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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References

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  Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 3  |  Page : 293-295
 

Elizabethkingia meningoseptica : An emerging pathogen causing meningitis in a hospitalized adult trauma patient


1 Department of Laboratory Medicine, Hospital Infection Control, New Delhi, India
2 Department of Surgery, Jai Prakash Narayan Apex, Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India

Date of Submission03-Dec-2012
Date of Acceptance01-Jun-2013
Date of Web Publication25-Jul-2013

Correspondence Address:
P Mathur
Department of Laboratory Medicine, Hospital Infection Control, New Delhi
India
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DOI: 10.4103/0255-0857.115653

PMID: 23883720

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 ~ Abstract 

A 23-year-old male patient who was a follow-up case of neurosurgery presented to our emergency department with a history of high-grade fever and clinical features of meningitis for 1 week. The cerebrospinal fluid (CSF) was sent to our laboratory for culture. The culture demonstrated growth of 1-2 mm in diameter light yellow coloured colonies of Gram-negative bacilli on chocolate and blood agar. There was no growth on MacConkey agar. The bacterium was multidrug resistant. Based upon the growth characteristics, bio-chemical reactions, drug susceptibility pattern and identification by Vitek 2 system the isolate was identified as Elizabethkingia meningoseptica. Patient was treated with injection piperacillin-tazobactam, injection vancomycin and cotrimoxazole tablets for 21 days along with intrathecal injection of tigecycline and finally, patient improved clinically and the CSF cultures became sterile. The presence in hospital environment along with multidrug resistance makes E. meningoseptica a successful emerging nosocomial pathogen.


Keywords: Elizabethkingia meningoseptica, meningitis, multidrug resistant, neurosurgery, nosocomial spread, trauma


How to cite this article:
Tak V, Mathur P, Varghese P, Misra M C. Elizabethkingia meningoseptica : An emerging pathogen causing meningitis in a hospitalized adult trauma patient. Indian J Med Microbiol 2013;31:293-5

How to cite this URL:
Tak V, Mathur P, Varghese P, Misra M C. Elizabethkingia meningoseptica : An emerging pathogen causing meningitis in a hospitalized adult trauma patient. Indian J Med Microbiol [serial online] 2013 [cited 2014 Dec 28];31:293-5. Available from: http://www.ijmm.org/text.asp?2013/31/3/293/115653



 ~ Introduction Top


Elizabethkingia meningoseptica was previously known as Chryseobacterium meningosepticum until 2005 and Flavobacterium meningosepticum until 1994. [1],[2],[3] It belongs to group II a of Centers for Disease Control and Prevention (CDC) classification of previously unclassified bacteria and consists of yellow pigment producing non-motile, catalase positive, oxidase positive, non-glucose fermenting Gram-negative bacilli. It was first isolated in 1959 by Elizabeth O King an American bacteriologist while she was working on unclassified bacteria associated with meningitis in infants at CDC Atlanta. [1] This bacteria is commonly found in plants, soil, food and both fresh and marine water. It causes meningitis in neonates with mortality rates of about 57% and is a less common cause of nosocomial pneumonia, sepsis and meningitis in both immunocompromised adults and neonates. [4],[5] Infection in adult patients is generally acquired nosocomially. In health-care settings this bacteria is generally found in saline solutions used for flushing and reconstitution of antibiotics as well as in the water sinks and tanks of the hospital. It has been also reported to cause endocarditis, eye infections, cellulitis, abdominal infections, epididymitis, bronchitis, sinusitis, etc. [4],[5] Immunosuppression, underlying medical diseases, prolonged hospital stay, prior use of higher antibiotics, indwelling central venous catheter and other invasive devices are some of the risk factors associated with the acquisition of this infection. [4],[5]

E. meningoseptica is an uncommon pathogen infrequently isolated from clinical specimens. Antimicrobial susceptibility data therefore is rather scarce regarding this rare pathogen. Moreover, results of susceptibility testing vary when different methods (viz. disc diffusion, microbroth dilution and E-test) are used. Even Clinical and Laboratory Standards Institute (CLSI) has no recommendations for performance and interpretation of antimicrobial susceptibility tests for this rare pathogen. [4],[5],[6]

E. meningoseptica has a unique antibiogram and this pathogen though being a Gram-negative bacillus is inherently resistant to many antimicrobial agents commonly used to treat infections caused by Gram-negative bacteria (aminoglycosides, beta-lactam antibiotics, tetracyclines and chloramphenicol) but are often susceptible to agents generally used to treat infections caused by Gram-positive bacteria (rifampicin, clindamycin, erythromycin, trimethoprim-sulfamethoxazole, quinolones and vancomycin). This often leads to inappropriate choice of antibiotics for initial empirical therapy and results in treatment failures. [4],[5],[6],[7],[8],[9],[10]

It is resistant to multiple antibiotics, especially beta-lactams as it produces two beta-lactamases viz. extended-spectrum beta-lactamase and a carbapenem hydrolyzing metallo beta-lactamase conferring resistance to many extended spectrum beta lactam antibiotics, aztreonam and carbapenems. However, various studies have found E. meningoseptica to be sensitive to piperacillin and piperacillin/tazobactam. [4],[5],[6],[7],[8],[9],[10] According to the results of the SENTRY antimicrobial surveillance program, the agents most active against E. meningoseptica are the quinolones, rifampin and trimethoprim-sulfamethoxazole while the susceptibility of the organism to aminoglycosides, beta-lactams, carbapenems and glycopeptides is low. [6]


 ~ Case Report Top


A sample of cerebrospinal fluid (CSF) was sent to our laboratory from a patient who presented to our emergency department with a history of high grade fever for past 1 week. This patient was a 23-year-old male victim of a road traffic accident and was earlier admitted in our trauma centre in May 2012. Patient suffered severe head injury and had right fronto-temporal contusion and intraventricular haemorrhage leading to post-traumatic hydrocephalus. The Glasgow Coma Scale (GCS) score of patient at that time was E 1 V T M 4 . Patient was operated the next day and decompression craniotomy was done. Patient was discharged after 15 days with GCS score of E 1 V T M 3 . After being discharged, patient returned to our trauma centre after 19 days with a history of high-grade fever of 1 week and GCS score E 2 V T M 4 . Lumbar puncture (LP) was carried out to drain the CSF and sample was sent to our laboratory for culture, cell counts and protein and sugar estimation. Patient was started on Injection cefoperazone-sulbactam, amikacin and metronidazole. The CSF protein was 1224 mg/dl, sugar 52 mg/dl, red blood cell 50 cells/mm 3 , white blood cell 210 cells/mm 3 with 90% polymorphs and 10% lymphocytes. Patient had leukocytosis with total lymphocyte counts of 22,800 cells/mm 3 and differential counts showed 85% neutrophils, 12% lymphocytes, 2% monocytes and 1% eosinophils. The LP drain was removed and was replaced by an Omaya shunt after 4 days.

The culture demonstrated growth of smooth circular 1-2 mm colonies with entire edges and regular margins with a slight yellow pigmentation on nutrient agar after 24 h incubation. The growth on blood agar showed 1-2 mm smooth, circular, greyish-white non-hemolytic colonies. There was no growth on MacConkey agar. The biochemical reactions of this Gram-negative bacillus were as follows - catalase positive, oxidase positive, non-motile, non-fermenting, mannitol-negative, indole-weak positive, TSI (Triple sugar iron) agar-K/K, urease-negative. The organism hydrolysed esculin and gelatin; it did not utilize citrate as the sole source of carbon and did not reduce nitrate. The organism was identified as E. meningoseptica by both conventional bio-chemicals and Vitek 2 system (BioMerieux, France). The CSF cultures were repeated on multiple occasions in the subsequent 10 days and continued to yield the growth of the same organism. Drug susceptibility was performed by the CLSI disc diffusion method as well as Vitek 2 automated system (BioMerieux, France) and the CLSI criteria for Gram-negative and Gram-positive bacteria were used to interpret the anti-microbial susceptibility as no recommendations regarding breakpoints are available for this rare pathogen. The bacteria was multidrug resistant showing resistance to ampicillin-sulbactam, ticarcillin, ceftazidime, ceftriaxone, cefepime, cefoperazone-sulbactam, cefepime-tazobactam, tetracycline, chloramphenicol, imipenem, meropenem, amikacin, gentamycin, tobramycin, ciprofloxacin, levofloxacin and colistin. The isolate was susceptible to piperacillin-tazobactam, cotrimoxazole, tigecycline and vancomycin. Patient was started on injection piperacillin-tazobactam, injection vancomycin and cotrimoxazole tablets after the susceptibility reports were received. The therapy continued for 21 days. The cultures sent 48 h after the antibiotic therapy were sterile and patient also became afebrile and clinically responded to the therapy.

Environmental samples were obtained from patients palm, soles, groin, axilla, nose, bed railings, saline solutions used for flushing and reconstitution of injections instilled through the Omaya shunt. Despite all our surveillance measures, we failed to identify the source of this pathogen. However, patient might have acquired the infection during the course of treatment in his previous stay at the hospital or during care at his home after the initial discharge and then came back to our centre when clinical signs and symptoms of meningitis developed. Therefore, it is quite possible that the opportunity to identify the source of infection was missed as environmental surveillance we did not perform during patient's earlier hospital visit as patient was asymptomatic then and collection of surveillance samples on subsequent admission was probably irrelevant and failed to yield the source of the pathogen.


 ~ Discussion Top


E. meningoseptica is an infrequent organism causing meningitis in immunocompromised adults. The first case of infection by this organism in India was reported way back in 1988-89 as a pathogen causing neonatal meninigitis. Subsequently, there have been various Indian studies, which have reported this rare pathogen causing neonatal and adult meningitis, septicemia and endocarditis in patients admitted for medical causes. [8],[9],[10],[11],[12] This is probably the first case report of meningitis caused by E. meningoseptica in trauma patients in India. It is an emerging pathogen in trauma victims with severe head injury and undergoing neurosurgical procedures. Trauma and neurosurgical procedures lead to intra-hospital stay of these predominantly young adult patients who are otherwise having no other co-morbidities. They have to be put on various invasive medical devices viz. central venous catheters, ventilators, urinary catheters, cerebrospinal shunts to support the physiological condition of these critically ill-patients and multiple antibiotics are also administered to prevent or treat infections in these patients. Moreover, this bacterium proliferates in the hospital environment growing on moist surfaces such as sinks, water tanks, ventilator tubings, saline solution used for flushing devices etc. This bacteria is resistant to multiple antibiotics viz. beta-lactams, aminoglycosides, tetracycline, colistin, etc., making it a very successful nosocomial pathogen causing serious life-threatening infections in these young adult trauma victims with impaired immunological response. In future, there is possibility of encountering increased number of infections due to this opportunistic pathogen particularly in intensive care units where there is selective antibiotic pressure due to the higher antibiotic use and presence of susceptible critically ill-patients on multiple life support devices. Thus, high degree of suspicion, rapid diagnosis and prompt institution of appropriate therapy for prolonged time period (about 3-4 weeks) are key factors in management of such infections.

 
 ~ References Top

1.King EO. Studies on a group of previously unclassified bacteria associated with meningitis in infants. Am J Clin Pathol 1959;31:241-7.  Back to cited text no. 1
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2.Vandamme P, Bernardet JF, Segers P, Kersters K, Holmes B. New perspectives in the classification of the flavobacteria: Description of Chryseobacterium gen. nov., Bergeyella gen. nov., and Empedobacter nom. rev. Int J Syst Bacteriol 1994;44:827-31.  Back to cited text no. 2
    
3.Kim KK, Kim MK, Lim JH, Park HY, Lee ST. Transfer of Chryseobacterium meningosepticum and Chryseobacterium miricola to Elizabethkingia gen. nov. as Elizabethkingia meningoseptica comb. nov. and Elizabethkingia miricola comb. nov. Int J Syst Evol Microbiol 2005;55:1287-93.  Back to cited text no. 3
    
4.Ceyhan M, Celik M. Elizabethkingia meningosepticum (Chryseobacterium meningosepticum) infections in children. Int J Pediatr 2011;2011:215237.  Back to cited text no. 4
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5.Hsu MS, Liao CH, Huang YT, Liu CY, Yang CJ, Kao KL, et al. Clinical features, antimicrobial susceptibilities, and outcomes of Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteremia at a medical center in Taiwan, 1999-2006. Eur J Clin Microbiol Infect Dis 2011;30:1271-8.  Back to cited text no. 5
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6.Kirby JT, Sader HS, Walsh TR, Jones RN. Antimicrobial susceptibility and epidemiology of a worldwide collection of Chryseobacterium spp: Report from the SENTRY antimicrobial surveillance program (1997-2001). J Clin Microbiol 2004;42:445-8.  Back to cited text no. 6
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7.Issack MI, Neetoo Y. An outbreak of Elizabethkingia meningoseptica neonatal meningitis in Mauritius. J Infect Dev Ctries 2011;5:834-9.  Back to cited text no. 7
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8.Bomb K, Arora A, Trehan N. Endocarditis due to Chryseobacterium meningosepticum. Indian J Med Microbiol 2007;25:161-2.  Back to cited text no. 8
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9.Sarma S, Kumar N, Jha A, Baveja U, Sharma S. Elizabethkingia meningosepticum: An emerging cause of septicemia in critically III patients. J Lab Physicians 2011;3:62-3.  Back to cited text no. 9
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10.Dias M, Fernandes A, Furtado Z. Case series: Elizabethkingia meningosepticum. J Clin Diagn Res 2012;6:1550-1.  Back to cited text no. 10
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11.Gokul BN, Chandramukhi A, Ravikumar R, Aroor S. Flavobacterium meningosepticum meningitis in a neonate. Indian J Pediatr 1989;56:524-7.  Back to cited text no. 11
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12.Padmaja P, Verghese S, Bhirmanandham CV, Ajith, Thirugnanasambandham S, Ramesh S. Chryseobacterium meningosepticum: An uncommon pathogen causing adult bacterial meningitis. Indian J Pathol Microbiol 2006;49:293-5.  Back to cited text no. 12
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