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A case of chronic scalp wound infection due to Rhodococcus equi in an immunocompetent individual following heavily contaminated traumatic injury was successfully treated by combining antibiotics and surgery. The agents used were erythromycin and rifampicin.
Rhodococcus equi is an opportunistic pathogen that usually causes infection in immunocompromised hosts. A heart transplant recipient who had been treated with amphotericin B for pulmonary aspergillosis showed newly developed multiple nodules with a central necrotic area in the right lower lobes. Cultures of several blood samples and an aspirate of the lung nodule yielded a Gram-positive coccobacillary bacterium, which was initially reported as a Corynebacterium species, but was later identified as R. equi by API CORYNE (bioMerieux SA, Marcy l'Etoile, France) and by demonstrating the production of 'equi factor'. The identification was subsequently confirmed by an R. equi-specific polymerase chain reaction (PCR). The patient was successfully treated with ciprofloxacin and azithromycin for 14 weeks. This is the first documented case of R. equi infection in Korea. There is a possibility of underestimation of R. equi infections due to the misidentification of the organism as a contaminating diphtheroid. Because R. equi will not respond to the conventional empirical therapy, the microbiology laboratory should identify R. equi in a timely manner. R. equi-specific PCR will be a useful confirmatory test in human infection.
Nine cat isolates and nine dog isolates of Rhodococcus equi from clinical material were investigated for the presence of the virulence-associated antigens (VapA and VapB) and virulence plasmids. Five of the cat isolates and one dog isolate were VapA positive and contained an 85-kb type I or an 87-kb type I plasmid. The remaining 12 isolates were avirulent R. equi strains and contained no virulence plasmids.
Infections of Rhodococcus equi, a well-known pathogen in animals which causes cavitated pneumonia similar to that caused by mycobacteria, were studied in three HIV-infected patients. This microorganism was isolated in the bronchoalveolar washings of two patients and in the sputum of the third. In two patients, Rh. equi represented the first clinical opportunistic manifestation of HIV disease. One patient died of concomitant Pneumocystis infection. The eradication of the microorganism occurred in two out of three patients. It was found that no isolates were resistant to erythromycin, claritromycin, rifampin, vancomycin, teicoplanin, imipenem, gentamycin or azithromycin (MIC values < or = 0.1 microgram/ml). Moreover, the quinolones (ciprofloxacin and ofloxacin) were found to be less effective, whereas neither the beta-lactam antibiotics nor chloramphenicol were effective therapy for this microrganism. At least two antimicrobial agents should be given contemporaneously to treat these infections for a period of up to several months. Our results suggest that the combinations erythromycin + rifampin or imipenem + teicoplanin are the most effective treatments in Rh. equi infections.
Mice inoculated intravenously with a sublethal dose of live virulent Rhodococcus equi ATCC 33701 that contained an 85-kb virulence plasmid were immune to a lethal intravenous challenge of ATCC 33701. This immunity depended upon the dose of immunization and developed rapidly: mice primed with 10(5) live ATCC 33701 eliminated the challenged bacteria more rapidly than mice primed with doses ranging from 10(2) to 10(4) bacteria, and mice given 10(5) live ATCC 33701 intravenously withstood the lethal challenge as early as 5 days after the initial inoculation. However, this protective immunity did not develop in mice immunized with doses of heat-killed ATCC 33701 ranging from 10(6) to 10(8), or in mice immunized with doses of live ATCC 33701P-, a plasmid-cured derivative (avirulent), in doses ranging from 10(5) to 10(7). These mice had positive antibody titers against R. equi at the challenge (14 days after priming). Adoptive transfer of resistance to virulent R equi was obtained with spleen cells from mice immunized with live ATCC 33701, but not monoclonal antibody to 15- to 17-kDa virulence-associated antigens. These results revealed that live ATCC 33701P-, a plasmid-cured derivative of virulent R equi, could not elicit protective immunity, and are consistent with previous observations that protective immunity was induced by live virulent, but not killed organisms.
To evaluate the contributions of T-lymphocyte subsets in pulmonary immunity against Rhodococcus equi, C.B-17 SCID/beige mice were adoptively transferred with splenic lymphocytes from congenic BALB/c mice previously infected with R. equi. Spleen cells were enriched for either CD4+ or CD8+ populations before inoculation, Flow cytometry showed that each enriched population contained less than 0.5% cross contamination. Groups of adoptively transferred SCID/beige mice were sacrificed 6 and 13 d after intranasal infection with R. equi. Bacterial clearance was measured in the lungs, liver and spleen. Lesion development was assessed by gross and histopathological score and the fate of transferred cells assessed by flow cytometry and by immunohistochemistry. SCID/beige mice receiving either CD4+ or CD8+ T-cells were able to clear the infection better than control mice. On d 6 post-infection, bacterial numbers were significantly lower in the lungs of CD4+ transferred mice as compared to CD8+ mice. By d 13, both groups had cleared R. equi from all organs. CD4+ cells were however identified in the lung and spleen of CD8+ recipients at d 13 making conclusions about the role of CD8+ cells in R. equi clearance impossible. By contrast, no significant increases in CD8+ lymphocytes were observed in the organs of CD4+ recipients. All mice developed suppurative bronchopneumonia but lesions were most severe in the CD4+ group. Immunohistochemistry and flow cytometry confirmed that CD4+ and CD8+ cells had migrated to the lungs of adoptively transferred mice. Serum antibody against R, equi was not detected by ELISA in the recipients. SCID/beige mice receiving CD4-CD8- cells were unable to clear R. equi. The study supports the suggestion that CD4+ cells have a central role in R. equi clearance in mice.
Rhodococcus equi and Arcanobacterium haemolyticum, formerly classified in the genus Corynebacterium, are members of the loosely defined taxon "coryneform" bacteria. Although they are the etiologic agents of distinct human infections, both organisms are frequently overlooked, which results in missed or delayed diagnoses. R. equi, long known as an important pathogen of immature horses, has become in the past three decades an opportunistic pathogen of severely immunosuppressed humans. Most cases are secondary to HIV infection. When specifically sought in throat swab cultures, A. haemolyticum is found responsible for 0.5% to 2.5% of bacterial pharyngitis, especially among adolescents. These two microorganisms represent a spectrum of disease in humans: from a mild, common illness to a rare life-threatening infection. Each organism elaborates lipid hydrolyzing enzymes (cholesterol oxidase by R. equi and sphingomyelinase D by A. haemolyticum) that are toxic to animals and humans and damaging to mammalian cell membranes. The participation of the cytotoxins in pathogenicity is discussed. Greater awareness of the properties of these two bacteria may promote faster, more accurate diagnoses and better clinical management.
An enzyme-linked immunosorbent assay (ELISA) was developed against Rhodococcus equi using Triton X-114 detergent extracted whole cell material, in which the virulence associated protein (VapA) predominated. Enzymelinked immunosorbent assay titres corresponded to antibody reacting with VapA on Western blots. There was considerable variation in antibody titres of nonimmunised mares and in the time when the colostrally derived antibody of their foals had declined to low or undetectable titres. In general, antibodies in foals declined to their lowest levels at age 4-8 weeks. Seroconversion occurred in foals age 8-10 weeks, but the precise time depended on maternal titre and the month in which the foal was born. Foals reaching age 8 weeks in late summer showed more marked seroconversion than foals born earlier. The ELISA was used to follow the response to immunisation with the same Triton X-114 extracted material. Six mares immunised before parturition with the antigen in aluminium hydroxide adjuvant developed high titres, up to > 102,400 and transferred them to their foals through colostrum. Their foals responded to immunisation with 0.5-1.0 mg antigen 3, 5, 7 and 9 weeks after birth. Antibody titres following immunisation with similar dosage reached up to > 102,400 in a separate group of foals of nonimmunised mares. Nonvaccinated control foals seroconverted at age 6-8 weeks. The VapA based ELISA is useful to follow the course of natural infection with R. equi or immunisation with VapA based antigen.
Rhodococcus equi is a rare form of opportunistic infection in humans, more common in the immunocompromised. We present a case of pulmonary infection and subsequent cerebral abscess secondary to R. equi in a patient receiving immunosuppression for a c-ANCA positive vasculitis. Heightened awareness of R. equi infection is important when considering immunocompromised patients presenting with sepsis, especially those with cavitating pulmonary lesions and normal respiratory commensals on culture. Delays in diagnosis and treatment can cause increased patient morbidity and mortality.
A case of pyogenic liver abscess (PLA) due to Rhodococcus equi in an immunocompetent individual was successfully treated by combining surgery and antibiotics. The R. equi-targeted antimicrobial agents erythromycin and rifampin were used only after surgical resection of the lesion and identification of the infective organism.
The specific capsular polysaccharide produced by Rhodococcus equi serotype 1 was found to be a high molecular weight acidic polymer composed of D-glucose, D-mannose, and D-glucuronic acid. Structural analysis of the polysaccharide employed a combination of chemical and nuclear magnetic resonance techniques, from which it was determined that the polysaccharide possessed a linear repeating tetrasaccharide unit containing a single O-acetyl substituent and and acetal-linked pyruvic acid moiety: [formula: see text] The 1H and 13C nuclear magnetic resonances of O-deacetylated and pyruvic-free serotype 1 polysaccharides were fully assigned by homo- and hetero-nuclear chemical shift correlation methods.
The specific capsular polysaccharide produced by Rhodococcus equi serotype 2 is a high-molecular-weight acidic polymer composed of D-glucose, D-mannose, D-glucuronic acid and 3-O-[(S)-1-carboxyethyl]-L-rhamnose in equimolar proportions. Structural analysis, employing a combination of chemical and n.m.r. techniques, established that the polysaccharide is composed of linear repeating tetrasaccharide units. (formula; see text) in which the beta-D-mannose residues carry O-acetyl groups at O-2 and O-3 to the extent of 1.7 mol equivalents. Unequivocal determination of the absolute chirality of the 3-O-[(S)-1-carboxyethyl]-alpha-L-rhamnose residues was achieved by chemical correlation with an authentic synthetic sample. The 1H and 13C-n.m.r. resonances of the native and O-deacetylated serotype 2 polysaccharides were fully assigned by homo- and heteronuclear chemical-shift correlation methods.
Some nutritional factors affecting the production of cholesterol oxidase (COX) by Rhodococcus equi no. 23 were investigated. Cholesterol and yeast extract respectively were the best carbon source and nitrogen source for the COX production. The optimum concentration of cholesterol and yeast extract was found to be about 0.1% and 0.4-0.5% (w/v) respectively. In addition, NH4Cl, NaCl and Tween 80 also exhibited enhancing effects on COX production, being maximal at 0.1% (w/v), 0.2% (w/v) and 1.0% (v/v) respectively. Moreover, optimal enzyme production occurred in medium that had an initial pH of 7.0.
Rhodococcus equi (Corynebacterium equi) is able to produce infections not only in animals but also in patients, usually immunosuppressed ones. We report a new case of bacteremic pneumonia in a drug addict who was also infected by HIV. X-ray film of the chest showed a cavitated infiltrate in right upper lobe. R. equi was recovered from blood, respiratory secretions and lung tissue. The patient was with a prolonged course of antibiotics and also surgical treatment. In spite of both therapies, the patient died. We believe that this infection has to be considered in HIV infected patients with cavitated pneumonia and that early surgical treatment, combined with a prolonged course of multiple antibiotics, is advisable. Finally, in view of the severity of this infection, and its relation with other opportunistic infections, we believe that could be included as AIDS diagnostic criteria.
This report outlines the radiological features observed in three cases of Rhodococcus equi (R. equi) pneumonia in AIDS (acquired immunodeficiency syndrome) and reviews another 45 radiological reports published of this emerging opportunistic pneumonia in Human Immunodeficiency Virus (HIV) infected patients. The clinical signs in our three patients consisted in a subacute onset of respiratory symptoms and fever. A low lymphocyte count (< 200 cells/mm3), pulmonary infiltrates, and pleural effusion was present in all three cases. Cavitary pneumonia was observed in two patients, and pericardial effusion in another. In this series CD4 lymphocyte count < 200/mm3 was seen in 29 of the 48 patients (60.4%). All 48 patients had abnormal findings on chest radiographs. Abnormalities involved the upper lobes in 26 of the 48 patients (55%). Cavitation was reported in 37 of the 48 cases (77%). R. equi pneumonia may not be as the paucity of case reports suggest. Consequently, a cavitary pneumonia in HIV infected patients with a low CD4 lymphocyte count (< 200 mm3) with a subacute onset, an upper lobe predilection, and/or a poor response to conventional antibiotic therapy should be considered as suspect of R. equi infection.
Two regions in the gene coding for 16S rRNA in Rhodococcus equi were selected as species-specific primer sequences for the polymerase chain reaction (PCR). PCR using these primers was tested against 10 strains of R. equi (including the type strain) and gave positive results for all but was negative for all other tested species of Rhodococcus; representatives of the most closely related genera and a number of other bacterial species. This method could therefore be used to identify this species which can infect the lungs or other organs of horses, pigs, humans and other animals.
To analyze further the role in virulence of the prominent cholesterol oxidase (ChoE) of Rhodococcus equi, an allelic exchange choE mutant from strain 103+ was constructed and assessed for virulence in macrophages, in mice, and in foals. There was no difference between the mutant and parent strain in cytotoxic activity for macrophages or in intra-macrophage multiplication. No evidence of attenuation was obtained in macrophages and in mice, but there was slight attenuation apparent in four intra-bronchially infected foals compared to infection of four foals with the virulent parent strain, based on a delayed rise in temperature of the choE-mutant infected foals. However, bacterial colony counts in the lung 2 weeks after infection were not significantly different, although there was a slight but non-significant (P=0.12) difference in lung:body weight ratio of the choE mutant versus virulent parent infected foals (mean 2.67+/-0.25% compared to 4.58+/-0.96%). We conclude that the cholesterol oxidase is not important for the virulence of R. equi.
The discrepancies between the current description of the CAMP test between Listeria monocytogenes and Rhodococcus equi in the latest edition of Bergey's Manual of Determinative Bacteriology (L. monocytogenes is described as CAMP test negative with R. equi) and routine findings (positive reactions are usually described in many laboratories) make it advisable to review the current interpretation of the CAMP test to avoid confusion among people working in microbiological laboratories. Overall, 98.4% of the L. monocytogenes strains examined in this study, regardless of their source or the intensity of their hemolytic activity, displayed a synergic hemolytic reaction (CAMP phenomenon) with R. equi, indicating that L. monocytogenes can generally be considered CAMP positive with R. equi. We propose that L. monocytogenes, together with Listeria ivanovii, should be considered CAMP test positive with R. equi (circular or racket and semicircular or shovel shapes, respectively).