We present a case of sinusitis and orbital cellulitis in a 9-year-old girl caused by the Gram-positive bacillus Arcanobacterium haemolyticum. In addition to antimicrobial chemotherapy, two surgical procedures were required to drain the ethmoid and maxillary sinus cavities and a subperiosteal abscess.
Arcanobacterium haemolyticum, a coryneform Gram-positive bacillus, causes acute pharyngitis in teenagers and young adults and other infectious processes. 1 This organism is a rare cause of head and neck infections and orbital cellulitis in children. 2, 3 We present a case of ethmoid and maxillary sinusitis caused by A. haemolyticum in a child who presented initially with orbital cellulitis.
A previously healthy 9-year-old girl was hospitalized because of a swollen right eye secondary to blunt trauma that occurred 4 days prior. At the time of presentation, the patient had an upper respiratory tract infection, headache and an earache; these symptoms appeared 3 days before admission. The patient’s body temperature was 102oF and the pulse rate was 112/min. She was alert and oriented. The area around the right eye was swollen, and there was exophthalmus, diplopia, decreased visual acuity (20/30) and increased intraocular pressure (26 mm). The right ear contained a yellowish exudate, and the tympanic membrane could not be visualized. A yellow mucus exudate was also present in the anterior nares. No nasopharyngeal or oropharyngeal inflammation or exudate was present. The white blood cell count on admission was 21 300/mm3 with 80% neutrophils. Computed axial tomography of the head and neck confirmed the presence of ethmoid and maxillary sinusitis with orbital cellulitis. The patient was treated with ceftriaxone and clindamycin given intravenously, otic corticosporin suspension and a nasal decongestant spray. The following day the patient underwent surgical drainage of a subperiosteal abscess, external ethmoidectomy and right endoscopic sinus surgery. A Penrose drain was placed for continuous drainage of the abscess cavity. Material aspirated from the right ethmoid abscess was submitted for culture of aerobic and anaerobic bacteria, fungi, mycobacteria and viruses. Subsequent to the surgery the patient remained febrile, and purulent exudate continued to drain through the Penrose site. An incision-and-drainage procedure was repeated on the subperiosteal abscess, and the orbit of the right eye was explored for the presence of other abscesses., but none was found. After these procedures and with continued antimicrobial therapy, the patient became afebrile and her condition improved. She was discharged from the hospital 5 days after admission.
Gram-stained smear of the purulent material aspirated from the right ethmoid abscess showed many polymorphonuclear neutrophils, moderate Gram-positive bacilli and rare Gram-variable cocci. Aerobic and anaerobic cultures grew moderate amounts of a Gram-positive bacillus. The cocci that were observed on Gram-stained smears were not recovered from either bacterial culture. Fungal, viral and mycobacterial cultures were negative. The isolate recovered in the aerobic and anaerobic cultures was catalase-negative and beta-hemolytic on sheep blood agar; hemolysis increased after 48 h incubation in CO2. This organism was identified as A. haemolyticum with the API Coryne identification panel (bioMèrieux, Inc., Hazelwood, MO). Antimicrobial susceptibility testing by the broth microdilution method (Dade MicroScan, West Sacramento, CA) was performed and interpreted using the National Committee for Clinical Laboratory Standards breakpoints for staphylococci, because no interpretive guidelines are available for coryneforms. 4 By this standard the organism was susceptible to penicillin (MIC 0.06 μg/ml), ampicillin (MIC 0.06 μg/ml), ceftriaxone (MIC ≤8 μg/ml), erythromycin (MIC <0.03 μg/ml), clindamycin (MIC <0.03 μg/ml) and vancomycin (MIC 0.5 μg/ml) and resistant to tetracycline (MIC 8 μg/ml) and trimethoprim-sulfamethoxazole (MIC >2/38 μg/ml).
Arcanobacterium spp. are facultative Gram-positive bacilli that may be slightly curved and may show rudimentary branching along with “Chinese letters” and V forms. Unlike Corynebacterium spp., these organisms are catalase-negative, do not possess cell wall mycolic acids and contain l-lysine and l-ornithine rather than meso-diaminopimelic acid as the peptidoglycan diamino acid. The genus Arcanobacterium currently includes six species:A. haemolyticum, Arcanobacterium pyogenes, Arcanobacterium bernardiae, Arcanobacterium phocae, Arcanobacterium pluranimalium and Arcanobacterium hippocoleae. 5–8A. haemolyticum, A. pyogenes and A. bernardiae were formerly members of the genus Corynebacterium and subsequently the genus Actinomyces before 16S ribosomal RNA sequence analysis established their membership in the genus Arcanobacterium.5, 6A. pyogenes is a normal inhabitant of the mucous membranes of domestic animals and a rare cause of human infections. 9A. bernardiae has been reported as an opportunistic human pathogen causing urinary tract infection and septic arthritis. 10–12A. phocae has been isolated from seals and other marine animals, whereas A. pluranimalium has been recovered from porpoises and deer. 6, 7 The newest member of the genus, A. hippocoleae, has been isolated only from the vaginal secretions of a horse. 8
A. haemolyticum is associated with acute pharyngitis in humans, with most cases occurring in the 15- to 18-year-old age group. 1 Cervical lymphadenopathy, tonsillitis and rash frequently accompany the infection. Because of the rash patients can be misdiagnosed with scarlet fever caused by group A beta-hemolytic streptococci. Extensive pharyngeal “pseudomembranes” resembling those seen with diphtheria have been present in some patients. 13A. haemolyticum has also been recovered from chronic skin ulcers, soft tissue infections, deep tissue abscesses (including brain, peritonsillar, paravertebral and intraabdominal abscesses) and posttraumatic joint space infections and has caused pneumonia, osteomyelitis, endocarditis and meningitis. 1, 14–16
Sinusitis with periorbital cellulitis and subperiosteal abscess is an uncommon presentation of A. haemolyticum infection. In 1984 Givner et al. 2 reported A. haemolyticum as the cause of both sinusitis and orbital cellulitis in a 16-year-old boy with concomitant primary Epstein-Barr infection. Their patient had polymicrobial bacteremia with A. haemolyticum and Bacteroides capillosus. In 1995 Ford et al. 3 reported a 16-year-old young man with left orbital cellulitis, ethmoid, maxillary and frontal sinusitis and a subperiosteal abscess in the superotemporal orbit. A. haemolyticum was also isolated from abscess material and from the blood, along with Fusobacterium necrophorum. Our patient was not bacteremic, as evidenced by negative blood cultures. Patient management in all three cases required antimicrobial therapy and repeated drainage procedures before an adequate clinical response was achieved.
The A. haemolyticum isolate obtained from this patient was broadly susceptible to many antibiotics, including penicillins, cephalosporins, macrolides and vancomycin, and was resistant only to tetracycline and trimethoprim-sulfamethoxazole. Other investigators have found that A. haemolyticum is usually susceptible to all classes of antimicrobial agents, with resistance to trimethoprim-sulfamethoxazole being a consistent finding. 17 Occasional isolates may be resistant to tetracycline, the macrolides, clindamycin and ciprofloxacin. 18
1. Mackenzie A, Fuite LA, Chan FT, et al. Incidence and pathogenicity of Arcanobacterium haemolyticum
during a 2-year study in Ottawa. Clin Infect Dis 1995; 21: 177–81.
2. Givner LB, McGehee D, Taber LH, Stein F, Sumaya CV. Sinusitis, orbital cellulitis and polymicrobial bacteremia in a patient with primary Epstein-Barr virus infection. Pediatr Infect Dis J 1984; 3: 254–6.
3. Ford JG, Yeatts RP, Givner LB. Orbital cellulitis, subperiosteal abscess, sinusitis, and septicemia caused by Arcanobacterium haemolyticum.
Am J Ophthalmol 1995; 120: 261–2.
4. National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing: 12th informational supplement. NCCLS Document M100–S12. Wayne, PA: National Committee for Clinical Laboratory Standards, 2002.
5. Collins MD, Jones D, Schofield GM. Reclassification of “Corynebacterium haemolyticum
” (MacLean, Liebow, and Rosenberg) in the genus Arcanobacterium
gen. nov. as Arcanobacterium haemolyticum
nom. rev., comb. nov. J Gen Microbiol 1982; 128: 1279–81.
6. Ramos CP, Foster G, Collins MD. Phylogenetic analysis of the genus Actinomyces
based on 16S rRNA gene sequences: description of Arcanobacterium phocae
sp. nov., Arcanobacterium bernardiae
comb. nov., and Arcanobacterium pyogenes
comb. nov. Int J Syst Bacteriol 1997; 47: 46–53.
7. Lawson PA, Falsen E, Foster G, Eriksson E, Weiss N, Collins MD. Arcanobacterium pluranimalium
sp. nov., isolated from porpoise and deer. Int J Syst Evol Microbiol 2001; 51: 55–9.
8. Hoyles L, Falsen E, Foster G, Rogerson F, Collins MD. Arcanobacterium hippocoleae
sp. nov., from the vagina of a horse. Int J Syst Evol Microbiol 2002; 52: 617–9.
9. Gahrn-Hansen B, Frederiksen W. Human infections with Actinomyces pyogenes
). Diagn Microbiol Infect Dis 1992; 15: 349–54.
10. Adderson EE, Croft A, Leonard R, Carroll K. Septic arthritis due to Arcanobacterium bernardiae
in an immunocompromised patient. Clin Infect Dis 1998; 27: 211–12.
11. Ieven M, Verhoeven J, Gentens P, Goossens H. Severe infection due to Actinomyces bernardiae
: case report. Clin Infect Dis 1996; 22: 157–8.
12. Lepargneur, Heller R, Soulie R, Riegel P. Urinary tract infection due to Arcanobacterium bernardiae
in a patient with a urinary tract diversion. Eur J Clin Microbiol Infect Dis 1998; 17: 399–401.
13. Green SL, LaPeter KS. Pseudodiphtheritic membranous pharyngitis caused by Corynebacterium haemolyticum.
JAMA 1981; 245: 2330–31.
14. Alos JI, Barros C, Gomez-Garces JL. Endocarditis caused by Arcanobacterium haemolyticum.
Eur J Clin Microbiol Infect Dis 1995; 14: 1085–8.
15. Dobinsky S, Noesselt T, Rucker A, Maerker J, Mack D. Three cases of Arcanobacterium haemolyticum
associated with abscess formation and cellulitis. Eur J Clin Microbiol Infect Dis 1999; 18: 804–6.
16. Skov RL, Sanden AK, Danchell VH, Robertsen K, Ejlertsen T. Systemic and deep-seated infections caused by Arcanobacterium haemolyticum.
Eur J Clin Microbiol Infect Dis 1998; 17: 578–82.
17. Carlson P, Kontiainen S, Renkonen OV. Antimicrobial susceptibility of Arcanobacterium haemolyticum.
Antimicrob Agents Chemother 1994; 38: 142–3.
18. Carlson P, Korpela J, Walder M, Nyman M. Antimicrobial susceptibilities and biotypes of Arcanobacterium haemolyticum
blood isolates. Eur J Clin Microbiol Infect Dis 1999; 18: 915–7.