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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 761-763
Hemodialysis catheter related rhodococcus bacteremia in immunocompetent host


1 Department of Internal Medicine, Mount Sinai Hospital (Chicago Medical School), Chicago, Illinois, USA
2 John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, USA

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Date of Web Publication9-Jul-2011
 

   Abstract 

Rhodococcus equi (R. equi) is an uncommon cause of infection in immunocompetent individuals. We describe a case of R. equi bacteremia associated with hemodialysis (HD) catheter in an immunocompetent patient. A 38-year-old female with end-stage renal disease (ESRD) of uncertain etiology, on HD for the past 15 months who was previously healthy otherwise, was admitted with the complaints of intermittent fever, mild nausea and occasional vomiting for two weeks. Last HD was performed four days earlier through a tunneled right internal jugular permacath. Clinically the patient was afebrile and in no acute distress. She was hemodynamically stable with no peripheral stigmata of an endovascular infection. Physical examination was essentially normal. Initially, the patient was treated with intravenous vancomycin with each HD, retaining the catheter. However, due to persistently positive blood cultures, HD catheter had to be removed. The patient became afebrile and nausea and vomiting resolved. She improved clinically, and repeated surveillance blood cultures done after the removal of catheter were reported negative. Subsequently, a new HD catheter was inserted for her. Although R. equi is an uncommon cause of infection in immunocompetent individuals, it does occur with considerable mortality and morbidity, and a high index of clinical suspicion is required to recognize this infection in immunocompetent individuals.

How to cite this article:
Dalal P, Dalal T, Shah G. Hemodialysis catheter related rhodococcus bacteremia in immunocompetent host. Saudi J Kidney Dis Transpl 2011;22:761-3

How to cite this URL:
Dalal P, Dalal T, Shah G. Hemodialysis catheter related rhodococcus bacteremia in immunocompetent host. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Jul 15];22:761-3. Available from: http://www.sjkdt.org/text.asp?2011/22/4/761/82684

   Introduction Top


Rhodococcus equi (R. equi) is an uncommon cause of infection in immunocompetent individuals. Previously, several case reports have been published about R. equi infection associated with peritoneal dialysis catheters. [1],[2],[3],[4] We describe a case of R. equi bacteremia associated with hemodialysis (HD) catheter in an immunocompetent patient.


   Case Report Top


A 38-year-old female got admitted with the complaint of intermittent fever without chills at home for two weeks. The patient also reported mild nausea and intermittent vomiting for the same duration. She had end-stage renal disease (ESRD) of unknown cause and was on HD for the past 15 months. Last HD was performed four days earlier through a tunneled right internal jugular permacath. She was otherwise healthy and the only medication she was on at the time of admission was calcium with vitamin D. The patient denied tobacco, alcohol or recreational intravenous drug use. She had no known exposure to farm or domestic animals and had no known immunodeficiency. There was no family history of malignancy or immunodeficiency disorder.

On examination, the patient was afebrile and in no acute distress. She was hemodynamically stable and there were no peripheral stigmata of an endovascular infection. There were no clinically apparent metastatic septic foci. There was no erythema or tenderness of the catheter exit site. Physical examination was essentially normal. She had no prior episode of catheter related bacteremia. On laboratory evaluation, WBC count and creatinine were 5.3/mm 3 and 5.3 mg/dL, respectively. Blood cultures done from permacath one week earlier at her dialysis center grew coagulase-negative, methicillin-sensitive Staphylococcus epidermidis (MSSE) and Corynebacterium species, and the patient was started on intravenous cefazolin and gentamicin based on sensitivity results. In our center, repeated blood cultures from permacath and peripheral veins grew gram-positive bacilli which were initially reported as Corynebacterium species but later identified as R. equi. Initially, the patient was treated with intravenous vancomycin with each HD, retaining the catheter. However, due to persistently positive blood cultures, HD catheter had to be removed. The patient became afebrile and nausea and vomiting resolved. She improved clinically, and repeated surveillance blood cultures done after the removal of catheter were reported negative. Subsequently, a new HD catheter was inserted for her. She was on intravenous vancomycin for a total of four weeks duration.


   Discussion Top


R. equi is a soil-borne, non-motile, non-spore forming, facultative, intracellular, gram-positive coccobacillus. It is weakly acid fast and its cell wall composition is closely related to that of Nocardia. The organism can survive inside macrophages and cell-mediated immunity is thought to be the major defense mechanism against it. R. equi was originally named as Corynebacterium equi in 1923, based upon its morphological appearance. In animals and fowls, it is an important respiratory and intestinal pathogen. Exposure to domestic animals like pigs and horses may play a role in acquisition of this organism. The first human case was reported in 1967. [5] In 1980, the organism was reclassified as genus Rhodococcus (ability to form a red pigment).

As the organism lives inside macrophages, HIV patients with impaired cell-mediated immunity are at risk of developing infection with R. equi. With recent epidemic of HIV and increasing number of patients getting organ transplantations and chemotherapy, infections with unusual organisms like Rhodococci have been increasingly reported. [6],[7],[8],[9] Necrotizing broncho-pneumonia is the most common form of human infection caused by R. equi. Various cases of R. equi causing wound infection, abscess formation in different body areas, peritonitis, pericarditis, osteomyelitis, septic arthritis, bacteremia, etc. have been reported in the literature. Pulmonary infections account for only 42% of infections in immunocompetent hosts, compared with 84% of infections in immunocompromised hosts. [7] Cases of R. equi peritonitis in patients with renal failure and peritoneal dialysis have been reported several times. To the best of our knowledge, there are no cases reported in literature about catheter related R. equi bacteremia in an immunocompetent patient. We present the first case of R. equi bacteremia related to permacath in a renal failure patient.

Delay in diagnosis is common due to the resemblance of R. equi to diphtheroids on gram stain and also because of a lower level of awareness about its existence. There is no standard treatment regimen for R. equi bacteremia. The organism is usually resistant to penicillin. It is usually susceptible to ciprofloxacin, imipenem, aminoglycosides, vancomycin, erythromycin, linezolid and rifampicin. Most authors recommend combination of two or more antibiotics with intracellular bactericidal activity for a duration of 2-9 months. [10] Antibiotic combinations can be decided based on sensitivity results. Topical infections without evidence of systemic disease or infections in immunocompetent individuals can be treated with shorter duration of antibiotic therapy. Prognosis depends of type of infection, time of diagnosis, underlying immunological status and whether there is relapse after treatment. Prognosis is usually good with early diagnosis and treatment and in those with only local infection, as well as in immunocompetent individuals. The mortality rate among immunocompetent patients is approximately 11%, compared with rates of 50-55% among human immunodeficiency virus (HIV)-infected patients and 20-25% among non-HIV-infected immunocompromised patients. [7]

In summary, although R. equi is an uncommon cause of infection in immunocompetent individuals, it does occur with considerable mortality and morbidity, and a high index of clinical suspicion is required to diagnose and treat this infection in immunocompetent individuals.

 
   References Top

1.Brown E, Hendler E. Rhodococcus peritonitis in a patient treated with peritoneal dialysis. Am J Kidney Dis 1989;14(5):417-8.  Back to cited text no. 1
    
2.Chow KM, Szeto CC, Chow VC, Wong TY, Li PK. Rhodococcus equi peritonitis in continuous ambulatory peritoneal dialysis. J Nephrol 2003; 16(5):736-9.  Back to cited text no. 2
    
3.Franklin DB Jr, Yium JJ, Hawkins SS. Coryne-bacterium equi peritonitis in a patient receiving peritoneal dialysis. South Med J 1989;82(8): 1046-7.  Back to cited text no. 3
    
4.Hoque S, Weir A, Fluck R, Cunningham J. Rhodococcus equi in CAPD-associated peritonitis treated with azithromycin. Nephrol Dial Transplant 1996;11(11):2340-1.  Back to cited text no. 4
    
5.Verville TD, Huycke MM, Greenfield RA, Fine DP, Kuhls TL, Slater LN. Rhodococcus equi infections of humans. 12 cases and a review of the literature. Medicine (Baltimore) 1994;73 (3):119-32.  Back to cited text no. 5
    
6.Cronin SM, Abidi MH, Shearer CJ, Chandrasekar PH, Ibrahim RB. Rhodococcus equi lung infection in an allogeneic hematopoietic stem cell transplant recipient. Transpl Infect Dis 2008;10(1):48-51.  Back to cited text no. 6
    
7.Kedlaya I, Ing MB, Wong SS. Rhodococcus equi infections in immunocompetent hosts: case report and review. Clin Infect Dis 2001;32(3): E39-46.  Back to cited text no. 7
    
8.Munoz P, Palomo J, Guinea J, Yañez J, Giannella M, Bouza E. Relapsing Rhodococcus equi infection in a heart transplant recipient successfully treated with long-term linezolid. Diagn Microbiol Infect Dis 2008;60(2):197-9.  Back to cited text no. 8
    
9.Tse KC, Tang SC, Chan TM, Lai KN. Rhodococcus lung abscess complicating kidney transplantation: Successful management by combination antibiotic therapy. Transpl Infect Dis 2008;10(1):44-7.  Back to cited text no. 9
    
10.Weinstock DM, Brown AE. Rhodococcus equi: an emerging pathogen. Clin Infect Dis 2002;34 (10):1379-85.  Back to cited text no. 10
    

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Correspondence Address:
Pranav Dalal
Assistant Professor, Chicago Medical School, Chicago, Illinois
USA
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PMID: 21743224

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    Abstract
   Introduction
   Case Report
   Discussion
    References
 

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