causing life-threatening infections in immunocompromised individuals.[1] There are at least 24 species recognised. Clinical cases of Burkholderia infection are usually seen in people with cystic fibrosis (CF).[2] In India, B. cepacia is associated with healthcare-associated infections and sepsis.[3] Among the different species of Bcc, Burkholderia cenocepacia and Burkholderia multivorans have been frequently encountered, while the association of Burkholderia vietnamiensis within Burkholderia CF lung infections is generally under 10%.[4],[5],[6],[7] In addition, the association of B. vietnamiensis with non-CF clinical infections is always linked to the environment from which it is being isolated.[8],[9] Infections are often difficult to treat due to the intrinsic resistance shown toward a broad spectrum of drugs and strong biofilm formation by this pathogen.[10] However, recent studies have highlighted the presence of B. vietnamiensis prophages through genomic characterisation, which could further help in the discovery of novel bacteriophages with potential therapeutic applications.[11]

A case of B. vietnamiensis infection identified by rec A sequencing is reported here. Consent was taken from the patient before starting the experiments.


 ~ Case Report Top


A 33-year-old woman presented with a 6-cm breast abscess on 21 March 2019 without any significant medical history. The pus was collected by ultrasound-guided aspiration with betadine ointment as the interface for ultrasound probe. Culture showed no growth, acid-fast bacilli/GeneXpert was found to be negative, and hence, the patient was treated with ceftum (cefuroxime) 500 mg. Since there was no resolution of symptoms, a repeat pus culture was taken 5 days later on 26 March 2019. Culture showed scanty growth of Staphylococcus epidermidis which was then treated with amoxicillin and clavulanate 625 mg for 5 days. Incision and drainage on 29 March 2019 showed no growth, and the patient was continued on amoxicillin-clavulanic acid for 10 days. Due to mild persistence of symptoms, a repeat culture on 23 April 2019 showed no growth, and hence, antibiotic therapy was stopped. However, the patient presented in 2 weeks with a new burst open abscess on 11 May 2019 which showed scanty growth of Gram-negative bacilli that were identified by Vitek II Compact (BioMerieux, France) and matrix-assisted laser desorption ionisation–time of flight (MALDI-TOF) as B. cenocepacia. However, recA sequencing revealed that the isolate was B. vietnamiensis. The infection was treated with levofloxacin for 3 weeks with complete resolution. The patient worked in an office and had only travelled to the neighbouring state, Kerala, for 10 days at the beginning of May. No other significant history could be elicited.

The pus aspirates taken from left breast abscess were subjected to Gram stain, aerobic and anaerobic culture and culture for Mycobacterium tuberculosis on MGIT (BD). The organism grew sparsely on 5% sheep blood agar. Initial bacterial identification was on Vitek II compact along with antimicrobial susceptibility. Antimicrobial susceptibility was based on Clinical and Laboratory Standards Institute M-100 2019 guidelines, and the isolate was found to be sensitive to ceftazidime, co-trimoxazole, meropenem, levofloxacin and minocycline. The isolate was stored at −20°C for further study. To revive the culture, the organism was streaked on B. cepacia selective agar (HiMedia Laboratories Pvt. Ltd). The colonies with light yellow-to-pink colour were selected for further identification. Genomic DNA from each of the colonies was extracted and used as a template for polymerase chain reaction (PCR) using genus-specific primer recA[12] and the amplicons sequenced. 16SrDNA was amplified using primers described by Mahenthiralingam et al.[12] Further characterisation of the isolate was done using recA and 16SrRNA restriction fragment length polymorphism (RFLP) using HaeIII and DdeI restriction enzymes, respectively. Randomly amplified polymorphic DNA (RAPD)[13] was done to check the genetic similarity of the isolates with other Burkholderia groups.

Ethical approval

Written informed consent has been taken from the patient before performing the experiments.


 ~ Discussion Top


Bcc consists of 24 species, mostly associated with soil, water and plants.[14] While the association between CF and Bcc complex infection is well known, association with other cases is not well established, but Bcc infection in immunocompromised individuals cannot be ignored. However, our patient was not immunocompromised. The pus sample initially yielded S. epidermidis, and antibiotic treatment followed by incision and drainage suggested that the infection is resolved. It is possible Burkholderia from water source, which could have invaded the site. Bcc can be isolated using a selective agar containing specific antibiotics. However, identification of different genomovars of the Bcc is possible mainly by the sequencing of Burkholderia-specific recA gene[8],[15] or by multilocus sequence typing analysis.[16],[17] As sequencing cannot be done as a routine diagnostic procedure, these organisms may be underreported due to the misidentification in automated systems such as Vitek II compact and MALDI-TOF.

The microorganism described in the present study was isolated from a patient with secondary non-lactational breast abscess. The isolate was identified as Burkholderia using recA PCR. This is in accordance with earlier studies, wherein recA PCR was mainly used as a reliable tool to identify Burkholderia complex.[3],[15],[18] Further, the sequencing of recA revealed that the isolate was B. vietnamiensis belonging to the genomovar V. The sequenced recA gene has been submitted to GenBank and assigned accession number MT551873 [Figure 1]. The recA gene showed 99.7% similarity with the B. vietnamiensis sequences available in the GenBank (CP02039, CP013433, CP009631 and AF143793). The recA sequencing also revealed the presence of six restriction sites for the enzyme HaeIII. However, the gel electrophoresis of recA RFLP could detect only 4 visible bands, namely 108 bp, 182 bp, 281 bp and 402 bp in size upon restriction digestion. 16SrRNA RFLP of B. vietnamiensis did not reveal any variation in the banding pattern from that of other Burkholderia strains. RAPD analysis grouped the isolate in R6 category (data not shown) with the highest similarity to genomovar 1. The isolate was also found to be invasive and replicative in NCIH-522 cell line.
Figure 1: DNA sequence of recA gene of Burkholderia vietnamiensis with the restriction sites (bold red) for the enzyme HaeIII

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Among Bcc, the majority of the human cases are associated with B. cenocepacia and B. multivorans, while B. vietnamiensis was found to be less frequently encountered in human infections.[8] Further, most of the reported cases of B. vietnamiensis infection are mainly associated with the patient with CF.[8],[10] A rarely encountered B. vietnamiensis from a non-CF patient is described in this case and may be the first report from a non-lactational breast abscess. Although a curable infection, if left untreated, can easily become life threatening in immunocompromised individuals. The patient in this case had no known risk factors and was not immunosuppressed.

In India, there are no precise reports on the occurrence of Bcc infections, however, few cases have described the prevalence of Bcc in non-CF patients.[19],[20] It has been recognised as the third most commonly isolated non-fermenting microorganisms next to Pseudomonas aeruginosa and Acinetobacter calcoaceticus-baumannii complex at PGIMER.[21] The incidence of individual species of Bcc in wound infections such as in this case is a cause of concern since it is one of the important species of nosocomial infections after ESKAPE pathogens.[3] However, it is important to understand that species identification of BCC is best achieved by hisA or recA sequencing rather than biochemical or MALDI-TOF-based identification.[3]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

We are grateful to acknowledge Nitte (Deemed to be University) for providing resources and infrastructure for the execution of this research.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
Madeira A, dos Santos SC, Santos PM, Coutinho CP, Tyrrell J, McClean S, et al. Proteomic profiling of Burkholderia cenocepacia clonal isolates with different virulence potential retrieved from a cystic fibrosis patient during chronic lung infection. PLoS One 2013;8:e83065.  Back to cited text no. 1
    
2.
Coenye T, Vandamme P. Diversity and significance of Burkholderia species occupying diverse ecological niches. Environ Microbiol 2003;5:719-29.  Back to cited text no. 2
    
3.
Ragupathi NK, Veeraraghavan B. Accurate identification and epidemiological characterization of Burkholderiacepacia complex: An update. Ann Clin Microbiol Anti 2019;18:7.  Back to cited text no. 3
    
4.
Zlosnik JE, Zhou G, Brant R, Henry DA, Hird TJ, Mahenthiralingam E, et al. Burkholderia species infections in patients with cystic fibrosis in British Columbia, Canada. 30 years' experience. Ann Am Thorac Soc 2015;12:70-8.  Back to cited text no. 4
    
5.
Pope CE, Short P, Carter PE. Species distribution of Burkholderia cepacia complex isolates in cystic fibrosis and non-cystic fibrosis patients in New Zealand. J Cyst Fibros 2010;9:442-6.  Back to cited text no. 5
    
6.
Lupo A, Isis E, Tinguely R, Endimiani A. Clonality and antimicrobial susceptibility of Burkholderia cepacia complex isolates collected from cystic fibrosis patients during 1998-2013 in Bern, Switzerland. New Microbiol 2015;38:281-8.  Back to cited text no. 6
    
7.
Lipuma JJ. The changing microbial epidemiology in cystic fibrosis. Clin Microbiol Rev 2010;23:299-323.  Back to cited text no. 7
    
8.
Kenna DT, Lilley D, Coward A, Martin K, Perry C, Pike R, et al. Prevalence of Burkholderia species, including members of Burkholderia cepacia complex, among UK cystic and noncystic fibrosis patients. J Med Microbiol 2017;66:490-501.  Back to cited text no. 8
    
9.
Medina-Pascual MJ, Valdezate S, Carrasco G, Villalón P, Garrido N, Saéz-Nieto JA. Increase in isolation of Burkholderia contaminans from Spanish patients with cystic fibrosis. Clin Microbiol Infect 2015;21:150-6.  Back to cited text no. 9
    
10.
Jassem AN, Zlosnik JE, Henry DA, Hancock RE, Ernst RK, Speert DP.In vitro susceptibility of Burkholderia vietnamiensis to aminoglycosides. Antimicrob Agents Chemother 2011;55:2256-64.  Back to cited text no. 10
    
11.
Weiser R, Yap ZL, Otter A, Jones BV, Salvage J, Parkhill J, et al. A Novel Inducible Prophage from Burkholderia vietnamiensis G4 is widely distributed across the species and has lytic activity against pathogenic Burkholderia. Viruses 2020;12:601.  Back to cited text no. 11
    
12.
Mahenthiralingam E, Bischof J, Byrne SK, Radomski C, Davies JE, Av-Gay Y, et al. DNA-based diagnostic approaches for the identification of Burkholderia cepacia complex bacterial pathogens: Burkholderia vietnamiensis, Burkholderia multivorans, Burkholderia stabilis, Burkholderia cepacia genomovar I and Burkholderia cepacia genomovar III. J Clin Microbiol 2000;38:3165-73.  Back to cited text no. 12
    
13.
Mahenthiralingam E, Campbell ME, Foster J, Lam JS, Speert DP. Random amplified polymorphic DNA typing of Pseudomonas aeruginosa isolates recovered from patients with cystic fibrosis. J Clin Microbiol 1996;34:1129-35.  Back to cited text no. 13
    
14.
Tavares M, Kozak M, Balola A, Sá-Correia I. Burkholderia cepacia complex bacteria: A feared contamination risk in water-based pharmaceutical products. Clin Microbiol Rev 2020;33:E00139-19.  Back to cited text no. 14
    
15.
Payne GW, Vandamme P, Morgan SH, Lipuma JJ, Coenye T, Weightman AJ, et al. Development of a recA gene-based identification approach for the entire Burkholderia genus. Appl Environ Microbiol 2005;71:3917-27.  Back to cited text no. 15
    
16.
Bach E, Sant'Anna FH, Magrich dos Passos JF, Balsanelli E, de Baura VA, Pedrosa FD, et al. Detection of misidentifications of species from the Burkholderia cepacia complex and description of a new member, the soil bacterium Burkholderiacatarinensis sp. nov. Pathog Dis 2017;75:Ftx076.  Back to cited text no. 16
    
17.
Gautam V, Patil PP, Kumar S, Midha S, Kaur M, Kaur S, et al. Multilocus sequence analysis reveals high genetic diversity in clinical isolates of Burkholderia cepacia complex from India. Sci Rep 2016;6:35769.  Back to cited text no. 17
    
18.
McDowell A, Mahenthiralingam E, Moore JE, Dunbar KE, Webb AK, Dodd ME, et al. PCR-based detection and identification of Burkholderia cepacia complex pathogens in sputum from cystic fibrosis patients. J Clin Microbiol 2001;39:4247-55.  Back to cited text no. 18
    
19.
Gautam V, Arora A, Madhup SK, Das A, Vandamme P, Sharma K, et al. Burkholderia cepacia complex in septicaemic non-cystic fibrosis cases from two tertiary care hospitals in north India. Indian J Med Res 2010;131:829-32.  Back to cited text no. 19
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20.
Gautam V, Ray P, Das A, Vandamme P, Malhotra P, Varma S, et al. Two cases of Burkholderia cenocepacia in septicemic patients. Jpn J Infect Dis 2008;61:133-4.  Back to cited text no. 20
    
21.
Gautam V, Ray P, Vandamme P, Chatterjee SS, Das A, Sharma K, et al. Identification of lysine positive non-fermenting gram negative bacilli (Stenotrophomonas maltophilia and Burkholderia cepacia complex). Indian J Med Microbiol 2009;27:128-33.  Back to cited text no. 21
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