A Rare Pathogen Comamonas Testosteroni: A Case Report and Review of the Literature

Introduction

Comamonas testosteroni, formerly known as Pseudomonas testosteroni, is a gram-negative, aerobic, motile, non-fermentative and non-spore forming bacillus [7]. The name “Testosteroni” comes from the bacteria’s ability to use the carbon in testosterone metabolism, as is observed in some types of Pseudomonas and fungi [10]. C. testosteroni is commonly found in soil, water, plants, animals and waste all over the world and is considered as an environmental microorganism which is not defined as a human endogenous microflora element [6,7]. Because of its ability to live in liquid environments, this organism is seen as an opportunistic nosocomial pathogen in hospitals and intensive care units. It grows well on routine bacteriologic media such as sheep blood agar and chocolate agar [7]. The need for minimal nutrients to grow even in distiled water and adaptation to differ¬ent physical conditions leads to its important role as an opportu¬nistic pathogen in hospitals. Since it became clinically important; it has been reported in publications as a causative agent of cellulitis, peritonitis, endocarditis, meningitis, endophthalmitis, tenosynovitis, pneumonia and bacteremia [10].

Case Report

A 4-year-old girl with frequent urinary incontinence and recur-rent urinary tract infection despite taking prophylaxis has ap-plied to our hospital for further examination. She was operated two years ago due to persistant cloaca, a total urogenital mo-bilization was performed, and postoperative uterus, vagen and partial bladder necrosis occured. She has a colostomy in the left lower quadrant, and has frequent urinary incontinence and recur¬rent urinary tract infection despite taking prophylaxis.

Urinalysis report was; leukocyte 14 p/HPF, leukocyte esterase ++, bacteria were trace and others were found within normal limits. Colonies grown on blood and MacConkey agar, incubated at 35–37°C , were identified as 99% probability C. testosteroni by mass spectrometry method MALDI-TOF MS (bioMérieux, France). Antibiotic susceptibility tests were performed with the automatic device of VITEK-2 Compact (bioMérieux, France) and interpreted in accordance with EUCAST criteria and it was susceptible to ceftazidime, ciprofloxacin; intermediate suscep¬tible to meropenem, piperacillin / tazobactam; resistant to gen¬tamicin, amikacin, imipenem, trimethoprim-sulfamethoxazole. Ceftazidime was added to the treatment of the patient who was already treated with amikacin. There was no growth in the control urine culture performed after 5 days of treatment. And then the patient was discharged with cure. The increase in patho-genicity and antibiotic resistance of C. testosteroni once again demonstrates the importance of rational antibiotic use. With this case report, C. testosteroni was reported as the first cause of urinary tract infection in our country and the third in the world

Discussion

C. testosteroni which was first reported in 1975, is an infection agent in samples such as cerebrospinal fluid, abdominal abscess and appendix tissue, most commonly from blood and peritoneal fluid [Table 1]. Most of the previously reported cases were immunodeficient due to malignancy, diabetes mellitus, chron¬ic liver disease, and end-stage renal disease [10]. The agent is most frequently isolated from the blood (20 cases), followed by peritoneal fluid (9 cases), cerebrospinal fluid (3 cases) and urine (2 cases). There are rare cases in which the agent was isolated from cord fluid, respiratory secretions, deep tracheal aspirate, abdominal abscess, bite site tissue (animal bite), aortic valve, appendicitis, stool and vitreous fluid. Appendicitis is found to be the most common predisposing factor in cases detecting C. testosteroni in peritoneal fluid. Although bacteria is not an en¬dogenous flora element, the isolation of a large number of patients with perforated appendicitis (7 out of 9 cases) made us think that this microorganism could create a unique location in the appendix [1].

Eight C.testosteroni cases have been reported in Turkey so far. The first case was purulent meningitis in a patient with recurrent cholesteatoma reported by Arda et al. in 2003. The microorgan¬ism was isolated from the cerebrospinal fluid and treated with meropenem [3].

The second case was C. testosteroni bacteremia in a patient with perforated acute appendicitis. It was isolated from the patient’s peritoneal fluid and blood cultures by Gul et al. in 2007. It had been treated with cefazolin [8].

The third case was reported in 2010 by Katircioglu et al. It was a case of bacteremia in an intensive care patient. This case isolated from blood cultures was the first case that showed the develop¬ment of multiple antibiotic resistance including imipenem [9].

The fourth case was the pneumonia case in an intensive care patient reported by Ozden et al. in 2011. Microorganism iso-lated from endotracheal aspirate culture; was found susceptible to amikacin, imipenem, levofloxacin, meropenem, netilmicin, piperacillin-tazobactam, ceftazidime, cefepime, tigecycline, tri-methoprim-sulfamethoxazole and resistant to aztreonam, colis¬tin, gentamicin, ciprofloxacin and tetracycline [11].

The fifth case was reported by Bayhan et al. in 2013. It was a case of 16-year-old perforated appendicitis with the complaints of acute abdominal pain, vomiting and constipation. The microorganism isolated from the peritoneal fluid was found susceptible to ampicillin, ampicillin-sulbactam, ceftazidime, cefazolin, gentamicin, amikacin, ciprofloxacin, imipenem, piperacillin and resistant to ceftriaxone, cefuroxime and trimethoprim-sulfame-thoxazole. It was treated with amikacin, ampicillin and clindamycin [6].

The sixth case was an endocarditis case reported by Duran et al. in 2015. The microorganism isolated from the aortic valve was resistant to piperacillin-tazobactam, imipenem, meropenem, gentamicin and netilmicin and was treated with ciprofloxacin [7]. The seventh case was C. testosteroni bacteremia, isolated from the blood cultures of a patient with diabetes and hemiplegia reported by Pekinturk et al. in 2016. The microorganism was found resistant to aztreonam and colistin [12].

The eighth case was the bacteremia due to C. testosteroni grown in the blood culture of a patient with neutropenia who presented with high fever reported by Aktar et al. in 2018. Cefixime and ceftazidime resistant microorganism was treated with moxifloxacin [2].

Although C. testosteroni can survive for a long time in hospi¬tal environments, C. testosteroni infections are community ac¬quired [7]. Gastrointestinal pathologies are often accompanied by intraabdominal infections, and these infections are the most commonly reported group of infections. Risk factors that may cause infections in other cases are the use of central venous cath¬eters, drug injections, skin cuts and subcutaneous lacerations, and surgical procedures [8].

C. testosteroni infections rarely cause death and mostly respond well to antibiotic therapy. In the reported cases, it was suscepti¬ble to aminoglycosides, fluoroquinolones, carbapenems, pipere-cillin-tazobactam, most cephalosporins and trimethoprim-sul-famethoxazole [3,15]. However, it should be kept in mind that antibiotic resistance has increased over the years and the resis¬tance profile may change. C. testosteroni was reported resistant to aminoglycosides in 2009, and resistant to aminoglycosides, carbapenems and piperacillin-tazobactam in 2015 [7,15].

The strain isolated in this case; was found susceptible to cef-tazidime (2.0 mg/L), ciprofloxacin (≤ 0.25 mg/L), intermediate susceptible to meropenem (8.0 mg/L ), piperacillin / tazobactam (64.0 mg/L), resistant to gentamicin ( ≥16.0 mg/L), amikacin (≥64.0 mg/L), imipenem (≥16.0 mg/L), trimethoprim- sulfa-methaxole (80.0 mg/L). Our patient’s urogenital disorder and multiple surgical interventions in this case were predisposing factors for infection. The isolate in our case was found suscep¬tible to ceftazidime and ciprofloxacin, while it was resistant to preparations such as carbapenem and piperacline-tazobactam, suggesting that it was an infectious agent in the hospital environment due to the widespread use of broad-spectrum antibiotics. With this case report, a rare pathogen was drawn to attention; the importance of rational antibiotic use and the contribution of ac¬curate and rapid diagnosis of microorganisms to treatment with new technologies have been emphasized.

Table 1: Comamonas testosterone-induced infection cases in the literature.

Funding

Not applicable.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics Approval

All procedures performed were under the institutional and/or na-tional research committee’s ethical standards and the 1964 Hel¬sinki declaration and its later amendments or comparable ethi¬cal standards. This report was supervised and approved by the Ankara City Hospital No.1 clinical research Ethics Committee. (reference no:E1/1539/2021)

Contributions

All authors contributed to the development of the manuscript. Literature review and manuscript writing were done by Dr. S.Gayenur Büyükberber. All authors read and approved the final manuscript.

References