Granulomatous infection of the hand and wrist due to Azospirillum spp. John Serelis a , Joseph Papaparaskevas b , Angeliki Stathi c, ⁎, Alexander L. Sawides d , Amalia D. Karagouni d , Athanassios Tsakris b , Anastasia Pangalis c a Department of Internal Medicine, Euroclinic Hospital, 11521, Athens, Greece b Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 11527, Athens, Greece c Department of Microbiology, “Aghia Sophia” Children Hospital, 11527, Athens, Greece d Department of Botany, Faculty of Biology, National and Kapodistrian University of Athens, 15781, Athens, Greece abstract article info Article history: Received 18 January 2013 Received in revised form 3 April 2013 Accepted 4 April 2013 Available online 16 May 2013 Keywords: Azospirillum spp. Granulomatous infection Tenosynovitis We report a case of Azospirillum infection manifestating as granulomatous tenosynovitis of the right hand, in an immunocompetent middle-aged female. We highlight the unusual source of the infection, the diagnostic workup, as well as the treatment approach. © 2013 Elsevier Inc. All rights reserved. 1. Case report presentation A 50-year-old Caucasian female presented to the outpatients department with signs and symptoms of inflammation of the right hand. She had been stung on her right thumb, while she was cleaning shrimps 6 weeks before. Two weeks after the incident, a collection developed under the nail and progressed with redness and swelling of the right thumb. A 2-week course of oral ciprofloxacin (500 mg, bd) was unsuccessful in controlling the symptoms, and the patient deteriorated with pain, redness, and swelling of the hand and numbness of the ulnar border of right forearm. The rest of her medical history was clear. She had the habit of frequent gardening as an outdoors activity. On admission, laboratory investigations showed white blood cell count of 7.5 × 10 3 /mm 3 (neutrophils 56%, lymphocytes 35%, and eosinophils 4%), erythrocyte sedimentation rate of 15 mm, and C- reactive protein of 28.4 mg/L (reference values, 0–5 mg/L). An ultrasound examination of the right wrist showed fluid collection over the sheath of the flexor tendons and tenosynovitis involving the extensor tendons. There were no palpable axillary lymph nodes. A punch biopsy of the thickened thumb skin showed multiple epithelial granulomas with Langhans multinuclear giant cells, but no necrosis (Fig. 1A) Acid-fast stain was negative. The patient continued to deteriorate on oral ciprofloxacin with progressive pain and hand swelling, extending into the lower part of the forearm. There was widespread crepitus on palpation of the tendons of the flexor apparatus. One week later, an extensive surgical debridement in association with synovectomy was undertaken, and multiple biopsies were obtained. Histology of tendon sheaths and fragments showed an abundance of granulomatous tissue, with lymphocytic and monocytic infiltrations and regional fibrin depositions (Fig. 1B). The tissue fragments were homogenized, and direct Gram stain showed clusters of weakly stained Gram-negative rods, which were acid-fast stain negative. Culture of the tissue was performed on McConkey and Sabouraud agar plates and Cooked Meat Broth, incubated at 37 °C under ambient air conditions; Columbia agar supplemented with 5% sheep blood and chocolate agar plates, incubated at 37 °C under 5% CO 2 conditions; Columbia agar supplemented with 5% sheep blood, hemin (5 mg/L), and vitamin K (1 mg/L), incubated at 37 °C under anaerobic conditions; and in duplicate Lowenstein-Jensen medium slants (LJ) for incubation at 37 °C and at room temperature (RT) (all media were obtained from Bioprepare, 16346, Gerakas, Greece). After a period of 10 days, growth was observed only on the LJ slant incubated at RT. The colonies were semitransparent, white, raised, with rough surface. Acid-fast stain was negative, whereas Gram stain revealed Gram-negative pleomorphic rods with enhanced clustering morphology (Fig. 2). Subculturing from the LJ slants on to the above mentioned culture media showed that the microorganism could grow very slowly (5–7 days) on blood agar plates, LJ slants, as well as on Mueller-Hinton (MH) agar plates incubated at 30 °C or RT, but poorly when incubated at 37 °C. The Diagnostic Microbiology and Infectious Disease 76 (2013) 513–515 ⁎ Corresponding author. Department of Microbiology, “Aghia Sophia” Children Hospital, Thivon and Levadeias, 11527, Athens, Greece. Tel.: +30-210-7467169; fax: +30-210-7462143. E-mail address: astathi@med.uoa.gr (A. Stathi). 0732-8893/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.diagmicrobio.2013.04.010 Contents lists available at SciVerse ScienceDirect Diagnostic Microbiology and Infectious Disease journal homepage: www.elsevier.com/locate/diagmicrobio