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Year : 2015  |  Volume : 33  |  Issue : 2  |  Page : 305--307

Bordetella trematum bacteremia in an infant: A cause to look for

R Saksena1, V Manchanda1, M Mittal2,  
1 Clinical Microbiology and Infectious Diseases Division, Chacha Nehru Bal Chikitsalaya and Associated Maulana Azad Medical College, New Delhi, India
2 Department of Pediatric Medicine, Chacha Nehru Bal Chikitsalaya and Associated Maulana Azad Medical College, New Delhi, India

Correspondence Address:
V Manchanda
Clinical Microbiology and Infectious Diseases Division, Chacha Nehru Bal Chikitsalaya and Associated Maulana Azad Medical College, New Delhi
India

Abstract

Bordetella trematum spp. nov. has been isolated from wounds, ear infections and diabetic ulcers. We report a case of a 7-month-old infant with fever, vomiting and abnormal body movements with bacteremia caused by this novel species. The infant responded to fluoroquinolone and macrolide combination therapy.

How to cite this article:
Saksena R, Manchanda V, Mittal M. Bordetella trematum bacteremia in an infant: A cause to look for.Indian J Med Microbiol 2015;33:305-307

How to cite this URL:
Saksena R, Manchanda V, Mittal M. Bordetella trematum bacteremia in an infant: A cause to look for. Indian J Med Microbiol [serial online] 2015 [cited 2019 Sep 23 ];33:305-307
Available from: http://www.ijmm.org/text.asp?2015/33/2/305/154891

Full Text

 Introduction



The genus Bordetella contains seven species: B. pertussis, B. parapertussis, B. bronchiseptica, B. avium, B. hinzii, B. holmesii and B. trematum. [1] These species are isolated from both humans and other animals. The name Bordetella trematum spp. nov. (tre-ma'tum. Gr. neut. n. trema, referring to something pierced or penetrated, an aperture, or a gap; N. L. gen. pl. n. trematum, pertaining to penetrated or open things, referring to the presence of these bacteria in wounds and other exposed parts of the human body) was first proposed in 1996 after genotypic and phenotypic analysis of ten strains of atypical or unclassified bordetellae. [2] The taxonomic position was determined by deoxyribonucleic acid (DNA)-ribosomal ribonucleic acid (rRNA) hybridization experiments, which revealed the organism belonged to family Alcaligenaecae and was phylogenetically more closely related to type species of genus Bordetella (B. pertussis) than to type species of genus Alcaligenes (A. faecalis). These strains had been recovered from wounds and cases of chronic otitis media. Thereafter, two cases of Bordetella trematum isolated from diabetic ulcers have been reported. [3],[4] However, bacteremia with this bacterium has not been yet reported in literature. This is a first case of Bordetella trematum bacteremia.

 Case Report



We present a case of a 7-month-old female child who presented to the emergency department of with the chief complaints of fever for the past 12 days, vomiting for three days and abnormal movements of both hands for 2 days.

The child was apparently well 12 days prior to presenting to the emergency when she started having fever which was initially low grade but had become high grade and continuous since last 3 days. She had also started vomiting for the last three days, 3-4 times a day, just after feed. The vomitus contained milk particles only. She developed abnormal movements of both hands which were tonic clonic movements with no fast and slow components and subsided on their own on the last 2 days of illness. There was no history of altered sensorium but she had not been playing for the past 15 days. There was also history of crying during micturition and decreased quantity of urine. The child is the youngest of three siblings and there is no history of seizures, asthma or tuberculosis in the family. The child was fed exclusively on breast milk and no complex feeds had been given. At 7 months of age, the child could not sit with support but exhibited tripod sitting. She could recognize her mother but could not vocalise monosyllables. Thus, developmental delay was noted.

On examination, the child was 'sick looking'. She had severe pallor, brown nails and pigmentation of knuckles. Tremor-like movements of both hands was noted. Respiratory and cardiovascular systems were normal. Anterior fontanelle was not raised. Liver was firm and palpable 3 cm below costal margin. Spleen was non-palpable. Weight of the child was 5.1 kg, length was 67 cm and head circumference was 39 cm. A provisional diagnosis of infantile tremor syndrome with protein energy malnutrition with developmental delay was made. A complete blood count with peripheral smear and serum vitamin B12, folate and ferritin levels were ordered to investigate the anaemia. A blood culture was sent in a conventional blood culture bottle with brain heart infusion broth (Oxoid, UK). A computed tomography (CT) scan was also planned.

Empirical antimicrobial therapy with injection ceftriaxone 50 mg/kg in divided doses 12 hourly intravenous (i.v.) was initiated. Injection Vitamin B12 1000 mg i.m. once a day on alternate days for 4 days was prescribed and 50 ml of packed red blood cells (RBCs) was infused. Tablet propanalol 10 mg was prescribed for tremors.

A complete blood count showed that haemoglobin was 5.5 gm/dL, total leucocyte count was 4050 cells/cu. mm. with 89% lymphocytes, 8% neutrophils and 1% monocytes. The red blood count was 1.51 lakh/cu mm. The platelet count was 1.04 lakh/cu.mm. Mean cell volume (MCV) was 109.9 fl, mean cell hemoglobin (MCH) 34.4 pg, mean cell hemoglobin concentration (MCHC) 31.5% and red blood cell distribution width standard deviation (RDW-SD) 18.2. The reticulocyte count was 0.7%. Peripheral smear showed predominantly macrocytic cells with macro-ovalocytes, moderate anisopoikilocytosis and polychromasia. Few MCHC cells, fragmented cells and few fully haemoglobinized were seen. No malaria parasite was observed. Serum B12 levels were 173 pmol/L and serum folate was 18.42 nmol/L. Above findings confirmed megaloblastic anaemia. The initial blood culture was sterile after 48 hours of incubation. CT revealed marked cerebral atrophy with bilateral thin subdural hygroma in frontoparietal region.

On day 5 of ceftriaxone therapy, fever still persisted with a daily spike of 102°F. Tremors also persisted and the general condition of the child was stable but poor. Total leucocyte count was 4400 cells/mm 3 with 40% lymphocytes and 53% neutrophils. The patient developed severe thrombocytopenia with a platelet count of 12,000 cells/mm 3 . C-reactive protein was raised (108 mg/L). Total serum bilirubin was 0.67 mg/dl, serum glutamic oxaloacetic transaminase (SGOT) 132 IU/ml, serum glutamic pyruvic transaminase (SGPT) 122 IU/ml and serum alkaline phosphatase (ALP) was 132 IU/ml. In view of continuing fever, ensuing thrombocytopenia and raised liver enzymes, a repeat blood culture was sent in a Bactec blood culture vial and the antibiotic therapy was modified to combination i.v. therapy with piperacillin + tazobactam 300 mg/kg, 8 hourly and amikacin 7.5 mg/kg 12 hourly. I.v. ceftriaxone was discontinued. This time the blood culture was positive on the 3 rd day of incubation and revealed growth of gram negative, non-spore forming, motile bacilli with non-lactose fermenting colonies 1-2 mm in size, circular in shape, low convex, non-pigmented with entire edges on MacConkey agar. The organism was identified as Bordetella trematum by VITEK 2 system.   Confirmation by molecular method or in a reference laboratory is required for such uncommon causative agents causing human disease.

The treating physician was informed of the blood culture results on day 5 of piperacillin + tazobactam therapy and a repeat specimen was sought to confirm the culture findings. On day 12 of piperacillin + tazobactam therapy, patient continued to have fever (101°F) but the tremors had subsided. She also started having loose stools with a high purge rate. A repeat blood culture was sent in a BACTEC blood culture bottle and the therapy was modified to injection ciprofloxacin 30 mg, 8 hourly and syrup azithromycin as per published susceptibility profile of Bordetella. [5] The bacterium has been isolated from human ear infections cases and limb wounds. [2] However, this child did not have either of the two. Thus, source of infection could not be established in this case.

This blood culture was positive on 2 nd day of incubation. On subculture, it revealed colonies similar to the previous culture and was again identified as Bordetella trematum by Vitek 2 compact system. The antimicrobial susceptibility was determined using VITEK 2 system. Minimum inhibitory concentrations (MICs) for ciprofloxacin and piperacillin+tazobactam were also determined by E-test. The susceptibility pattern using interpretative criteria for other non-Enteriobacteriaceae gram negative as defined by Clinical and Laboratory Standards Institute (CLSI) was as follows [6] [Table 1]:{Table 1}

A blood culture received 2 days after the change in therapy was sterile. After 5 days of the above therapy, the patient improved clinically with resolution of fever and loose stools, was accepting feed well and was discharged with stable vitals.

 Discussion



To the best of our knowledge, bacteremia has not been previously reported due to Bordetella trematum. The non-responsiveness of the clinical condition of Bordetella trematum bacteremia to the commonly used broad spectrum first and second line antibiotics emphasizes the need for early identification of such cases and treatment with appropriate antimicrobial therapy. In our case, in view of deteriorating clinical condition despite treatment with broad spectrum first and second line antibiotics and known susceptibility pattern of Bordetella spp., combination of injectable ciprofloxacin and oral azithromycin were initiated which led to the microbiological and clinical cure of the patient.

Interestingly, although the isolate was susceptible to piperacillin + tazobactam in vitro by E-test but the patient did not improve even after 12 days of injectable piperacillin + tazobactam therapy. One of the possibility could be mismatch of in vitro and in vivo susceptibility, thus monitoring of other such strains is required before revisiting the breakpoints for piperacillin + tazobactam.

The comparison of susceptibility pattern with that of earlier reported case [4] showed no clear pattern as the strain isolated by us was resistant to ceftazidime, meropenem and aminoglycosides which was not reported earlier. The strain was susceptible to ciprofloxacin whereas the earlier resistance has been reported. Thus, overall susceptibility patterns and breakpoints should be explored and defined.

As the bacteria was isolated after 72 hours of incubation, longer incubation may be required for blood cultures than the usual 24-48 hours in order to increase the isolation of this organism. Infantile tremor syndrome was a co-morbid condition in this case. Thus, Bordetella trematum should be considered as a cause of prolonged fever especially in cases of pyrexia of unknown origin and further cases need to be studied to determine the risk factors and associated morbid conditions.

References

1Winn WC, Koneman EW, Allen SD, Procop GW, Janda WM, Schreckenberger PC, et al. Miscellaneous fastidious Gram-negative bacilli. Koneman's Color Atlas and Textbook of Diagnostic Microbiology. 6 th ed., Ch. 9. Philadelphia: Lippincott William and Wilkins; 2006. p. 510-7.
2Vandamme P, Heyndrickx M, Vancanneyt M, Hoste B, De Vos P, Falsen E, et al. Bordetella trematum sp. nov., isolated from wounds and ear infections in humans, and reassessment of Alcaligenes denitrificans Ruger and Tan 1983. Int J Syst Bacteriol 1996;46:849-58.
3Daxboek F, Goerzer E, Apfalter P, Nehr M, Krause R. Isolation of Bordetella trematum from a diabetic leg ulcer. Diabet Med 2004;21:1247-8.
4Hernández-Porto M, Cuervo M, Miguel-Gómez MA, Delgado T, Lecuona M. Diabetic leg ulcer colonized by Bordetella trematum. Rev Esp Quimioter 2013;26:72-3.
5Loeffelholz MJ, Sanden GN. Bordetella. In: Murray PR, Baron EJ, Jorgensen JH, Landry ML, Pfaller MA, editors. Manual of Clinical Microbiology. 9 th ed., Vol 1. Washington: ASM Press; 2007. p. 810.
6Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing, 23 rd Informational Supplement. Vol. 27. CLSI Document M100-S23. Wayne, PA: Clinical and Laboratory Standards Institute; 2013.