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CASE REPORT
Year : 2015  |  Volume : 1  |  Issue : 2  |  Page : 108-110

A Case Report of Staphylococcus aureus Induced Cutaneous Botryomycosis in a Patient with Acquired Immune Deficiency Syndrome


1 Department of Microbiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of Microbiology, National Medical College, Kolkata, West Bengal, India
3 Department of Microbiology, Government College of Medicine and Sagar Dutta Hospital, Kolkata, West Bengal, India

Date of Web Publication1-Jun-2015

Correspondence Address:
Dr. Kalidas Rit
70B T C Mukherjee Street P.O. Rishra, Hooghly - 712 248, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-7438.157929

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  Abstract 

Botryomycosis is a rare bacterial infection that can involve the skin and viscera. It is multifocal in development, characterized by granulomatous bacterial infection. The organisms form granules, which are composed of bacterial masses that are adhered to each other. Here, we describe one unusual case of culture proved Staphylococcus aureus induced botryomycosis in patients with the acquired immune deficiency syndrome who was successfully treated.

Keywords: Botryomycosis, granulomatous, Staphylococcus aureus


How to cite this article:
Rit K, Saha R, Chakrabarty P. A Case Report of Staphylococcus aureus Induced Cutaneous Botryomycosis in a Patient with Acquired Immune Deficiency Syndrome. MAMC J Med Sci 2015;1:108-10

How to cite this URL:
Rit K, Saha R, Chakrabarty P. A Case Report of Staphylococcus aureus Induced Cutaneous Botryomycosis in a Patient with Acquired Immune Deficiency Syndrome. MAMC J Med Sci [serial online] 2015 [cited 2019 Dec 8];1:108-10. Available from: http://www.mamcjms.in/text.asp?2015/1/2/108/157929


  Introduction Top


Botryomycosis is a rare condition that involves the skin and viscera, and can mimic mycetoma in an immunocompetent individual. [1] It is multifocal in its development, characterized by granulomatous bacterial infection. [2] It also occurs in an immunosuppressed patient. [3],[4] We describe here a very uncommon case of culture proved Staphylococcus (s.) aureus induced botryomycosis in a patient with the acquired immune deficiency syndrome (AIDS) who was successfully treated.


  Case Report Top


A 36-year-old man by occupation truck driver had a 7 week history of a mildly tender skin eruption on the chin and right mandibular area. The patient had a history of exposure with commercial sexual worker 6 years back. The patient was reactive to human immunodeficiency virus (HIV) 1 antibody. The patient had a history of recurrent genital herpes simplex virus infection that required long-term acyclovir therapy and oral hairy leukoplakia. He began antiretroviral therapy (ART) with zidovudine and lamivudine 7 months before the onset of the eruption. Immune reconstitution inflammatory syndrome (IRIS) refers to a disease or pathogen-specific inflammatory response in a HIV-infected individual that is usually triggered after initiation or reinitiating of ART and change to more active ART therapy. Here the lesions probably were not associated with IRIS.

A through physical examination revealed a healthy appearing man with reddish papules and nodules 1-3 cm in diameter, some with central crusting on the chin and adjoining right mandibular area [Figure 1]. An abnormal laboratory finding included a total neutrophil count of 800/mm 3 and absolute helper T-lymphocyte (CD4) count of 55/mm 3 . The associated viral load was 30,000 copies/ml of blood.
Figure 1: Botryomycosis involving chin and adjoining mandibular area presented with multiple nodular lesions

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A skin biopsy specimen was taken aseptically. A portion of biopsy material was sent for histopathological (H/P) study and another portion for bacteriological and fungal culture. Histopathologically, the papules showed the basophilic bacterial granules surrounded by eosinophilic amorphous material constituting a typical Splendore-Hoeppli phenomenon [Figure 2]. The bacteriological culture of homogenized skin biopsy specimen on nutrient agar and blood agar media yielded pure growth of S. aureus, whereas no other growth for fungi or actinomycetes could be observed. Growth on blood agar media showed beta hemolytic colonies of  S.aureus Scientific Name Search . The colonies of S.aureus were confirmed by gram staining, positive catalase test, mannitol fermentation test and by positive slide and tube coagulase test. It was sensitive to the amoxycillin + clavulanic acid combination, linezolid, teicoplanin, vancomycin and cefoxitin, but resistant to co-trimoxazole and tetracycline. The patient was treated with amoxicillin + clavulanic acid combination for 5 weeks. After 2 months the eruptions resolved, leaving atrophic scar [Figure 3]. During 6 months post-treatment follow-up, no new botryomycotic lesions appeared.
Figure 2: Histopathological appearance of botryomycotic lesion showing basophilic bacterial granules surrounded by eosinophilic amorphous material

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Figure 3: Post-treatment appearance of the affected individual

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  Discussion Top


Botryomycosis is a rare, chronic bacterial granulomatous disease that usually involves the skin, subcutaneous tissue and infrequently, the viscera. [5] Its treatment consists of antibiotic therapy and if required surgical debridement. The choice of antibiotics should be based on bacterial culture and sensitivity report. Even in immunocompetent, it sometimes happens that antibiotic therapy may be insufficient. However in our case, though the patient was immunodeficient, he responded well to oral amoxicillin + clavulanic acid combination therapy.

Botryomycosis of the skin should be differentiated from mycetoma, actinomycosis, abscess and tuberculosis. [1] The treatment depends on the site of infection. There are several reported cases of botryomycosis from different regions of the globe, [6],[7] but, there are only very occasional case reports associated with AIDS patient. [3],[4]

The pathogenesis of botryomycosis is not well-known. It is associated with defects of cellular immunity particularly with low lymphocyte counts. [8] Botryomycosis requires a delicate balance between number of microorganisms inoculated, their low virulence, and host tissue response for it to occur.

The condition may present in cutaneous or visceral form. In the cutaneous form patient presents with a suppurative, granulomatous and usually chronic condition, as in our patient. [2] The etiological role of S.aureus is supported by the following observations (a) the microscopy of the grain showed presence of Gram-positive spherical cocci, (b) the grain yielded heavy and pure growth of beta-hemolytic colonies of S.aureus which was coagulase positive, (c) in the tissue section basophilic bacterial granules surrounded by eosinophilic amorphous material constituting a typical Splendore-Hoeppli phenomenon, (d) there was no evidence of any other pathogens in the grain, pus or tissue section in microscopy or culture and (e) the patient responded well to amoxycillin + clavulanic acid combination therapy.

Botryomycosis is a rare condition, but now-a-days incidence is increasing. Cases may be missed or mistakenly identified, mainly confused with fungal infections. It is advised that when a patient presents, all investigations be correlated to reach a proper diagnosis.

 
  References Top

1.
Bonifaz A, Carrasco E. Botryomycosis. Int J Dermatol 1996;35:381-8.  Back to cited text no. 1
    
2.
Mehregan DA, Su WP, Anhalt JP. Cutaneous botryomycosis. J Am Acad Dermatol 1991;24:393-6.  Back to cited text no. 2
    
3.
Saadat P, Ram R, Sohrabian S, Vadmal MS. Botryomycosis caused by Staphylococcus aureus and pneumocystis carinii in a patient with acquired immunodeficiency disease. Clin Exp Dermatol 2008;33:266-9.  Back to cited text no. 3
    
4.
de Vries HJ, van Noesel CJ, Hoekzema R, Hulsebosch HJ. Botryomycosis in an HIV-positive subject. J Eur Acad Dermatol Venereol 2003;17:87-90.  Back to cited text no. 4
    
5.
Mehregan DA, Su WP, Anhalt JP. Cutaneous botryomycosis. J Am Acad Dermatol 1991;24:393-6.  Back to cited text no. 5
    
6.
Bonifaz A, Carrasco E. Botryomycosis. Int J Dermatol 1996;35:381-8.  Back to cited text no. 6
    
7.
Findlay GH, Vismer HF. Botryomycosis. Some African cases. Int J Dermatol 1990;29:340-4.  Back to cited text no. 7
    
8.
Brunken RC, Lichon-Chao N, van der Broek H. Immunologic abnormalities in botryomycosis. A case report with review of the literature. J Am Acad Dermatol 1983;9:428-34.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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