An Unusual Cause of

Osteomyelitis
Dr Summiya Nizamuddin

Sample received on 23.1.2010 from Multan
Pus aspirate sent for routine bacteriology
Male, 31 years
Pus sample from finger
Gram stain

Pus cells: Numerous
Gram Negative Rods:
Rare
Gram Positive Cocci
(chains): Rare

As per protocol, the swab was inoculated on to:
Chocolate agar
Blood Colistin Naladixic acid (BCNA) agar
MacConkeys agar

After 24 hours of incubation, growth
suggestive of mixed oral flora

Few alpha hemolytic
colonies on chocolate
and BCNA agar
Few grayish tinged
colonies on chocolate
agar
No growth on MacConkeys agar

??? Pus from oral cavity

The alpha hemolytic small colonies were isolated
and identified

Gram positive cocci in chains on grams stain
Catalase negative
Caramel like smell

Most probably S. milleri

The grayish colonies were found to be:

Small, slender, straight GNR on grams stain
Oxidase positive
Catalase negative
Not growing on MacConkeys agar
A bleachy odour was noted once the plates
were opened
Colonies were digging into
the agar



What sort of gram negative rods could
these most probably be
Fastidious gram negative rods
Fastidious gram negative rods
catalase negative
oxidase positive
pits into the agar
smells of bleach

Brucella species

Cardiobacterium hominis

Kingella kingae

Moraxella catarrhalis

Neisseria species

Haemophilus influenzae

Capnocytophaga species
Eikenella corrodens

Brucella species

Cardiobacterium hominis

Kingella kingae

Moraxella catarrhalis

Neisseria species

Haemophilus influenzae

Capnocytophaga species
Eikenella corrodens

Brucella species

Cardiobacterium hominis

Kingella kingae

Moraxella catarrhalis

Neisseria species

Haemophilus influenzae

Eikenella corrodens

Cardiobacterium hominis

Kingella kingae

Eikenella corrodens

Something missing
History
31 year old male
Police Officer
Recent human bite history approximately 1
month 10 days ago
Had seen many doctors because of recurrent
infections at the site of bite before being
referred to a orthopedic surgeon in Multan



RapID NH System
RapID NH System

4 hour identification
Able to identify over 30 taxa based on
enzyme technology
Reagents impregnated wells In clear plastic
tray

At the end of four hours
Eikenella corrodens with 99.9% accuracy
Reported as:
Streptococcus milleri
Sensitive to: Penicillin, Chloramphenicol, Ceftriaxone,
Clindamycin, Erythromycin, Ciprofloxacin

Eikenella corrodens
Sensitive to: Co-amoxiclauv, Ampicillin, Ceftriaxone,
Ciprofloxacin, Tetracycline, Imipenem

Eikenella corrodens
When first isolated in 1948, it was noted to pit or corrode
the agar surface, producing colonies that grew in
depressions, hence was called the corroding bacillus

Previously known as Bacteroides corrodens

Genus Eikenella belongs to the family of Neisseriaceae

Only one species, E. corrodens has been recognized so far

E. corrodens is a periodontopathogen that inhibits the
human oral cavity, intestinal tract, and genital tract

Are slender, straight, small, non motile, facultative
anaerobic GNR

Characterisitic feature: Colonies are 1 to 2mm in
diameter after 48hrs of growth and show clear centers
that are surrounded by spreading growth and they may
pit the agar

Smell of hypochlorite

Fail to grow on most selective media

Biochemically inactive, lacking oxidative and
fermentative capabilities

Fail to produce urease, indole, or hydrogen sulfide

Are oxidase positive and most isolates are capable
of reducing nitrate to nitrite

Catalase is usually negative

According to CLSIs Approved Guideline for
Abbreviated Identification:

This is the only MacConkey-negative, catalase-
negative, oxidase-positive, gram-negative rod
that is ornithine positive
E. corrodens is generally regarded as an organism of
low virulence

Little is known about to the organism's virulence
factors and it has a low level of pathogenicity for
animals

Like other HACEK bacteria, it is responsible for SBE



Eikenella corrodens also may be the cause of
endocarditis, meningitis, brain abscesses, subdural
empyema, septic arthritis, pneumonia, postsurgical
infections, and soft-tissue diseases
Therapeutic options beyond thegold standard penicillin:

Broad spectrum beta-lactams (such as ceftriaxone,
cefixime, meropenem and ampicillin/sulbactam), rifampin
and the newer fluoroquinolones appear to be excellent
choices

Generally resistant to the first generation cephalosporins,
oxacillin, aminoglycosides and the traditional
antimicrobials active against anaerobes, such as
clindamycin and metronidazole

In normal human hosts, Eikenella is usually
involved in mixed bacterial infections, often with
viridans group streptococci, and less frequently
with Enterobacteriaceae

Most concomitant streptococcal isolates are
members of the S. anginosis group, which
consists of three species, S.anginous, S.
constellatus and S. intermedius
Eikenella are also responsible for 729% of human
hand-bite wound infections, as well as clenched-fist
injuries, which are frequently complicated by bone
resorption and osteomyelitis.





Bilos, Z. J., A. Kucharchuk, and W. Metzger. 1978. Eikenella corrodens in human bites. Clin.
Orthopaedics 134:320 324.
Goldstein, E. J. C., D. M. Citron, B. Wield, U. Blachman, V. L. Sutter, T. A. Miller, and S. M.
Finegold. 1978a. Bacteriology of human and animal bite wounds. J. Clin. Microbiol. 8:667
672.
Peeples, E., J. Boswick, and F. Scott. 1980. Wounds of the hand contaminated by human or
animal saliva. J. Trauma 20:383389.
Brook, I. 1987. Microbiology of human and animal bite wounds in children. Ped. Infect. Dis. J.
6:2932.

A multicenter prospective study of 50 patients with
infected human bites

56% of injuries were clenched-fist injuries and 44% were
occlusional bites

Median number of isolates per wound culture was 4 (3
aerobes and 1 anaerobe)

Isolates included Streptococcus anginosus (52%),
Staphylococcus aureus (30%), Eikenella corrodens (30%),
Fusobacterium nucleatum (32%), and Prevotella
melaninogenica (22%). Candida species were found in
8%.



Clinical Presentation and Bacteriologic Analysis of Infected Human Bites in Patients
Presenting to Emergency Departments
Clinical Infectious Diseases 2003; 37:14819

In IV drug abusers, E. corrodens endocarditis,
osteomyelitis, and septicemia have been reported in
association with the practice of licking needles or
injection sites prior to drug inoculation



J Infect. 1994 Jan;28(1):102-3.
Eikinella corrodens septicaemia among drug injectors: a possible association with
'licking wounds'

A 65-year-old man from Indonesia developed slowly
progressive vertebral collapse and worsening neck pain.
History suggested a previous pharyngeal injury while
eating fish.

Cultures grew out E. corrodens as the causative organism
of this patient's osteomyelitis.

Spine. 2000 May 1;25(9):1185-7.
Eikenella corrodens vertebral osteomyelitis secondary to direct inoculation: a case
report
E. corrodens has been reported as the causative agent
of infections at many sites, largely secondary to
contamination with oral secretions.

E. corrodens osteomyelitis in a young woman, that
resulted from puncture of her foot with a toothpick
which had apparently been used.


Infection. 2000 Sep;28(5):332-3.
Tale of a toothpick: Eikenella corrodens osteomyelitis
Severe cellulitis and septic arthritis due to E. corrodens
and a viridans group streptococcus developed following
dental manipulation in a patient with a history of
hemarthrosis.

Isolation of E. corrodens on a culture of a knee
aspirate. Antimicrobial (ampicillin) therapy resulted in a
therapeutic response.


J Clin Microbiol. 1989 Nov;27(11):2606-8.
Eikenella corrodens cellulitis and arthritis of the knee

Take home message:
Knowledge of the spectrum of microorganisms
present in the oral cavity and their antibiotic
sensitivity is important for guiding empiric
therapy

The laboratory should also be notified when oral
flora are suspected to enable the optimum
isolation of causative organisms
Thank you