JOURNAL OF CLINICAL MICROBIOLOGY, June 2005, p. 3009–3010
Copyright © 2005, American Society for Microbiology. All Rights Reserved.
Vol. 43, No. 6
Recurrent Breast Abscess Caused by Gordonia bronchialis in an
Anja M. Werno,1Trevor P. Anderson,1Stephen T. Chambers,2,3Heather M. Laird,1
and David R. Murdoch1,3*
Microbiology Unit, Canterbury Health Laboratories,1Department of Infectious Diseases, Christchurch Hospital,2and
Department of Pathology, Christchurch School of Medicine and Health Sciences,3Christchurch, New Zealand
Received 8 August 2004/Returned for modification 28 October 2004/Accepted 14 February 2005
We present the first reported case of a recurrent breast infection caused by Gordonia bronchialis. The
infection occurred in a 43-year-old immunocompetent female, and species level identification was obtained with
16S rRNA sequencing.
A 43-year-old female presented to hospital with a 4-day
history of a tender mass in her left breast. On examination,
there was marked fullness with erythema on the lateral aspect
of the left breast extending to the areola and a palpable mass
measuring 4 to 5 cm in diameter. Ultrasonic examination
showed an extensive area of inflammatory changes but no
abscess formation. There was no mammographic evidence of
malignancy. Microscopic examination of a core biopsy showed
acute inflammatory changes and intra- and extracellular gram-
positive organisms. The peripheral white blood cell count re-
mained normal, a human immunodeficiency virus antibody test
was negative, and immunoglobulin levels were normal. The
histological diagnosis was granulomatous mastitis with no ev-
idence of malignancy.
Intravenous penicillin and flucloxacillin therapy was started,
but this was changed to oral amoxicillin-clavulanate and metro-
nidazole after 3 days. A further 3 days later, she was discharged
from hospital taking oral doxycycline (100 mg daily) and oral
clindamycin (150 mg 4 times a day), which was continued for 12
days. In the following 2 weeks, the area of inflammation en-
larged and an abscess formed, requiring readmission to hospi-
tal. The abscess was incised, and approximately 10 ml of
purulent material was drained. At this stage, she was recom-
menced on doxycycline (200 mg daily). Two further drainage
procedures were required, after which the skin healed and the
induration resolved, leaving a small palpable lesion thought to
be scar tissue. Antibiotic therapy was stopped after 5 months of
continuous treatment, but within 2 weeks pain returned and
the abscess reformed.
Of note in the patient’s past medical history is a pituitary
adenoma with galactorrhea detected 3 years before. This has
been controlled with cabergoline. There was no history of prior
breast abscess, breast implants, trauma to the breast, or other
conditions that might predispose to breast abscess formation.
Dry, crinkled, creamy-white colonies were seen on culture of
pus aspirated at the time the abscess was first incised. A Gram
stain could not be performed at this time, as there was an
insufficient amount of specimen available. Morphologically
similar colonies were identified from a follow-up swab taken 5
days after the lesion was first incised and from a swab and
aspirate taken a further 5 days later. On this occasion, gram-
positive cocci were seen in the aspirated material with micros-
copy. After the second incision and drainage, cultures of three
further wound swabs and one tissue specimen all grew the
previously isolated organism. Coagulase-negative staphylo-
cocci were coisolated from two of the samples, but no other
microorganisms were cultured.
Upon nonstandardized susceptibility testing by disk diffusion,
the organism was found to be sensitive to penicillin, erythro-
mycin, vancomycin, tetracycline, and ciprofloxacin (break-
points used for the interpretation of the resulting zone sizes
were those established by NCCLS for Staphylococcus spp.) (7).
Using Etest (AB BIODISC, Sweden), the minimum inhibitory
concentrations of the drugs against the organism were 0.25
?g/ml for penicillin and clindamycin, 1.0 ?g/ml for vancomy-
cin, and 2.0 ?g/ml for ceftriaxone.
More-extensive phenotypic and genotypic testing was per-
formed on the first and last isolates, and the following charac-
teristics were observed. The organism grew after 3 days of
incubation at 37°C in 5% CO2on chocolate and 5% sheep
blood agar. No growth occurred anaerobically. The colonies
showed two distinct morphologies: a dry, wrinkled, crumbly,
cream-colored colony and a smooth, larger colony variant.
Both colonial variants were nonhemolytic and produced no
aerial hyphae, and a yellow-orange pigmentation was observed
in older cultures. On Gram stain, the isolate was a beaded
gram-positive bacillus, weakly acid fast by modified Ziehl-
Neelsen stain. The isolate was initially incorrectly identified as
a Rhodococcus sp. by a commercial identification system (API
Coryne, bioMe ´rieux) with the API code 1111104, a misidenti-
fication that has been previously reported (11). Biochemically,
the isolate was positive for catalase, nitrate, and urease. The
identification as Gordonia bronchialis of the initial isolate and
the isolate from the most recent clinical recurrence of the
patient’s breast abscess was confirmed by 16S rRNA bacterial
sequencing using eubacterial primers described elsewhere
(12). There was a 100% match of both isolates to G. bronchialis
(GenBank accession number X81919.1) over the 517-bp se-
quence. The other species with the closest matches were Gor-
* Corresponding author. Mailing address: Canterbury Health Lab-
oratories, P.O. Box 151, Christchurch, New Zealand. Phone: 64 3 364
1530. Fax: 64 3 364 0238. E-mail: email@example.com.
donia rubropertinctus (GenBank accession number X81915.1) Download full-text
and Gordonia desulfuricans (GenBank accession number
X101417.1), both with 98% matches. To our knowledge, this is
the first reported case of breast infection and associated gran-
ulomatous mastitis caused by G. bronchialis.
Gordonia species, previously classified as a Rhodococcus
species and as a Gordona species, are a recognized pathogen in
immunocompromised as well as immunocompetent patients,
causing bacteremia (2, 6, 8, 10, 11), endocarditis (6), and cen-
tral nervous system infections (3, 4). G. bronchialis has been
reported to date only in a case of bacteremia in a patient with
a sequestrated lung (11) and in sternal wound infections after
coronary artery bypass surgery (9).
A recent case report describes G. terrae infection in an im-
munocompetent patient who developed granulomatous masti-
tis following nipple piercing (13). Biochemically, G. bronchialis
and G. terrae cannot always be distinguished conclusively; how-
ever, the two species can be separated by 16S rRNA gene
sequence differences (4).
The inability to clear the infection in our case with pro-
longed antimicrobial therapy deserves special attention. The
recurrence of infection with Gordonia species has been de-
scribed previously (3, 4, 8), usually with subsequent clearance.
More frequently, the infections were cleared only after pro-
longed antimicrobial treatment and surgical debridement
where appropriate (2, 6, 8, 9, 10, 11).
The nonstandardized antimicrobial susceptibility testing in
this case, as well as in other reported cases, indicates a high
level of in vitro susceptibility to a wide range of commonly used
antibiotics. However, other factors could have been responsi-
ble for the failure of treatment in our patient, such as the
known ability of Gordonia to form sessile communities (1, 5).
It is conceivable that the formation of sessile communities
contributes to chronic infections, such as infections caused by
Gordonia spp., and that the associated decreased activity of
antimicrobials in this setting is responsible for relapses and
The slow growth of the organism not only hinders the effect
of antimicrobial agents but also makes isolation of the bacte-
rium in the laboratory less reliable. Gordonia spp. can be
missed in clinical specimens if a laboratory follows standard
procedures and limits incubation times to less than 72 h. Gor-
donia can also be misidentified as commensal coryneform bac-
teria, which are not uncommonly found as contaminating flo-
ras, especially in cutaneous abscesses. In clinically relevant
cases such as the case presented here, Analytab Products strip
identification of a gram-positive bacillus as a Rhodococcus sp.,
a Gordonia sp., or any other morphologically related bacterium
may not be correct. Additional testing using conventional bio-
chemical tests or 16S rRNA sequencing, most likely to be
performed at a reference center, is recommended.
We thank Lois Seaward and the staff of the Microbiology Unit,
Canterbury Health Laboratories, Christchurch, New Zealand, for their
helpful assistance in the testing and identification process of the iso-
lates. We also acknowledge LabPlus, Auckland, New Zealand, for the
16S rRNA sequencing of the initial isolate.
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3010 CASE REPORTSJ. CLIN. MICROBIOL.