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Trueperella pyogenes pharyngitis in an immunocompetent 40-year-old man
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  1. Zachary Meili
  1. New York Institute of Technology College of Osteopathic Medicine at Arkansas State University, Jonesboro, Arkansas, USA
  1. Correspondence to Zachary Meili; zmeili{at}nyit.edu

Abstract

A 40-year-old man presented to his primary care physician with a constellation of systemic symptoms and new biofilm forming along his upper airway. He had brought home a deer 10 days prior from a day of hunting, and discovered green purulent material oozing from the entrance/exit wounds. The patient smokes cigarettes and did not use any protective equipment or wash his hands between dressing the deer and smoking. Several days following exposure, he became increasingly short of breath, fatigued, constipated and developed a cough productive of orange sputum. Speaking with state wildlife biologists led to the diagnosis of a zoonotic Trueperella pyogenes infection. Initial treatment with broad spectrum antibiotics was ineffective in resolving the infection. An infectious disease appointment was made, but the patient’s infection resolved with the use of a veterinarian antibiotic taken under physician’s supervision.

  • infectious diseases
  • TB and other respiratory infections
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Background

Trueperella pyogenes is a gram-positive, facultatively anaerobic rod that inhabits the biota of mucous membranes of the upper respiratory tract and urogenital tract in many animals.1 It is an opportunistic pathogen known to most commonly cause suppurative infections including mastitis, abscesses and pneumonia in animals.2 For many in the agricultural world it is known for its negative economic effect on agriculture by means of infection of livestock, including but not limited to cattle, swine and sheep. Virulent strains of T. pyogenes have recently been identified as a cause of mortality in populations of white-tailed deer in the USA. T. pyogenes is a known opportunistic pathogen of humans3 but very few cases of primary infection have been recorded.3 This case will discuss an immunocompetent 40-year-old man with a primary infection of the respiratory tract after exposure to an abscess filled white-tailed deer.

Case presentation

A 40-year-old man presented to his primary care physician (PCP) after 1 week of worsening nausea, shortness of breath and fatigue. He smokes cigarettes and drinks 2–3 beers on weekends. He has a medical history of hypertension well controlled with diet and exercise and has arachnoid cysts for which he takes over the counter ibuprofen daily. He has no known history of metabolic syndrome or diabetes mellitus. He is up to date on all his vaccinations. One week prior to presentation, he had brought home a male deer after the day of hunting. The deer seemed normal in the field, but on cleaning and dressing (removal of internal organs), it was found to have liquefactive abscesses throughout its respiratory tract (figure 1). The patient did not wear any protective equipment while dressing the animal and proceeded to smoke a cigarette immediately after handling the carcass. He began to develop nausea and shortness of breath with palpitations over the next few days. Oropharyngeal exudates developed on the left side first, followed by a biofilm (figure 2) down his tongue and upper airway. He experienced fatigue, a constant headache, rigours, constipation and subjective fevers. During a shift, his measured O2 saturation was 89% at 2200 m above the mean sea level. He had gained 6.4 kg, weighing in at 107.5 kg.

Figure 1

An excised suppurative abscess.

Figure 2

Exudative biofilm covering the posterior oropharynx and uvula.

On examination, his temperature was 37°C; blood pressure of 130/62 mm Hg; pulse 71 beats/min and weight 107.5 kg. Bilateral tympanic membranes had air-fluid levels, with clear nasal discharge and mild congestion but no sinus tenderness. His throat was covered with exudates and had moderate oropharyngeal erythema. Mild anterior cervical adenopathy was present bilaterally. On pulmonary auscultation, rhonchi were present in both lung bases. The rest of the examination was non-contributory.

Laboratory values were mostly unremarkable. White blood cell count was 10.4×109/L with the rest of the complete blood count being within the normal range. His throat swab did not detect group A Streptococcus; throat culture and mononucleosis screen were all negative. His chest X-ray showed an unremarkable cardiac silhouette with no cardiomegaly, no acute infiltrates or effusions, costophrenic angles were clear, bronchial wall thickening consistent with bronchitis was noted and no masses were observed. An HIV screening was not performed, as the patient was believed to be at low risk by the treating physician, given the low infection rate in the area. However, given he is a healthcare worker, HIV is something we worry about.

Differential diagnosis

Given the odd presentation of the deer, the patient did much of the research himself as to the likely source of his infection. While asymptomatic, he reached out to local state department which was focused on the outbreak of chronic wasting syndrome in local deer populations, and thus unable to respond. Further concerned about the possibility of vertical transmission, the patient reached out to federal office without success. Finally, he managed to speak with a state wildlife biologist regarding the deer. A zoonotic case of pulmonary tuberculosis transmission was published just this past year,4 which is identifiable in deer based on behaviour and abscess quality. Expert advice from the state wildlife biologist included that Mycobacterium was unlikely in this case as it normally presents in deer with odd behaviour and spongy (rather than liquefactive) abscesses. Based on the description the patient was able to give, the diagnosis of Trueperella was made and the deer carcass was disposed off properly. No other household contacts were infected. This is attributed to the patient being the only one handling the abscessed meat, and from inhalation of tobacco without proper hand washing. After meeting with his PCP, they agreed that this was the likely pathogen. Given the patients vaccination status, pathogens such as Diphtheria were considered unlikely. Throat cultures were ordered, but due to a lab error, the organisms were never isolated.

Treatment

The patient was initially given an intramuscular injection of ceftriaxone 1 g and started on amoxicillin-clavulanic acid 875/125 mg plus metronidazole 500 mg each two times per day by mouth for 10 days. Coverage of gram-positive and anaerobic bacteria on this antibiotic regimen was thought to be sufficient, given the suspected infectious organism. An albuterol nebuliser was also prescribed for symptomatic relief of shortness of breath. Completing this antibiotic regimen had no effect on clearing this infection. Antibiotic resistance has become an emerging problem with T. pyogenes infections secondary to the commonplace use of antibiotics in agriculture.1 As the patient’s health continued to decline despite broad spectrum treatment, he was referred to infectious disease department in the nearest major city for further testing. Feeling worse daily and having no outpatient resources available in his rural community and the infectious disease appointment several weeks away, the patient found a veterinarian resource online that suggested cefoperazone, a third generation cephalosporin as treatment for T. pyogenes. After reaching out to some local farmers, the patient found oral cefoperazone. After 2 days on cefoperazone 250 mg three times per day, the erythema and oropharyngeal exudates entirely resolved.

Outcome and follow-up

The patient did not present to his PCP for follow-up. His symptoms cleared up after 2 days of the new medication, and he felt well enough to go back to work. He took 3 days of antibiotics in total and called the physician to report his improvement. His weight returned to normal (6.4 kg difference) as the constipation resolved.

DISCUSSION

T. pyogenes, formerly classified as Arcanobacterium pyogenes, Actinomyces pyogenes and Corynebacterium pyogenes,1 is a well-discussed opportunistic organism of many animal hosts. Documented cases of the zoonotic transmission of T. pyogenes are all-but absent, with one reported case of pneumonia5 and a few abscess-forming soft tissue infections.1 It occurs primarily in immunocompromised populations and those with occupational exposure. Ultimately, there is very little published data on its presence or virulence in humans.

The diagnosis of infection in this case was made clinically in collaboration with state wildlife biologists. A culture looking specifically for T. pyogenes was ordered, but due to the obscurity of the order, the lab changed the order thinking it was a mistake. The delay in an effective treatment was in part from systemic delay and lack of recommendation for this uncommon pathogen. A referral to infectious disease department was made for the patient but the soonest outpatient spot available was 2 weeks post presentation. While this patient did not require hospitalisation, they could not wait the suggested time frame due to symptom progression. Empiric treatment was unsuccessful, pushing the patient to seek out alternative treatments from online veterinarian recommendations. Proper use of personal protective equipment may have prevented transmission entirely, and a prompter consultation with infectious disease department may have prevented the need for patient sourced treatment, although the results of which were successful clearance of infection. This speaks to a much larger issue regarding availability of resources in smaller medical communities and the importance of protective equipment when working with animal carcasses. Evaluation and treatment were initiated promptly from patient presentation; however, lack of access and uncommon things being uncommon made this case less than straightforward when the diagnosis was well supported.

Learning points

  • More research is needed in zoonotic vectors of transmission, especially in populations with increased exposure to potential pathogen hosts.

  • Centers for Disease Control and Prevention recommendations for proper protective equipment should be stressed by providers to patients who hunt.

  • More availability should be made for outpatient consults of infectious disease, especially in more rural areas, possibly through telecommunication or technology which improves access to healthcare.

  • Mycobacterium is not the only abscess forming micro-organism that can be transmitted from animal hosts.

References

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Footnotes

  • Contributors ZM contributed to the planning and conduct of this article, collected and analysed all data in this clinical case and prepared the manuscript draft. He is the guarantor, responsible for everything from the patient interviewing to choosing to publish the case report.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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