A Rare Pathogen Comamonas Testosteroni: A Case Report And Review of The Literature

Comamonas testosteroni is a Gram-negative, aerobic, motile, non-spore-forming bacillus. It has not been recognized as a component of the endogenous human micro�ora. Due to its ability to survive in liquid environments, it can survive for a long time in a hospital environment and cause opportunistic infections. Although rare, C. testosteroni has been reported as a cause of cellulitis, peritonitis, endocarditis, meningitis, endophthalmitis, tenosynovitis, pneumonia and bacteremia. Here, we present a case of a 4-year-old girl who was operated on for persistent cloaca with C. testosteroni isolated in her urine culture. Identi�cation studies were performed by MALDI-TOF MS (bioMerieux, France) mass spectrophotometer method. Antibiotic susceptibility tests were performed with the automatic device VITEK-2 Compact (bioMérieux, France). Microorganism was found susceptible to ceftazidime and cipro�oxacin; intermediate susceptible to meropenem and piperacillin / tazobactam and resistant to gentamicin, amikacin, imipenem and trimethoprim-sulfamethoxazole. With this case report, C. testosteroni was reported as the �rst cause of urinary tract infection in our country and the third in the world.


Introduction
Comamonas testosteroni, formerly known as Pseudomonas testosteroni, is a gram-negative, aerobic, motile, non-fermentative and non-spore forming bacillus [7].The name "Testosteroni" comes from the bacteria's ability to use the carbon in testosterone metabolism, as is observed in some types of Pseudomonas and fungi [10].C. testosteroni is commonly found in soil, water, plants, animals and waste all over the world and is considered as an environmental microorganism which is not de ned as a human endogenous micro ora element [6,7].Because of its ability to live in liquid environments, this organism is seen as an opportunistic nosocomial pathogen in hospitals and intensive care units.It grows well on routine bacteriologic media such as sheep blood agar and chocolate agar [7].The need for minimal nutrients to grow even in distiled water and adaptation to different physical conditions leads to its important role as an opportunistic pathogen in hospitals.Since it became clinically important; it has been reported in publications as a causative agent of cellulitis, peritonitis, endocarditis, meningitis, endophthalmitis, tenosynovitis, pneumonia and bacteremia [10].

Case Report
A 4-year-old girl with frequent urinary incontinence and recurrent urinary tract infection despite taking prophylaxis has applied to our hospital for further examination.She was operated two years ago due to persistant cloaca, a total urogenital mobilization was performed, and postoperative uterus, vagen and partial bladder necrosis occured.She has a colostomy in the left lower quadrant, and has frequent urinary incontinence and recurrent urinary tract infection despite taking prophylaxis.Urinalysis report was; leukocyte 14 p/HPF, leukocyte esterase ++, bacteria were trace and others were found within normal limits.Colonies grown on blood and MacConkey agar, incubated at 35-37°C, were identi ed as 99% probability C. testosteroni by mass spectrometry method MALDI-TOF MS (bioMérieux, France).Antibiotic susceptibility tests were performed with the automatic device of VITEK-2 Compact (bioMérieux, France) and interpreted in accordance with EUCAST criteria and it was susceptible to ceftazidime, cipro oxacin; intermediate susceptible to meropenem, piperacillin / tazobactam; resistant to gentamicin, amikacin, imipenem, trimethoprim-sulfamethoxazole.Ceftazidime was added to the treatment of the patient who was already treated with amikacin.There was no growth in the control urine culture performed after 5 days of treatment.And then the patient was discharged with cure.The increase in pathogenicity and antibiotic resistance of C. testosteroni once again demonstrates the importance of rational antibiotic use.With this case report, C. testosteroni was reported as the rst cause of urinary tract infection in our country and the third in the world.

Discussion
C. testosteroni which was rst reported in 1975, is an infection agent in samples such as cerebrospinal uid, abdominal abscess and appendix tissue, most commonly from blood and peritoneal uid [Table 1].Most of the previously reported cases were immunode cient due to malignancy, diabetes mellitus, chronic liver disease, and end-stage renal disease [10].The agent is most frequently isolated from the blood (20 cases), followed by peritoneal uid (9 cases), cerebrospinal uid (3 cases) and urine (2 cases).There are rare cases in which the agent was isolated from cord uid, respiratory secretions, deep tracheal aspirate, abdominal abscess, bite site tissue (animal bite), aortic valve, appendicitis, stool and vitreous uid.Appendicitis is found to be the most common predisposing factor in cases detecting C. testosteroni in peritoneal uid.Although bacteria is not an endogenous ora element, the isolation of a large number of patients with perforated appendicitis (7 out of 9 cases) made us think that this microorganism could create a unique location in the appendix [1].The sixth case was an endocarditis case reported by Duran et al. in 2015.The microorganism isolated from the aortic valve was resistant to piperacillintazobactam, imipenem, meropenem, gentamicin and netilmicin and was treated with cipro oxacin [7].
The seventh case was C. testosteroni bacteremia, isolated from the blood cultures of a patient with diabetes and hemiplegia reported by Pekinturk et al. in 2016.The microorganism was found resistant to aztreonam and colistin [12].
The eighth case was the bacteremia due to C. testosteroni grown in the blood culture of a patient with neutropenia who presented with high fever reported by Aktar et al. in 2018.Ce xime and ceftazidime resistant microorganism was treated with moxi oxacin [2].

Table 1 .
[11]monas testosterone-induced infection cases in the literature.Eight C.testosteroni cases have been reported in Turkey so far.The rst case was purulent meningitis in a patient with recurrent cholesteatoma reported by Arda et al. in 2003.The microorganism was isolated from the cerebrospinal uid and treated with meropenem [3].The second case was C. testosteroni bacteremia in a patient with perforated acute appendicitis.It was isolated from the patient's peritoneal uid and blood cultures by Gul et al. in 2007.It had been treated with cefazolin [8].The third case was reported in 2010 by Katircioglu et al.It was a case of bacteremia in an intensive care patient.This case isolated from blood cultures was the rst case that showed the development of multiple antibiotic resistance including imipenem[9].The fourth case was the pneumonia case in an intensive care patient reported by Ozden et al. in 2011.Microorganism isolated from endotracheal aspirate culture; was found susceptible to amikacin, imipenem, levo oxacin, meropenem, netilmicin, piperacillin-tazobactam, ceftazidime, cefepime, tigecycline, trimethoprim-sulfamethoxazole and resistant to aztreonam, colistin, gentamicin, cipro oxacin and tetracycline[11].The fth case was reported by Bayhan et al. in 2013.It was a case of 16-year-old perforated appendicitis with the complaints of acute abdominal pain, vomiting and constipation.The microorganism isolated from the peritoneal uid was found susceptible to ampicillin, ampicillin-sulbactam, ceftazidime, cefazolin, gentamicin, amikacin, cipro oxacin, imipenem, piperacillin and resistant to ceftriaxone, cefuroxime and trimethoprim-sulfamethoxazole.It was treated with amikacin, ampicillin and clindamycin [6].