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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 202-204

Early-onset Trueperella bernardiae bacteremia in a preterm neonate


1 Department of Pediatrics, Section of Neonatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
2 Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada

Date of Submission03-Apr-2019
Date of Decision12-Apr-2020
Date of Acceptance13-Apr-2020
Date of Web Publication07-Aug-2020

Correspondence Address:
Dr. Amuchou Singh Soraisham
Department of Pediatrics, Foothills Medical Centre, Cumming School of Medicine, University of Calgary, 1403 29th Street NW, Calgary, Alberta T2N 2T9
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_38_19

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  Abstract 


Trueperella bernardiae is a Gram-positive coccobacilli and is a commensal on human skin. It is an opportunistic pathogen and has been known to cause infections in human beings ranging from mild septicemia to brain abscess in adult population. This pathogenic organism is unheard of in neonatal population. We report a case of early-onset T. bernardiae bacteremia in a preterm neonate who was treated successfully with ampicillin and gentamicin. This is the first case report of T. bernardiae infection in neonates. This case illustrates a rare cause of early-onset sepsis in neonates.

Keywords: Neonate, preterm, sepsis, Trueperella bernardiae


How to cite this article:
Kaur S, Roychoudhury S, Berenger B, Soraisham AS. Early-onset Trueperella bernardiae bacteremia in a preterm neonate. J Clin Neonatol 2020;9:202-4

How to cite this URL:
Kaur S, Roychoudhury S, Berenger B, Soraisham AS. Early-onset Trueperella bernardiae bacteremia in a preterm neonate. J Clin Neonatol [serial online] 2020 [cited 2020 Sep 25];9:202-4. Available from: http://www.jcnonweb.com/text.asp?2020/9/3/202/291646




  Introduction Top


Trueperella bernardiae is a nonmotile, Gram-positive coccobacilli that is a likely part of the skin and/or gastrointestinal microflora. T. bernardiae was originally classified within the Center for Disease Control and Prevention (CDC) as fermentative coryneform group 2,[1] later classified as a part of genus Arcanobacterium,[2] and finally reclassified to the genus Trueperella.[3]T. bernardiae was first isolated from a variety of clinical sources, but the first isolation in pure culture was reported by Ieven et al. in 1996.[4] To the best of our knowledge, 17 cases of human infection have been reported in the medical literature, which consist of kidney and urinary tract infections, bone and joint infections, skin and wound infections, eye infection, and brain abscess.[4],[5],[6],[7],[8],[9] All reported cases except one[9] were seen in adult population with risk factors such as diabetes mellitus, prosthetic joint, or ureteric diversion. As far as we could ascertain, no cases of T. bernardiae infection have been reported in neonatal population. We report the first case of T. bernardiae early-onset neonatal bacteremia in an extremely preterm infant, who was treated successfully with intravenous antibiotics and recovered uneventfully.


  Case Report Top


A preterm male infant weighing 455 g was born at ~23 weeks to a 33-year-old gravida 2, para 0 mother by spontaneous vaginal delivery. The pregnancy was complicated by preterm premature rupture of membranes (PROM) at 22 weeks. The mother was given full course of antenatal steroids and intravenous erythromycin and ampicillin in view of PROM. The antenatal workup was negative for infections. She was given intrapartum penicillin prophylaxis. There was no maternal fever or foul-smelling amniotic fluid at the time of labor.

The infant was intubated at the delivery room and ventilated. The Apgar scores were 2, 5, and 6 at 1, 5, and 10 min, respectively. He was admitted to the neonatal intensive care unit (NICU) due to prematurity, suspected sepsis, and respiratory distress. On admission, his temperature was 36.9°C, heart rate 188 beats/min, respiratory rate 60/min, and blood pressure 26/18 mmHg. There was bruising over his face. The remainder of the systemic examination was unremarkable. He was treated with one dose of surfactant for respiratory distress syndrome. Under aseptic condition, umbilical arterial and venous catheters were inserted soon after admission to the NICU. Blood samples were drawn from umbilical arterial line for complete blood count(CBC) and blood culture. Intravenous ampicillin 50 mg/kg q12 h and gentamicin 5 mg/kg q 48 h were commenced empirically for the treatment of infection. CBC revealed total hemoglobin of 14.4 g/dl, total white blood cell count of 11,200/mm3, total neutrophil count of 2,400/mm3, and platelet count of 141,000/mm3, no left shift. C-reactive protein (CRP) level on day 2 was 74.2 mg/L (normal value: 0–8 mg/L). The single blood culture vial collected (BACT/ALERT PF Plus, bioMérieux) grew Gram-positive coccobacilli, which was identified as T. bernardiae initially by matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) (VITEK® MS, bioMérieux) at 53 h of age and confirmed by 16sRNA sequencing.[10],[11] This isolate was susceptible to penicillin and vancomycin and intermediate to cefotaxime (as per the Clinical Laboratory Standards Institute M45, 3rd edition). Repeat CBC on day 3 showed normal white blood cell count with severe thrombocytopenia (platelet was 50,000/mm3 for which he received platelet transfusion). After receiving the blood culture, lumbar puncture was performed, and cerebrospinal fluid was noninfectious (2.8 × 106/L white blood cells) with a negative bacterial culture and polymerase chain reaction for herpes simplex, varicella zoster, Enterovirus, and Parechovirus. Repeat blood culture on day 3 was negative. Ampicillin and gentamicin were given for a total of 7 days.

On day 8, he was clinically unstable with increasing oxygen requirement on ventilator. Sepsis workup was performed and started on vancomycin and cefotaxime. CBC showed neutrophilic leukocytosis and mild thrombocytopenia with a platelet count of 100,000/mm3. CRP was normal (3.3 mg/L). Chest radiograph showed bilateral increased density over the upper zone suggestive of consolidation. Blood culture was negative. He was also started on azithromycin 10 mg/kg/day for 7 days (i.e., day 8–15) during this period, as the results of endotracheal aspiration sent on day 1 age grew Ureaplasma urealyticum (Mycoplasma Duo Kit, Bio-Rad, Montreal, QC). Sputum bacterial cultures on day 3, 7, and 13 were negative. Cranial ultrasounds on multiple occasions were normal. The infant recovered well with antibiotics, but the remaining hospital course was complicated by patent ductus arteriosus (treated with indomethacin), acute renal failure, chronic lung disease (discharge on home oxygen), retinopathy of prematurity (treated with ranibizumab eye injection), transient adrenal insufficiency, cholestasis, metabolic bone disease, and anemia of prematurity. He was discharged home on 147 days of life at a corrected gestational age of 43 weeks, 5 days.


  Discussion Top


T. bernardiae is a nonmotile, nonspore-forming, facultative anaerobic, Gram-positive coccobacilli first described by the CDC as an opportunistic pathogen in 1987 and originally classified within CDC fermentative coryneform group.[1] The case presented here is significant as the patient developed an early-onset infection with a rare Gram-positive coccobacilli, never seen before in the NICU setting. T. bernardiae bacteremia is rare in human beings, and there has been no reported case in the neonatal population. In the pediatric population, there is a single reported case of T. bernardiae brain abscess in a 5-year-old child who had suppurative otitis media.[9] To the best of our knowledge, this is the first case reported of T. bernardiae infection in neonatal population. Early-onset sepsis in neonates is unique and is usually caused by organisms acquired during delivery. The microorganisms can ascend from birth canal to the amniotic fluid when amniotic membranes rupture or leak before or during the course of labor. The common pathogens are Group B Streptococcus and Escherichia coli. The most likely source of infection in our case seems to be the maternal genital tract similar to other cases of early-onset sepsis. As it is likely a part of normal flora, it may have been transmitted to the infant during vaginal delivery.

The diagnosis of T. bernardiae infection could be missed because the organism would likely be identified as skin flora or catalase-negative coryneform bacilli. The use of MALDI-TOF mass spectrometry analysis has allowed easy and rapid identification of this organism and other coryneform bacteria.[10] These organisms would have previously been dismissed as skin flora or culture contamination. Identification of these organisms allows the discovery of new disease association, but should be interpreted within the clinical context. This case report should also be interpreted with caution. The first being that only one blood culture vial was obtained, making it difficult to be certain that the T. bernardiae was responsible for the sepsis. Unlike in adults, a single blood culture is considered standard in neonatal population due to small blood volume. Second, the organism grew later during incubation and confirmed after 48 h of age. However, such bacteria tend to grow slower compared to fast-growing organism. U. urealyticum was also isolated, which could have also contributed to the clinical picture.

The findings of an elevated CRP, clinical signs of sepsis (tachycardia and respiratory distress), and pure culture of T. bernardiae argue the possibility of contamination. Our patient was treated successfully with ampicillin and gentamicin for 7 days, and the repeat blood cultures were negative, suggesting effective treatment.


  Conclusion Top


We conclude that T. bernardiae is an unusual cause of early-onset sepsis. This case illustrates the first occurrence of T. bernardiae sepsis in a neonate.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for images and other clinical information of the patient to be reported in the journal. The patient's parents understand that the patient's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Na'Was TE, Hollis DG, Moss CW, Weaver RE. Comparison of biochemical, morphologic, and chemical characteristics of Centers for Disease Control fermentative coryneform groups 1, 2, and A-4. J Clin Microbiol 1987;25:1354-8.  Back to cited text no. 1
    
2.
Ramos CP, Foster G, Collins MD. Phylogenetic analysis of the genus Actinomyces based on 16S rRNA gene sequences: Description of Arcanobacterium phocae sp. nov., Arcanobacterium bernardiae comb. nov., and Arcanobacterium pyogenes comb. nov. Int J Syst Bacteriol 1997;47:46-53.  Back to cited text no. 2
    
3.
Yassin AF, Hupfer H, Siering C, Schumann P. Comparative chemotaxonomic and phylogenetic studies on the genus Arcanobacterium collins et al. 1982 emend. Lehnen et al. 2006: Proposal for Trueperella gen. nov. and emended description of the genus Arcanobacterium. Int J Syst Evol Microbiol 2011;61:1265-74.  Back to cited text no. 3
    
4.
Ieven M, Verhoeven J, Gentens P, Goossens H. Severe infection due to Actinomyces bernardiae: Case report. Clin Infect Dis 1996;22:157-8.  Back to cited text no. 4
    
5.
Rattes AL, Araujo MR, Federico MP, Magnoni CD, Neto PA, Furtado GH. Trueperella bernardiae:First report of wound infection post laparoscopic surgery. Clin Case Rep 2016;4:812-5.  Back to cited text no. 5
    
6.
Otto MP, Foucher B, Lions C, Dardare E, Gérôme P. Trueperella bernardiae soft tissue infection and bacteremia. Med Mal Infect 2013;43:487-9.  Back to cited text no. 6
    
7.
Parha E, Alalade A, David K, Kaddour H, Degun P, Namnyak S. Brain abscess due to Trueperella bernardiae. Br J Neurosurg 2015;29:728-9.  Back to cited text no. 7
    
8.
Cobo F, Rodríguez-Granger J, Sampedro A, Gutiérrez-Fernández J, Navarro-Marí JM. Two rare cases of wound infections caused by Trueperella bernardiae. Jpn J Infect Dis 2017;70:682-4.  Back to cited text no. 8
    
9.
Pan J, Ho AL, Pendharkar AV, Sussman ES, Casazza M, Cheshier SH, et al. Brain abscess caused by Trueperella bernardiae in a child. Surg Neurol Int 2019;10:35.  Back to cited text no. 9
  [Full text]  
10.
Hijazin M, Alber J, Lämmler C, Weitzel T, Hassan AA, Timke M, et al. Identification of Trueperella (Arcanobacterium) bernardiae by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry analysis and by species-specific PCR. J Med Microbiol 2012;61:457-9.  Back to cited text no. 10
    
11.
Kommedal Ø, Simmon K, Karaca D, Langeland N, Wiker HG. Dual priming oligonucleotides for broad-range amplification of the bacterial 16S rRNA gene directly from human clinical specimens. J Clin Microbiol 2012;50:1289-94.  Back to cited text no. 11
    




 

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