You are on page 1of 6


Copyright © 1998, American Society for Microbiology

Vol. 36, No. 4

Molecular Identification of Gemella Species from
Three Patients with Endocarditis



Unite´ des Rickettsies, CNRS UPRESA 6020, Faculte´ de Me´decine, Universite´ de la
Me´diterranne´e, 13385 Marseille Cedex 05, France
Received 31 July 1997/Returned for modification 10 October 1997/Accepted 30 December 1997

Gemella morbillorum and Gemella haemolysans are grampositive coccal commensal organisms of the mucous membranes of humans and other warm-blooded animals. However,
as “opportunistic pathogens,” gemellae are able to cause severe localized and generalized infections.
The cases of Gemella infection reported to date have been
predominantly endovascular infections (1, 6, 8–12, 15, 22, 25,
28, 29, 31, 33–35, 39, 40, 43, 45). Among these cases of Gemella
infection, most are endocarditis, usually associated with previous valvular damage and/or poor dental state. Central nervous
system and skeletal infections have also been described (4, 13,
23, 36, 38, 48). In a study of 52 cases of “streptococcal” endocarditis, gemellae represented 6% of the viridans group streptococci and 5% of all isolates (17). In our hospital center,
gemellae were the cause of 6% of the cases of endocarditis due
to nonstaphylococcal gram-positive cocci, were the cause of
13.3% of the cases of endocarditis caused by viridans group
streptococci, and represented 2.9% of all bacterial isolates
causing 70 cases of endocarditis diagnosed during a 3-year
period (unpublished data).
These bacteria are easily decolorized during Gram staining
and sometimes appear as elongated cells, explaining why they
were first described as Neisseria (46). They may also be more
involved in clinical disease than is presently recognized, because they can be incorrectly identified as viridans group streptococci or left unidentified (42).
In this paper we report on two patients with G. morbillorum
endocarditis and one patient with G. haemolysans endocarditis.
The identification of one G. morbillorum strain was achieved
with the help of partial 16S rRNA gene sequencing, since the
bacterial isolate appeared to be gram negative. Partial 16S
rRNA gene sequencing was also used as a reference technique
to confirm the identities of a further two strains of Gemella.
The results obtained by electron microscopy and analysis of

cell wall fatty acids are reported, and the previous cases of
endocarditis caused by G. haemolysans and G. morbillorum are
Patient 1. A 63-year-old man who was a heavy smoker with
chronic obstructive bronchitis and a very poor dental state was
admitted to hospital complaining of intermittent fever, loss of
weight, and anorexia over a 1-month period. He had no history
of rheumatic disease, although a moderate heart murmur had
been discovered 1 year previously, and at that time an echocardiogram had yielded moderate mitral valve regurgitation.
On initial examination, the patient had an increased heart
murmur, a temperature of 38.5°C, and a pulse of 100 beats/
min. An ejection systolic murmur was heard at the apex of the
heart. Laboratory investigations showed a hemoglobin concentration of 100 g/liter, an erythrocyte sedimentation rate of 97
mm/h, and a leukocyte count of 8.53 3 109/liter (77% neutrophils). A transesophageal echocardiogram demonstrated the
presence of vegetation on the mitral valve with moderate mitral valve regurgitation. Six sets of blood samples for cultures
were taken on admission and the following day, and the blood
samples were inoculated into BACTEC aerobic (NR 6-A*)
and anaerobic (NR-7A*) bottles in a BACTEC NR-860 automated instrument (Becton Dickinson Diagnostic Instrument
Systems, Sparks, Md.). All yielded slowly growing, gram-positive cocci, subsequently identified as G. haemolysans. A kidney
echography, carried out for microscopic hematuria, yielded a
lesion inside of the left kidney which was compatible with an
abscess. The patient’s treatment began the day after his admission, in which treatment with amoxicillin (4 g intravenously at
6-h intervals) and amikacin (5 mg/kg of body weight intravenously at 8-h intervals) was begun. His condition improved
rapidly, and after 2 weeks of this regimen, he underwent cardiac surgery in order to remove the motile vegetation. One
week after surgery antibiotic therapy was discontinued. After 2
years of follow-up he remains well.
Patient 2. A 74-year-old man with a history of Pott’s disease
in infancy, chronic alcoholism, and a poor dental state was

* Corresponding author. Mailing address: Unite´ des Rickettsies,
CNRS UPRESA 6020, Faculte´ de Me´decine, Universite
´ de la Mediterranne´e, 27 Blvd. Jean Moulin, 13385 Marseille Cedex 05, France.
Phone: (33). Fax: (33). E-mail: Didier

Downloaded from on June 9, 2015 by guest

Gemella morbillorum and Gemella haemolysans are opportunistic pathogens which cause endocarditis and
other severe infections. We report on three patients with endocarditis, one with endocarditis caused by G.
haemolysans and two with endocarditis caused by G. morbillorum. The paucity of reports concerning these
bacteria is probably related to the difficulties associated with their identification. For example, one of the
strains reported in this study was originally sent to our laboratory with a preliminary characterization as a
short “gram-negative” coccobacillus, highlighting the specific problem associated with Gram staining of these
bacteria. The usefulness of 16S rRNA gene amplification, partial sequencing, and comparison of the nucleotide
sequence to those in databases when standard phenotypic identification schemes are not helpful is emphasized.
We also suggest that the use of simple tests, such as testing susceptibility to vancomycin for gram-negative
bacteria and colistin for gram-positive bacteria, could prevent misinterpretation of Gram staining in gramvariable bacteria such as Gemella spp.

morbillorum ATCC 27824 were grown on Trypticase soy agar with 5% sheep blood (Becton Dickinson) at 38°C for 48 h. Seraing. Each experiment included sterile water (no DNA) as a negative control and Escherichia coli DNA as a positive control. DNA extracts were amplified by a PCR incorporating universal primers fD1 and rP2 (49) (Eurogentec. Standard phenotypic characterization methods for gram-negative rods also failed to provide an identity. All primer sets used in this study are listed in Table 1. annealing for 30 s. The patient’s treatment began the day after his admission and comprised amoxicillin (4 g intravenously at 6-h intervals) and gentamicin (1 mg/kg intravenously at 8-h intervals). France) and Mueller-Hinton broth with 5% sheep blood agar (BioMerieux) by the conventional disk diffusion test method (2). A transesophageal echocardiogram demonstrated aortic valve incompetence but failed to show any vegetation. When the primer annealing temperature was $50°C. On initial examination. PCR amplifications were performed in 100-ml volumes incorporating 10 ml of extracted DNA.1 M sucrose. PCR amplification and sequencing of the PCR product. Sequencing reactions were carried out on a Perkin-Elmer 9600 thermal cycler. and the blood samples were inoculated into BACTEC aerobic (NR 6-A*) and anaerobic (NR-7A*) bottles in a BACTEC NR-860 automated instrument.asm. gram-variable cocci and coccobacilli subsequently identified as G. with each cycle comprising denaturation at 95°C for 30 s.2) containing 0. and a leukocyte count of 12. 1998 MATERIALS AND METHODS Phenotypic identification. The fixed cells were washed overnight with the same buffer and were then fixed for 1 h at room temperature with 1% osmium tetroxide in 0. haemolysans ATCC 10379 and G. annealing for 30 s. hemolysis on Columbia agar with 5% sheep blood (BioMerieux. Presumptive identification of the Gemella organisms was achieved through assessment of colonial morphology.). Summary of primers used for PCR amplification and sequencing in this study Primer purpose and primer PCR fD1 rP2 Sequencinga fD1 rP2 800f 800r 1050f 1050r a Sequences (59 to 39) -AGAGTTTGATCCTGGCTCAG-ACGGCTACCTTGTTACGACTT- -AGAGTTTGATCCTGGCTCAG-ACGGCTACCTTGTTACGACTT-ATTAGATACCCTGGTAG-CTACCAGGGTATCTAAT-TGTCGTCAGCTCGTG-CACGAGCTGACGACA- Primer specificity or hybridization temp (°C) Eubacterial 16S rRNA gene Eubacterial 16S rRNA gene 55 55 50 50 43 43 Primers 59 labelled with fluorescein. Growth was also attempted in broth containing 6. All yielded slowly growing. Attempts to amplify citrate synthase and 16S rRNA genes with specific primers for Bartonella (27) were unsuccessful. Cellular fatty acids. Partial 16S rRNA gene sequences derived from each reaction mixture with the ALF manager were combined in a complete sequence by using PC Gene software (IntelliGenetics Inc. After 1 year of follow-up he remains well. RESULTS Bacterium from patient 1. 2015 by guest admitted to hospital complaining of intermittent fever. Marcy l’Etoile. with each cycle comprising denaturation at 95°C for 30 s. microscopic appearance after Gram staining.1 M cacodylate buffer. were observed. an initial denaturation step at 95°C for 1 min was followed by 30 cycles. and extension at 60°C for 2 min. Sequence analysis. Susceptibility to vancomycin and colistin was assessed with 30-mg vancomycin and 50-mg colistin disks (Sanofi Diagnostic Pasteur. and basithoracic pain over a 3-month period. Amplifications were carried out in a Perkin-Elmer 9600 thermal cycler for 35 cycles. respectively. suitable for use as templates in PCRs. 0. a temperature of 38°C. the patient had a diastolic heart murmur.2 mM (each) primer. Belgium).org/ on June 9. and amoxicillin was discontinued 3 weeks later. He had neither a history of rheumatic disease nor a previous heart murmur.5% NaCl. by using the multisequence comparison program FASTA (part of the BISANCE software package) (14). Sweden) according to the manufacturer’s instructions. Bacterial cells were harvested from colonies grown on Columbia agar and for fixation were suspended in 2. distilled water. A small. and sterile.). The thermal cycle used in each sequencing reaction was dependent on the base sequence of the primer (Table 1). it was necessary to transfer him to a cardi-thoracic unit because he was also suffering from significant aortic valve regurgitation and a dilated left ventricle. and extension at 72°C for 1 min. When the primer annealing temperature was . The patient was a farmer and suffered from a bicuspid aortic valve. an initial denaturation step at 95°C for 1 min was followed by 25 cycles. The aortic valve was successfully replaced with a prosthetic device. because it was thought that it could be a Bartonella sp.5% glutaraldehyde in 0. 36. with each cycle consisting of denaturation at 95°C for 30 s. Dehydration was performed by washing the cells in gradually increased concentrations (25 to 100%) of ethanol. They were then saponified. loss of weight. but only poor growth was obtained under anaerobic conditions. and the patient made an uneventful postoperative recovery. and one of six 59 fluorescein-labelled primers was incorporated into the reaction mixture (Table 1).MOLECULAR IDENTIFICATION OF GEMELLA SPECIES VOL. The success of the amplification was determined by ethidium bromide staining following the resolution of products by 1% agarose gel electrophoresis. Six sets of blood samples for culture were taken on admission and the following day. haemolysans on the basis of conventional phenotypic identification. and extension at 72°C for 60 s. morbillorum. Microscopic examination after Gram staining yielded gram-positive cocci which became Downloaded from http://jcm. morbillorum by 16 rRNA gene sequencing. Clinical symptoms included intermittent fever and a weight loss of 12 kg over a period of several months. and a pulse of 100 beats/min. Sequencing reactions were prepared by using the Amplicycle sequencing kit (Perkin-Elmer). The strain was considered to be susceptible to vancomycin and to colistin when inhibition zone diameters of $12 and $15 mm. Gentamicin was discontinued 1 week later. Marnes la Coquette. and cell wall fatty acids were extracted and analyzed by gas chromatography as reported previously (37). Patient 3. The cells were then embedded in Epon 812. Ten supplementary cycles of denaturation at 95°C for 10 s and extension at 60°C for 90 s were performed in order to increase the amount of polymerization. Germany) according to the manufacturer’s instructions. fastidious. Growth was easily achieved on Columbia agar with incubation at 37°C under 5% CO2. 100 mM (each) deoxynucleoside triphosphate. an erythrocyte sedimentation rate of 63 mm/h. Amplification was completed by an extension step of 5 min at 72°C to allow complete extension of the amplified products. Uppsala. sweating. The bacterium was identified as G. primer annealing at 55°C for 30 s. Laboratory investigations showed a hemoglobin concentration of 95 g/liter. DNA extracts. Colonies were small and weakly betahemolytic after 5 days of incubation. TABLE 1. Conn. according to the manufacturer’s instructions. The bacterium isolated from patient 1 was thought to be a strain of G. Processing for electron microscopy. gram-negative rod which had been isolated from the blood of a male patient with infectious endocarditis by using BACTEC aerobic (NR 6-A*) and anaerobic (NR-7A*) bottles was sent to our laboratory for identification. Hilden. The products of 16S rRNA gene amplification were purified for sequencing by using Microspin S-400 HR columns (Pharmacia Biotech. France). Colonies of the three isolates and of the type strains G. Thin sections were cut from embedded blocks with an LKB Ultratome III microtome and were poststained with a saturated solution of methanol-uranyl acetate and lead citrate in water before examination on a Jeol JEM 1200 EX electron microscope. Although his condition improved rapidly. 867 .1 M cacodylate buffer (pH 7. and reaction products were resolved by electrophoresis on a 6% polyacrylamide gel incorporated into an ALF Automatic Sequencer (Pharmacia Biotech).50°C. were made from 200 ml of a bacterial suspension by using a QIA ampBlood kit (Qiagen. The complete sequence was then compared with all bacterial sequences available in the GenBank database. and the results of biochemical tests (with the API 20 Strep and the API 20A systems according to the manufacturer’s instructions). 10 ml of 103 reaction buffer. 2 U of Taq polymerase (Perkin-Elmer Cetus. Norwalk.8 3 109/liter (87% neutrophils).

and 8 cases have been recorded among 364 cases of streptococcal endocarditis (19).asm. Rapid phenotypic identification systems are unable to identify accurately all strains of these species (3. morbillorum on the basis of conventional phenotypic identification. 10. 15. the Rapid ID 32 Strep database [21]). G. following demonstration of biochemical differences with other Neisseria species.5% NaCl Vancomycin susceptibility Patient 1. After removing ambiguities.. (30). Nevertheless. but the species was reclassified into a new genus. However during Gram staining.8% similarity to the 16S rRNA gene sequence of G. the sequence demonstrated 99. we now routinely use cell wall fatty acid Downloaded from http://jcm.9% similarity to the 16S rRNA gene sequence of G. reassessment of phenotypic characteristics revealed a correct identity. thus. analysis of its 16S rRNA gene also revealed that this isolate was G. morbillorum and G. LA SCOLA AND RAOULT TABLE 2. isolated from a patient with infectious arthritis. however. 20). short chains. haemolysans (GenBank accession no. it was proposed that S. morbillorum endocarditis have been recorded among 52 apparent failures of endocarditis prophylaxis (17). “gram-negative” bacillus. Some cells appeared as short bacilli. The major fatty acids in cells were identified as C16 and C18. which had been sent to our laboratory for identification. G. Visible growth was obtained after 3 or 4 days on Columbia agar with incubation at 37°C under 5% CO2. L14326) (50). In most cases. as confirmed by electron microscopy in this study. The nucleotide sequence of the 16S rRNA gene of Streptococcus morbillorum was found to closely resemble that of G. L14327). The results of biochemical reactions and enzyme analyses are summarized in Table 2. a review of the literature reveals only 10 cases caused by G. haemolysans are uncommon causes of infectious endocarditis. cells are easily decolorized and may therefore may appear to be gram variable and even gram negative. to other gram-positive bacteria are presented in Fig. The phylogenetic relationships of Gemella spp. perhaps for the fact that so few cases of Gemella infection are reported. 43). Cellular fatty acids. The same problem had already occurred with a short. or clusters and of various sizes. It is likely that Gram staining abnormality and morphological polymorphism are responsible for the misidentification of Gemella spp. Growth was easily obtained on Columbia agar with incubation at 37°C under 5% CO2 and under anaerobic conditions. 6. morbillorum was originally proposed as Diplococcus rubeolae (47). haemolysans (32). haemolysans was first described in 1938 as Neisseria haemolysans (46) (demonstrating its indeterminate Gram staining characteristic). MICROBIOL. on reappraisal the two Diplococcus species were considered to be identical and were unified under the name D. Microscopic examination after Gram staining yielded gram-variable cocci and coccobacilli arranged in pairs. Sequence data for 948 bp of the 16S rRNA gene were obtained. haemolysans as the causative agents was achieved by standard phenotypic identification schemes. However. morbillorum (GenBank accession no. After its identification had been achieved by the PCR-based approach with the 16S rRNA gene and the bacterium had been recognized as being gram positive. Bacterium from patient 3. and. morbillorum 1 1 1 1 2 1 1 1 1 1 2 2 1 2 2 1 2 2 1 1 1 2 1 1 2 1 2 2 1 (weak) 2 2 1 1 1 1 1 2 2 1 G. Conventional biochemical identification was reassessed. and on this basis it was transferred to the genus Peptostreptococcus (44). CLIN. morbillorum or G. usually when they were in the process of dividing. 1. 11. Patient 2. 45) and 12 cases caused by G. 34. Electron microscopy. but definite identification was not achieved by this technique. and on the basis of DNA-DNA hybridization results and G1C content analysis. 35. a more complete 16S rRNA gene sequence was determined. 39. G. The colonies were small and nonhemolytic. possess a typical gram-positive cell wall structure. 40.73% similarity with the 16S rRNA gene sequence of G. Previous valvular damage is also a common occurrence. or clusters and were of various sizes. 29. 2015 by guest gram-variable after subculture. morbillorum could be grown under aerobic conditions. the sequence demonstrated 99. Sequence data for 949 bp of the 16S rRNA gene were obtained. morbillorum (1. identification of G. the infections were successfully treated with antibiotic therapy. Cocci were arranged in pairs. Gemella (7). short chains. morbillorum be transferred to the genus Gemella as G. Colonies were weakly alpha-hemolytic only when they were incubated under 5% CO2. 12. The bacterium isolated from patient 2 was thought to be a strain of G. Gemella spp.68% similarity to the 16S rRNA gene sequence of G. 31. haemolysans G. for two cases of infection described in this report. Identification of the organism causing infection in patient 3 was difficult. even though manufacturers have significantly improved their databases over recent years (e. even though a large number of biochemical tests were performed. morbillorum on June 9. After removing ambiguities. 22. Patient 3. usually benzylpenicillin or amoxicillin associated with gentamicin. The results are summarized in Table 2 and are compatible with the identification of the bacterium as G. nov. morbillorum (GenBank accession no. as in patients with endocarditis caused by viridans group streptococci. This 1. the sequence demonstrated 99. L14327). morbillorum (unpublished data). The results of biochemical reactions and enzyme analyses are summarized in Table 2.474-bp sequence demonstrated 99. Although D. 25. Conventional phenotypic characterization of the gram-negative coccobacilli yielded no definite identification. Sequence data for 1. morbillorum G. In our laboratory.022 bp of the 16S rRNA gene were obtained. haemolysans (8. 9. DISCUSSION . The patients described in Table 3 and Table 4 demonstrate that poor dental state and/or dentistry are predisposing factors. Bacterium from patient 2. it was primarily anaerobic.868 J. 33. Results of phenotypic characterization of strains isolated in this study Feature Voges-Proskauer Alkaline phosphatase Leucine aminopeptidase Pyrrolidone arylamidase Esculin hydrolysis Acid from glucose Acid from sucrose Acid from maltose Acid from mannitol Acid from mannose Acid from trehalose Growth in 6. morbillorum. and a second member of the genus named Diplococcus morbillorum was added soon after (41). Subsequently. All bacteria studied presented with a typical gram-positive membrane organization. Two additional cases of G. morbillorum with the exception of the results obtained by Gram staining. 28. only to be reclassified into the genus Streptococcus (26). morbillorum.g. After removing ambiguities.

org/ on June 9. the bacterium may be considered to be identi- TABLE 3. No evidence of vegetation on echocardiogram. 1990 No Cure (?. f. rifampin Left colonic resection for rectal neoplasia Tri Cefuroxime. teicoplanin. About 0.1% of all isolates fall into this category./ age (yr)/sexa Underlying conditions or source of infection Infected valve 1/60/m 2/38/m Dental manipulation Anal subcutaneous sphincterotomy. not available. 1998 869 analysis and/or 16S rRNA gene analysis when a bacterium is not easily identified by phenotypic schemes. 1. 1995 Yes Cure Patient 2 NA NA Patient 3 Abbreviations: Ao. and sequence comparison take less than 3 days. female. 1994 29. gentamicin Bicuspid aortic valve Ao NA 7/64/m 8/29/f 9/74/m 10/75/m 11/74/m 12/NA/m a b NA Mi Therapy Penicillin. gentamicin Benzylpenicillin.05 to 0. Na Benzylpenicillin. Tri. 1989 Yes Cure 35. The bar represents a 1% difference in nucleotide sequence. NA. cure Cure 45. year No No Cure Cure 12. rifampin Benzylpenicillin. 1994 No Pulmonary embolism. gentamicin. 1993 Yes No Acute appendicitis. chronic ethylism Aob Amoxicillin. erythromycin Poor dentition. streptomycin Flucloxacillin. male. Downloaded from http://jcm. rifampin. aortic valve. 2015 by guest FIG. morbillorum endocarditisa Patient no. 36. . 1992 No Wrist arthritis. haemolysans and G. sigmoidoscopy 3/39/m Dental manipulation. gentamicin Vancomycin Valve replacement Outcome Reference. Amplification with universal primers. bicuspid aortic valve Ao 4/42/m Mi regurgitation Mi 5/19/m Intravenous drug abuser Tri 6/48/m Poor dentition. 1995 No Allergic reaction to antimicrobial agents. Ao Benzylpenicillin Hypertrophic obstructive cardiomyopathy.MOLECULAR IDENTIFICATION OF GEMELLA SPECIES VOL. partial sequencing (about 900 bp) with con- served primers.asm. 1989 No Cerebral mycotic aneurysm. Mi end-stage renal disease Dental manipulation Mi. morbillorum endocarditis and features of our two patients with G. erythromycin. cure 33. Mi. mitral valve. Phylogenetic tree based on 16S rRNA gene sequences available in the GenBank database obtained by the neighbor-joining method. reduction in the size of vegetation) 6. systolic heart murmur. benzylpenicillin Rheumatic fever in infancy Mi Benzylpenicillin. benzylpenicillin. Summary of patients with reported cases of G. The phylogenetic relationships of G. amikacin. 1984 35. erythromycin Benzylpenicillin. cure 40. dental manipulation gentamicin. cure 10. gentamicin. If the partial 16S rRNA gene sequence obtained shares more than 99% similarity with a specific 16S rRNA gene sequence in the database. cure 1. tricuspid valve. m. morbillorum with selected gram-positive bacteria with low G1C contents are shown.

MICROBIOL. the method is expensive. provided that the genes of closely related species share a significantly lower degree of similarity. not available. A mistake at this stage can lead to the application of inappropriate tests and therefore unnecessary delays in processing. amoxicillin Benzylpenicillin. benzylpenicillin allergy 13/63/m Chronic obstructive bronchitis. dental manipulation Aortic insufficiency Bioprosthetic aortic valve. mitral valve. both of which may not be routinely available in the diagnostic laboratory and thus would require referral to a reference laboratory. male. respiratory viral syndrome Mi insufficiency. The vancomycin-susceptible grampositive bacterium is G. and the vancomycin-resistant gramnegative bacteria are Acinetobacter (B). No evidence of vegetation on echocardiogram. cure Allergic neutropenia due to cefuroxim. however. ciprofloxacin. cure 11. The reference method for assessing cell wall type is electron microscopy. gentamicin. this approach also allows the description of new pathogens (16) which may have been misidentified by standard phenotypic identification schemes. it is important that all efforts be made to ensure correct interpretation of the Gram staining result. (C). asymptomatic dental sepsis. First. with Gram staining being one of the most important first steps of most routine identification schemes (5). With increasing availability and decreasing costs. gentamicin Benzylpenicillin.870 LA SCOLA AND RAOULT J. as described for patient 3 of this study. erythromycin No Mi Amoxicillin. 1984 39. since a Downloaded from http://jcm. fusidic acid. 1982 31. and although it is accurate. If this is not possible. benzylpenicillin. f. 1991 22. gentamicin Benzylpenicillin. However. such equipment is likely to become a feature of more and more routine laboratories in the years to come. haemolysans endocarditis and features of our patient with G. The test is easy to perform (Fig. CLIN. Most gram-positive bacteria are susceptible to vancomycin. NA. for the present. 1995 Abbreviations: Ao. TABLE 4. and requires specialized equipment. poor dentition Ao on June 9. tobramycin. haemolysans endocarditisa Case/age (yr)/sex Underlying conditions or source of infection Infected valve 1/62/m Dental manipulation Mi 2/48/m Poor dentition. confirmation can be achieved by a few simple additional FIG. 1982 Mi Ao Ao Benzylpenicillin. gentamicin 9/71/m Colonic carcinoma 10/53/f Mi regurgitation 11/20/m None a Outcome . infective endocarditis. Furthermore. Arrowheads indicate the limits of the inhibition zone around vancomycin (VA) and colistin (CS) disks. provided that they are equipped with an automated sequencer. and Kingella kingae (D). phenotypic characterization remains the standard approach to bacterial identification. This method is quick and cheap. cure 11. gentamicin No No No Cure Cure Cure 28. haemolysans (A). 1993 No Yes Yes Cure Cure Right dorsalis pediculis territory embolus. m. 1994 Kidney abscess. cure 25. gentamicin. that this test is not definitive. the use of this technique for identification does not require an experienced microbiologist and gives a universal bacterial identification ability to all laboratories. but it avoids the need for additional phenotypic or specific antibody tests.asm. if this is not the case. aortic valve. periodontal disease None Mi prolapse Aortic insufficiency. gentamicin Amoxicillin 1 clavulanic acid. Summary of reported cases of G. Such a method has previously been shown to be beneficial for the determination of cell wall type among nonenterobacterial rods (24). clindamycin Benzylpenicillin. tricuspid valve. cure Patient 1 12/34/m Multiple valve replacements with prosthetic valve. However. amoxicillin Vancomycin. rifampin No Yes Yes Cure Cure Cure 11. Tri. gentamicin Benzylpenicillin. but it requires that a bacterium be easily subcultured. whereas most gram-negative bacteria are susceptible to colistin. 2) and is inexpensive. Finally. 1993 34. 1985 Mi Mi Aob Benzylpenicillin. year Cefamandole. streptomycin Erythromycin. 1982 Ao Yes Phlebitis. biochemical tests. fied. 1989 8. scalp wound 3/56/m 4/68/m 5/47/m 6/62/f 7/74/m 8/42/m Therapy Valve replacement Spondylodiscitis. amikacin Yes 43. additional sequencing can be used in order to determine a complete 16S rRNA gene sequence. thus. female. Examples of the usefulness of vancomycin test to determine the Gram reaction for gram-variable bacteria. As an alternative we have added vancomycin and colistin to our standard antibiotic susceptibility tests. It must be noted. amoxicillin. Moraxella sp. 2015 by guest No Mi Mi Ao b Reference. complete identification can be achieved in two ways. tobramycin. Mi. 1993 15. is time-consuming. This second approach is more expensive and timeconsuming. 2.

J. H. 38. Laudat. Lane. Wauters. Med. Smith. Bacteriol. 42. 48:52–53. Cocci anae´robies. Crist. Baltimore. Tunnicliff. Breed. 7. C. 12:1–4. C. 1989. However. S. M. Weissfeld. 1993. 35. D. Gemella haemolysans endocarditis. Facklam. Weizenegger. p. Ika ¨valko.. L. 20:894–898. J. Pfaller. Tenover. and J. P. 18:67–72. M. 15. p. R. Murray. and N. C. 71:188. Koot. 1993. 24. Md. C. S. Arima. In R. Niel. 3. and B. 12:644–645. Graevenitz. 4th ed. R. Matsis... J. Antimicrobial susceptibility of Gemella haemolysans isolated from patients with subacute endocarditis. Appelbaum. Cosnay. M. Etudes de syte´matique bacte´rienne. A. O. Aguilar. Venomachi. Infect. H. 1. 1933. Microbiol. 1993. Gemella haemolysans endocarditis with colonic carcinoma. R. M. M. P. J. Mal. Appl. and C. Minerva Med. Syst. Clin.MOLECULAR IDENTIFICATION OF GEMELLA SPECIES VOL. haemolysans has been encountered (18). P. T. P. Friart. 1984. 6:355–356. P. Maxwell.. Acar. Bressan. 40. A. 23:503–505. Clin. A proposed new genus of gram negative cocci: Gemella. Rueda. 1996. Debast. 1974. Lu ¨tticken. 50. Gerard. 10. Physiological differentiation of viridans streptococci. Berger.. Aubert. J. The Williams & Wilkins Co. Accuracy of the KOH and vancomycin tests in determining the Gram reaction of nonenterobacterial rods. 37:527–531.. Biosci. Samuel. W. comb. 1988. 1990.. Brochier. Sonoda. J. Berk. 9. Brenner. Infection 17:385–387. Gouvernet.. Jones. Raoult. Bell. 1983. and A. 1917.. E. Boeufgras. 5. and T. Croize. May. 27. Holdeman. and G. Postgrad. Endocarditis caused by Streptococcus morbillorum. Bacteriol. Helft. Isolement de Gemella haemolysans dans trois cas d’endocardites bacte´riennes. A. 1985. 1993. 19:164–168. 25:110–112. Acta Clin. 20. Eur. P. 16S rRNA gene analysis is becoming more competitive in terms of efficiency and accuracy for fastidious bacteria or those not easily identified by phenotypic schemes. Kaufhold. V. Fresard. for bacteria which are easily identified by phenotypic schemes (especially with the help of commercial identification kits or simple additional tests) and which represent more than 99. Downloaded from http://jcm. 13. 1984. Bimet. T. Dis. 2:369–370. Description and evaluation of the semiautomated 4-hour Rapid ID 32 Strep method for identification of streptococci and members of related genera. P. 533–541. M. Hainaut. Dis. J. II. 1993. In P. Martin. and R.). and R. G. Int. Microbiol. L. Peptostreptococcus Kluyver and van Niel (1936). 31. Duffett. Infect. Unknown multiresistant gram negative bacterium causing meningitis in HIV-positive patient in Africa. Pa. U. D. 46.. Bacteriol. M. 63:108–110. R. and J. 1991.. A case of Gemella morbillorum endocarditis. 33:1879–1883. J. 1995.. Pelletier. J. Gemella haemolysans endocarditis. and T. Eur. The use of 16S rRNA gene analysis should also lead to an increase in the number of descriptions of new pathogens and in the recovery of unexpected pathogens. M. N. L. J. BISANCE: a French service for access to biomolecular sequences databases. G. Fleurette. Rylander. Washington. G. E.. 30. and C. M. Rarity and potential severity of Gemella haemolysans endocarditis. P. and F. 1938. Evaluation of the Rapid Strep system for the identification of clinical isolates of Streptococcus species. J.. and P. Stritoni.. and J. 1985. Clin. Endocardite `a Gemella haemolysans: une nouvelle observation. C. Weisburg. Barns. H. Schleifer. 1984. Metzger. E. 1995.. 871 .. M. J. Kilpper-Ba ¨lz. Dorche. Gigi. Buu-Hoi. 1994. J. Microbiol. and S. Identification of Bartonella (Rochalimea) species among fastidious gramnegative bacteria on the basis of partial sequence of the citrate-synthase gene. P. 16:586–587. 1984. J. Microbiol. 25. C. J. A. Clin. Sci. D. J. and A. J. B. Bacterial identification by gas chromatography of whole cell fatty acids. Syst. Infect. Microbiol. Rouge.. A haemolytic species of Neisseria Treviscan. 16:131–134. R.. Phylogenetic relationships of anaerobic streptococci.. Med. Naugle. Meis. and M. Transfer of Streptococcus morbillorum to the genus Gemella as Gemella morbillorum. 1–51. 4:159–161. J. Acta Clin. Bucher. R. p. Lucht. 36. Kerr. Raynaud. Ludwig. Michel. Easthorpe. Am. and R. Miyahara. Whitney. 1993. Isolation of Gemella morbillorum from joint fluid. Scand. F. Woodford. Campbell. Lancet 342:927–928. 81:69. 21. O. 1993. K. and A. Massot. A. Ann. 1995. W. 24:260–277. 1993. Thjo ¨ta. twelve new species. G. and A. Prosthetic valve endocarditis by Gemella haemolysans. Deux cas d’endocardite tricuspidienne isole´e apre`s intervention colique. Ruoff. Kaplan.. Clin. 1990. Stahl. P. 38:442–443. Garavelli. and A. L. Dis. A. J. and N. 6. Tabone.. Aspevall. J. K. 36. Gemellae: a tale of two new species (and five genera). R. Clin. C. G. F. J. R. Belg. Drancourt. 287:54–57. Med. Bull. 1991. Wood. and F. Gemella haemolysans: a rare and unusual cause of infective endocarditis. 24:417–418. C. Munier. Infect. M. 43. 15:23–260. R. Efstratiou. C. W. Chatelain. 4. Glycopeptide-resistant Gemella haemolysans from blood. J. Infect. Brack. A. 34. Infections caused by Gemella morbillorum. S. Heald. Bo¨e. 249–264. Clin. M. R. A. F. Meningite da Streptococcus morbillorum. 18:983–985. 7th ed. L. Freney. and S. A. The cultivation of a micrococcus from blood in preeruptive and eruptive stage of measles. J. Intern.. 33:628–631.). Valencien. Facklam. no additional identification technique is required. Lancet 346:1168. and W. 32. Bacteriol. Bacteriol. Infect. A. Mitchell. Amiel. P. Lancet 342:177–178.. Rhoden. J. Lancet 342:560. Bisno. Postgrad. J. In V. L. 23. ACKNOWLEDGMENT We thank Richard Birtles for correcting the manuscript. A. I. Taxon. B. Gemella morbillorum in an intravenous drug abuser.. 39. and F. Schleifer. nov. J. Clin. Murray.. J. and P. 45. J. Abboud. Peres. J. H. M. 14. Moore. R. Meningitis due to Gemella haemolysans after neurosurgical treatment of trigeminal neuralgia. 1998 vancomycin-resistant strain of G. 71:188. A. Coto.. Med. F. Morrisson. Bacteriol. Clin. Scand. Infect. H. McGimpsey. A. W. R. Auvergnat. Postgrad. A. Meningitis due to Gemella haemolysans. L. Giant basilar aneurysm in the course of subacute bacterial endocarditis. C. 1:25–30. D. J.. Disk susceptibility test. J.. 1983. Comput. S. Swann. Yolken (ed. 33. 67:210–212. and R. Microbiol. Frondat. Microbiol. 1994. Microbiol. 49. New genus Coprococcus. Syst. 11. E. J. R. Endocarditis due to Streptococcus morbillorum. and D. O’Connor. N. Endovascular infection and septic arthritis caused by Gemella morbillorum. The Williams & Wilkins Co. J.. X. Classification and identification of bacteria. 11:17–19. R. Baron. and P. Nat. V. 1982. M. Med.. Int. M. P. 17. Toni. H.. Comparative evaluation of the API 20S system and the AutoMicrobic System Gram-Positive Identification Card for species identification of streptococci. J. M. L. 1995. J. Bergey’s manual of determinative bacteriology. Teddy. R. Phylogenetic relationship of Gemella morbillorum to Gemella haemolysans. 12. J. Palko. Newsl. Gemella haemolysans prosthetic valve endocarditis.. Lois ge´ne´rals. Microbiol. Stroke 21:1625–1627. J. Neisseria haemolysans... Ulster Med. Apparent failures of endocarditis prophylaxis. 38:558–560. 1:102–106. Pathol. and D. 50:242–245. L. Smith. Canton. Aust. Microbiol. Goldstein. P. Avery. M. Weber. T. Infection 19:446. Jacobs. 43:832– 838. 16. and K. 1990. Endocarditis caused by Gemella haemolysans. Clin. 41. J. S. 38:15–18. J. Antibiotics in laboratory medecine. 26. 37. G. and P. Morea. and D. R. 6th ed. Fuselier. 47. R. Med. Suppl.. V. Forsblom. Smith (ed. 1993.asm. X. H. G. Sanada. 1961. Joblet.). 1977. 1994. Md. Belg. and P.. Y. Roux. D. Eur. 2.C. Vacheron. Dis. L. R. Med. 1988.. on June 9. 19:184–201. and D. S. Bland. A. 19. Sapoetra. Z. Lorian (ed. P. 48. JAMA 68:1028–1030. Nomencl. Webb. and M. Icole. D. Mal. Diagn. 1992. B. H. P. C. J. JAMA 250:2318–2322.. P. and K. Infective endocarditis due to Gemella morbillorum complicating hypertrophic obstructive cardiomyopathy. F. Raoult. J. Infect.. 1989. Int. 1990. 1991. and N. and G. Kilpper-Ba ¨lz. Raoult. and J. E. L. Syst. 22. Meningitis due to Gemella haemolysans after radiofrequency trigeminal rhizotomy. Drancourt. P. B.. J. Acar. A. 1991. E. J. 173:697– 703. Baltimore. and P. Hewlett-Packard application note 228–241. Linderoth. Dessen. Von Essen. Avondale. A. 18. Buu-Hoi. Clin. A. J. E. 16S ribosomal DNA amplification for phylogenic study. Berger. Baron. Terada. 44. Desmonceaux. R. G. U. Hubner. C.. Omran. Med. Hillebrandt. Branger. J.. Franzen. D. Int. J. 1995. Int. Acta Pathol. Bloomfield. 1957. A. and emended description of four previously described species from human feces. C. M. Rubio. Devuyst. Hewlett-Packard. 8. M. Dabernat. and J. Etienne. 30:2657–2661. Med. Manual of clinical microbiology. Infective endocarditis caused by an indigenous bacterium (Gemella morbillorum). Lion. B. 1995. Calopa. 1992. McCartney. S. 1982. 29. Sohara. D. Wright. A. Microbiol.9% of the bacteria isolated in clinical microbiology laboratories. In conclusion. Prevot. Durack. L. 2015 by guest REFERENCES 28. Miller. P.. P. R. American Society for Microbiology.