THE JOHNS HOPKINS MICROBIOLOGY NEWSLETTER Vol. 24, No. 10
Tuesday, March 8, 2005
A. Provided by Sharon Wallace, Division of Outbreak Investigation, Maryland Department
of Health and Mental Hygiene.
7 outbreaks were reported to DHMH during MMWR Week 9 (February 27 - March 5):
3 Respiratory Outbreaks
2 outbreaks of INFLUENZA LIKE ILLNESS associated with Nursing Homes in Garrett Co. and Calvert Co.
1 outbreak of MRSA associated with a Detention Center in Howard Co.
3 Gastroenteritis Outbreaks
2 outbreaks of GASTROENTERITIS associated with a Nursing Homes in Worcester Co. and Baltimore City.
1 outbreak of GASTROENTERITIS associated with a Hospital in Calvert Co.
1 Other Outbreak
1 outbreak of CONJUNCTIVITIS associated with a school in Howard Co.
B. The Johns Hopkins Hospital, Department of Pathology, Information provided by,
Kathleen Burns, M.D., Ph. D
The Clinical Case
A 45-year-old African American woman with ischemic nephropathy and end stage renal disease presented with
a history of fevers over the preceding few days. She denied other symptoms. The patient undergoes hemodialysis
three times weekly with circulatory access by a Davol catheter. She was admitted to the Johns Hopkins Hospital
with temperatures nearing 40oC for management of a probable catheter infection. White blood cell count was
within normal limits at 5470, but with a neutrophil predominance of 83.9%. Blood cultures were sent to the
microbiology laboratory. She began a course of vancomycin and was given a single dose of gentamicin.
The Laboratory Diagnosis
Four separate blood cultures drawn on admission and over the following two days all were positive for growth
at one day with pleomorphic, clumped and branching Gram-positive bacilli. The technician reviewing Gram
stain morphology proceeded to perform an acid fast stain, which showed the organism was acid fast positive.
Upon referral for gas-liquid chromatography identification, findings were diagnostic of Tsukamurella species.
The Clinical Outcome
Gentamicin was discontinued, and the patient continued on vancomycin. The patient was discharged still
transiently febrile, but feeling well and with instructions to return with any changes. She followed up on the
second day for replacement of the Davol catheter at which time cultures were sent again. She said she no
longer had fevers. This culture exhibits no growth for one week at the time this is written.
Clinical Comment
This patient has a number of factors that put her at risk for infectious diseases, given her renal condition and
the need for circulatory access through an indwelling catheter. Catheter-related infections are common. Leading
the organisms associated with sepsis in patients with catheters are the coagulase-negative staphylococci, followed
in comparison, but case reports continue to be published 1, 2 3 4 5. Tsukamurella has also been associated with
peritonitis in the setting of peritoneal dialysis 6.
by Candida spp.; S. aureus and entercocci are also commonly associated. Tsukamurella species are quite rare
Tsukamurella
Named for Tsukamura, the Japanese microbiologist well-known for his studies of Gordona spp. in lung disease
in the 1970s 7, Tsukamurella were first classed as a separate genus by Collins et al. in the late 1980s after they
discovered strong sequence homology between organisms previously classed as both Corynebacterium
paurometabola and Rhodococcus aurantiacus 8. Individual species of Tsukamurella associated with disease
include T. paurometabola, T. inchonensis, T. pulmonis, T. tyrosinosolvens, and T. wratislaviensis.
Tsukamurella are obligately aerobic, gram-positive organisms that now fall within the order Actinomycetales
along with Nocardia, Gordonia, Streptomyces, and Rhodococcus. They are bacilli that form branching
hyphae-like structures, and are partially acid fast. Like Mycobacterium, Corynebacterium, Nocardia, and
Rhodococcus, the Tsukanurella cell wall is high in mycolic acid content. Tsukamurella are found in soil
and grow quickly in culture when compared to many mycobacteria. When grown on agar, the tan-to-grey
colonies appear dry and may look rough with rhizoid edges after time.
Differentiation of Tsukanurella from similar staining organisms at the genus level (i.e., from Nocardia and
Rhodococcus genera) relies on gas-liquid chromatography or HPLC. Pattern recognition programs have
been applied for automating identification once the chromatography result is generated 9. In addition to
this classic methodology, molecular approaches are being developed which facilitate identification of
Tsukamurella and differentiation from other genera. These include 16S rRNA sequencing 10, which can
be used for Tsukamurella identification to the species level, and restriction fragment length polymorphism
(RFLP) analysis of a 439bp PCR amplicon of the 65kDa heat shock protein gene 11.
Clinically, Tsukamurella may be considered an opportunistic infection, with most cases being caused in
the immunecompromised. Collections of Tsukamurella cases have been published for patients with indwelling
central venous catheters; in a recent report of six such cases 4 five were markedly immunocompromized because
of inherited severe combined immunodeficiency (SCID), leukemia, a myelodysplastic bone marrow pathology,
or immunosuppressive chemotherapy for treatment of metastatic cancer or graft-verses-host disease (GVHD)
after bone marrow transplant. One of the patients had only chronic renal failure from IgA nephropathy and may
be though of as similar to our case in terms of predisposing factors.
References:
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