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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.
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).
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