|Year : 2015 | Volume
| Issue : 2 | Page : 44-47
Comamonas testosteroni endocarditis in Turkey: A case report and review of the literature
Arzu Duran1, Ahmet Feyzi Abacilar2, Ihsan Sami Uyar2, Mehmet Besir Akpinar2, Veysel Sahin2, Faik Fevzi Okur2, Mehmet Ates2, Emin Alp Alayunt2
1 Department of Medical Microbiology, Sifa University, Bayrakli, Izmir, Turkey
2 Department of Cardiovascular Surgery, Sifa University, Bayrakli, Izmir, Turkey
|Date of Web Publication||25-Feb-2015|
Dr. Arzu Duran
Department of Medical Microbiology, Sifa University, 35100 Bayrakli, Izmir
Source of Support: None, Conflict of Interest: None
Introduction: Comamonas testosteroni is a gram-negative bacillus which commonly occurs in various environments worldwide. Comamonas testosteroni is rarely recognized as a human pathogen. The case we report is the first Comamonas testosteroni endocarditis in Turkey and the fourth case in the world. Case Presentation: A 51-year-old male patient with a history of chest pain, dyspnea, and tachycardia was admitted to our hospital. Coronary angiography and echocardiography results revealed mobile lesions and plaques in aortic valve. Cardiovascular surgery was performed; aortic valve vegetation was detected and the aortic valve was excised. Aerobic culture was studied. After the biochemical identification tests and the use of VITEK-2 Compact (Biomerieux, France) automated microbial identification system, pathogenic bacteria was identified as Comamonas testosteroni. The patient who had no risk factors was diagnosed with endocarditis and treated with Ciprofloxacin. The case recovered from Comamonas testosteroni infection. Conclusion: There has been an increase in bacterial infections caused by Comamonas testosteroni and antibiotic resistance of the bacteria. For this reason, Comamonas testosteroni infections have increasingly become important. There have only been four cases from Turkey so far. This paper also examines the other cases in the literature as a whole.
Keywords: Case report, Comamonas infection, Comamonas testosteroni, endocarditis, Turkey
|How to cite this article:|
Duran A, Abacilar AF, Uyar IS, Akpinar MB, Sahin V, Okur FF, Ates M, Alayunt EA. Comamonas testosteroni endocarditis in Turkey: A case report and review of the literature. Sifa Med J 2015;2:44-7
|How to cite this URL:|
Duran A, Abacilar AF, Uyar IS, Akpinar MB, Sahin V, Okur FF, Ates M, Alayunt EA. Comamonas testosteroni endocarditis in Turkey: A case report and review of the literature. Sifa Med J [serial online] 2015 [cited 2019 May 23];2:44-7. Available from: http://www.imjsu.org/text.asp?2015/2/2/44/152117
| Introduction|| |
Comamonas testosteroni is a gram-negative, motile, aerobic, non-spore-forming bacillus which is commonly found worldwide.  Formerly known as Pseudomonas testosteroni, this bacillus was reclassified with molecular methods in 1987 and renamed as Comamonas testosteroni as it is known to use testosterone as the solely carbon source to grow.  Genus Comamonas involves Comamonas acidovorans, Comamonas testosteroni, and Comamonas terrigenaspecies.  Comamonas testosteroni commonly found in soil, water, animals and leftovers. Indeed, it has also been detected in the water of in-use hospital oxygen humidifier reservoirs, hemodialysis solutions, scar tissues, urine, mucus, prostate tissues, stool samples, and respiratory secretions of cystic fibrosis patients. However, it has not been recognized as a component of the endogenous human microflora. , Thirty-two cases have been reported in the literature concerning C. testosteroni infection so far. This case report is issued because it is the first endocarditis case in Turkey which C. testosteroni was isolated. The other cases reported in the literature which is related to this microorganism were also discussed.
| Case Report|| |
A 51-year-old male patient with a history of chest pain, dyspnea, and tachycardia presented to our cardiovascular surgery polyclinic. Coronary angiography was performed and 70-95% Left Anterior Desendan (LAD) thrombus, OM 2 : 80%, Right Coronary Artey (RCA): 70% plaque was detected. Findings of echocardiography demonstrated calcification around the aortic valve and a mobile lesion, which was thought to be a thrombus. Cardiovascular surgery was performed to the patient. Aortic valve vegetation was detected and the valve was excised. Aerobic culture and antibiogram were studied under sterile conditions. Aortic valve culture was incubated in aerobic conditions at 37°C after being inoculated on 5% sheep blood agar, chocolate agar, and Eosin Metilen Blue (EMB) agar plates. Bacterial colonies, which are 2-3 mm in diameter, were visible in all of the plates after 24 hours. Non-hemolytic colonies were detected on the blood agar and pink pigmented S type colonies appeared on EMB agar plate. Gram-negative bacilli were observed with gram staining. Biochemical identification tests showed that it is a urease negative, citrate and indole negative, oxidase and catalase-positive motile bacterium which does not ferment glucose. In addition, VITEK-2 Compact (Biomerieux, France) automated microbial identification system identified the bacterium as Comamonas testosteroni with 94% possibility using its global and phenotypic Clinical and Laboratory Standarts Institute criteria. Antibiotic susceptibility of the bacterium was studied using VITEK-2 Compact (Biomerieux, France) automatized system and Kirby-Bauer disk diffusion test. The microorganism was found to be resistant to piperacillin-tazobactam, imipenem, meropenem, gentamicin, and netilmicin; moderately susceptible to amikacin; and susceptible to ciprofloxacin, ceftazidime, cefoperazone-sulbactam, cefepime, tigecycline, and colistin. The case responded to the treatment with ciprofloxacin, which was given after the susceptibility test and was released from the hospital seven days after the surgery. There were no signs of pathology in physical examination and echocardiography, which was performed one month later.
| Discussion|| |
Although Comamonas testosteroni is rarely seen as a human infection agent, there has been an increase in the number and variety of cases which Comamonas testosteroni is the infectious agent. Because this bacterium has been more frequently encountered, we anticipate that this case will beneficial for clinicians and laboratory physicians as a diagnosis and clinical approach.
Endocarditis cases, which Comamonas testosteroni is the agent pathogen, are extremely infrequent: there have only been three reported cases in the literature so far. The first endocarditis case is thought to have rheumatic heart disease with Comamonastes testosteroni bacteremia. C. testosteroni reproduced in patient's both of the blood cultures. However, endocarditis diagnose may be questionable as it does not meet Duke Criteria.  Second endocarditis case is reported by Cooper et al. and supported by blood culture, clinic examination, echocardiogram results, and histopathology records. The case is thought to get the infectious bacteria from the shallow cuts on the skin surface while working in construction industry. There was no heart valve disease, intravenous drug use, and dental surgical intervention in the patient's history and he was in good health. The course of this endocarditis case was very severe, so mitral valve was replaced and the patient's infection resolved completely with appropriate antibiotic therapy. 
The third case is a hemodialysis patient who has diabetes mellitus, together with endocarditis suspected bacteremia. C. testosteroni was isolated from the patient's three blood cultures and the catheter culture used in hemodialysis. This patient's death is caused by septic shock and decompensated heart failure. Other fatal cases reported in the literature are the two babies of a woman who uses intravenous drugs. The other patients who developed C. testosteroni infection responded to the treatment. 
Our case is the fourth reported endocarditis case worldwide. There is no immunosuppression, heart valve disease, or intravenous drug use in our patient's history, which are predisposing factors to develop endocarditis. The endocarditis infection responded to ciprofloxacin treatment and the healthy patient was released from the hospital seven days after the surgery. There were no signs of pathology in physical examination and echocardiography, which was performed one month later.
Gram negative endocarditis infections are generally severe and the mortality rates of them are high, and may also cause long-term complications. It is stated in the literature that patients who develop C. testosteroni sepsis may develop vegetation on heart valves. 
C. testosteroni infections which were published before are; purulent meningitis in a patient with relapsing cholesteatoma, cellulitis infection of a patient who fell down while fishing and injured his leg by a fish fin, central venous catheter infection of a breast cancer patient, C. testosteroni isolated from lung secretions of a group of cystic fibrosis patients and C. testosteroni bacteremia in a patient with perforated acute appendicitis. ,,,, Case reports of infection by C. testosteroni whose clinic findings and treatments were reported in the literature are shown in [Table 1].
There have been four reported cases of C. testosteroni infection from Turkey so far. First case was reported by Arda et al. in 2003, which is a purulent meningitis case in a patient with relapsing cholesteatoma.  The bacteria were isolated from cerebrospinal fluid and the infection of this case was treated with Meropenem. Second case is C. testosteroni bacteremia in a patient with perforated acute appendicitis, which is reported by Gül et al. C. testosteroni was isolated from the patient's peritoneal fluid and blood cultures and the case was treated with cefazolin.  Third case was reported by Katırcıoğlu et al. in 2010. This is a bacteremia case which developed in an intensive care patient. The bacteria were isolated from the blood.  This is the first case which shows the development of multiple-antibiotic resistance together with imipenem resistance. Last case is an intensive care patient who was reported by Özden et al. in 2011. The reproduction was detected in the respiratory tract in this case. The microorganism in this patient is only susceptible to colistin, and resistant to piperacillin-tazobactam, imipenem, amikacin, ciprofloxacin, ceftazidime, cefoperazone-sulbactam, and cefepime.  The fact that the bacteria in our case are resistant to Imipenem and Meropenem shows that the pathogenicity and antibiotic resistance of C. testosteroni increased, and the problems relating rational antibiotic use practices continue.
C. testosteroni is able to survive in hospital environments for a long time. No matter what part of the body they develop, C. testosteroni infections are community-acquired.  Gastrointestinal pathologies are usually accompanied by intra abdominal infections and these infections are the most frequently reported infection group.  Risk factors which may have caused infections in the other cases are central venous catheter use, medicine injections, skin cuts, and subcutaneous lacerations and surgical procedures. ,,,
| Conclusion|| |
It is anticipated that nosocomial infections related with this bacterium will increase over time by looking at the increase of the number of long-stay hospital patients with impaired immune system and long-term use of intravascular catheter. The infections due to C. testosteroni micro-organism may sometimes be life threatening although there are infrequent fatal cases of C. testosteroni infections. More research should be conducted regarding pathogenicity, virulence, and increasing antibiotic resistance of C. testosteroni. 
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