braz j infectdis.2015;19(1):82–84
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
w w w . e l s e v i e r . c o m / l o c a t e / b j i d
Brief
communication
Endocarditis
by
Kocuria
rosea
in
an
immunocompetent
child
Jorge
Salomão
Moreira
a,
Adriana
Gut
Lopes
Riccetto
b,∗,
Marcos
Tadeu
Nolasco
da
Silva
b,
Maria
Marluce
dos
Santos
Vilela
b,
Study
Group
Centro
Médico
de
Campinas/Franceschi
Medicina
Laboratorial
1aPontificiaUniversidadeCatólicadeCampinas/Puccamp,Campinas,SP,Brazil
bPediatricImmunology,CenterforInvestigationinPediatrics(CIPED),PediatricsDepartment,FacultyofMedicalSciences,State
UniversityofCampinas/Unicamp,Campinas,SP,Brazil
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r
t
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c
l
e
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n
f
o
Articlehistory: Received27June2014 Accepted30September2014 Availableonline15December2014
Keywords: Infectiousendocarditis Kocuriarosea Immunesystem Children
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b
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c
t
KocuriaroseabelongstogenusKocuria(Micrococcaceaefamily,suborderMicrococcineae,order Actinomycetales)thatincludesabout11speciesofbacteria.Usually,Kocuriasparecommensal organismsthatcolonizeoropharynx,skinandmucousmembrane;Kocuriaspinfectionshave beendescribedinthelastdecadecommonlyaffectingimmunocompromisedpatients,using intravenouscatheterorperitonealdialysis.Thesepatientshadmainlybacteremia/recurrent sepsis.Weherebydescribethecaseofa10-year-oldgirl,immunocompetent,whohad endo-carditis/sepsisbyK.roseawhichwasidentifiedinfivedifferentblood culturesbyVitek 2ID-GPC card(BioMérieux, France). NegativeHIVserology, blood countwithin normal rangeofleukocytes/neutrophils andlymphocytes,normalfractionsofthecomplement, normallevelofimmunoglobulinsfortheage;lymphocyteimmunophenotypingwasalso withintheexpectedvalues.ThymusimagewasnormalatchestMRI.Nocatheterswere required.IdentificationofK.roseawasessentialtothiscase,allowingthedifferentiationof coagulase-negativestaphylococcianduseofaneffectiveantibiotictreatment.Careful labo-ratoryanalysisofGram-positiveblood-borninfectionsmayrevealmorecasesofKocuriasp infectionsinimmunocompetentpatients,whichmaycollaborateforabetterunderstanding, preventionandearlytreatmentoftheseinfectionsinpediatrics.
©2014ElsevierEditoraLtda.Allrightsreserved.
∗ Correspondingauthorat:CenterforInvestigationinPediatrics,PediatricsDepartment,FacultyofMedicalSciences,StateUniversityof
Campinas/Unicamp,RuaTessáliaVieiradeCamargo,126,Campinas,SãoPauloCEP13083-887,Brazil. E-mailaddress:aglriccetto@gmail.com(A.G.L.Riccetto).
1 Address:PrivateHospital,CentroMédicodeCampinasandPrivateLaboratoryService,FranceschiMedicinaLaboratorial,Campinas,
SP,Brazil.
http://dx.doi.org/10.1016/j.bjid.2014.09.007
brazj infect dis.2015;19(1):82–84
83
KocuriaroseabelongstogenusKocuria(Micrococcaceae fam-ily,suborderMicrococcineae,orderActinomycetales)thatincludes about11speciesofbacteria,characteristicallygrampositive andaerobic(althoughsomespecieslikeKocuriakristinae, Kocu-riamarinaandKocuriarhizophilamayproliferateinanaerobic conditions).1
Usually, Kocuria sp are commensal organisms that colo-nize oropharynx, skin, and mucous membrane; Kocuria sp infectionshavebeendescribedinthelastdecadecommonly affectingimmunocompromised patients, usingintravenous catheter or peritoneal dialysis. These patients had mainly bacteremia/recurrentsepsis.1–5Itisnoticeable,however,that theimmunocompromisewasnotmandatoryinallreported cases.3
MostpediatriccaseswerecausedbyK.kristinae;K.rosea wasonlydescribedinonechilduntilnow,withperitonitis2–7
(Table1).
Laboratory identification of Kocuria sp by biochemistry methodsisdifficultduetosimilaritywithother pathogens, especially coagulase-negative staphylococci, which delays the propertreatment.1,3
We herein describe a case of a 10-year-old girl who wasdiagnosedwithaorticcoarctation,whichwassurgically corrected at the age of 11 days. Since then she has had compensatedcongestiveheartfailureusingpropranololand furosemide.Thisgirlhadappropriateweightandheightfor her age and no other co-morbidity during her life.At the ageof10yearsshebeganhavingdailyfever(without identi-fiedcause)andsplenomegaly.Thirtydaysafterthefirstfever episode,shehadclinicalandradiologicaldiagnosisof pneu-monia, at first treated with oral clarithromycin. After one weekoftreatment,thepatienthadagainfeverassociatedwith
headache,heartfailure,andsignsofsepsis;complementary imaging evaluation showed subarachnoid hemorrhage and bacterialendocarditis(vegetationinthemitralvalve).During thisperiod,fivebloodcultures,inthreedifferentdays,were positiveforK.rosea.Thepatientrespondedwelltointravenous amoxicillinandclavulanateandsupportmeasures(oxygenby mask,diuretics);centralintravenouscatheterorother inva-siveprocedureswerenotrequired.
AsKocuriaspinfectionisclassicallyrelatedto immunodefi-ciency,aspecificinvestigationwascarriedoutthatnegative for HIV infection, leukocytes/neutrophils and lymphocytes withinnormalrange, normalfractions ofthe complement, normal levelsofimmunoglobulins forthe age; lymphocyte immunophenotyping was also withinthe expected values. ThethymuslookednormalatchestMRI.
Kocuria sp laboratory identification was performed in a three-phasebloodsamplesystem(Probac);fivesamples,on three different days (day 0, 3 and 28), were positive for Gram-positive cocci in tetrads;the colonygrew under aer-obic conditionsat37◦C;replication tookplacein5%sheep bloodmedium(BioMérieux,France).Kocuriaspidentification wasperformedbyVitek2ID-GPCcard(BioMérieux,France). Analysisofthegenomethroughmolecularmethodsis desir-able,butduetoeconomicandtechnicallimitationsitsusewas notpossibleinourservice.
Infectiveendocarditis(IE)isadiseasewithhighmortality rate,despitemedicaladvances.IEisuncommoninchildren under17-year-oldandmostcasesareassociatedwith struc-tural heart defects. Arecent Canadian study involving 136 childrenwithIEshowedthatcyanoticcongenitalcardiopathy andsurgicalcorrectionbeforesixmonthsoldweremajorrisk factors.8Inthecaseshownhere,bothsituationswerepresent.
Table1–ReportedcasesofKocuriaspinfectionsinpediatricpatients.
Author/Year Patient/Age Clinicalpresentation Etiology Underlyingcondition
Presentcase2014 Female
10yearsold
Endocarditis K.rosea Congenitalheartdisease(Aortic
coarctation/earlysurgicalcorrection)
Chen2013 12infants (0.6–3.3 months) Apnea,bradicardia, desaturation, thrombocytosis, neutropenicfever,high fever
K.kristinae 6–prematurity;1–acuteleukemia(all7 withcentralvenouscatheter);5without underlyingdiseases(withperipheral catheter)
Dotis2012 Female
8yearsold
Peritonitis K.rosea Peritonealdialysis/dysplastickidneys
Moissenet2012 Female
3yearsold
Persistentbloodstream infection
K.rhizophila TotalcolonicformofHirschsprung’s disease/Terminalileostomyand colostomy/Subcutaneousimplantable vascular-accessportforhomeparenteral nutrition
Karadag2012 Female
4months-old
Bloodstreaminfectionand Blackhairytongue.
K.kristinae ProlongeddiarrheaandSeverefailureto thrive.Totalparenteralnutritionviaacentral venouscatheter
Lai2010 Male
2years-old
Bloodstreaminfection K.kristinae CongenitalshortbowelSyndrome,
hypogammaglobulinemia,Porth-A-cathfor totalparenteralnutrition
Becker2008 Male
8yearsold
Repeatedsepticepisodes K.kristinae Methylmalonicaciduriaduetoa
noncobalamin-responsivedeficiencyof methylmalonylcoenzymeAmutase. Subcutaneousimplantablevascular-access port(Port-A-Cath;Vital-Port)forintravenous diet
84
braz j infectdis.2015;19(1):82–84ThemostcommonetiologicalagentsforIEareStreptococcus viridans, Staphylococcus aureus, coagulase-negative Staphylo-coccus, and Streptococcus pneumoniae. Enterococcus and other Gram-negativearerare. ThegenusKocuria isconsidered an atypical cause of endocarditis1; one case of IE by K. rosea was described in a 35-year-oldwoman, but no cases have beendescribedinchildren.9Regardingantibiotic susceptibil-ity,Kocuria spissensitivetoavarietyofdrugs(amoxicillin, cephalosporin, aminoglycoside, vancomycin, clindamycin); variable sensitivityto quinolonesand sulfa.3,9 Amoxicillin-clavulanate has been proposed as the initial antibiotic treatment,1 asdone inthis case. Potentially contaminated catheters,ifpresent,mustberemoved.
ManyaspectsofKocuriaspinfectionsarenotyetentirely understood; besides human and other mammals, these bacteriamaybefoundindrinkingwatersources,different sed-iments,seedandfermentedfood,beingnotableforitstropism for plastics. Kocuria sp usually form a biofilm, frequently inassociationwith otherbacteria.2 ArecentlyidentifiedK. rosea strain (BS1) is capable of producing an exopolysac-charide(calledKocuran),that has,in vitro, antioxidantand immunosuppressiveproperties–inhuman polymorphonu-clear cultures stimulated with PHA, Kocuran inhibit the proliferationofthesecellsandalsoinhibitcomplement medi-atedhemolysis.10
There are few sporadic reports of Kocuria sp infections (especiallybyK. rosea); in the present case,despite IE risk factors,thelabscreeningforprimaryimmunodeficiencywas negative and there was no prolonged use of any kind of catheters. Genomic methods, as 16S RNA gene sequence, are desirable for correct identification of coagulase-negative staphylococciwhichpresentsalargephenotypicvariation;this kindofapproachisequallyusefultoconfirmKocuriaspecies.11 However,despitenothavingusedgenomicmethodsandsome restriction about Vitek 2ID GPCcard,11,12 identification of K. rosea was essential in this case, and subsequent use of effectiveantibiotictreatment.Carefullaboratoryanalysisof Gram-positivebloodinfectionmayrevealmorecasesof Kocu-riaspinfectionsinimmunocompetentpatients,whichmay contribute for better understanding, prevention, and early treatmentoftheseinfectionsinpediatrics.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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