Propionibacterium acnes causing an aortic root abscess

Cardiac Tamponade Caused by Cutibacterium acnes: An Updated and Comprehensive Review of the Literature

Bacterial pericarditis is a critical diagnosis caused by a wide range of organisms including Streptococcus pneumoniae and other anaerobic organisms like Cutibacterium acnes which has been gaining more importance as a causative organism. Cutibacterium species are Gram-positive microaerophilic rods that constitute part of the normal flora of skin and mucosal membranes. The incidence of pericarditis caused by this organism is underreported as it is often dismissed as a skin flora contaminant. However, if left untreated, Cutibacterium acnes can cause pericarditis with serious complications. In this paper, we present a comprehensive review of the literature regarding pericarditis caused by Cutibacterium acnes along with a case presentation from our institution. In our institution, a 20-year-old man with history of atrial septal defect presented with chest pain radiating to the back along with symptoms of upper respiratory tract infection including headaches and myalgia. Electrocardiogram was remarkable for diffuse low-voltage waves. Echocardiography revealed a large pericardial effusion with tamponade features. Pericardiocentesis drained 1.2 L of milky fluid. Pericardial fluid analysis grew Cutibacterium acnes after being cultured for 8 days. The patient received 3 weeks of IV penicillin followed by 3 weeks of oral amoxicillin along with nonsteroidal anti-inflammatory agents and colchicine with no recurrence. Pericarditis caused by Cutibacterium acnes requires a high clinical suspicion since isolation of this organism can be dismissed as a skin flora contaminant. Literature review reveals that this infection may be underdiagnosed and underreported. Prompt diagnosis may lead to timely initiation of antibiotics which can help prevent devastating complications like constrictive pericarditis. Prospective studies are needed to evaluate the true incidence and prevalence of this disease.

Propionibacterium acnes Recovered from Atherosclerotic Human Carotid Arteries Undergoes Biofilm Dispersion and Releases Lipolytic and Proteolytic Enzymes in Response to Norepinephrine Challenge In Vitro

In the present study, human atherosclerotic carotid arteries were examined following endarterectomy for the presence of the Gram-positive bacterium Propionibacterium acnes and its potential association with biofilm structures within the arterial wall. The P. acnes 16S rRNA gene was detectable in 4 of 15 carotid artery samples, and viable P. acnes was one among 10 different bacterial species recoverable in culture. Fluorescence in situ hybridization analysis of 5 additional atherosclerotic carotid arteries demonstrated biofilm bacteria within all samples, with P. acnes detectable in 4 samples. We also demonstrated that laboratory-grown cultures of P. acnes biofilms were susceptible to induction of a biofilm dispersion response when challenged with physiologically relevant levels of norepinephrine in the presence of iron-bound transferrin or with free iron. The production and release of lipolytic and proteolytic extracellular enzymes by P. acnes were shown to increase in iron-induced dispersed biofilms, and these dispersion-induced P. acnes VP1 biofilms showed increased expression of mRNAs for the triacylglycerol lipases PPA2105 and PPA1796 and the hyaluronate lyase PPA380 compared to that in untreated biofilms. These results demonstrate that P. acnes can infect the carotid arteries of humans with atherosclerosis as a component of multispecies biofilms and that dispersion is inducible for this organism, at least in vitro, with physiologically relevant levels of norepinephrine resulting in the production and release of degradative enzymes.

Propionibacterium acnes endocarditis of a prosthetic aortic valve

In the few reported cases of Propionibacterium infective endocarditis involving prosthetic aortic valves, abscess is common and frequently requires surgery. We report a case of P. acnes infective endocarditis identified on prolonged blood cultures with aortic root abscess involving a Starr-Edwards valve. Intravenous antibiotics and valve replacement led to recovery.

Propionibacterium endocarditis: A case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study

Propionibacterium species are occasionally associated with serious systemic infections such as infective endocarditis. In this study, we examined the clinical features, complications and outcome of 15 patients with Propionibacterium endocarditis using the International Collaboration on Endocarditis Merged Database (ICE-MD) and Prospective Cohort Study (ICE-PCS), and compared the results to 28 cases previously reported in the literature. In the ICE database, 11 of 15 patients were male with a mean age of 52 y. Prosthetic valve endocarditis occurred in 13 of 15 cases and 3 patients had a history of congenital heart disease. Clinical findings included valvular vegetations (9 patients), cardiac abscesses (3 patients), congestive heart failure (2 patients), and central nervous system emboli (2 patients). Most patients were treated with beta-lactam antibiotics alone or in combination for 4 to 6 weeks. 10 of the 15 patients underwent valve replacement surgery and 2 patients died. Similar findings were noted on review of the literature. The results of this paper suggest that risk factors for Propionibacterium endocarditis include male gender, presence of prosthetic valves and congenital heart disease. The clinical course is characterized by complications such as valvular dehiscence, cardiac abscesses and congestive heart failure. Treatment may require a combination of medical and surgical therapy.

Chronic prosthetic valve endocarditis due to Propionibacterium acnes: an unexpected cause of prosthetic valve dysfunction

INTRODUCTION AND OBJECTIVES

To determine the characteristics of Propionibacterium acnes prosthetic valve endocarditis (PAPVE).

METHODS

Prospective descriptive study of 16 consecutive cases of PAPVE.

RESULTS

Seven patients developed PAPVE early and 9 developed it late. In all those who developed PAPVE late, there was a history of mucocutaneous barrier manipulation. The delay in diagnosis was >3 months in 75%. The clinical presentation was asymptomatic prosthetic valve dysfunction in 31%, heart failure in 19%, coronary syndrome in 12.5%, fever in 25%, and neurological deficits in 19%. At diagnosis, 62.5% had heart failure and 44% had fever. The predominant echocardiographic finding was prosthesis dysfunction due to dehiscence of metallic aortic valves (6 out of 7) or stenosis of metallic mitral valves (4 out of 7). In 2 of the 3 biological aortic prostheses, dysfunction was due to leaflet distortion. Blood cultures and surgical specimens tested positive after a mean of 11.6 and 12.2 days, respectively. In 2 cases, the diagnosis was confirmed by PCR. The principle intraoperative finding was the presence of abundant grayish pannus. Histology demonstrated the absence of acute inflammatory features. Twelve patients received antibiotic treatment with valve replacement: 7 were cured, 4 experienced early prosthesis dehiscence and 1 relapsed. All 3 patients who were initially treated with antibiotics alone suffered relapses.

CONCLUSIONS

Generally, PAPVE presents as prosthetic valve dysfunction with few symptoms of infection. Prolonged incubation of cultures is essential for diagnosis. Antibiotic treatment provides clinical control but does not eradicate the infection, and valve replacement is necessary for a cure. The postoperative course can be complicated by prosthesis dehiscence.

Infective endocarditis due to Propionibacterium species

Propionibacterium species rarely cause infective endocarditis. When identified in blood cultures, they may be inappropriately disregarded as skin flora contaminants. The purpose of this study was to characterize the clinical presentation and management of endocarditis due to Propionibacterium species. All cases of endocarditis due to Propionibacterium species that were treated at the Mayo Clinic, Rochester, USA were retrospectively reviewed, and the English language medical literature was searched for all previously published reports. Seventy cases, which included eight from the Mayo Clinic, were identified (clinical details were available for only 58 cases). The median age of patients was 52 years, and 90% were males. In 79% of the cases, the infection involved prosthetic material (39 prosthetic valves, one left ventricular Teflon patch, one mitral valve ring, one pulmonary artery prosthetic graft, three pacemakers, and one defibrillator). Blood cultures were positive in 62% of cases. All 22 cases with negative blood cultures were microbiologically confirmed by either positive valve tissue cultures (n = 21) or molecular methods (n = 1). Endocarditis was complicated by abscess formation in 36% of cases. The majority (81%) of patients underwent surgery, either for valve replacement and debridement of a cardiac abscess, or removal of an infected device. Crude in-hospital mortality was 16%. The median duration of postoperative antibiotic treatment was 42 days. Patients were commonly treated with a penicillin derivative alone or in combination with gentamicin. On the basis of the above data, it is recommended that infective endocarditis should be strongly suspected when Propionibacterium species are isolated from multiple blood cultures, particularly in the presence of a cardiovascular device.

Cardiac Magnetic Resonance Imaging for Detection of an Abscess Associated with Prosthetic Valve Endocarditis: A Case Report

Propionibacterium acnes is an organism frequently isolated in cultures and often dismissed as a contaminant. A patient with a febrile illness and prosthetic aortic valve was suspected of having infectious endocarditis. Magnetic resonance imaging was useful in defining a paravalvular abscess associated with prosthetic valve endocarditis due to Propionibacterium acnes that was then successfully surgically repaired.

Endocarditis caused by Propionibacterium acnes: an easily ignored pathogen

Propionibacterium acnes, which usually considered as a contaminant, has been found to be an emerging pathogen in human diseases. We describe a case of prosthetic valve related endocarditis caused by P. acnes. Sequencing of the genetic coding of 16S ribosomal RNA was used to identify the pathogen and random amplified polymorphic DNA patterns further confirmed the persistent bacteraemia, which help to determine the diagnosis.

Propionibacterium acnes as a cause of prosthetic valve aortic root abscess

Propionibacterium acnes isolates usually have relatively low virulence and are often classified as contaminants when isolated from blood and tissue cultures. We report a patient with Propionibacterium acnes bacteremia and late prosthetic valve endocarditis, complicated by an aortic root abscess.

Endocarditis caused by Propionibacterium species: a report of three cases and a review of clinical features and diagnostic difficulties

Propionibacterium species are members of the normal flora of skin and the mouth but their pathogenic potential is often overlooked. Three fatal cases of endocarditis caused by Propionibacterium species over an 8-year period are reported, and a review is presented of a further 33 cases from the world literature. In most cases, infection was protracted, with minimal signs in the early stages. Fourteen cases (42.4%) involved native valves, 16 (48.5%) involved prosthetic valves and three (9.1%) were associated with other intracardiac prosthetic material. Intracardiac abscesses were commonly encountered, with Propionibacterium endocarditis occurring in 28.6% of native valve infections and 52.9% of prosthetic valve infections. A very high proportion of all of the cases (70.6%) required surgical intervention. Several factors appeared to delay institution of appropriate therapy and may have contributed to abscess formation, including an indolent clinical course, negative or delayed culture results, and the tendency to consider this organism as a blood-culture contaminant. The authors recommend careful clinical evaluation before disregarding a blood-culture isolate of Propionibacterium spp. as a skin contaminant, and consideration of this bacterium as a potential cause of apparently culture-negative endocarditis.

[Acute endocarditis of the native aortic valve caused by Propionibacterium acnes]

Propionibacterium acnes is often considered to be a contaminant but it has also been found to be the principal pathogen in serious infections. P. acnes is a rare cause of infective endocarditis. It has been suggested that aortic root abscesses are caused by bacteria that are particularly virulent. The strongest risk factor for serious infections by this bacteria is the presence of foreign bodies. A case is presented in which endocarditis of a native aortic valve caused by P. acnes was associated with an aortic root abscess. Transesophageal echocardiography is particularly helpful in the diagnosis of this severe complication of infective endocarditis. The literature for P. acnes endocarditis is reviewed.

Severe infections caused by Propionibacterium acnes: an underestimated pathogen in late postoperative infections

Propionibacterium acnes belongs to the cutaneous flora of humans and is rarely considered a pathogen in human diseases. It is a frequent contaminant in blood cultures; however, in some patients it has been identified as the causative agent of life-threatening infections. Within the last years we have observed an abrupt increase in severe P. acnes infections which prompted us to study in detail the clinical and microbiological features, risk factors, and outcomes of these cases. In a retrospective review of microbiological records of 905 Propionibacterium isolates from a five-year period (1990-95), 70 were identified from 20 patients with clinical and microbiological evidence of a P. acnes infection. The clinical syndromes included endocarditis (7 patients), post-craniotomy infections (6 patients), arthritis and spondylodiscitis (4 patients), endophthalmitis (2 patients) and pansinusitis (1 patient). The predominant predisposing conditions were previous surgery preceding the infection from 2 weeks to 4 years and implantation of foreign bodies such as prosthetic heart valves, intraocular lenses and ventriculo-peritoneal shunts. Therapy consisted of intravenous antibiotics in all cases and surgical procedures to remove infected tissue in eighteen patients. The outcome was favorable in sixteen patients (80 percent) who had a complete recovery. These data confirm the pathogenic potential of P. acnes in late post-surgical infections, in particular after implantation of a foreign body, and suggest a combined therapeutic approach with intravenous antibiotics and surgical removal of the infected tissue.

Propionibacterium acnes as a cause of aggressive aortic valve endocarditis and importance of tissue grinding: case report and review

A case of prosthetic valve endocarditis with Propionibacterium acnes is described. The diagnosis was documented by histology and isolation of P. acnes from both blood and anulus tissue. Grinding of the tissue, which was first omitted to avoid contamination, was indispensable for cultivating the agent. The literature for P. acnes endocarditis is reviewed.

Propionibacterium species diversity in Leerdammer cheese

Thirteen 'classical' Propionibacterium strains, isolated from Leerdammer cheese samples, using three different media were characterized phenotypically. The phenotypic data of 74 tests, conducted on 27 propionibacteria, including four type, 10 reference strains and the 13 cheese isolates were analysed by numerical taxonomical techniques, using the simple matching coefficient and single linkage cluster analysis. All the strains were grouped in four major clusters, with a final linkage at the 81% S-level. The clusters were equated with the 'classical' P. acidipropionici, P. freudenreichii, P. jensenii and P. thoenii species. The species were identified by relating them to specific type strains and by comparison of phenotypic characteristics. Differential characteristics of each cluster were determined. Strains of P. acidipropionici, P. freudenreichii and P. jensenii, but no P. thoenii strains were isolated from the Leerdammer cheese samples. No 'cutaneous' propionibacteria were isolated. The largest cluster, representing 46% of the cheese isolates was equated with P. jensenii. Various red/brown pigmented strains, which could be identified as the old 'P. rubrum' species were isolated from the cheese. These strains were, however, phenotypically identified as P. jensenii and also grouped in the P. jensenii cluster.