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Suppurative flexor tenosynovitis from Tsumakurella and Trichosporon: case report and literature review.

Case report

A 61-year-old man with a history of multiple medical problems including coronary artery disease, chronic obstructive lung disease and pacemaker placement, sustained a needle-stick injury at work to his left third finger one day before admission. He worked for a medical waste disposal company and a needle in a bag of refuse punctured the finger through two pairs of gloves. He wakened on the morning of admission with pain and swelling in the finger that became progressively worse. He denied fever or chills. In our emergency department he was given a tetanus booster, hepatitis B vaccine and intravenous cefazolin. His initial white blood cell count was 9400/cmm with 73% neutrophils (normal 41-72%).The remaining laboratory tests were within normal limits. Physical exam revealed all four of Kanavel's signs of suppurative flexor tenosynovitis (1).

In the operating room he underwent incision and drainage of the left ring finger, flexor tendon sheath and palm with tenosynovectomy. Purulent exudate was seen from the flexor tendon sheath at the level of the distal phalanx down to the palmar aponeurotic pulley. Tenosynovium and cultures for aerobic and anaerobic organisms were sent to the laboratory. On post-operative day one the infectious disease service was consulted.

At the consultation the patient reported no allergies. He was afebrile. His physical exam was normal except for the left hand, which was wrapped in a heavy bandage. No foul odor was detected. The third digit was tender to palpation. Additional tests included HIV 1 and 2 antibodies (nonreactive), HIV RNA (not detected) and a viral hepatitis panel (negative for hepatitis A, B, and C). The Gram stain from the operating room showed rare white blood cells and no organisms. The culture grew a Gram-variable bacillus, identified at a reference laboratory as Tsukamurella spp, and a yeast, Trichosporon spp. The susceptibility pattern of the two organisms is shown in Table 1. The patient was discharged home on clarithromycin, doxycycline, voriconazole and ertapenem. The clarithromycin was chosen to cover possible atypical mycobacteria, as final culture results were not available at the time of discharge. In addition to antibiotics, treatment also included local wound care with twice daily soaks and dressing changes. He also went for weekly occupational therapy visits. He was seen in the office six weeks later. His inflammatory markers had normalized and he had no further pain or swelling in the hand so we elected to stop therapy and observe. A repeat HIV 1 and 2 antibody test was again negative. He has done well and is now back to work.

Discussion

To our knowledge this is the first report of tenosynovitis caused by Trichosporon. It is also interesting that Trichosporon and Tsukamurella were isolated from the same wound. It is reasonable to conclude that they were acquired concomitantly at the time of the needle stick injury. The patient had a rather rapid clinical course, presenting to our emergency department the day after the injury with pain and swelling in the left ring finger. He had no signs or symptoms of systemic toxicity. Initially our antibiotic coverage was designed to cover for skin pathogens although we were aware of the possibility for environmental (i.e. soil) pathogens. The only culture information available on the day of discharge was that a Gram-variable rod had grown aerobically on sheep blood agar plates as well as a yeast. The cultures had already been sent out to the reference lab, so no acid fast smear was done. We chose voriconazole because the needle was medical waste and because of the concern for a possible resistant yeast, like Candida glabrata or Candida krusei. Because of scheduling issues he was not seen in our office until six weeks later, although we did follow routine labs every week. Of the three antibacterials chosen only one, doxycycline, had activity against the Tsukamurella. Nonetheless, he did well and all signs and symptoms of infection resolved. Voriconazole is active against Trichosporon and azole therapy is the standard for treatment.

Tsukamurella is one of the actinomycetes. It is a partially acid-fast, aerobic, Gram-positive filamentous rod that can fragment into cocci. Currently there are six identified species: paurometabola, pulmonis, ichonensis, tyrosinosolvens, strandjordae, and wratislaviensis (2). The organism can be isolated from environmental sources including a soil, farm animals, and both fresh and salt water. Tsukamurella infections in humans are rare. Of the 15 reported cases, most were in patients with chronic illness or immunosuppression. It has been isolated in an AIDS patient with multiple cavitary lung lesions (3), a 5-year-old girl with acute myelogenous leukemia (4), and patients on peritoneal (5) and hemodialysis (6). Woo and colleagues described the first three cases of Tsukamurella conjunctivitis, all of whom responded to treatment with either polymixin B-neomycin or chloramphenicol eye drops (7). A recent paper from Japan described a patient with gastric cancer in whom a culture of bloody sputum grew Tsukamurella tyrosinosolvens (8). There have been multiple case reports of Tsukamurella catheter-related bloodstream infections (9-12) and one of an infected implantable cardioverter-defibrillator (13). In addition to our case two other orthopedic infections have been reported. Larkin et al. described a 69-year old woman with multiple postoperative wound infections from a knee replacement (14). She was initially treated with vancomycin and pipercillin-tazobactam followed by a course of clarithromycin, ciprofloxacin and ethambutol with a successful outcome. In 1988 Tsukamurella et al. reported a case of necrotizing tenosynovitis caused by Rhodococcus aurantiacus which was subsequently renamed Tsukamurella paurometabol (15).

Trichosporon, the other organism isolated from our patient's culture, is also a rare cause of human disease. It produces septate hyphae, arthroconidia, and yeastlike growth on culture media. Trichosporon is found in the environment, on plants, and colonizing human skin, stool and urine. Like Tsukamurella it shares a predisposition toward patients with chronic illnesses. More than 100 patients with deep trichosporonosis have been described and 60% had severe neutropenia, usually with acute leukemia (16). Among immunocompetent patients Trichosporon has been reported to cause urinary tract infection (17), postoperative wound infections (18-20), endocarditis (21), fungemia and pneumonia in a trauma patient (22), superficial skin infection (23) and a cutaneous abscess after a steroid injection (24). This fungus is usually susceptible to fluconazole, itraconazole, and the broad-spectrum azoles. MIC testing should be performed. The MIC to caspofungin and other echinocandins is high and these drugs should not be used to treat Trichosporon infections.

In conclusion, we report a case of suppurative flexor tenosynovitis from Tsukamurella and Trichosporon. These two organisms are rare human pathogens and usually cause infection in immunocompromised hosts. Our patient had the misfortune of acquiring them after a needle stick injury while handling medical waste.

References

(1.) Kanavel AB. Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative Processes in the Fingers, Hand, and Forearm. 7th ed. Philadelphia: Lea and Febinger, 1943.

(2.) Forbes BA, Sahm DF, Weissfeld AS. Bailey and Scott's Diagnostic Microbiology.12th ed. St. Louis: Mosby Elsevier, 2007: 311-22.

(3.) Alcaide ML, Espinoza L, Abbo L. Cavitary pneumonia secondary to Tsukamurella in an AIDS patient. First case and review of the literature. J Infect . 2004; 49:17-9.

(4.) Kattar MM, Cooksoon BT, Carlson LD, et al. Tsukamurella strandjordaesp.nov., a proposed new species causing sepsis. J Clin Microbiol. 2001; 39:1467-76.

(5.) Jones RS, Fekete T, Traunt AL, et al. Persistent bacteremia due to Tsukamurella paurometabolum in a patient undergoing hemodialysis: case report and review. Clin Infect Dis. 1994; 18:830-2.

(6.) Shaer AJ, Gadegbeku CA. Tsukamurella peritonitis associated with continuous ambulatory peritoneal dialysis. Clin Nephrol. 2001; 56:241-6.

(7.) Woo PC, Ngan AH, Lau SK, et al. Tsukamurella conjunctivitis: a novel clinical syndrome. J Clin Microbiol. 2003; 41: 3368-71.

(8.) Matsumoto T, Shiraishi M, Yoshimura H, et al. Tsukamurella tyrosinosolvens cultured from sputum of a patient who received total gastrectomy for gastric cancer. Kekkaku. 2006; 81:487-90.

(9.) Schwartz MA, Tabet SR, Collier AC, et al. Central venous catheter-related bacteremia due to Tsukamurella species in the immunocompromised host: a case series and review of the literature. Clin Infect Dis. 2002; 35:e72-7.

(10.) Maertens J, Wattiau P, Verhaegen J, et al. Catheter-related bacteremia due to Tsukamurella pulmonis. Clin Microbiol Infect. 1998; 4:51-53.

(11.) Elshibly S, Doherty J, Xu J, et al. Central line-related bacteraemia due to Tsukamurella tyrosinosolvens in a haematology patient. Ulster Med J. 2005; 74:43-6.

(12.) Sheridan EA, Warwick S, Chan A, et al. Tsukamurella tyrosinosolvens intravascular catheter infection identified using 16S ribosomal DNA sequencing. Clin Infect Dis. 2003; 36:e69-70.

(13.) Almehmi A, Pfister AK, McCowan R, et al. Implantable cardioverter-defibrillator infection caused by Tsukamurella. WV Med J. 2004; 100:185-86.

(14.) Larkin JA, Lit L, Sinnott J, et al. Infection of a knee prosthesis with Tsukamurella species. South Med J. 1999; 92:831-2.

(15.) Tsukamura M, Hikosaka K, Nishimura K et al. Severe progressive subcutaneous abscesses and necrotizing tenosynovitis caused by Rhodococccus aurantiacus. J Clin Micro. 1988;26:201-05.

(16.) Hospenthall DR. Uncommon Fungi. In: Mandell GL, Dolin R, Bennett JE, eds.

Principles and practice of infectious diseases. 6th ed. New York: Churchill Livingston, 2005:3068-79.

(17.) Sood S, Pathak D, Sharma R, et al. Urinary tract infection by Trichosporon asahii. Indian J Med Microbiol. 2006;24:294-6.

(18.) Davies F, Logan S, Johnson E, et al. Sternal wound infection by Trichosporon inkin following cardiac surgery. J Clin Microbiol. 2006; 44:2657-9.

(19.) Greenberg RG, Berger TG. Postoperative Trichosporon beigelii soft tissue infection. J Dermatol Surg Oncol. 1989; 15:432-4.

(20.) Tian HH, Tan SM, Tay KH. Delayed fungal infection following augmentation mammoplasty in an immunocompetent host. Singapore Med J. 2007; 48:256-8.

(21.) Keay S, Denning DW, Stevens DA. Endocarditis due to Trichosporon beigelii: in vitro susceptibility of isolates and review. Rev Infect Dis. 1991; 13:383-6.

(22.) Miro O, Sacanella E, Nadal P, et al. Trichosporon beigelii fungemia and metastatic pneumonia in a trauma patient. Eur J Clin Microbiol Infect Dis. 1994; 13:604-6.

(23.) Pulvirenti N, Dall'Oglio F, Greco AM, et al. Superficial cutaneous Trichosporon asahii infection in an immunocompetent host. Int J Dermatol. 2006; 45:1428-31.

Richard R.Watkins, MD, MS

Division of Infectious Disease, Akron

General Medical Center Akron, OH & Northeastern Ohio Universities

College of Medicine Rootstown, OH

Drew Engles, MD

Division of Orthopedic Surgery, Akron

General Medical Center, Akron, OH
Table 1. Antibiotic susceptibility pattern for Tsukamurella and
Trichosporon isolated from left ring finger wound culture.

Organism          Antibiotic        Susceptibility

Tsukamurella      Ciprofloxacin     Susceptible
                  Linezolid         Susceptible
                  Clarithromycin    Resistant
                  Trimeth sulfa     Susceptible
                  Ceftriaxone       Resistant
                  Imipenem          Resistant
                  Tobramycin        Intermediate
                  Amikacin          Susceptible
                  Minocycline       Susceptible
                  Amphotericin B    MIC= 0.5
Trichosporon      Fluconazole       MIC= 2
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Author:Watkins, Richard R.; Engles, Drew
Publication:West Virginia Medical Journal
Article Type:Case study
Geographic Code:1USA
Date:Nov 1, 2009
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