neisseria - journal of clinical...

Prosthetic valve Endocarditis due to Neisseria skkuensis, novel Neisseria 1

species 2

3

So Yeon Parka, Seung Ji Kangb, Eun-Jeong Jooa, Young Eun Haa, Jin Yong 4

Baekc, Yu Mi Wid, Cheol-In Kanga, Doo Ryeon Chunga, Kyong Ran Pecka, Nam 5

Young Leee, and Jae-Hoon Songa,c 6

7

Division of Infectious Diseases, Samsung Medical Center, Skungyunkwan 8

University School of Medicine, Seoul, Republic of Koreaa 9

Division of Infectious Diseases, Chonnam National University Hospital, 10

Chonnam National University School of Medicine, Gwang-ju, Republic of 11

Koreab 12

Asian-Pacific Foundation for Infectious Diseases (APFID), Seoul, Republic of 13

Koreac 14

Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan 15

University School of Medicine, Changwon, Republic of Koread 16

Department of Laboratory Medicine, Samsung Medical Center, Sunkyunkwan 17

University School of Medicine, Seoul, Republic of Koreae 18

19

Running head: Endocarditis caused by Neisseria skkunensis 20

Keywords: Neisseria skkunensis; endocarditis 21

Copyright © 2012, American Society for Microbiology. All Rights Reserved.J. Clin. Microbiol. doi:10.1128/JCM.00676-12 JCM Accepts, published online ahead of print on 6 June 2012

on June 27, 2018 by guesthttp://jcm

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* Corresponding author: Kyong Ran Peck, MD 22

Professor of Medicine 23

Division of Infectious Diseases, Department of Internal Medicine 24

Samsung Medical Center, Sungkyunkwan University School of Medicine, 25

50 Irwon-ro 81, Gangnam-gu, Seoul 135-710, Republic of Korea 26

Phone: +82-2-3410-0322 27

Fax :+ 82-2-3410-0064 28

Email address: [email protected] 29

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Absctract 48 49

We reported the first case of endocarditis due to Neisseria skkuensis. The organism 50

from the blood cultures taken on admission day was identified initially as unidentified 51

gram negative cocci by VITEK2. Finally, it was identified as a Neisseria skkuensis by 16 52

rRNA gene sequence analysis. 53

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CASE REPORT 57

A 41-year old man was admitted to our hospital with a 1-week history of febrile 58

sense, chills, sweating, aggravation on dyspnea, and hypotension during hemodialysis. He 59

had a complicated past history, including liver cirrhosis caused by chronic hepatitis B 60

infection and chronic kidney disease due to glomerulonephritis. He had received entecavir 61

since 2009 and hemodialysis since 2000. In addition to these, he had undergone a mechanical 62

mitral valve replacement due to infective endocarditis caused by methicillin resistant 63

Staphylococcus aureus before one year ago. He denied dental treatment and drug abuse since 64

mitral valve replacement. 65

On arrival at the emergency department, the patient’s vital sign were blood pressure, 66

86/52 mmHg; respiratory rate, 22 breaths per min; and temperature, 37 ℃. Physical 67

examination revealed metallic heart sounds without murmur and no abdominal tenderness 68

with positive shifting dullness. A chest radiography showed cardiomegaly and pulmonary 69

edema. Laboratory investigations revealed a C-reactive protein concentration of 10.0 mg/dl 70

(normal [N], <0.3mg/dl), an erythrocyte sedimentation rate of 37mm/h (N, <22mm/h), a 71

procalcitonin concentration of 152.2 ng/ml. The white blood cell (WBC) count was 72

9850/mm3 with dominant segmented neutrophils (85%), hemoglobin (Hb) 7.5 g/dl, platelet 73

count 57000/ mm3, blood urea nitrogen 49.5mg/dl, creatinine 6.55mg/dl (N, < 1.3mg/dl), and 74

total bilirubin 1.2 mg/dl (N, < 1.5 mg/dl). He was coagulopathic with a prothrobin time of 75

23.1 seconds (N, 12.6 to 14.9), international normalized ratio (INR) of 2.0, activated partial 76

thromboplastin time (APTT) of 72.7 seconds (N, 29.1 to 41.9), and D-dimer of 3.42 ug/ml (N, 77

0 to 0.5). Ascites analysis showed WBC count of 310/mm3, with 39% neutrophils, an albumin 78

level of 1.3 g/dl, and a negative gram stain. Fluid was cultured and none grew any organism. 79

The transthoracic echocardiography showed well functioning prosthetic mitral valve and 80


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moderate tricuspid valve regurgitation. There was no dilatation of the left ventricle and no 81

vegetation was visualized. The transesophageal echocardiography showed oscillating mass 82

lesions on prosthetic mitral valve (Fig. 1). 83

Blood cultures were conducted on admission day prior to antibiotic treatment. The 84

aerobic bottles from each of three separately taken sets of blood cultures were incubated in a 85

BacT/ALERT 3D (bioMérieux, Durham, NC., USA) and grew gram negative cocci in all 86

three bottles. The Vitek 2 GNI card system (bioMérieux, Durham, NC., USA) didn’t identify 87

them. For molecular identification, we performed 16S rRNA gene sequence analysis and it 88

was formally identified at the Asian-Pacific Foundation for Infectious Diseases (APFID) as 89

Nesseria skkuensis based on the sequence of the 16S rRNA gene. The 16S rRNA gene was 90

amplified using primer sets 16S-F2 (5′-AGAGTTTGATCMTGGCTCAG-3′) and 16S-R2 (5′-91

GGTTACCTTGTTACGACTT-3′). A 1406 bp sequence of the 16S rRNA gene was obtained 92

from our strain. The 16S rRNA gene sequence was compared with those in the EzTaxone 93

public database (http://www.eztaxon.org) (Table 1) and the GenBank database 94

(http;//www.ncbi.nlm.nih.gov/blast) using BLAST searches (1). When the sequence was 95

compared to the 16S rRNA sequence of strain SMC-A9199T of Nesseria skkuensis (AC N 96

FJ763637, GenBank AC N FJ763637.1), it was 100% identical to SMC-A9199T. 97

Antibiotic susceptibility tests were performed and the MICs determined by the 98

broth microdilution method in accordance with the guidelines established by the Clinical and 99

Laboratory Standards Institute (CLSI) (2). The MICs were as follows: penicillin, 1 mg/liter; 100

ceftriaxone, 0.12 mg/liter; piperacillin/tazobactam 0.25 mg/liter; rifampicin 1 mg/liter; and 101

ciprofloxacin, <0.06 mg/liter. It was susceptible to ceftriaxone, piperacillin/tazobactram, 102

rifampicin, and ciprofloxacin, but was showed intermediate resistance against penicillin. 103

Interpretive criteria for susceptibility were those for Nesseria gonorrhoeae because no 104

breakpoints were provided by CLSI (2). 105


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The patient was treated for prosthetic valve endocarditis with intravenous vancomycin 1g 106

every three days, piperacillin/tazobactam 2.25g four times daily, gentamicin 100mg daily, and 107

oral rifampicin 900mg daily. On hospital day 4, the patient was received mitral valve 108

replacement and tricuspid anuuloplasty. Gram staining and culture of mitral valve specimen 109

removed at operation were performed. No microorganism were recovered from culture of the 110

replaced mitral valve after surgery. We applied 16S rRNA gene sequencing to identify 111

bacterial species in mitral valve tissue, too. However, the result was negative. We performed 112

acid-fast stain and mycobacterial culture on specimen of mitral valve tissue taken during the 113

operation. The results of acid-fast stain and mycobacterial culture were negative. The next 114

day after surgery, rifampicin was stopped. On hospital day 28, a result of 16S rRNA gene 115

sequence was identified as Nesseria skkuensis and we changed the antibiotics regimen. We 116

stopped intravenous administration of vancomycin and piperacillin/tazobactam. Therapy was 117

continued with 2g intravenous ceftriaxone daily for 6 weeks. All blood cultures performed 118

after the beginning of antibiotics remained negative. The patient recovered fully. 119

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The genus Neisseria includes a group of closely related gram negative bacteria that 122

are primarily commensal inhabitants of the mucus membrane of mammals. Within the 15 123

species are of human origin, only Neisseria gonorrhoeae and Neisseria meningitides are 124

considered important pathogens, whereas the others are opportunistic pathogen sporadically 125

involved in infections (4). However, several Neisseria species other than N. gonnhoeae and N. 126

meningitides cause human infections. Neisseria elongata and Neisseria sicca have been 127

isolated from endocarditis (3, 5). Neisseria bacilliformis, also causes endocarditis and various 128

human infections (4, 8, 9). 129

A novel Neisseria species, ‘Neisseria skkuensis’ was first described in 2010 (7). N. 130


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skkuensis isolated from blood and wound pus of a diabetic patient with a foot ulcer. The 131

bacteria was identified as Neisseria spp by conventianl methods, but comparative 16S rRNA 132

gene sequence analysis along with phenotypic analysis showed that the isolate is a novel 133

species of Neisseria (7). Lee et al performed phenotypic analysis and N. skkuensis showed 134

oxidase and catalase positive, consistent with most Neisseria species (6, 7). In addition, N. 135

skkuensis could produce acid from ribose, glucose, fructose, mannitol, sucrose and gluconate, 136

but not the remaining carbohydrates (7). Based on the 16S rRNA gene sequence, that isolate 137

was most closely related with Nesseria animalis same as our case. 138

We examined the genetic relationship of the two N. skkuensis isolates (one reported in 139

reference 7 and one in this study) by pulsed-field gel electrophoresis (PFGE). PFGE DNA 140

preparation followed standard procedure and PFGE analyses were performed following the 141

interpretative procedures described previously (10-12). The PFGE patterns were analyzed 142

using GelCompar II software (Applied Maths, Belgium). Isolates that produced patterns that 143

were < 85% similar were considered different. The PFGE patterns showed the two isolates 144

were different strain from each other (Fig2). 145

To our knowledge, there have been no prior case reports of endocarditis due to N. 146

skuuensis. In present case, the patient had prosthetic mitral valve, predisposing factor for 147

infective endocarditis, and had received hemodialysis since 2000. The previous reported 148

patient was admitted to our hospital in 2009 and the N. skkuensis was identified at the Asian-149

Pacific Foundation for Infectious Diseases (APFID) (7). In our case, N. skkuensis was 150

identified as Neisseria spp. by 16S rRNA sequence analysis in a clinical microbiology lab, 151

but correct identification at the species level could not be obtained. It was identified at APFID 152

as Nesseria skkuensis based on the sequence of the 16S rRNA gene. 153

In conclusion, we describe the first reported case of endocarditis due to N. 154

skkuensis, identified by 16S rRNA sequence analysis. Although most Nesseria spp. are 155


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opportunistic pathogens, physicians should be aware of the possibility of endocarditis due to 156

Neiserria species. More Neisseria species may cause human disease. 157

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References 181

1. Chun, J., J. H. Lee, Y. Jung, M. Kim, S. Kim, B. K. Kim, and Y. W. Lim. 2007. 182

EzTaxon: a web-based tool for the identification of prokaryotes based on 16S 183

ribosomal RNA gene sequences. Int J Syst Evol Microbiol 57:2259-61. 184

2. CLSI. 2011. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-185

First Informational Supplement, M100-S21, Wayne, PA. Clinical and Laboratory 186

Standards Institute. 187

3. Evans, M., F. Yazdani, H. Malnick, J. J. Shah, and D. P. Turner. 2007. Prosthetic 188

valve endocarditis due to Neisseria elongata subsp. elongata in a patient with 189

Klinefelter's syndrome. J Med Microbiol 56:860-2. 190

4. Han, X. Y., T. Hong, and E. Falsen. 2006. Neisseria bacilliformis sp. nov. isolated 191

from human infections. J Clin Microbiol 44:474-9. 192

5. Heiddal, S., J. T. Sverrisson, F. E. Yngvason, N. Cariglia, and K. G. Kristinsson. 193

1993. Native-valve endocarditis due to Neisseria sicca: case report and review. Clin 194

Infect Dis 16:667-70. 195

6. Lawson, P. A., H. Malnick, M. D. Collins, J. J. Shah, M. A. Chattaway, R. 196

Bendall, and J. W. Hartley. 2005. Description of Kingella potus sp. nov., an 197

organism isolated from a wound caused by an animal bite. J Clin Microbiol 43:3526-9. 198

7. Lee, M. Y., E. G. Park, J. Y. Choi, H. S. Cheong, D. R. Chung, K. R. Peck, J. H. 199

Song, and K. S. Ko. 2010. 'Neisseria skkuensis' sp. nov., isolated from the blood of a 200

diabetic patient with a foot ulcer. J Med Microbiol 59:856-9. 201

8. Masliah-Planchon, J., G. Breton, V. Jarlier, A. Simon, O. Benveniste, S. Herson, 202

and L. Drieux. 2009. Endocarditis due to Neisseria bacilliformis in a patient with a 203

bicuspid aortic valve. J Clin Microbiol 47:1973-5. 204

9. Michaux-Charachon, S., J. P. Lavigne, A. Le Fleche, N. Bouziges, A. Sotto, and P. 205


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A. Grimont. 2005. Endocarditis due to a new rod-shaped Neisseria sp. J Clin 206

Microbiol 43:886-9. 207

10. Starnino, S., and P. Stefanelli. 2009. Azithromycin-resistant Neisseria gonorrhoeae 208

strains recently isolated in Italy. J Antimicrob Chemother 63:1200-4. 209

11. Su, X., and I. Lind. 2001. Molecular basis of high-level ciprofloxacin resistance in 210

Neisseria gonorrhoeae strains isolated in Denmark from 1995 to 1998. Antimicrob 211

Agents Chemother 45:117-23. 212

12. Tenover, F. C., R. D. Arbeit, R. V. Goering, P. A. Mickelsen, B. E. Murray, D. H. 213

Persing, and B. Swaminathan. 1995. Interpreting chromosomal DNA restriction 214

patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain 215

typing. J Clin Microbiol 33:2233-9. 216

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Finacial: Nothing to disclose 228

Conflict of Interest: Nothing to disclose 229


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Table 1. Results of 16S rRNA Gene Sequence (1,406) Alignment (EzTaxon Server) 230 231 Rank Name/Title Authors Strain Accession Pairwise

Similarity

Different

nucleotides/

Total

nucleotides

1 Neisseria

skkuensis

Lee et al. 2010 SMC-

A9199(T)

FJ763637 100 0/1406

2 Neisseria

animalis

Berger 1960 NCTC

10212(T)

AJ239388 97.491 34/1355

3 Neisseria

cinerea

(Von Lingelsheim

1906) Murray

1939

ATCC

14685(T)

ACDY020

00019

97.021 42/1410

4 Neisseria

subflava

(Flugge 1886)

Trevisan 1889

U37(T) AJ239291 96.753 44/1355

5 Neisseria

meningitidis

(Albrecht and

Ghon 1901)

Murray 1929

MC58 AE002098 96.738 46/1410

232


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Figure legends. 233

FIG 1 Transesophageal echocardiogram showing (0.84cm x 0.61 cm and 0.42 x 0.3cm) 234

mobile vegetations (arrow) on the prosthetic mitral valve strut. 235

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FIG 2 PFGE analysis of genomic DNA from N. skkuensis strains digested with NheI and 237

SpeI. A and B show N. skkuensis strains digested with NheI and SpeI respectively. Two 238

isolates showed <85% similarity. The isolates were considered unrelated to each other. N. 239

skkuensis 1 is SMC-A9199 (reference 7). N. skkuensis 2 is the isolate from this case patient. 240

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