- Case report
- Open Access
- Open Peer Review
Erythema caused by a localised skin infection with Arthrobacter mysorens
© Imirzalioglu et al; licensee BioMed Central Ltd. 2010
- Received: 22 September 2010
- Accepted: 15 December 2010
- Published: 15 December 2010
Skin erythemas of unknown origin are a frequent reason for consulting the general practitioner or dermatologist.
Here we report a case of an erythema resembling the erythema migrans manifestation of Lyme disease, but with atypical symptoms like persistent pruritus. The patient had no history of a recent tick-bite but displayed a positive serology for an advanced stage of Lyme borreliosis, which stood in contrast to the clinical manifestation of erythema migrans as a symptom of early Lyme disease. Three skin swabs and soil samples, collected in the area where the patient possibly acquired the infection, were examined by bacterial and fungal culture methods. Microorganisms were identified by using 16 S rRNA gene sequencing and bioinformatics. The patient and soil isolates were compared by employing RAPD analysis. The serum samples of the patient were examined by immunoblotting. Arthrobacter mysorens, a soil bacterium, was isolated from the collected skin and soil samples. The identity of both isolates was determined by molecular fingerprinting methods. A. mysorens was proven to be causative for the erythema by direct isolation from the affected skin and a positive serology, thus explaining the atypical appearance of the erythema compared to erythema migrans caused by Borrelia infection.
Infections with A.mysorens might be underreported and microbiological diagnostic techniques should be applied in cases of patients with unclear erythemas, resembling erythema migrans, without a history of tick bites.
- Lyme Disease
- Borrelia Burgdorferi
- Lyme Borreliosis
- Cefuroxime Axetil
Skin erythemas of unknown origin are a frequent reason for consulting the general practitioner or dermatologist. Among many clinicians, laminary spreading erythemas often lead to the diagnosis of a tick bite-associated erythema migrans (EM), a symptom of early localized infection with Borrelia burgdorferi (sensu lato) [1, 2]. As the development of an immunologic response to this infection usually takes 4 to 6 weeks and the incubation period for EM is typically 7 to 14 days, early Lyme borreliosis often presents itself with a negative serology [3, 4]. In addition, tick bites are not always described or remembered by the patient. Thus, the diagnosis is mostly based on clinical symptoms. In its typical appearance, EM is a homogenous spreading, indolent, erythematous, oval shaped lesion with a bright red border and a central clearing. Minimal pruritus might be present at an early stage. EM develops at the site of the tick bite and therefore can be located on any part of the body. Mild systemic symptoms like low-grade fever and chills might be present. EM in the United States is often associated with more prominent signs of inflammation, as compared to that in Europe [1–4]. This case report illustrates that erythemas caused by other pathogens might resemble this clinical picture, thus a false diagnosis may be made which may complicate and prolong the disease process and prevent adequate therapy.
To our knowledge, this is the first documented case of a skin infection with A. mysorens, probably reflecting a new relevant human clinical isolate of this genus. In order to identify the possible source of the infection, we collected forest soil samples (n = 50) from the area where the infection most likely occurred and could indeed isolate A. mysorens from one sample. Randomly amplified polymorphic DNA (RAPD) analysis using two different primers revealed clonal identity between the soil and the skin isolate (Figure 2A) . Therefore, the localised skin infection caused by this particular soil bacterium was likely to be caused by contamination with forest soil. The mobile pathogen (Figure 2) seems to be capable of epidermal spread and could be detected only in the centre and at the edge of the erythema (Figure 1). Arthrobacter species have been occasionally isolated from patients with immunodeficiencies . Furthermore, Arthrobacter species have been described as microbial allergens which can cause allergic reactions in furniture factory workers and in people occupationally exposed to herbal dust [10, 11]. The ability of Arthrobacter species to cause allergic reactions is a plausible explanation for the clinical symptom of pruritus described by the patient.
Because of the difficulties in culturing and identifying Arthrobacter isolates by conventional culture methods and biochemical assays, it is likely that infections with these coryneform bacteria are underreported, especially as the standard treatment regime for EM (doxycyline, amoxicillin, cefuroxime axetil) would also treat Arthrobacter infections. Cultivation of these bacteria was possible by using incubation at room temperature, which is in general not performed or recommended for these types of samples. Therefore, we advise incubation at room temperature and prolonged incubation for the bacterial culture of skin samples derived from erythema and, in case of bacterial growth the use of molecular diagnostic techniques like 16 S rRNA gene sequencing or MALDI-TOF MS for the identification of unusual bacterial isolates. This report shows the importance of clearly distinguishing such an infection from the well-described early manifestation of Lyme disease, namely EM, after a tick bite.
Written informed consent was obtained from the patient's parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors thank Martina Klös-Langsdorf and Sylvia Krämer for excellent technical assistance, Dr. Martin Hardt for scanning electron microscopy and Dr. Shneh Sethi and Madhu Singh for critical reading of the manuscript. This work was supported by grants from the Bundesministerium fuer Bildung und Forschung, Germany, within the framework of the National Genome Research Network (NGFN; contract no. 01GS0401).
- Nau R, Christen HJ, Eiffert H: Lyme disease-current state of knowledge. Dtsch Arztebl Int. 2009, 106: 72-81.PubMedPubMed CentralGoogle Scholar
- Dandache P, Nadelman RB: Erythema migrans. Infect Dis Clin North Am. 2008, 22: 235-60. 10.1016/j.idc.2007.12.012.View ArticlePubMedGoogle Scholar
- Stanek G, Strle F: Lyme disease: European perspective. Infect Dis Clin North Am. 2008, 22: 327-39. 10.1016/j.idc.2008.01.001.View ArticlePubMedGoogle Scholar
- Bratton RL, Whiteside JW, Hovan MJ, Engle RL, Edwards FD: Diagnosis and treatment of Lyme disease. Mayo Clin Proc. 2008, 83: 566-71. 10.4065/83.5.566.View ArticlePubMedGoogle Scholar
- McGinley-Smith DE, Tsao SS: Dermatoses from ticks. J Am Acad Dermatol. 2003, 49: 363-92. 10.1067/S0190-9622(03)01868-1.View ArticlePubMedGoogle Scholar
- Wilske B, Zöller L, Brade V, Eiffert H, Göbel UB, Stanek G: Quality standards for the microbiological diagnosis of infectious diseases (number 12): Lyme borreliosis. Urban & Fischer Verlag, Munich, Germany. 2000Google Scholar
- Funke G, Bernard KA: Coryneform gram-positive rods. Manual of clinical microbiology. Edited by: Murray PR, BaronEJ, Pfaller MA, Jorgensen JH, Yolken RH. 2003, ASM Press, Washington, D.C, 472-501. 8Google Scholar
- Bernasconi E, Valsangiacomo C, Peduzzi R, Carota A, Moccetti T, Funke G: Arthrobacter woluwensis subacute infective endocarditis: case report and review of the literature. Clin Infect Dis. 2004, 38: 27-31. 10.1086/381436.View ArticleGoogle Scholar
- van Belkum A, Struelens M, de Visser A, Verbrugh H, Tibayrenc M: Role of genomic typing in taxonomy, evolutionary genetics, and microbial epidemiology. Clin Microbiol Rev. 2001, 14: 547-60. 10.1128/CMR.14.3.547-560.2001.View ArticlePubMedPubMed CentralGoogle Scholar
- Golec M, Skorska C, Mackiewicz B, Dutkiewicz J: Immunologic reactivity to work-related airborne allergens in people occupationally exposed to dust from herbs. Ann Agric Environ Med. 2004, 11: 121-7.PubMedGoogle Scholar
- Skorska C, Krysinska-Traczyk E, Milanowski J, Cholewa G, Sitkowska J, Gora A, Dutkiewicz J: Response of furniture factory workers to work-related airborne allergens. Ann Agric Environ Med. 2002, 9: 91-7.PubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/10/352/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.