J. Clin. Microbiol. 34(12):3235-3236. source.Veillonella parvula bacteremia without an underlying1996.

RG Fisher and MR Denison  

an underlying sourceVeillonella parvula bacteremia without

http://jcm.asm.orgUpdated information and services can be found at:

These include:

CONTENT ALERTS more>>this article), eTOCs, free email alerts (when new articles citeRSS Feeds,Receive:

http://journals.asm.org/subscriptions/To subscribe to an ASM journal go to: http://journals.asm.org/misc/reprints.dtlInformation about commercial reprint orders:

at Univ of D

undee July 23, 2010 jcm

.AS

M.O

RG

- D

OW

NLO

AD

ED

FR

OM

JOURNAL OF CLINICAL MICROBIOLOGY, Dec. 1996, p. 3235–3236 Vol. 34, No. 120095-1137/96/$04.0010Copyright q 1996, American Society for Microbiology

Veillonella parvula Bacteremia without an Underlying SourceRANDALL G. FISHER* AND MARK R. DENISON

Department of Pediatric Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee

Received 12 February 1996/Returned for modification 12 April 1996/Accepted 11 September 1996

Veillonella parvula is an anaerobic gram-negative coccus that is part of the normal human flora. It has rarelybeen identified as a pathogen in humans, and the most frequently reported infection caused by V. parvula isosteomyelitis. We report a case of bacteremia unrelated to a central venous catheter and without an underlyingsource of infection.

Veillonella parvula is a small, nonfermentative anaerobicgram-negative coccus that is part of the normal flora of themouth, gastrointestinal tract, and vagina in humans. It fluo-resces red under UV light and reduces nitrate. When isolatedfrom clinical specimens, it is often regarded as a contaminantor a commensal. However, it has been isolated in pure culturefrom various sites and implicated as a pathogen in the sinuses,lungs, liver, central nervous system, heart, and bone. Bactere-mia in the absence of an underlying source, however, is ex-tremely rare; to our knowledge, there is only one prior casedescribed in the literature (6). We report a case of V. parvulabacteremia.The patient was a 5-year-old boy with recurrent stage IV

neuroblastoma who presented to the hematology-oncologyclinic at Vanderbilt University Medical Center with a 5-dayhistory of fever to 1028F (38.98C) and intermittent leg pain. Onthe day of his clinic visit, his temperature was 1048F (408C) anda blood specimen was obtained from a peripheral site andcultured. He had been off chemotherapy for 10 days. His leu-kocyte count at presentation was 2,500/mm3, with 57% seg-mented neutrophils. Three days earlier, however, his leukocytecount had been 1,100/mm3, with 35% segmented cells, yieldingan absolute neutrophil count of 374. The blood culture, whichwas inoculated into a Peds plus/F bottle (Becton-Dickinson,Sparks, Md.) and processed by a Bactec 9240 nonradiometricsystem (BD), grew gram-negative cocci within 18 h, and theboy was admitted to the hospital and treated with vancomycinand ceftazidime. Repeat cultures were performed with blooddrawn from both ports of his Hickman catheter at the time ofadmission. Physical examination revealed a patient who wasactive and alert, with an oral temperature of 101.38F (38.58C)and mild tachycardia. The findings in the remainder of thephysical examination were normal, except for slight tendernessin the right upper quadrant of the patient’s abdomen.Following admission, the patient was afebrile until day 3 of

hospitalization, when his temperature rose to 101.98F (38.88C).The original peripheral blood culture, which had been subcul-tured on Trypticase soy agar with sheep blood (BBL Microbi-ology Systems, Cockeysville, Md) and incubated at 358C in 7%CO2, and in an anaerobic GasPak jar (BBL), grew gram-neg-ative cocci only in the anaerobic state. Blood was drawn fromthe patient’s Hickman catheter and from a peripheral site andcultured. The next morning, the new peripheral-site culturewas also growing gram-negative cocci in pairs and short chains.

Antimicrobial therapy was changed to ceftriaxone and clin-damycin. A careful physical examination showed the patient tohave good dentition, without obvious carious lesions, mucosi-tis, or gingivitis. No bony tenderness or joint swelling wasnoted. The original isolate was identified as a Veillonella spe-cies by the rapID ANA II System (Innovative Diagnostic Sys-tems, Norcross, Ga.). A source for the bacteremia was sought.A bone scan gave negative results, and a gallium scan showeduptake in the superior mediastinum and lower posterior thoraxthat was confirmed by a CT scan to be due to tumor. A bonemarrow biopsy showed persistent involvement by a tumor butwas otherwise unremarkable. Bone marrow culture and sinusX rays gave negative results.The isolate was sent to the state laboratory for identification

to species level, and it was positively identified as V. parvula onthe basis of its biochemical profile. It grew well in both thio-glycolate and chopped-meat carbohydrate-enriched thioglyco-late broth, but not on thioglycolate gel; it was asacchrolytic; itwas indole and bile esculin negative; and it reduced nitrate.Gas-liquid chromatography showed peaks at acetic and propi-onic acids. These reactions differentiated this organism fromAcidaminococcus species and Megasphaera species, both ofwhich are nitrate negative and have gas-liquid chromato-graphic peaks at butyric acid. Antimicrobial susceptibility test-ing was not performed. The patient became afebrile on therapywith ceftriaxone and clindamycin, and all subsequent bloodcultures were negative.Isolation of a clinically relevant anaerobic gram-negative

coccus is rare. V. parvula is the only one reported to causeinfection in humans. Additionally, most cases of V. parvulainfection are localized to one anatomic site. Bacteremia hasbeen reported, but it is almost always in association with anunderlying infection such as osteomyelitis (1, 2, 14).V. parvula bacteremia in the absence of an underlying site

has been described once, in a 48-year-old man with posthepa-titic cirrhosis (6). The authors speculated that an emergencycentral line may have been the source of his infection. Inter-estingly, although our patient had an indwelling Hickman cath-eter, only blood drawn from peripheral sites yielded positiveculture results. There is also a report of a 71-year-old institu-tionalized man who was infected with V. parvula as part of apolymicrobial bacteremia (17). The literature describing an-aerobic bacteremia in neonates contains references to threebabies with blood cultures positive for V. parvula (5, 15). Nofurther clinical detail of the cases is available, although in areview paper Brook states that all three patients had concom-itant pneumonia (3).Anaerobic bacteremia, once considered fairly commonplace

(in one study, anaerobes were identified in 49% of positive

* Corresponding author. Mailing address: Pediatric Infectious Dis-eases, D-7235 Medical Center North, Vanderbilt University MedicalCenter, Nashville, TN 37235. Phone: (615) 322-2250. Fax: (615) 343-9723.

3235

at Univ of D

undee July 23, 2010 jcm

.AS

M.O

RG

- D

OW

NLO

AD

ED

FR

OM

blood cultures over a 2-year period [11]), has decreased infrequency over the past 19 years (7). The reasons for thedecline in the incidence of anaerobic bacteremia are not clear.Even when anaerobic bacteria were being isolated with highfrequency, however, the isolation of V. parvula was not com-mon. It is noteworthy that Martin’s study of 10,998 anaerobicisolates did not include a single case (11).Veillonella species have been reported as a cause of endo-

carditis (10), obstructive pneumonitis (9), lung abscess (12),chronic sinusitis (16), chronic tonsillitis (4), liver abscess (8),and even meningitis, in a child who injured her eyelid with atoothbrush (13). The most frequently reported infection withV. parvula is osteomyelitis, of which five reports exist. In onlyone case, however, was V. parvula the only organism identified(14).As is the case with many localized anaerobic infections, V.

parvula is usually isolated as part of a polymicrobial process.This, combined with the fact that V. parvula is a normal inhab-itant of the mouth, gastrointestinal tract, and vagina, has madeelucidation of its pathogenetic role difficult. The case we de-scribe, in which the organism was isolated twice in pure culturefrom a patient with symptoms compatible with bacteremia,illustrates that V. parvula cannot always be considered a com-mensal and that it should be eradicated in cases where it islikely to be a true pathogen. In patients with underlying im-mune deficiencies or exogenous immune suppression, V. par-vula should be considered a pathogen. The finding of anaero-bic gram-negative cocci on blood culture should promptalternatives to standard fever and neutropenia antimicrobialregimens, especially given that V. parvula is vancomycin resis-tant. Although our patient had no identifiable underlyingsource of infection, one should be sought. V. parvula infectiontypically responds well to therapy with a penicillin. Other an-timicrobial agents to which the organism is usually susceptiblein vitro include cephalosporins, clindamycin, metronidazole,and chloramphenicol, although large susceptibility trials usingclinical isolates have not been performed. This case also illus-trates that in vitro susceptibility patterns do not always corre-late with clinical cure.

We thank Rosemary Verrall for reviewing the manuscript and mak-ing helpful suggestions.

REFERENCES

1. Barnhart, R. A., M. R. Weitekamp, and R. C. Aber. 1983. Osteomyelitiscaused by Veillonella. Am. J. Med. 74:902–904.

2. Borchardt, K. A., M. Baker, and R. Gelber. 1977. Veillonella parvula septi-cemia and osteomyelitis. Ann. Intern. Med. 86:63–64.

3. Brook, I. 1990. Bacteremia due to anaerobic bacteria in newborns. J. Peri-natol. 10:351–355.

4. Chaturved, V. N., A. Methwani, P. Chaturved, and P. Narang. 1989. Bacte-rial flora in chronic tonsillitis. Indian Pediatr. 26:52–56.

5. Chow, A. W., R. D. Leake, T. Yamauchi, B. F. Anthony, and L. B. Guze. 1974.The significance of anaerobes in neonatal bacteremia: analysis of 23 casesand review of the literature. Pediatrics 54:736–745.

6. Gessoni, G., N. Saccheto, S. Gelmi, et al. 1989. Veillonellae: personal obser-vation of a fatal bacteremia. Boll. Ist. Sieroter. Milan 68:193–196.

7. Gransden, W. R., S. J. Eykyn, and I. Phillips. 1991. Anaerobic bacteremia:declining rate over a 15-year period. Rev. Infect. Dis. 13:1255–1256.

8. Lambe, D. W., and V. E. DelBeve. The incidence and clinical significance ofanaerobic cocci in certain infections. Presented at the 72nd Annual Meetingof the American Society for Microbiology, Philadelphia, 23 to 28 April 1972.

9. Liaw, Y. S., P. C. Yang, Z. G. Wu, et al. 1994. The bacteriology of obstructivepneumonitis. A prospective study using ultrasound-guided transthoracic nee-dle aspiration. Am. J. Resp Crit. Care Med. 149:1648–1653.

10. Loughrey, A. C., and E. W. Chew. 1990. Endocarditis caused by Veillonelladispar. J. Infect. 21:319–320.

11. Martin, W. 1974. Isolation and identification of anaerobic bacteria in theclinical laboratory. A two-year experience. Mayo Clin. Proc. 49:300–308.

12. Mori, T., T. Ebe, M. Takahashi, H. Isonuma, H. Ikemoto, and T. Oguri.1993. Lung abscess: analysis of 66 cases from 1979 to 1991. Intern. Med.32:278–284.

13. Nukina, S., A. Hibi, and K. Mishida. 1989. Bacterial meningitis caused byVeillonella parvula. Acta Paediatr. Jpn. 31:609–614.

14. Singh, N., and V. L. Yu. 1992. Osteomyelitis due to Veillonella parvula. Casereport and review. Clin. Infect. Dis. 14:361–363.

15. Spector, S. A., W. Ticknor, and M. Grossman. 1981. Study of the usefulnessof clinical and hematologic findings in the diagnosis of neonatal bacterialinfections. Clin. Pediatr. 20:385–392.

16. Su, W. Y., C. Liu, S. Y. Hung, and W. F. Tsai. 1983. Bacteriologic study inchronic maxillary sinusitis. Laryngoscope 93:931–934.

17. Wilson, W. R., W. J. Martin, C. J. Wilkowske, and J. A. Washington II. 1972.Anaerobic bacteremia. Mayo Clin. Proc. 47:639–646.

3236 NOTES J. CLIN. MICROBIOL.

at Univ of D

undee July 23, 2010 jcm

.AS

M.O

RG

- D

OW

NLO

AD

ED

FR

OM