Cutibacterium (Propionibacterium) Infections Clinical Presentation

Updated: Dec 03, 2019
  • Author: Sajeev Handa, MBBCh, BAO, LRCSI, LRCPI; Chief Editor: John L Brusch, MD, FACP  more...
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Presentation

History

Acne vulgaris

C acnes plays an important role in the pathogenesis of inflammatory acne–producing proinflammatory mediators, including lipases, neuraminidases, phosphatases, and proteases.

Acne usually affects the face and, to a lesser degree, the back, chest, and shoulders. On the trunk, lesions tend to be near the midline.

The 4 major pathophysiologic features of acne include the following:

  • Hyperkeratinization

  • Sebum production

  • Bacterial proliferation

  • Inflammation

Lesions can be described in 3 categories, as follows:

  • Comedonal: Comedones are either open (blackheads) or closed (whiteheads). The open comedo appears as a flat or slightly raised lesion with a central dark-colored follicular impaction of keratin and lipid. The closed comedo is a pale, slightly elevated, small papule without a visible orifice and is a potential precursor for the larger inflammatory lesions.

  • Inflammatory: Inflammatory lesions vary from small papules with an inflammatory areola to pustules (papulopustular) to large, tender, fluctuant nodules (nodular).

    Cutibacterium infection. Nodular-cystic acne. Cutibacterium infection. Nodular-cystic acne.
    Cutibacterium infection. Pustular acne. Cutibacterium infection. Pustular acne.
  • Scars: These appear as depressed or hypertrophic papules of varying sizes and shapes.

Exacerbations of acne vulgaris may follow the ingestion of numerous types of drugs, such as iodides, bromides, glucocorticoids, and lithium, as well as the application of occlusive compounds that can block follicles.

Breast implantation

A known local complication of breast implantation is capsular contracture, reported in 5.2%-30% of cases. C acnes, along with coagulase-negative staphylococci and Corynebacterium species, has a well-established role in subclinical infection in capsular contracture. [6]

Endovascular

Cutibacterium species are an underrecognized cause of endocarditis and, as noted above, have been associated with both native and prosthetic valves. The indolent nature of the organism results in cases typically associated with a relatively long history with minimal clinical signs of infection at initial presentation.

In the review performed by Clayton et al, fever was noted to be the most common presenting complaint (81.8%), followed by lethargy and malaise (42.4%) and sweats and chills (27.2%). There was a paucity of examination findings, limited to a murmur reported in 45.4% of cases, and only 12.1% of the cases had the classical stigmata of infective endocarditis (eg, Osler nodes, Janeway lesions, splinter hemorrhages, macular hemorrhages).

Complications may be serious, with the development of intracardiac abscesses [4] and CNS emboli, congestive cardiac failure, cardiac abscesses, and valve dehiscence. [7]

C acnes is the most frequently implicated, but rarely is C granulosum implicated. [8]

C acnes cardiovascular device–related infections typically have a subtle presentation that can include low-grade fever, weight loss, malaise, and myalgias.

Orthopedic

C acnes is frequently implicated in anaerobic arthritis in association with prosthetic joints. In rare cases, it has also been found to be responsible for osteomyelitis and prosthetic vascular graft infections.

Spinal osteomyelitis is an infection of the vertebral body and/or the intervertebral space and can be associated with indwelling hardware. It may present acutely, with delayed onset, or, most frequently, late (years) following spinal surgery. The rate of C acnes infection following spinal surgery is generally low but increases to up to 12% of all infections when instrumentation is used. [6]

C acnes has been isolated from involved joints in rare cases of rheumatoid arthritis and chronic juvenile arthritis, presumably as a result of bacterial inoculation, usually during infiltration (injection).

C acnes has been implicated in certain spondyloarthropathies associated with florid acne vulgaris, in which it was isolated from bone foci and joints. [9]

C acnes has been implicated in infections following rotator cuff repair, as well as an outbreak of postoperative shoulder infections linked to a ventilation system. The shoulder appears to have a propensity for C acnes, and the bacterium should not be considered a contaminant. [1] In a review performed by Millett et al on 10 patients presenting with pain (average age, 57 y) with Cacnes following shoulder surgery, it was found that at the time of confirmation of the diagnosis, clinical signs of infection were absent. C-reactive protein and the erythrocyte sedimentation rates were inconsistently elevated. Cultures took an average of 7 days to confirm growth. Of note, the average time from surgery to diagnosis was 1.8 years. All the patients ended up undergoing irrigation and debridement and received antibiotic treatment for 6 weeks. [10]

Neurosurgical

C acnes has been known to infect internal or external shunts, including Ommaya reservoirs. [11]

In a retrospective analysis of shunt infections by Conen et al in adults aged 12 years or older, out of 78 episodes, C acnes was isolated in 9% of cases, ranking third. The most common organisms were coagulase-negative staphylococci, followed by Staphylococcus aureus. [12]

C acnes shunt infections characteristically present with a paucity of symptoms. When present, they are related to obstruction and/or shunt malfunction, with signs of raised intracranial pressure (ie, headache, nausea, vomiting, lethargy, and/or mental status changes). Fever and meningeal symptoms may or may not be present. Ventriculoperitoneal shunt infections may manifest as peritonitis; ventriculoatrial shunt infections may manifest as fever and bacteremia, with the potential to progress to endocarditis. C acnes infection of a distal external shunt typically manifests as a soft-tissue infection.

In rare cases, Cutibacterium species have been implicated as a cause of brain abscess [13] and subdural empyema. A case report describes a patient who developed C acnes cerebral abscess as a consequence of severe chronic sinus disease. [14]

Other infections

C acnes has been reported as a cause of vision-threatening infectious keratitis when the cornea is compromised. C acnes has also been implicated in chronic pseudophakic-related endophthalmitis following cataract surgery and placement of an artificial intraocular lens. The presentation is characterized by low-grade intraocular inflammation, possibly chronic, and may be misdiagnosed as noninfectious iritis.

In rare cases, Cutibacterium species have been implicated as a cause of dental infections, conjunctivitis associated with contact lenses, peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD), and breast-implant infections.

C acnes has been isolated in cases of transfusion-transmitted bacterial infection, which typically manifests as fever and chills with or without tachycardia and hypotension during or after transfusion of blood or blood products. [15]

C acnes infection has been suggested as a possible trigger for primary biliary cirrhosis. [16]

C granulosum infection has been reported as a potential primer of the immune system prior to the development of sarcoidosis. [17] Latent infection of C acnes has been implicated as a cause of sarcoidosis since it is the only microorganism that been isolated from sarcoid lesions by bacterial culture. [18]

C avidum has been implicated in causing a splenic abscess post cardiac catheterization. [19]

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Complications

The prognosis of acne vulgaris is usually favorable, and the only sequela is scarring, which can be minimized. In patients with scarring, cosmetic options include dermabrasion, excision, subcision, punch grafting, and laser resurfacing.

Complications for other infections are described in the Clinical section.

Isotretinoin is contraindicated in pregnancy. A pregnancy test should be performed prior to commencing treatment, and patients should be warned about the drug's teratogenic effects. Patients must sign written consent forms and be enrolled into the iPledge program. Female patients of childbearing potential must be on two forms of birth control.

Although Cutibacterium species are frequently nonpathogenic, the presence of Cutibacterium species in a sterile body fluid culture should never be automatically assumed as contamination until a thorough history and physical examination and assessment is completed.

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