Chronic granulomatous disease presenting as severe sepsis due to Burkholderia gladioli

Multiple skin abscesses associated with bacteremia caused by Burkholderia gladioli: A case report

BACKGROUND

Burkholderia gladioli (B. gladioli) is regarded as a rare opportunistic pathogen. Only a few patients with abscesses caused by B. gladioli infections have been reported, and these are usually abscesses at the incision caused by traumatic surgery.

CASE SUMMARY

A 74-year-old male patient with abscesses and pain throughout his body for 1 mo was admitted to our hospital. Some of the abscesses had ruptured with purulent secretions on admission. Color Doppler ultrasound examination of the body surface masses showed mixed masses 75 mm × 19 mm, 58 mm × 17 mm, 17 mm × 7 mm, and 33 mm × 17 mm in size in the muscle tissues of both the right and left forearms, the posterior area of the right knee and the left leg, respectively. Abscess secretions and blood cultures grew B. gladioli. The following 3 methods were used to jointly identify the bacterium: an automatic microbial identification system, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, and full-length 16S rDNA sequencing. After 27 d of treatment with meropenem, etimicin, trimethoprim-sulfamethoxazole and other antibiotics, most of his skin abscesses were flat and he was discharged without any symptoms.

CONCLUSION

This is the first reported case of multiple skin abscesses associated with bacteremia caused by B. gladioli. Our study provides important reference values for the clinical diagnosis and treatment of B. gladioli infections.

Burkholderia gladioli sepsis in newborns

Burkholderia gladioli is a rare cause of bacteremia and sepsis in the absence of such predisposing factors as chronic granulomatous disease, cystic fibrosis, and immunosuppression. Little is known about B. gladioli infection in newborns. The aim of this study was to present the features of B. gladioli infection in newborns. Clinicopathological characteristics, patterns of antimicrobial susceptibility, predisposing factors, and outcomes of B. gladioli bloodstream infection were retrospectively analyzed in newborns treated between 2008 and 2011. During the 3-year study period, B. gladioli was isolated from the blood cultures of 14 patients (3.7 per 1,000 admissions). In all, 5 (35.7 %) of the 14 cases had a positive blood culture at the time of initial admission. Primary diagnoses in the neonates were severe major congenital anomalies, congenital leukemia, prematurity with respiratory distress syndrome, pneumonia, and parapneumonic pleural effusion. In total, 10 (71.4 %) of the patients underwent ≥2 invasive procedures. The overall in-hospital mortality rate was 21.4 %, whereas the mortality rate due to B. gladioli infection was 7 %.

CONCLUSION

B. gladioli might be a causative microorganism of both early neonatal and nosocomial sepsis in newborns. To the best of our knowledge, this is the first study on B. gladioli infection in newborns. Invasive procedures and severe major congenital anomalies may be predisposing factors for B. gladioli bloodstream infection in neonates. Although it appears to have low pathogenic potential and an insidious clinical course in newborns, resistance to antibiotics may be a potential problem. Mortality was primarily associated with underlying diseases.

Two cases of keratitis and corneal ulcers caused by Burkholderia gladioli

We report two cases of protracted keratitis complicated by corneal ulcer. Burkholderia gladioli, primarily known as a plant pathogen, was cultured from corneal swabs. The epithelial defects healed after extended adequate antibiotic therapy. Despite identical patterns of both strains in restriction fragment length polymorphism analysis, a common infection source was not detectable.

Burkholderia pseudomallei infection in chronic granulomatous disease

Melioidosis is a severe illness caused by Burkholderia pseudomallei, a sepsis-causing bacterial pathogen that is common in East Asia. We reexamined the underlying diagnosis in a 12-year-old boy who was diagnosed in the French West Indies with melioidosis when he was 4 years old. Our investigations led to the determination of chronic granulomatous disease (CGD), an inherited condition characterized by phagocytic cell dysfunction. This is the third reported case of melioidosis associated with CGD to be reported, lending support to an association between the two. The molecular determinants of the susceptibility of CGD patients to B. pseudomallei are still unknown. Our report suggests that CGD should be suspected in children with melioidosis, both in the Americas and probably in other regions world-wide.

Burkholderia gladioli osteomyelitis in association with chronic granulomatous disease: case report and review

We describe a case of insidious small bone osteomyelitis and soft tissue abscess with Burkholderia gladioli in a 6-year-old Caucasian boy with chronic granulomatous disease. DNA sequencing of the 16S ribosomal RNA gene confirmed the bacterial identification. Clinical cure was achieved with a combination of antimicrobial therapy and surgical debridement. A review of infections caused by Burkholderia spp., other than Burkholderia cepacia complex, in pediatric patients with chronic granulomatous disease is provided.

Burkholderia gladioli keratitis associated with consecutive recurrent endophthalmitis

PURPOSE

To report a case of Burkholderia gladioli keratitis with consecutive endophthalmitis.

METHODS

Case report and literature review.

RESULTS

A 76-year-old man with a history of diabetes mellitus developed bacterial keratitis and consecutive endophthalmitis in the corneal graft of the left eye. Corneal, aqueous, and vitreous cultures yielded Burkholderia gladioli. Emergent keratoplasty, pars plana vitrectomy, and injection of intravitreal antibiotics led to resolution of the infection and improved vision. Four months later, the patient developed recurrent Burkholderia keratitis and endophthalmitis, necessitating a total keratoplasty and repeat injection of intravitreal antibiotics.

CONCLUSION

This is the first report, to our knowledge, of ocular Burkholderia gladioli infection, an uncommon aerobic, gram-negative rod, recently subclassified from the genus Pseudomonas based on DNA-rRNA homology studies.

Distinguishing species of the Burkholderia cepacia complex and Burkholderia gladioli by automated ribotyping

Several species belonging to the genus Burkholderia are clinically relevant, opportunistic pathogens that inhabit major environmental reservoirs. Consequently, the availability of means for adequate identification and epidemiological characterization of individual environmental or clinical isolates is mandatory. In the present communication we describe the use of the Riboprinter microbial characterization system (Qualicon, Warwick, United Kingdom) for automated ribotyping of 104 strains of Burkholderia species from diverse sources, including several publicly accessible collections. The main outcome of this analysis was that all strains were typeable and that strains of Burkholderia gladioli and of each species of the B. cepacia complex, including B. multivorans, B. stabilis, and B. vietnamiensis, were effectively discriminated. Furthermore, different ribotypes were discerned within each species. Ribotyping results were in general agreement with strain classification based on restriction fragment analysis of 16S ribosomal amplicons, but the resolution of ribotyping was much higher. This enabled automated molecular typing below the species level. Cluster analysis of the patterns obtained by ribotyping (riboprints) showed that within B. gladioli, B. multivorans, and B. cepacia genomovar VI, the different riboprints identified always clustered together. Riboprints of B. cepacia genomovars I and III, B. stabilis, and B. vietnamiensis did not show distinct clustering but rather exhibited the formation of loose assemblages within which several smaller, genomovar-specific clusters were delineated. Therefore, ribotyping proved useful for genomovar identification. Analysis of serial isolates from individual patients demonstrated that infection with a single ribotype had occurred, despite minor genetic differences that were detected by pulsed-field gel electrophoresis of DNA macrorestriction fragments. The automated approach allows very rapid and reliable identification and epidemiological characterization of strains and generates an easily manageable database suited for expansion with information on additional bacterial isolates.

Species-specific PCR as a tool for the identification of Burkholderia gladioli

Burkholderia gladioli colonizes the respiratory tracts of patients with cystic fibrosis and chronic granulomatous disease. However, due to the high degree of phenotypic similarity between this species and closely related species in the Burkholderia cepacia complex, accurate identification is difficult. Incorrect identification of these species may have serious repercussions for the management of patients with cystic fibrosis. To develop an accurate procedure for the identification of B. gladioli, a molecular method to discriminate between this species and other species commonly isolated from the sputa of patients with cystic fibrosis was investigated. The 23S ribosomal DNA was cloned from several clinical isolates of B. gladioli, and the nucleotide sequence was determined. Computer-assisted sequence comparisons indicated four regions of the 23S rRNA specific for this species; these regions were used to design three primer pairs for species-specific PCR. Two of the primer pairs showed 100% sensitivity and specificity for B. gladioli when tested against a panel of 47 isolates comprising 19 B. gladioli isolates and 28 isolates of 16 other bacterial species. One of the primer pairs was further assessed for species specificity by using a panel of 102 isolates obtained from the Burkholderia cepacia Research Laboratory and Repository. The species-specific PCR was positive for 70 of 74 isolates of B. gladioli and was negative for all other bacterial species examined. Overall, this primer pair displayed a sensitivity and specificity of 96% (89 of 93) and 100%, respectively. These data demonstrate the potential of species-specific PCR for the identification of B. gladioli.

Identification of Burkholderia spp. in the clinical microbiology laboratory: comparison of conventional and molecular methods

Cystic fibrosis (CF) predisposes patients to bacterial colonization and infection of the lower airways. Several species belonging to the genus Burkholderia are potential CF-related pathogens, but microbiological identification may be complicated. This situation is not in the least due to the poorly defined taxonomic status of these bacteria, and further validation of the available diagnostic assays is required. A total of 114 geographically diverse bacterial isolates, previously identified in reference laboratories as Burkholderia cepacia (n = 51), B. gladioli (n = 14), Ralstonia pickettii (n = 6), B. multivorans (n = 2), Stenotrophomonas maltophilia (n = 3), and Pseudomonas aeruginosa (n = 11), were collected from environmental, clinical, and reference sources. In addition, 27 clinical isolates putatively identified as Burkholderia spp. were recovered from the sputum of Dutch CF patients. All isolates were used to evaluate the accuracy of two selective growth media, four systems for biochemical identification (API 20NE, Vitek GNI, Vitek NFC, and MicroScan), and three different PCR-based assays. The PCR assays amplify different parts of the ribosomal DNA operon, either alone or in combination with cleavage by various restriction enzymes (PCR-restriction fragment length polymorphism [RFLP] analysis). The best system for the biochemical identification of B. cepacia appeared to be the API 20NE test. None of the biochemical assays successfully grouped the B. gladioli strains. The PCR-RFLP method appeared to be the optimal method for accurate nucleic acid-mediated identification of the different Burkholderia spp. With this method, B. gladioli was also reliably classified in a separate group. For the laboratory diagnosis of B. cepacia, we recommend parallel cultures on blood agar medium and selective agar plates. Further identification of colonies with a Burkholderia phenotype should be performed with the API 20NE test. For final confirmation of species identities, PCR amplification of the small-subunit rRNA gene followed by RFLP analysis with various enzymes is recommended.

Discrimination of Burkholderia gladioli from other Burkholderia species detectable in cystic fibrosis patients by PCR

A procedure for molecular identification of Burkholderia gladioli is described. Specific 16S and 23S rRNA gene signature sequences were defined as primers for PCR. The method allows rapid and specific discrimination of B. gladioli from related species (B. cepacia, B. multivorans, B. vietnamiensis, B. mallei, B. pseudomallei, Ralstonia pickettii, and R. eutropha) and should contribute to the clarification of its role as a human pathogen, e.g., in cystic fibrosis.

Structural studies of the O-specific side-chain of lipopolysaccharide from Burkholderia gladioli pv. gladioli strain NCPPB 1891

A polymeric fraction (the O-antigenic side-chain) has been isolated from the lipopolysaccharide of Burkholderia gladioli pv. gladioli strain NCPPB 1891 after mild acid hydrolysis. The components of the polymer and their molar proportions were L-Rha (1), D-Gal (1), D-Man (1), and O-acetyl (1). By means of chemical degradations and NMR studies, the repeating unit of the polymer was shown to be a linear trisaccharide of the structure shown. [formula: see text]

Abnormal technetium labelled white cell scan in the colitis of chronic granulomatous disease

A child with colitis was treated for Crohn's disease, diagnosed on history, clinical and colonoscopic findings, radiolabelled white cell bowel scan, and colonic histology. After septicaemia caused by an unusual organism, further investigation lead to a diagnosis of chronic granulomatous disease (CGD). The granulomatous colitis of CGD is clinically, histologically, and on white cell scanning, indistinguishable from that in Crohn's disease and should be considered in atypical cases. Infection with unusual 'pseudomonads' should prompt the exclusion of this disorder.