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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
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  Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 4  |  Page : 405-409
 

Cupriavidus pauculus (Ralstonia paucula) concomitant meningitis and septicemia in a neonate: First case report from India


1 Department of Microbiology, Dr. Baba Saheb Ambedkar Hospital, New Delhi, India
2 Department of Paediatrics, Dr. Baba Saheb Ambedkar Hospital, New Delhi, India

Date of Submission26-Mar-2013
Date of Acceptance31-May-2013
Date of Web Publication25-Sep-2013

Correspondence Address:
S Duggal
Department of Microbiology, Dr. Baba Saheb Ambedkar Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.118871

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 ~ Abstract 

Ralstonia paucula (formerly classified as CDC (Centre for Disease Control) group IVc-2, Wautersia paucula; recently renamed as Cupriavidus pauculus) is an environmental Gram-negative bacillus isolated from water sources and can cause serious human infections. Patients recover bacteriologically indicating low virulence. A total of 32 cases have been reported world-wide, but no isolation has ever been reported from cerebrospinal fluid or in India. The first case of R. paucula meningitis and septicemia is being reported here along with the brief summary of cases reported world-wide.


Keywords: Cupriavidus pauculus, meningitis, neonate, septicemia


How to cite this article:
Duggal S, Gur R, Nayar R, Rongpharpi S R, Jain D, Gupta R K. Cupriavidus pauculus (Ralstonia paucula) concomitant meningitis and septicemia in a neonate: First case report from India. Indian J Med Microbiol 2013;31:405-9

How to cite this URL:
Duggal S, Gur R, Nayar R, Rongpharpi S R, Jain D, Gupta R K. Cupriavidus pauculus (Ralstonia paucula) concomitant meningitis and septicemia in a neonate: First case report from India. Indian J Med Microbiol [serial online] 2013 [cited 2019 Dec 7];31:405-9. Available from: http://www.ijmm.org/text.asp?2013/31/4/405/118871



 ~ Introduction Top


Cupriavidus pauculus of family Burkholderiaceae is an environmental Gram-negative bacillus, which can rarely cause opportunistic infections especially in high risk patients. Isolation from a clinical specimen is generally treated with high index of suspicion and usually regarded as contamination unless proven otherwise. It has been incriminated in pseudo-outbreaks, [1],[2] but may be considered a pathogen if isolated from a sterile body fluid and correlates with clinical condition. We report hereby, the first case of Ralstonia paucula from cerebrospinal fluid (CSF) and blood of a neonate in India.


 ~ Case Report Top


A 6-day old neonate presented to our institution in July 2012 with complaints of fever, poor feeding, lethargy and abnormal cry. He was delivered full term vaginally by a trained birth attendant at a small neighbourhood clinic. The parents informed that his cry was delayed at birth and suctioning was done. The baby could not accept mother's feed; therefore, enteral feeds were started with diluted cow's milk using an unsterile cotton swab. On day three, he developed fever for which he was treated with oral cefaclor. The baby's condition continued to deteriorate and on 6 th day of life, he was brought to paediatric emergency of our hospital.

On examination, baby had facial grimace, occasional tonic posturing and shrilled cry. Mild icterus and subtle seizures were noted. He weighed 3.15 kg; heart rate and respiratory rate were increased, temperature was 100°F. Systemic examination revealed distended abdomen, but no organomegaly. There was a large cephalhematoma, anterior fontanelle was normal and no sutural diastasis was seen. Tone was slightly increased, neonatal reflexes including sucking and rooting were sluggish, but deep tender reflexes were normal. In light of the above findings a provisional diagnosis of 'late onset neonatal sepsis with meningitis' was made and treatment was initiated with parenteral cefotaxime and amikacin in anti-meningitic doses.

Investigations revealed mild thrombocytopenia, hyperbilirubinemia and raised C-reactive protein; haemoglobin, leukocyte count and blood sugar were normal. CSF cell count was 270/mm 3 with 90% lymphocytes and 10% polymorphs, protein was 195 mg% and sugar 13 mg%. Gram stain of centrifuged CSF deposit showed pus cells with faint staining Gram-negative bacilli, mostly extracellular [Figure 1]. CSF culture showed pure growth of Gram-negative organisms (>10 5 CFU/ml) after overnight incubation at 37°C on blood agar, chocolate agar and MacConkey agar. The colonies were non haemolytic, non-lactose fermenter, non-pigmented 1-2 mm size and easily emulsifiable. The bacilli were actively motile; catalase and oxidase positive, therefore presumptively identified as Pseudomonas spp. Conventional biochemical reactions showed positive results for urease hydrolysis, citrate production and nitrate reduction while indole test was negative, hydrogen sulphide was not produced and sugars (glucose, lactose, sucrose) were not fermented. Gram-negative panel was also set up (N34 panel, Dade Behring Microscan Autoscan-4, Siemens, 2007) for identification and antimicrobial susceptibility testing. The isolate was identified as R. paucula (listed in its software) with 99.99% probability. The paediatric Bactec blood culture also signalled positive and on subculture, similar growth was obtained with identical biotype and antibiograms [Figure 2]. The panels were read manually also and compared with biochemical reactions mentioned in the literature. [3] Molecular analysis of the isolate could not be done. The isolates were susceptible to ceftazidime, levofloxacin, co-trimoxazole, amoxicillin/clavulanic acid, piperacillin/tazobactam, ticarcillin/clavulanic acid, imipenem and meropenem; intermediate susceptible to ciprofloxacin; resistant to amikacin, gentamicin, tobramycin, ceftriaxone, cefotaxime, aztreonam and tetracycline (determined by Minimum inhibitory concentration in μg/ml). Final diagnosis of 'R. paucula septicemia with Ralstonia paucula meningitis was made. Antibiotic therapy was changed to injection ceftazidime (150 mg/kg/day in two divided doses) and steroids were not given. Defervescence was observed after 4 days and repeat blood culture was sterile. The baby started accepting mother's feed, his cry improved; he depicted age-appropriate activities and was discharged in stable condition after 3 weeks.
Figure 1: Gram‑negative bacilli with necrotic cells in centrifuged cerebrospinal fluid deposit

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Figure 2: Gram‑negative panel (Dade Behring) showing biochemical reactions and antimicrobial susceptibility of the test isolate

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Epidemiological investigations were done to rule out transmission. Mother's blood, urine and breast milk cultures were sterile; they were done to rule out vertical transmission as she had given history of fever and urinary tract infection in second trimester. She also revealed that for enteral feeding, diluted cow's milk was used. It was boiled and stored in plastic bottle at room temperature till further use. Therefore, cow's milk, water used for dilution and a sample of cotton swab were also cultured. All these samples showed growth of different types of bacteria, but none was identified as Ralstonia paucula. Though the exact source of this infection could not be identified, it was thought to have possibly resulted from environmental contamination during feeding. The importance of hand and environmental hygiene was explained to the parents.


 ~ Discussion Top


Ralstonia paucula belongs to genus 'Ralstonia', named in honour of an American bacteriologist; E. Ralston and species 'paucula' to indicate that these strains only rarely cause human infections. It was initially known as CDC group IV c-2 organism, [4] later genus Wautersia was introduced to include species of Ralstonia, which were carbohydrate non fermenters, colistin (10 μg) susceptible and motile by peritrichous flagella. However, after 16S rRNA gene sequencing, it has finally been placed in the genus Cupriavidus, species pauculus.

These are environmental bacteria which may be found in soil, water or on plants. It has been implicated in pseudo-outbreaks of skin and superficial site infections [1] and bacteremia. [2] Nosocomial transmission is ruled out in this case as patient was admitted with features of septicemia and meningitis. Contamination in laboratory is also not possible since both CSF and blood samples were received in sterile containers; gram stain of CSF was suggestive of bacterial infection, CSF count of this organism was high [5] and Ralstonia was not isolated from any other samples. This infection appears to have either been community acquired; through oral route, as indicated by the feeding history or acquired during suctioning at birth as Ralstonia has been frequently isolated from indwelling devices.

Cephalhematoma was present, which could have formed during prolonged delivery. In this case, concomitantly positive CSF and blood cultures have supported its role as a pathogen. Patient was successfully treated with ceftazidime, the only third generation cephalosporin to which it was sensitive. Though, validated methods of antimicrobial susceptibility test and treatment guidelines are lacking for Cupriavidus, results were inferred on the basis of lowest MIC values showing no growth. Few reports have cited dual antibiotic therapy for this organism, in other cases cure has been achieved by a third generation cephalosporin or carbapenem [Table 1].
Table 1: Chart review of CDC group IV c‑2/Ralstonia paucula/Cupriavidus pauculus infections identified world‑wide (chronological order)

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Case reports on this organism are limited, including cases of bacteremia, peritonitis, pneumonia, tenosynovitis [Table 1]. This organism has never been implicated as a causative agent of meningitis before. Also, this is the first case reporting its isolation from India. This case highlights the fact that these organisms can cause community acquired infections, which can be completely cured if identified and treated appropriately. Therefore, initial effort should be to prevent spread of these organisms, but if infection occurs, it should be promptly identified, treated and tracked to prevent further spread.[25]

 
 ~ References Top

1.Balada-Llasat JM, Elkins C, Swyers L, Bannerman T, Pancholi P. Pseudo-outbreak of Cupriavidus pauculus infection at an outpatient clinic related to rinsing culturette swabs in tap water. J Clin Microbiol 2010; 48:2645-7.  Back to cited text no. 1
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2.Romano-Mazzotti L, Alcántar-Curiel MD, Silva-Mendez M, Olivar-López V, Santos-Preciado JI, Alpuche-Aranda CM. Outbreak of Ralstonia paucula pseudobacteraemia in a paediatric accident and emergency department. J Hosp Infect 2011;78:155-6.  Back to cited text no. 2
    
3.Forbes BA, Sahm DF, Weissfield AS. Pseudomonas, Burkholderia, and similar organisms. In: Bailey and Scott's Diagnostic Microbiology. 11 th ed. USA: Mosby; 2002. p. 385-98.  Back to cited text no. 3
    
4.Vandamme P, Coenye T. Taxonomy of the genus Cupriavidus: A tale of lost and found. Int J Syst Evol Microbiol 2004;54:2285-9.  Back to cited text no. 4
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5.Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004;39:1267-84.  Back to cited text no. 5
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6.Hansen W, Glupczynski PD. Group IV c-2 associated peritonitis. Clin Microbiol Newsl 1985;7:43-4.  Back to cited text no. 6
    
7.Dan M, Berger SA, Aderka D, Levo Y. Septicemia caused by the gram-negative bacterium CDC IV c-2 in an immunocompromised human. J Clin Microbiol 1986;23:803.  Back to cited text no. 7
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10.Arduino S, Villar H, Veron MT, Koziner B, Dictar M. CDC group IV c-2 as a cause of catheter-related sepsis in an immunocompromised patient. Clin Infect Dis 1993;17:512-3.  Back to cited text no. 10
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11.Ramos JM, Soriano F, Bernacer M, Esteban J, Zapardiel J. Infection caused by the nonfermentative gram-negative bacillus CDC group IV c-2: Case report and literature review. Eur J Clin Microbiol Infect Dis 1993;12:456-8.  Back to cited text no. 11
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15.Arance A, Montes A, Cisnal M, Mesía R, Falo C, García del Muro J, et al. CDC group IV c-2 infection in a stem cell transplant recipient. Bone Marrow Transplant 1997;20:1005-6.  Back to cited text no. 15
    
16.Martino R, Pericas R, Romero P, Sierra J. CDC group IV c-2 bacteremia in stem cell transplant recipients. Bone Marrow Transplant 1998;22:401-2.  Back to cited text no. 16
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17.Salar A, Carratalà J, Zurita A, González-Barca E, Grañena A. Bacteremia caused by CDC group IV c-2 in a patient with acute leukemia. Haematologica 1998;83:670-2.  Back to cited text no. 17
    
18.Noyola DE, Edwards MS. Bacteremia with CDC group IV c-2 in an immunocompetent infant. Clin Infect Dis 1999;29:1572.  Back to cited text no. 18
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19.Thayu M, Baltimore RS, Sleight BJ, Reyes-Mugica M, Hotez PJ. CDC group IV c-2 bacteremia in a child with recurrent acute monoblastic leukemia. Pediatr Infect Dis J 1999;18:397-8.  Back to cited text no. 19
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20.Vay C, García S, Alperovich G, Almuzara M, Lasala M, Famiglietti A. Bacteremia due to Cupriavidus pauculus (formerly CDC group IVc-2) in a hemodialysis patient. Clin Microbiol Newsl 2007;29:30-2.  Back to cited text no. 20
    
21.Kim DS, Choi HW, Shin JW, Moon SW, Kim JS, Lee JW. A case of corneal ulcer caused by Ralstonia paucula infection. Korean J Ophthalmol 2007;48:445-8.  Back to cited text no. 21
    
22.Azcona-Gutiérrez JM, Buendía-Moreno B, Sáez-Nieto JA, López-Brea-Calvo M. Cupriavidus pauculus isolation in the intensive care unit. Enferm Infecc Microbiol Clin 2008;26:397-8.  Back to cited text no. 22
    
23.Taþbakan MS, Yamazhan T, Aydemir S, Bacakoðlu F. A case of ventilator-associated pneumonia caused by Cupriavidus pauculus. Mikrobiyol Bul 2010;44:127-31.  Back to cited text no. 23
    
24.Stovall SH, Wisdom C, McKamie W, Ware W, Dedman H, Fiser RT. Nosocomial transmission of Cupriavidus pauculus during extracorporeal membrane oxygenation. ASAIO J 2010;56:486-7.  Back to cited text no. 24
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25.Aydýn B, Dilli D, Zenciroðlu A, Okumuþ N, Ozkan S, Tanýr G. A case of newborn with community acquired pneumonia caused by Cupriavidus pauculus . Tuberk Toraks 2012;60:160-2.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]

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