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We report a case of Rhodococcus equi cavitary pneumonia in a 37-year-old patient with occult HIV infection. Because of his good immune status, the patient was given oral erythromycin and rifampin which rapidly resolved the infection. This modality of treatment may be sufficient in HIV-positive selected patients fur the resolution of Rhodococcus equi pneumonia.
Rhodococcus equi, a Gram positive organism, is a cause of infections in immunocompromised individuals. In humans, it mainly causes disease in those infected with human immunodeficiency virus (HIV), and generally presents as chronic pulmonary infection. It may also cause intracranial infections, which manifest as brain abscesses. This report describes a case of rhodococcus brain and pulmonary infection in a patient who did not have HIV or another disorder of cell mediated immunity. He was treated with intravenous imipenem, vancomycin, and rifampin for eight weeks and recovered from the infection.
Rhodococcus equi is a facultative intracellular opportunistic pathogen of immunocompromised people and a major cause of pneumonia in young horses. An effective live attenuated vaccine would be extremely useful in the prevention of R. equi disease in horses. Toward that end, we have developed an efficient transposon mutagenesis system that makes use of a Himar1 minitransposon delivered by a conditionally replicating plasmid for construction of R. equi mutants. We show that Himar1 transposition in R. equi is random and needs no apparent consensus sequence beyond the required TA dinucleotide. The diversity of the transposon library was demonstrated by the ease with which we were able to screen for auxotrophs and mutants with pigmentation and capsular phenotypes. One of the pigmentation mutants contained an insertion in a gene encoding phytoene desaturase, an enzyme of carotenoid biosynthesis, the pathway necessary for production of the characteristic salmon color of R. equi. We identified an auxotrophic mutant with a transposon insertion in the gene encoding a putative dual-functioning GTP cyclohydrolase II-3,4-dihydroxy-2-butanone-4-phosphate synthase, an enzyme essential for riboflavin biosynthesis. This mutant cannot grow in minimal medium in the absence of riboflavin supplementation. Experimental murine infection studies showed that, in contrast to wild-type R. equi, the riboflavin-requiring mutant is attenuated because it is unable to replicate in vivo. The mutagenesis methodology we have developed will allow the characterization of R. equi virulence mechanisms and the creation of other attenuated strains with vaccine potential.
Rhodococcus equi is an emerging opportunistic pathogen of human immunodeficiency virus-infected patients. Thirty-nine isolates of R. equi from immunocompromised patients with and without AIDS were analyzed for the presence of virulence plasmid DNA, expression of 15- to 17-kDa antigens, and their pathogenicities in mice. Of the human isolates, eight contained an 85-kb virulence plasmid, expressed 15- to 17-kDa antigens, and were virulent in mice. Nineteen isolates carried cryptic plasmids of various sizes, and the remaining 12 isolates did not contain any plasmids. These 31 isolates did not express virulence-associated antigens and were not virulent in mice. The results suggested that opportunistic infections in immunocompromised patients could be caused by both virulent and avirulent R. equi strains and that the pathogenesis of R. equi infection in immunocompromised patients appears to be different from that which occurs in foals.
Rhodococcus equi is a major cause of foal morbidity and mortality. We have investigated the presence of lipoglycan in this organism as closely related bacteria, notably Mycobacterium tuberculosis, produce lipoarabinomannans (LAM) that may play multiple roles as virulence determinants. The lipoglycan was structurally characterized by gas chromatography-mass spectrometry following permethylation, capillary electrophoresis after chemical degradation, and (1)H and (31)P and two-dimensional heteronuclear nuclear magnetic resonance studies. Key structural features of the lipoglycan are a linear alpha-1,6-mannan with side chains containing one 2-linked alpha-d-Manp residue. This polysaccharidic backbone is linked to a phosphatidylinositol mannosyl anchor. In contrast to mycobacterial LAM, there are no extensive arabinan domains but single terminal alpha-d-Araf residue capping the 2-linked alpha-d-Manp. The lipoglycan binds concanavalin A and mannose-binding protein consistent with the presence of t-alpha-d-Manp residues. We studied the ability of the lipoglycans to induce cytokines from equine macrophages, in comparison to whole cells of R. equi. These data revealed patterns of cytokine mRNA induction that suggest that the lipoglycan is involved in much of the early macrophage cytokine response to R. equi infection. These studies identify a novel LAM variant that may contribute to the pathogenesis of disease caused by R. equi.
Inhalation of the soil-borne organism, Rhodococcus equi, can lead to a chronic and severe pyogranulomatous pneumonia in young horses and immunocompromised people. In addition, ulcerative colitis is a common sequela to infection in foals, and dissemination from the lung to other body sites is not uncommon in either the horse or man. Although the facultative intracellular bacterium is susceptible to neutrophil-mediated killing, it is able to resist innate macrophage defenses and establish residence within the intracellular environment of that phagocyte. Definitive virulence factors of R. equi have not yet been determined, but potential candidates include capsular polysaccharide, the exoenzyme cholesterol oxidase, cell wall mycolic acids, and the products encoded by a virulence-associated plasmid. The ability to replicate within the macrophage is associated with virulence, and correlates in animals with the possession of a large plasmid and expression of the plasmid-encoded, surface-expressed lipoprotein, VapA. All strains of R. equi isolated from horses with clinical disease possess a large plasmid and express VapA antigens. In addition, bacterial clearance and granuloma development in mice is linked to plasmid possession and VapA expression. Plasmid containing strains replicate within the tissues of the mouse. whereas plasmid-cured strains are rapidly cleared. At present, the function of the VapA protein is unknown. In contrast to what is observed in the foal, only a small percentage of R. equi strains isolated from humans with rhodococcal disease express VapA antigens, although a high proportion of others express a related protein which is associated with reduced virulence and is also plasmid-encoded. In a limited number of plasmid-negative human isolates, virulence has been linked to beta-lactam resistance, and preliminary evidence suggests that the phenotype may be phage encoded. It is likely that the immune status of the patient can influence whether a particular strain of R. equi is able to produce clinical disease, and certainly experimental infection in mice has confirmed that an intact cellular immune response is necessary for clearance of the organism.
Virulent strains of the facultative intracellular bacterium Rhodococcus equi isolated from young horses (foals) with R. equi pneumonia, carry an 80-90 kb virulence plasmid and express a highly immunogenic 15-17 kDa protein of unknown function called VapA (Virulence Associated Protein A). Recent sequencing of the virulence plasmid identified a putative pathogenicity island encoding a novel family of seven Vap proteins including VapA. These proteins exhibit a significant sequence similarity to each other but have no homologues in other organisms. In this study, we describe the construction of an R. equi mutant lacking a 7.9 kb DNA region spanning five vap genes (vapA, -C, -D, -E and -F ). This vap locus mutant was attenuated for virulence in mice as it was unable to replicate in vivo and was rapidly cleared in comparison to the virulent wild-type strain. Complementation analysis of the vap locus mutant showed that expression of vapA alone could restore full virulence, whereas expression of vapC, -D and -E could not. We subsequently constructed an R. equi strain lacking only the vapA gene and found that it was attenuated for growth in vivo to the same degree as the vap locus mutant. Unlike wild-type R. equi which replicates intracellularly, both of the mutant strains exhibited a growth defect in macrophages although their attachment to the macrophages was unaffected. These studies provide the first proof of a role for vapA in the virulence of R. equi, and demonstrate that its presence is essential for intracellular growth in macrophages.
REASONS FOR PERFORMING STUDY: Prognosis of Rhodococcus equi pneumonia can be challenging because the course of the disease is often insidious and overt clinical signs are subtle. Early diagnosis is considered desirable because it may offer the chance of more successful implementation of treatment and, thereby, improved outcome. Serological tests have previously failed to be accurate for early detection or diagnosis. Measurement of serum amyloid A (SAA) prior to and at the time of clinical signs was therefore chosen in order to assess its potential clinical use. OBJECTIVE: To determine whether SAA concentrations differentiate foals affected with R. equi pneumonia from unaffected foals, either prior to the onset of disease or at the time of onset of clinical signs. HYPOTHESIS: SAA concentrations are significantly higher among foals that develop R. equi pneumonia than in foals from the same environment that remain clinically unaffected. METHODS: Serum samples were obtained from 212 foals 7-14 days and 196 foals 21-28 days post partum, and from affected foals and age-matched controls at the time of onset of signs of pneumonia. SAA concentration was determined for each sample. RESULTS: There were no significant differences between SAA concentrations of foals with R. equi and clinically unaffected foals during the 2 periods of examination or at the time of onset of clinical signs of R. equi pneumonia. CONCLUSIONS: Concentrations of SAA are variable among foals with R. equi pneumonia and cannot be used reliably either as an ancillary diagnostic tool or to screen for early detection of disease during the first month post partum. POTENTIAL RELEVANCE: Bimonthly monitoring concentration of SAA is not useful as a screening test for early detection of R. equi pneumonia and does not facilitate diagnosis of this disease when used according to the protocol of this study.
OBJECTIVE: To determine whether isolation and virulence of Rhodococcus equi from soil and infected foals are associated with clinical disease. DESIGN: Cross-sectional and case-control study. SAMPLE POPULATION: R equi isolates from 50 foals with pneumonia and soil samples from 33 farms with and 33 farms without a history of R equi infection (affected and control, respectively). PROCEDURE: R equi was selectively isolated from soil samples. Soil and clinical isolates were evaluated for virulence-associated protein antigen plasmids (VapA-P) and resistance to the beta-lactam antibiotics penicillin G and cephalothin. Microbiologic cultures and VapA-P assays were performed at 2 independent laboratories. RESULTS: VapA-P was detected in 49 of 50 (98%) clinical isolates; there was complete agreement between laboratories. Rhodococcus equi was isolated from soil on 28 of 33 (84.8%) affected farms and 24 of 33 (72.7%) control farms, but there was poor agreement between laboratories. Virulence-associated protein antigen plasmids were detected on 14 of 66 (21.2%) farms by either laboratory, but results agreed for only 1 of the 14 VapA-P-positive farms. We did not detect significant associations between disease status and isolation of R equi from soil, detection of VapA-P in soil isolates, or resistance of soil isolates to beta-lactam antibiotics. No association between beta-lactam antibiotic resistance and presence of VapA-P was detected. CONCLUSIONS AND CLINICAL RELEVANCE: On the basis of soil microbiologic culture and VapA-P assay results, it is not possible to determine whether foals on a given farm are at increased risk of developing disease caused by R equi.
Virulence-associated protein A (VapA) of Rhodococcus equi has been proposed for use both as a vaccine and as a target for antibodies in immunotherapy and diagnostic tests. Epitope mapping of VapA allowed the identification of two B cell epitopes associated with R. equi pneumonia. The peptide NLQKDEPGRASDT was confirmed as an immunodominant N-terminal B cell epitope recognized by all sera from infected foals while VSFQYNAVGPYLNINFFDSS (C-terminal B cell epitope) was exclusively recognized by IgA from the tracheal aspirates. Moreover, specific antibodies produced against the VapA-specific peptide reacted with a major protein (approximately 20 kDa) from R. equi antigens separated by two-dimensional gel electrophoresis. The strong reactivity of mucosal IgA from infected foals with the conserved peptides might constitute an attractive target for diagnosis and vaccine.
The prevalence of virulent Rhodococcus equi in soil collected from 17 domestic animal farms (from 12 cattle, 1 pig, and 4 horse farms) and in 6 clinical specimens from patients with acquired immune deficiency syndrome (AIDS) in Chiang Mai, Thailand, was investigated. The isolates were tested for the presence of 15-17-kDa antigens (VapA) and a 20-kDa antigen (VapB) by immunoblotting and for the presence of virulence plasmid DNA. Rhodococcus equi was isolated from most soil samples (68 of 80) obtained from the 17 farms, with 2.0 x 10(2) to 6.0 x 10(5) colony-forming units per gram of soil. We detected VapA in none of the 537 isolates from the soil samples. In one isolate from a pig farm, both VapB and virulence plasmid DNA were detected. Of the 6 clinical isolates from patients with AIDS, however, 4 isolates contained both VapB and virulence plasmid DNA. The remaining 2 isolates were avirulent.
Rhodococcus equi causes severe pyogranulomatous pneumonia in foals. This facultative intracellular pathogen produces similar lesions in immunocompromised humans, particularly in AIDS patients. Virulent strains of R. equi bear a large plasmid that is required for intracellular survival within macrophages and for virulence in foals and mice. Only two plasmid-encoded proteins have been described previously; a 15- to 17-kDa surface protein designated virulence-associated protein A (VapA) and an antigenically related 20-kDa protein (herein designated VapB). These two proteins are not expressed by the same R. equi isolate. We describe here the substantial similarity between VapA and VapB. Moreover, we identify three additional genes carried on the virulence plasmid, vapC, -D, and -E, that are tandemly arranged downstream of vapA. These new genes are members of a gene family and encode proteins that are approximately 50% homologous to VapA, VapB, and each other. vapC, -D, and -E are found only in R. equi strains that express VapA and are highly conserved in VapA-positive isolates from both horses and humans. VapC, -D, and -E are secreted proteins coordinately regulated by temperature with VapA; the proteins are expressed when R. equi is cultured at 37 degrees C but not at 30 degrees C, a finding that is compatible with a role in virulence. As secreted proteins, VapC, -D, and -E may represent targets for the prevention of rhodococcal pneumonia. An immunologic study using VapA-specific antibodies and recombinant Vap proteins revealed no evidence of cross-reactivity despite extensive sequence similarity over the carboxy terminus of all four proteins.
Rhodococcus (Corynebacterium) equi pneumonia is diagnosed by thoracic auscultation, radiographic and hematologic examination, and transtracheal aspiration. Treatment may be unsuccessful because of the organism's tendency to cause pulmonary abscesses. A 2-month-old, depressed, anorectic, febrile Quarter Horse colt, previously unresponsive to penicillin therapy, had loud, moist breath sounds in the ventral lung fields. Chest radiographs revealed pneumonia. Based on culture and sensitivity tests on organisms isolated from transtracheal washes, chloramphenicol and erythromycin, and then oral trimethoprim-sulfadiazine, were given, in addition to supportive therapy. The animal was fully recovered within 2 months.
We describe a case of pulmonary malacoplakia and Rhodococcus equi cavitary pneumonia in a patient with AIDS. The relationship between Rhodococcus equi, a rare bacterial human pathogen, and malacoplakia, an unusual type of chronic granulomatous inflammation, is discussed.
Rhodococcus equi is an unusual cause of infection in humans. Infection in immunocompetent patients is extremely rare-only 19 cases in immunocompetent hosts have been reported. Localized infections represent nearly 50% of reported cases. Pulmonary infections account for only 42% of infections in immunocompetent hosts, compared with 84% of infections in immunocompromised hosts. 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. Treatment of infections in immunocompetent hosts depends on the site of infection. Serious infections need to be treated with combinations of parenteral antibiotics, followed by combinations of oral antibiotics. Surgical treatment is necessary for certain types of local infections. We report a pulmonary infection due to R. equi in an immunocompetent patient, and we review all reported cases of R. equi infection in immunocompetent hosts.
Serological survey of Rhodococcus equi infection in horses in Hokkaido was performed using ELISA. Of 2,879 horse sera, 318 (11.0%) gave antibody-positive (OD greater than or equal to 0.3) reactions. The antibody-positive rate of female was significantly higher (p less than 0.01) than that of male, and no statistical difference between Anglo-Arab and thoroughbred was detected in the antibody-positive rate. The maximum antibody-positive rate (27.1%) was shown at 14 years of age. The antibody-positive rates on the 160 farms were found to vary widely from 0 to 78.9%. A significant difference (p less than 0.01) in the antibody-positive rate was detected among horse farms. It was elucidated that 100 (62.5%) out of 160 horse farms had an antibody-positive horse. These results indicate that R. equi was widespread on horse farms, and the level of environmental contamination with R. equi differed among horse farms.
We treated a patient with acquired immunodeficiency syndrome for a brain abscess caused by Rhodococcus equi, an actinomycete that usually infects the lung in immunosuppressed hosts. Rhodococcus equi brain abscess is an extremely rare lesion that has never been reported in a patient with acquired immunodeficiency syndrome. The infection was cured by lengthy therapy with multiple antibiotics after aspiration of the lesion to identify the infective organism and determine its sensitivity to antibiotics.
Twelve foals, between 27 and 83 days old, were infected with 2 strains of Rhodococcus equi by intratracheal administration. Ten of the 12 foals were inoculated with 10(4)-10(10) colony forming units (cfu) of ATCC 33701 strain. The other 2 foals were inoculated with 10(9) cfu of a plasmid-cured derivative of the ATCC 33701 strain (ATCC 33701P-). All of the 10 foals challenged with the ATCC 33701 strain showed clinical signs of pulmonary disease within 5-13 days, such as gross lesions associated with acute bronchopneumonia and microscopic lesions associated with granulomatous pneumonia. The two foals challenged with the ATCC 33701P- strain showed neither clinical signs of disease nor gross lesions. Apparently, when lacking plasmid, the virulent Rhodococcus equi lost its pathogenicity.