braz j infect dis.2014;18(5):561–564
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
Case
report
Rothia
aeria
endocarditis
in
a
patient
with
a
bicuspid
aortic
valve:
case
report
Antonio
Carlos
Nicodemo
a,∗,
Luiz
Guilherme
Gonc¸alves
a,
Fatuma
Catherine
Atieno
Odongo
a,
Marines
Dalla
Valle
Martino
c,
Jorge
Luiz
Mello
Sampaio
baDepartmentofInfectiousandParasiticDiseases,MedicalSchool,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil bDepartmentofClinicalAnalysis,SchoolofPharmacy,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil
cMicrobiologyLaboratory,HospitalIsraelitaAlbertEinstein,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received11April2014
Accepted6May2014
Availableonline4June2014
Keywords: Rothiaaeria Endocarditis Intestinaltranslocation Moleculardiagnosis
a
b
s
t
r
a
c
t
Rothiaaeriaisanuncommonpathogenmainlyassociatedwithendocarditisincasereports.
Inpreviousreports,endocarditisbyR.aeriawascomplicatedbycentralnervoussystem
embolization.Inthecasewereportherein,endocarditisbyR.aeriawasdiagnosedafteracute
self-limiteddiarrhea.InadditiontothecommontranslocationofR.aeriafromtheoralcavity,
wehypothesizethepossibilityofintestinaltranslocation.Matrix-assistedlaserdesorption
ionization-timeofflightmassspectrometryandgeneticsequencingareimportanttoolsthat
cancontributetoearlyandmoreaccurateetiologicdiagnosisofsevereinfectionscausedby
Gram-positiverods.
©2014ElsevierEditoraLtda.Allrightsreserved.
Introduction
RothiaisagenusofGram-positive,non-acid-fastbacteria
pro-posedbyGeorgeandBrownin1967.Thisgenusgrowswell
under aerobic conditions on BHI agar. Young colonies are
smooth,tendingtobecomerough,dry,convexandadherent
totheculturemediumwhenmature.Thebacterialcellscan
appearcoccoid,cocco-bacillaryor filamentous.Thespecies
Rothiaaeriawascharacterizedin2004afterisolationfromthe
RussianspacestationMir.Initially,itwasknownasRothia
den-tocariosagenomovarII.1R.aeriaisknowntocolonizehuman
oralcavity,buthasalsobeenidentifiedinduodenalbiopsyas
∗ Correspondingauthor.
E-mailaddresses:acnicodemo@uol.com.br,clinicanicodemo@uol.com.br(A.C.Nicodemo).
acolonizeroftheuppergastrointestinaltract.2Toour
knowl-edge,thisisthesixthcasereportofendocarditisbyR.aeria.
Case
report
Apreviouslyhealthy25-year-oldmanpresentedwithacute
self-limited diarrhea for three days after a trip to
Sal-vador, Brazil. After diarrhea resolution, he started to
experience daily fever spikes. He visited a physician who
prescribedlevofloxacin500mgdailyforsevendayswith
symp-tom improvement. However, fever recurred after stopping
http://dx.doi.org/10.1016/j.bjid.2014.05.001
562
braz j infect dis.2014;18(5):561–564Table1–SummarizedcasereportsofRothiaaeriaclinicalinfections.
Author/Year Reference Disease Riskfactor/chronicdz Age Treatment Outcome
HiraiwaTetal. Japan.2013 3 Endocarditis (positiveaerobic bloodcultures) Renaltransplantation duetorenalcell carcinomaon tacrolimusand everolimususe Dentalcariesand gingivitis 63years PenicillinG 8weeks Brainseptic embolizationas complication Survived ThiyagarajanA etal. UK.2013 4 Endocarditis (positiveaerobic bloodcultures)
Notreportedonabstract 61years Benzylpenicillin+ Rifampicin+ Gentamicin Brainseptic embolizationas complication Survived CroweAetal. Australia.2013 5 Endocarditis (positiveaerobic bloodcultures) Ex-smoker Hypertension 48years Benzylpenicillin+ Gentamicin2weeks; Benzylpenicillin+ Ceftriaxone8weeks; Rifampicin+ Ciprofloxacin12 weeks Brainseptic embolizationas complication Spleen,leftkidney infarction Rightrenalartery andhepaticartery aneurysms Survived TarumotoNetal.
Japan.2012
6 Endocarditis Smoking 40years Ceftriaxone+ Gentamicin Diedon15thdayof hospitaladmission ofbrainstem hemorrhagic complication HolleranKand RasiahS. Australia.2012
7 Endocarditis Notreported 48years Notreported Diedofhemorrhagic complication FalconeELetal.
USA.2012
8 Neckabscess X-linkedchronic granulomatousdisease andprednisoneusefor colitis 18years Amoxicillin-probenecidfor2 months Survived VerrallAJetal. NewZealand. 2010
9 Dentaldecayand shoulder articulation infection Dentalcaries Methotrexateand hydrocortisonefor rheumatoidarthritis
88years Penicillinfor14days Survived
MichonJetal. France.2010
10 Acutebronchitis Anti-TNFtherapy (etanercept)for rheumatoidarthritis 66years Amoxicillin+ Moxifloxacinfor1 week Survived HiyamutaHetal. Japan.2010 11 Pulmonary cavitaryinfection Steroidand
azathioprinetherapyfor neurosarcoidosis
53years Penicillinfor8 weeks+Amoxicilin for5months
Survived
MonjuAetal. Japan.2009
12 Neonatalsepsis Motherunderwent decayedtooth extraction4daysbefore delivery
3hoflife Ampicillin+ Cefotaximefor11 days
Survived
levofloxacin. He sought further medical assistance on the
4thweekofillness.Examinationwasremarkableforagrade
2/6aorticmurmurandanenlargedspleen.Transesophageal
echocardiography showed abicuspid aorticvalve with
sig-nificantregurgitation and avegetationof4mm. Two blood
culturesamples obtainedfrom different venous sites both
yieldedGram-positiverods.Empiricaltreatmentwith
ampi-cillin2gq4handvancomycin,initialloadingdoseof25mg/kg
and maintenance dose of 15mg/kg q12h, was started due
to initialorganism identification asRothia spp. After
com-plete identification of the bacteria as R. aeria, vancomycin
wasdiscontinued.Ampicillinwasmaintainedbecause
antimi-crobialsusceptibilitytestshoweda0.032mcg/mLminimum
inhibitoryconcentration(MIC)forpenicillin.Thisisolatewas
susceptibletoallofthetestedantimicrobials(ciprofloxacin
1mcg/mL,gentamicin1.5mcg/mL,linezolid0.38mcg/mL,and
vancomycin1.5mcg/mL),exceptfordaptomycinwithaMICof
6.0g/mL.Endocarditistreatmentwasuneventful.Thepatient
progressivelyimproved,fevercompletelyresolvedand
inflam-mationmarkersnormalized.Ampicillinwasstoppedafterfive
weeksandfollow-upechocardiographyrevealedcomplete
brazj infect dis.2014;18(5):561–564
563
Discussion
RothiaisagenusofGram-positive,non-acid-fastbacteria
pro-posedbyGeorgeandBrownin1967.Thisgenusgrowswell
under aerobic conditions on BHI agar. Young colonies are
smooth,tendingtobecomerough,dry,convexandadherent
totheculturemediumwhenmature.Thebacterialcellscan
appearcoccoid,cocco-bacillaryorfilamentous.ThespeciesR.
aeriawascharacterizedin2004afterisolationfromthe
Rus-sianspacestationMir.Initially,itwasknownasR.dentocariosa
genomovarII.1R.aeriaisknowntocolonizehumanoralcavity,
buthasalsobeenidentifiedinduodenalbiopsyasacolonizer
oftheuppergastrointestinaltract.2Toourknowledge,thisis
thesixthcasereportofendocarditisbyR.aeria.
AfteraliteraturesearchofR.aeriainfections,ourcaseis
the eleventhcasereportofclinical infection and the sixth
casereportofendocarditis.3–12Thecasereportsincludefive
casesofendocarditis,3–7onecaseofneckabscess,8onecase
ofshoulderjointinfection9;twocasesoflunginfection10,11;
andonecaseofneonatalsepsis,12asshowninTable1.Three
caseshadaprevioushistoryofdentalcariesandthe
neona-talsepsisoccurredaftermaternaltoothextraction.3–9These
previouscasereportsshowthatR.aeriaiscapableofinfecting
variousbodysitesandalsoshowthatinfectionbythisagent
isprobablymoreinimmunocompromisedpatients,assome
patientswere on immunosuppressivemedications.3,8–11 All
fivecasereportsofendocarditisbyR.aeriahadcentralnervous
systememboliccomplications;twocaseshadfatalcentral
ner-voussystemhemorrhage.3–7Inonerecentcasereportofmitral
valveendocarditiswithconfirmedbrainsepticemboli,prompt
antibiotictreatmentandurgentmetallicmitralvalve
replace-mentmayhavepreventedfurthercomplicationsandallowed
thepatienttobesuccessfullydischargedonoutpatient
antibi-otictreatment.4Sofar,ourcaseistheonlyR.aeriaendocarditis
infectionwhereemboliccomplicationshavenotoccurred.
R. aeria and R.dentocariosa are both known to colonize
unhealthyoralcavities.Theymaythentranslocateintoblood
anddisseminate,causingendocarditisor otherinfection in
individuals at risk.3,9,12 Our patient had excellent dental
hygieneandhadnotbeensubmittedtoanydentalprocedures
inthelastsixmonths.Somestudieshavesuggested
coloniza-tionofthesmallintestine(duodenum)bythisbacteriaand
its role in gluten metabolism.2 Therefore, consideringthat
thispatient initiallypresentedwithacuteself-limited
diar-rhea,wehypothesizedthatendocarditismay haveresulted
fromintestinaltranslocationandinfectionofthethickened
bicuspidaorticvalve.
Inourclinicalcase,initialidentificationafterbloodculture
onagarrevealedaGram-positiverod,whichwasidentifiedby
Vitek2asR.aeria.SinceR.aeriaisararelyreportedhuman
pathogenand duetocommonlyinconclusiveresultsofthe
biochemicalidentificationofGram-positiverods,itwas
rea-sonable to confirm diagnosis by molecular methods. Gene
sequenceanalysisbyMicroSeqLibraryidentifiedR.aeriawith
a99.98%match.Additionally,thesequencewascomparedto
thoseofotherRothiaspeciesavailableattheGenBankdatabase
–http://www.bacterio.net/qr/rothia.html.13Thehighest
simi-larityindex(99.77%)wasobservedwithadepositpertaining
tothe type strainR. aeria(GenBank assession CP001368.1).
ThesameresultwasobtainedwhenperformingalocalBLAST
usingtheRothiaspecies16SrRNAnucleotidesequence.The
secondhighestsimilarity(98.62%)wasobservedwiththe
Gen-Bank deposit CP002280.1, corresponding to the type strain
ofR.dentocariosa.Early identificationofR.aeriacanalsobe
achievedusing matrix-assistedlaser desorption
ionization-timeofflightmassspectrometry(MALDI-TOFMS).5,8
TreatmentofR.aeriainfectionisvariableanddependenton
theassistingphysiciansandsusceptibilitytests,aswehave
seenfromthecasereports(Table1).Allcasereportisolates
wereshowntobesensitivetopenicillins,whichseemedtobe
thedrugsofchoiceinsomeofthecases.3,8–11Onecasewas
ini-tiallytreatedwithacombinationtherapyofbenzylpenicillin,
rifampicinandgentamicin.Ourpatientpromptlyresponded
to treatment with ampicillin after antibiotic susceptibility
results according to the Clinical and Laboratory Standards
Institute(CLSI)guidelines.14
Inconclusion,wesummonattentiontotheseeminglyhigh
emboliccomplicationsofendocarditisbyR.aeria.Therefore,R.
aeriaendocarditisshouldbepromptlymanagedwithadequate
antibiotictreatmentandsurgicalvalvereplacementwhenever
necessaryinordertoimprovepatientprognosis.Inaddition
tocommontranslocationofR.aeriafromtheoralcavity,we
hypothesizethepossibilityofintestinaltranslocation.
MALDI-TOFMSandgeneticsequencingareimportanttoolsthatcan
contributetoearlyandmoreaccurateetiologicdiagnosisof
severeinfectionscausedbyGram-positiverods.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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Rhodococcusbaikonurensissp.nov.andArthrobacterrussicussp. nov.,isolatedfromairintheRussianspacelaboratoryMir.Int JSystEvolMicrobiol.2004;54:827–35.
2.MaramZ,GuoxianW,FloydD,etal.IdentificationofRothia
bacteriaasgluten-degradingnaturalcolonizersoftheupper gastro-intestinaltract.PLoSONE.2011;6:e24455.
3.HiraiwaT,IzumiM.SuccessfulmanagementofRothiaaeria
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5.CroweA,DingN,YongE,etal.Rothiaaeriamitralvalve endocarditiscomplicatedbymultiplemycoticaneurysms: laboratoryidentificationexpeditedusingMALDI-TOFMS. Infection.2014;42(2):419–23.
6.TarumotoN,SujinoK,YamaguchiT,etal.Afirstreportof
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7.HolleranK,RasiahS.Atypicalthunderclapheadache.Case reportpresentedtothe2ndinternationalcongresson neurologyandepidemiology.Neuroepidemiology. 2012;39:177–283.
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9. VerrallAJ,RobinsonPC,TanCE,MackieWG,BlackmoreTK.
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10.MichonJ,JeulinD,LangJM,CattoirV.Rothiaaeriaacute bronchitis:thefirstreportedcase.Infection.2010;38:335–7.
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13.Listofprokaryoticnameswithstandinginnomenclature.
http://www.bacterio.net/qr/rothia.html[accessed10.03.14]. 14.ClinicalandLaboratoryStandardsInstitute(CLSI).Methods forantimicrobialdilutionanddisksusceptibilitytestingof infrequentlyisolatedorfastidiousbacteria.seconded;2010. M45-A2.
