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Volume 11, Number 8—August 2005
Letter

Mycobacterium neoaurum Contamination

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To the Editor: In reviewing "Rapidly Progressive Dementia due to Mycobacterium neoaurum Meningoencephalitis," by Heckman et al. (1), I found, contrary to the authors' conclusion, that M. neoaurum was more likely a contaminant than a cause. First, within the granulomatous brain lesions, the strongest evidence for the authors' conclusion, no acid-fast bacilli were isolated or identified on special stains; thus, the Kochs postulates were not satisfied. Rather, the lesions were likely rheumatoid nodules. Longstanding rheumatoid arthritis commonly causes granulomalike rheumatoid nodules. I did a PubMed search using "rheumatoid nodule in the brain" and 7 articles were found (2,3). A "rheumatoid endarteritis" search found 25 articles. Heckman et al. failed to exclude or discuss this possibility.

Second, M. neoaurum is a rare environmental mycobacterium that grows in ≤2 days on sheep blood agar and is not difficult to culture. As the authors stated, there have been 8 reports of this organism, 7 isolated from blood and 1 from urine. The blood isolates were associated with either central venous catheter or intravenous drug use. Thus, M. neoaurum is of low virulence and unlikely to cause spontaneous infection in tissue unless inoculated accidentally, perhaps. Third, polymerase chain reaction (PCR) is exquisitely sensitive and prone to contamination. The problem is worse when bacterial DNA is amplified by using highly conserved primers. The PCR reagents, from the Taq polymerase (of bacterial origin) to water, contain sufficient, despite minute quantity, bacterial DNA to be amplified (4). Although direct sequencing of the amplicon is often blurry because of its low quantity and mixed content, when cloned, each amplicon may be ligated to the vector and proliferates and gets sequenced later.

Therefore, I believe the presence of M. neoaurum DNA, not the organism itself, represented contamination. Generally, drawing cause-disease conclusion based on PCR sequencing needs vigilance to satisfy the modified Koch postulates (5).

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Xiang Y. Han*Comments to Author 
Author affiliation: *University of Texas, Houston, Texas, USA

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References

  1. Heckman  GA, Hawkins  C, Morris  A, Burrows  LL, Bergeron  C. Rapidly progressive dementia due to Mycobacterium neoaurum meningoencephalitis. Emerg Infect Dis. 2004;10:9247.PubMedGoogle Scholar
  2. Karam  NE, Roger  L, Hankins  LL, Reveille  JD. Rheumatoid nodulosis of the meninges. J Rheumatol. 1994;21:19603.PubMedGoogle Scholar
  3. Kim  RC, Collins  GH. The neuropathology of rheumatoid disease. Hum Pathol. 1981;12:515. DOIPubMedGoogle Scholar
  4. Han  XY, Pham  AS, Tarrand  JJ, Sood  PK, Luthra  R. Rapid and accurate identification of mycobacteria by sequencing hypervariable regions of the 16S ribosomal RNA gene. Am J Clin Pathol. 2002;118:796801. DOIPubMedGoogle Scholar
  5. Fredericks  DN, Relman  DA. Sequence-based identification of microbial pathogens: a reconsideration of Koch's postulates. Clin Microbiol Rev. 1996;9:1833.PubMedGoogle Scholar

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Cite This Article

DOI: 10.3201/eid1108.040861

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In Response: In response to our report on a case of rapidly progressive dementia (1,2), Dr. Han argues that Mycobacterium neoaurum was "more likely a contaminant than the cause" and that the actual cause of death was most likely rheumatoid pachymeningitis. Dr. Han bases his argument on the absence of positive acid-fast stains or mycobacterial cultures and his assessments that the identification of M. neoaurum DNA was due to contamination and that the pathologic findings represented rheumatoid nodules.

The inability to stain or culture an organism in this case is not unusual, as paucibacillary mycobacterial infections, such as tuberculous lymphadenitis and leprosy, are common (3,4). Though the possibility is not inconceivable, environmental contamination is unlikely, because tissue samples were positive with M. neoaurum–specific primers, whereas controls containing identical reagents but no tissue were not.

Dr. Han expresses a valid concern that rheumatoid pachymeningitis was not given due consideration. Rheumatoid pachymeningitis is a rare complication of rheumatoid arthritis, in which patients may exhibit headache, cranial neuropathies, focal deficits, seizures, or cognitive dysfunction (5,6). Rheumatoid pachymeningitis usually, but not exclusively, occurs in patients with long-standing rheumatoid arthritis characterized by erosive disease and extra-articular manifestations, although the systemic disease may be quiescent when neurologic complications arise. Cerebrospinal fluid analysis is generally nonspecific. Magnetic resonance imaging may show prominent meningeal enhancement. Pathologic features may include vasculitis, rheumatoid nodules, and meningeal inflammation, with the latter 2 features being most common (5). The dura may demonstrate inflammation with fibrinoid necrosis (6). We reviewed the pathologic specimens of this case and confirmed the presence of abundant giant cells, endarteritis proliferans, and, most notably, extensive caseation necrosis typical of mycobacterial infection. We found no evidence of rheumatoid nodules, dural inflammation, or fibrinoid necrosis.

Though this case does not satisfy Kochs postulates, neither do most novel infectious diseases. Substantial international efforts were required to satisfy the postulates in the case of SARS (7). In this case, the identification of DNA from a "rare environmental mycobacterium" in a patient with overwhelming pathologic evidence of mycobacterial infection provides strong, though not foolproof, evidence of a possible causal role.

George A. Heckman, Department of Medicine, Hamilton Health Sciences, Chedoke Campus and Freeport Health Centre, 3570 King Street East, Kitchener, Ontario, Canada, N2C 2W1; fax: 519-894-8326
Author affiliations: *Chedoke Campus and Freeport Health Centre, Kitchener, Ontario, Canada; †University of Toronto, Toronto, Ontario, Canada; ‡McMaster University, Hamilton, Ontario, Canada; §Toronto Western Hospital, Toronto, Ontario, Canada

References

  1. Han  XY. Mycobacterium neoaurum contamination. Emerg Infect Dis. 2005;11:13167.PubMedGoogle Scholar
  2. Heckman  GA, Hawkins  C, Morris  A, Burrows  LL, Bergeron  C. Rapidly progressive dementia due to Mycobacterium neoaurum meningoencephalitis. Emerg Infect Dis. 2004;10:9247.PubMedGoogle Scholar
  3. Chao  SS, Loh  KS, Tan  KK, Chong  SM. Tuberculous and nontuberculous cervical lymphadenitis: a clinical review. Otolaryngol Head Neck Surg. 2002;126:1769. DOIPubMedGoogle Scholar
  4. Ustianowski  AP, Lockwood  DNJ. Leprosy: current diagnostic and treatment approaches. Curr Opin Infect Dis. 2003;16:4217. DOIPubMedGoogle Scholar
  5. Kato  T, Hoshi  K, Sekijima  Y, Matsuda  M, Hashimoto  T, Otani  M, Rheumatoid meningitis: an autopsy report and review of the literature. Clin Rheumatol. 2003;22:47580. DOIPubMedGoogle Scholar
  6. Tan  HJ, Raymond  AA, Phadke  PP, Rozman  Z. Rheumatoid pachymeningitis. Singapore Med J. 2004;45:3379.PubMedGoogle Scholar
  7. Osterhaus  ADME, Fouchier  RAM, Kuiken  T. The aetiology of SARS: Koch's postulates fulfilled. Philos Trans R Soc Lond B Biol Sci. 2004;359:10812. DOIPubMedGoogle Scholar

Table of Contents – Volume 11, Number 8—August 2005

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Please use the form below to submit correspondence to the authors or contact them at the following address:

X.Y. Han, Department of Laboratory Medicine, Unit 84, University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston 77030, Texas, USA; fax: 713-792-0936

George A. Heckman, Department of Medicine, Hamilton Health Sciences, Chedoke Campus and Freeport Health Centre, 3570 King Street East, Kitchener, Ontario, Canada, N2C 2W1; fax: 519-894-8326

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Page created: April 23, 2012
Page updated: April 23, 2012
Page reviewed: April 23, 2012
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
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