C. testosteroni which was first reported in 1975, is an infection agent in samples such as cerebrospinal fluid, abdominal abscess and appendix tissue, most commonly from blood and peritoneal fluid [Table 1]. Most of the previously reported cases were immunodeficient 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 fluid (9 cases), cerebrospinal fluid (3 cases) and urine (2 cases). There are rare cases in which the agent was isolated from cord fluid, respiratory secretions, deep tracheal aspirate, abdominal abscess, bite site tissue (animal bite), aortic valve, appendicitis, stool and vitreous fluid. Appendicitis is found to be the most common predisposing factor in cases detecting C. testosteroni in peritoneal fluid. Although bacteria is not an endogenous flora 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].
Table 1. Comamonas testosterone-induced infection cases in the literature.
No
|
Age / Gender
|
Specimens isolated
|
Predisposing factor
|
Antibiotic therapy
|
Outcome
|
References
|
1
|
31/F
|
blood
|
rheumatic heart disease
|
kanamycin, tetracycline
|
recovered
|
Atkinson et al. (1975) [4]
|
2
|
31/M
|
abdominal abscess drainage fluid
|
perforated appendicitis
|
cefoxitn, ampicillin then drainage, gentamicin, clindamisn
|
recovered
|
Barbaro et al. (1987) [5]
|
3
|
24/F
|
cerebrospinal fluid
|
intravenous drug abuse
|
moxalactam, nafcillin
|
recovered
|
Barbaro et al. (1987) [5]
|
4
|
59/F
|
peritoneal fluid
|
alcoholic cirrhosis
|
cefoxitin
|
recovered
|
Barbaro et al. (1987) [5]
|
5
|
11/M
|
peritoneal fluid
|
perforated appendicitis
|
ampicillin, clindamycin, tobramycin
|
recovered
|
Barbaro et al. (1987) [5]
|
6
|
12/F
|
peritoneal fluid
|
perforated appendicitis
|
cefoxitin
|
recovered
|
Barbaro et al. (1987) [5]
|
7
|
21/F
|
peritoneal fluid
|
perforated appendicitis, pregnancy
|
cefoxitin
|
recovered
|
Barbaro et al. (1987) [5]
|
8
|
Stillborn
|
Cord fluid
|
maternal intravenous drug abuse
|
could not be cured due to death
|
dead
|
Barbaro et al. (1987) [5]
|
9
|
84/F
|
urine
|
congestive heart failure
|
ampicillin
|
recovered
|
Barbaro et al. (1987) [5]
|
10
|
Newborn
|
blood
|
maternal intravenous drug abuse, prematurity
|
ampicillin
|
dead
|
Barbaro et al. (1987) [5]
|
11
|
17/F
|
peritoneal fluid
|
appendicitis
|
no data
|
recovered
|
Barbaro et al. (1987) [5]
|
12
|
59/M
|
no data
|
no data
|
no data
|
recovered
|
Barbaro et al. (1987) [5]
|
13
|
66/M
|
peritoneal fluid
|
no data
|
no data
|
recovered
|
Barbaro et al. (1987) [5]
|
14
|
14/M
|
appendix
|
appendicitis
|
no data
|
recovered
|
Barbaro et al. (1987) [5]
|
15
|
15/M
|
peritoneal fluid
|
no data
|
no data
|
recovered
|
Barbaro et al. (1987) [5]
|
16
|
4/M
|
blood
|
no data
|
no data
|
recovered
|
Barbaro et al. (1987) [5]
|
17
|
28/M
|
blood
|
no data
|
no data
|
recovered
|
Barbaro et al. (1987) [5]
|
18
|
24/M
|
peritoneal fluid
|
perforated appendicitis
|
cefoxitin
|
recovered
|
Barbaro et al. (1987) [5]
|
19
|
No data
|
respiratory secretions
|
AIDS-related complex
|
ceftazidime
|
recovered
|
Franzetti et al. (1992)
|
20
|
35/M
|
animal bite tissue
|
zoonotic infection
|
ceftazidime, gentamicin
|
recovered
|
Isolato et al. (2000)
|
21
|
75/F
|
blood, central venous catheter
|
cancer central venous catheter
|
ceftazidime, gentamicin
|
recovered
|
Le Moal et al. (2001)
|
22
|
89/M
|
blood
|
advanced age
|
levofloxacin
|
recovered
|
Smith et al. (2003)
|
23
|
50/M
|
cerebrospinal fluid
|
cholesteatoma
|
meropenem
|
recovered
|
Arda et al. (2003) [3]
|
24
|
49/M
|
Blood, mitral valve
|
infective endocarditis
|
cefepime, gentamicin then ampicillin and surgery
|
recovered
|
Cooper et al. (2005)
|
25
|
22/M
|
blood, peritoneal fluid
|
perforated appendicitis
|
cefazolin
|
recovered
|
Gul et al. (2007) [8]
|
26
|
54/F
|
blood
|
chemotherapy, central venous catheter
|
cefepime, ciprofloxacin
|
recovered
|
Abraham et al. (2007) [1]
|
27
|
54/M
|
cerebrospinal fluid
|
chronic alcoholic car accident
|
no data
|
dead
|
Jin et al. (2008)
|
28
|
82/F
|
vitreous biopsy
|
advanced age, diabetes
|
ceftazidime, ciprofloxacin
|
recovered
|
Reddy et al. (2009) [13]
|
29
|
83/M
|
blood
|
advanced age, ischemic cerebrovascular accident
|
amikacin, piperacillin / tazobactam
|
recovered
|
Katircioglu et al (2010) [9]
|
30
|
64/F
|
blood
|
hemodialysis
|
no data
|
recovered
|
Nseir et al. (2011)
|
31
|
54/M
|
blood
|
foot injury
|
oxacillin, flomoxef then ciprofloxacin
|
recovered
|
Tsui et al. (2011) [15]
|
32
|
73/M
|
blood
|
hepatocellular cancer, chronic hepatitis B
|
metasin, gentamicin followed by levofloxacin
|
recovered
|
Tsui et al. (2011) [15]
|
33
|
10/M
|
Endotracheal aspirate
|
Cerebral palsy, tracheostomy
|
ceftriaxone, clarithromycin
|
recovered
|
Ozden et al. (2011) [11]
|
34
|
10/M
|
blood
|
medullablastoma, chemotherapy
|
ciprofloxacin, amikacin
|
recovered
|
Farshad et al. (2012)
|
35
|
19/F
|
blood
|
osteosarcoma
|
imipenem, vancomycin, ciprofloxacin
|
recovered
|
Farshad et al. (2012)
|
36
|
16/M
|
peritoneal fluid
|
perforated appendicitis
|
amikacin, ampicillin, clindamycin
|
recovered
|
Bayhan et al. (2013) [6]
|
37
|
80/F
|
blood
|
diabetes
|
cefazolin, doripenem
|
recovered
|
Orsini et al. (2014) [10]
|
38
|
51/M
|
aortic valve
|
no
|
ciprofloxacin
|
recovered
|
Duran et al. (2015) [7]
|
39
|
42/F
|
Blood
|
septic shock
|
ceftazidime and levofloxacin
|
recovered
|
Who h. et al (2015)
|
40
|
62/M
|
blood
|
diabetes, ischemic serbrovascular accident
|
could not be cured due to death
|
dead
|
Pekinturk N., Akgunes A. (2016) [12]
|
41
|
1/F
|
blood
|
acute gastroenteritis, sepsis
|
ceftriaxone
|
recovered
|
Ruziaki W., Hashami H. (2017) [14]
|
42
|
65/F
|
stool
|
acute gastroenteritis , cholelithiasis
|
ciprofloxacin
|
recovered
|
Farooq S. et al. ( 2017)
|
43
|
30/F
|
Blood
|
neutropenia
|
moxifloxacin
|
recovered
|
Aktar et al. (2018) [2]
|
44
|
46/F
|
Blood and urine
|
sepsis
|
Gentamicin and imipenem
|
recovered
|
Tiwari S et al. (2019)
|
45
|
4/F
|
urine
|
persistent cloaca
|
ceftazidime, amikacin
|
recovered
|
This case
|
Eight C.testosteroni cases have been reported in Turkey so far. The first case was purulent meningitis in a patient with recurrent cholesteatoma reported by Arda et al. in 2003. The microorganism was isolated from the cerebrospinal fluid 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 fluid 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 first 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, levofloxacin, meropenem, netilmicin, piperacillin-tazobactam, ceftazidime, cefepime, tigecycline, trimethoprim-sulfamethoxazole and resistant to aztreonam, colistin, gentamicin, ciprofloxacin and tetracycline [11].
The fifth 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 fluid was found susceptible to ampicillin, ampicillin-sulbactam, ceftazidime, cefazolin, gentamicin, amikacin, ciprofloxacin, imipenem, piperacillin and resistant to ceftriaxone, cefuroxime and trimethoprim-sulfamethoxazole. It was treated with amikacin, ampicillin and clindamycin [6].
The sixth case was an endocarditis case reported by Duran et al. in 2015. The microorganism isolated from the aortic valve was resistant to piperacillin-tazobactam, imipenem, meropenem, gentamicin and netilmicin and was treated with ciprofloxacin [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. Cefixime and ceftazidime resistant microorganism was treated with moxifloxacin [2].
Although C. testosteroni can survive for a long time in hospital environments, C. testosteroni infections are community acquired [7]. Gastrointestinal pathologies are often accompanied by intraabdominal infections, and these infections are the most commonly reported group of infections. Risk factors that may cause infections in other cases are the use of central venous catheters, drug injections, skin cuts and subcutaneous lacerations, and surgical procedures [8].
C. testosteroni infections rarely cause death and mostly respond well to antibiotic therapy. In the reported cases, it was susceptible to aminoglycosides, fluoroquinolones, carbapenems, piperecillin-tazobactam, most cephalosporins and trimethoprim-sulfamethoxazole [3, 15]. However, it should be kept in mind that antibiotic resistance has increased over the years and the resistance profile may change. C. testosteroni was reported resistant to aminoglycosides in 2009, and resistant to aminoglycosides, carbapenems and piperacillin-tazobactam in 2015 [7, 15].
The strain isolated in this case; was found susceptible to ceftazidime (2.0 mg/L), ciprofloxacin (≤ 0.25 mg/L), intermediate susceptible to meropenem (8.0 mg/L ), piperacillin / tazobactam (64.0 mg/L), resistant to gentamicin (≥ 16.0 mg/L), amikacin (≥ 64.0 mg/L), imipenem (≥ 16.0 mg/L), trimethoprim- sulfamethaxole (80.0 mg/L). Our patient's urogenital disorder and multiple surgical interventions in this case were predisposing factors for infection. The isolate in our case was found susceptible to ceftazidime and ciprofloxacin, while it was resistant to preparations such as carbapenem and piperacline-tazobactam, suggesting that it was an infectious agent in the hospital environment due to the widespread use of broad-spectrum antibiotics. With this case report, a rare pathogen was drawn to attention; the importance of rational antibiotic use and the contribution of accurate and rapid diagnosis of microorganisms to treatment with new technologies have been emphasized.