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First reported case of Rothia dentocariosa spondylodiscitis in an immunocompetent patient
SCHWOB, Jean-Marc, et al.
SCHWOB, Jean-Marc, et al . First reported case of Rothia dentocariosa spondylodiscitis in an immunocompetent patient. IDCases , 2020, vol. 19, p. e00689
DOI : 10.1016/j.idcr.2019.e00689 PMID : 31908950
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http://archive-ouverte.unige.ch/unige:128367
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Case report
First reported case of Rothia dentocariosa spondylodiscitis in an immunocompetent patient
Jean-Marc Schwob
a,*, Violène Porto
b, Sigiriya Aebischer Perone
a, Christian Van Delden
c, Gilles Eperon
a, Alexandra Calmy
daDivisionofTropicalandHumanitarianMedicine,GenevaUniversityHospitalsandUniversityofGeneva,Geneva,Switzerland
bDepartmentofInternalMedicine,RehabilitationandGeriatrics,InternalMedicineUnit,GenevaUniversityHospitalsandUniversityofGeneva,Geneva, Switzerland
cDivisionofInfectiousDiseases,TransplantInfectiousDiseasesUnit,UniversityHospitalsandUniversityofGeneva,Geneva,Switzerland
dDivisionofInfectiousDiseases,HIVUnit,UniversityHospitalsandUniversityofGeneva,Geneva,Switzerland
ARTICLE INFO
Articlehistory:
Received11October2019
Receivedinrevisedform16December2019 Accepted16December2019
Keywords:
Rothiadentocariosa Spondylodiscitis Bacteremia Osteomyelitis
ABSTRACT
Rothiadentocariosaispartofthenormalhumanoropharyngealmicrofloraandisfrequentlyassociated with dental caries and periodontal disease. Invasive disease has been described essentially in immunocompromisedhostsand/orpatientswithunderlyingconditionsaspredisposingfactors.We presentacaseofanotherwisehealthy46-yearsoldmalewithspondylodiscitiscausedbythispathogen.
Treatmentwithceftriaxoneandrifampinwassuccessful.Toourknowledge,thisisthefirstR.dentocariosa spondylodiscitisreportedinanimmunocompetentpatient,andthesecondoneintheliteratureoverall.
©2019TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Rothiadentocariosa ispartofthenormal humanoropharynx microflora in 1.3%–29% of healthy individuals [1,2] and is commonlyassociatedwithdentalcariesandperiodontaldisease [1].Invasivediseasehasbeendescribedessentiallyinimmuno- compromisedhosts[3]and/orpatientswithapredisposingfactor, suchascardiacvalvulardiseaseorIntravenous(IV)-drugusers[4].
Wepresentauniquecaseofahealthypatientwithspondylodiscitis causedbythispathogen.
Casedescription
A 46-years old male, known for chronic epigastric pain, consulted a tropical and travel related infectious diseases outpatient clinic on day 7 of persistent fever. His symptoms started with febrile diarrhea followed by transfixing epigastric pain,twodaysafterhisarrivalintheMiddle-Eastfortourism.On
day5thediarrheadisappeared.However,nightfeversof38.5C persisted, associated with severe diaphoresis, epigastric trans- fixing left paravertebralpain, and diffuse myalgia. The patient deniedcardiopulmonary,urinaryorcutaneoussymptoms.
Thepatientisworkinginthefinancialsector.Whiletravelling, hestayedinanupper-rangehotelanddidnoteatrawfoodnor dairyproducts,hadnocontactwithsickpeopleoranimals,andhad nostillwaterormosquitobitesexposure.Thepatientlivedina monogamousrelationshipandhadnohistoryofIV-druguse.One daybeforetravellingandthreedayspriortotheonsetofhisillness, hehaddentalscaling.
Clinically,thepatienthadGlasgowComaScaleof15,presented a low-grade fever (37.8C), his heart rate was 83/min, blood pressure 156/83mmHg and was in no apparent distress with slightly painfulepigastricpalpation withleftparavertebralpain radiationandmoderateperiodontaldiseasewithgumsrecession withoutsignsofacutegingivitis.Hehadnolymphadenopathyor organomegaly, cardiac and neurological status showed no abnormality.Spinalpercussionandmobilizationwerenotpainful orlimited.
The initial blood test on day 7 of fever showed normal leucocytes counts (7.5109/L), with a mild lymphocytopenia (0.95109/L), normalneutrophils counts (5.93109/L) and an isolatedmildrelativemonocytosisonday9(11.3%of6.7109/L).
C-reactiveproteinwas37mg/Landthenfluctuatedbetween18 and 54mg/Lfor more than oneweek. Liver enzymes, creatine
* Correspondingauthorat: DivisionofTropicalandHumanitarianMedicine, Geneva University Hospitals, 6 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.
E-mailaddresses:[email protected](J.-M.Schwob),
[email protected](V.Porto),[email protected] (S.AebischerPerone),[email protected](C.VanDelden), [email protected](G.Eperon),[email protected](A.Calmy).
https://doi.org/10.1016/j.idcr.2019.e00689
2214-2509/©2019TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
IDCases19(2020)e00689
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IDCases
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kinase,lipaseandurinetestswerenormal.Twobloodcultures andabroad-rangePCRinthefeceswerenegativeforpathogens tested. Active cytomegalovirus, Epstein-Barr virus, Parvovirus B19,HIV,Humanherpesviruses6and7,RubellaandToxoplasma gondii infections were excluded by negative serum PCRs and serology.The chest X-ray was normal. QuantiFERON1, Brucella serologyandRoseBengalTests,asbacterialbroad-rangebloodPCR werenegative.
A transthoracic echocardiogram was negative for signs of endocarditisbyday21.Athoracic-abdominalCT-scanonday23, showedsignsofvertebralendplatemirrorerosionsregardingthe T10-T11 discus. The patient was then hospitalized for further workup.
Onday24,anaerobicbottlefromabloodculture,donebyday 17, became positive for Gram-positive cocci identified as R.
dentocariosa by MALDI-TOF MS (Matrix-Assisted-Laser Desorp- tion/Ionization-TimeofFlightMassSpectrometer)(MALDI-TOF MicroFlexLTBrukerDaltonik)withthehighestscoreat2.43.
A spinal Magnetic Resonance Imaging (MRI) on day 28 confirmed a T10-T11 spondylodiscitis with vertebral endplates mirrorerosionsandsignalabnormalityoftheadjacentvertebral bodiesshowingT1hyposignal,STIRhypersignalandT1contrast enhancement(Fig.1).Onday29,discusandvertebrabiopsywere performed;thedirectGramstainwaspositiveforGram-positive cocci,identifiedasR. dentocariosabyMALDI-TOF.A subsequent aerobicbottlebloodculturebecamepositiveforGram-labilerods, also identified as R. dentocariosa by MALDI-TOF MS. A trans- esophageal echocardiogram revealed no signs suggestive of endocarditis. Minimum inhibitory concentrations (MIC) were determinedaccordingtoEUCASTguidelines[5]forthefollowing antibiotics:penicillin0.004susceptible(S),ceftriaxone0.023(S), gentamicin8resistant(R),ciprofloxacin>32(R),clindamycin1(R), trimethoprim-sulfamethoxazole (TMP-SMX) 0.23 (S), rifampin 0.023(S),andvancomycin1.5(S;unitsin
m
g/ml).Ceftriaxone was started on day 30 (2g IV qd) for 34 days, followedbyaswitchtooralTMP-SMX(800/160mgtid)for14days.
Rifampin(450mgorallybid)wasaddedfortheentire48daysof treatment.
After treatment initiation, the patient did not present any recurrenceoffever,andinflammatorymarkersnormalized.Dueto persistent spinal pain, we repeated an MRI six weeks after antibioticscessation,whichshowedlowresidualinflammation.
Discussionandconclusion
R.dentocariosaisafacultativeanaerobic,pleomorphicGram- positive bacteriumwithvaryingmorphology including coccoid, diphtheroid, and filamentous forms. Its identification can be challengingforclinicallaboratories[6].Inourcase,R.dentocariosa pleomorphismmanifestedasGram-positivecocciandGram-labile rods;definitiveidentificationwasobtainedthroughMALDI-TOF.
OurpatientpresentedwithT10-T11spondylodiscitis,likelya resultfromtheminorperiodontalintervention.InareviewofR.
dentocariosaendocarditis,periodontaldiseasewasfoundin60%of patients,75%ofwhomweremale[4].Inthegeneralpopulation, infectionsothersthancariesthatinvolveR.dentocariosaarevery rare.SystemicinfectionsassociatedwithR.dentocariosahavebeen mostlybacteremia[3].Highcomplicationratesinupto35%cases have beendescribed for endocarditis, includingmycotic aneur- ysms, brain abscesses, intracerebral and subarachnoid hemor- rhages[4].InSeptember2015,Chowdharyetal.countedonly24 publishedendocarditiscasesintheliterature[7].Boneandjoint infectionshavebeenveryrarelyreportedwithonlyonecaseof vertebralosteomyelitissecondarytoendocarditis[8]andonecase ofnativejointsepticarthritis[9],bothdescribedinimmunocom- promisedpatients.
In the present case, R. dentocariosa was initially considered dubiousasetiologicalagentinabsenceofpreviouslyreportedbone
Fig.1.SpinalMRIT1wimagesaftergadoliniumcontrastinjection,inthesagittalplanethroughthethoracicvertebraeshowinflamedT10andT11vertebralbodies.
2 J.-M.Schwobetal./IDCases19(2020)e00689
andjointinfectionsinimmunocompetentpatientsforthisbacterial species.However,duetotheclinicaldeterioration,antibioticswere startedbeforeR.dentocariosawasidentified indiscusandbone biopsies. There is limited data available on R. dentocariosa antimicrobialsusceptibilities.Themostfrequentlyusedantimicro- bialtherapyisacombinationofpenicillinandgentamicin[3,4].In ourcase, R. dentocariosawas gentamicin-resistant.Publications reportahighsensibilitytopenicillin,cephalosporinandrifampin [4,10], and cephalosporin-rifampinhas beensuggested asfirst- choice combination [10]. Accordingly, our patient received a combinationoftwoactiveantibioticsbasedonpublishedendocar- ditisdata.Noultrasonographic signssuggestiveforendocarditis werefound(twominorDukeCriteria)andnoimmunesuppression was identified basedonpatient and family’shistory,full blood counts,andHIVvirusdetection.
In conclusion, we find that Rothia dentocariosa, part of the normalhumanoropharyngealmicroflora,hasaninvasivepotential eveninimmunocompetentpatients.R.dentocariosacancausea serioussystemicinfectionthatcliniciansshouldbeawareof,and treataccordingly.
Competinginterests None.
Funding
Thisresearchdidnotreceiveanyspecificgrantfromfunding agenciesinthepublic,commercial,ornot-for-profitsectors.
Consent
Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopyof thewrittenconsentisavailableforreviewbytheEditor-in-Chiefof thisjournalonrequest
Acknowledgements
We want to thank M. René Studer, M. Arnaud Riat, micro- biologists,andMs.NouriaAzamatthelaboratoryofbacteriologyof Geneva University Hospitals forlaboratory analysisand discus- sionsandDr.RobvanHooftvanHuijsduijnenforcriticalreadingof themanuscript.
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