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 ~ Case Report
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  Table of Contents  
Year : 2014  |  Volume : 32  |  Issue : 4  |  Page : 451-454

Sphingomonas paucimobilis bacteraemia and shock in a patient with rheumatic carditis

1 Department of Pediatric Cardiology, Izmir Dr. Behcet Uz Children's Hospital, İzmir, Turkey
2 Department of Microbiology, Izmir Dr. Behcet Uz Children's Hospital, İzmir, Turkey

Date of Submission03-Oct-2013
Date of Acceptance31-Jan-2014
Date of Web Publication4-Oct-2014

Correspondence Address:
Y Yozgat
Department of Pediatric Cardiology, Izmir Dr. Behcet Uz Children's Hospital, İzmir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.142253

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 ~ Abstract 

Acute rheumatic fever (ARF) carditis is treated with steroids, which can cause changes in the cellular immune response, especially decreased CD3 (+) T cells. Nosocomial infections due to steroid use for treatment of ARF carditis or secondary to the changes in the cellular immune response have not been reported in the literature. Sphingomonas paucimobilis is a Gram-negative bacillus causing community- and hospital-acquired infections. It has been reported as causing bacteraemia/sepsis, pneumonia or peritonitis in patients with malignancies, immunosuppression or diabetes. We present a case with S. paucimobilis bacteraemia/sepsis and shock after administration of steroids for treatment of ARF carditis. We suggest early identification of the causative agent and appropriate adjustments of the treatment plan to avoid shock and possible mortality. This is the first reported case of S. paucimobilis bacteraemia/sepsis in the setting of steroid use for ARF carditis.

Keywords: Acute rheumatic fever, bacteraemia, shock, Sphingomonas paucimobilis

How to cite this article:
Yozgat Y, Kilic A, Karadeniz C, Ozdemir R, Doksoz O, Gulfidan G, Mese T. Sphingomonas paucimobilis bacteraemia and shock in a patient with rheumatic carditis . Indian J Med Microbiol 2014;32:451-4

How to cite this URL:
Yozgat Y, Kilic A, Karadeniz C, Ozdemir R, Doksoz O, Gulfidan G, Mese T. Sphingomonas paucimobilis bacteraemia and shock in a patient with rheumatic carditis . Indian J Med Microbiol [serial online] 2014 [cited 2020 Nov 30];32:451-4. Available from:

 ~ Introduction Top

Acute rheumatic fever (ARF) is a multisystemic disorder seen after group A streptococcal pharyngitis, which is frequently encountered in children and adolescents between the ages of 5 and 15. ARF carditis has been reported in 35-50% of patients with ARF. [1] In cases with ARF, changes in cellular immune response, especially decreased quantities of CD3 (+) T cells, have been reported. Nosocomial infections secondary to steroid use during treatment of ARF carditis or changes in the cellular immune response have not yet been reported.

Sphingomonas paucimobilis (formerly referred to as Pseudomonas paucimobilis) is a yellow pigment-forming, aerobic, non-fermentative, non-spore-forming, oxidase and catalase-positive Gram-negative bacillus. [2] The bacterium is commonly found in nature, particularly in soil and drinking water and on the surface of plants; in the hospitals it has been isolated in haemodialysis instruments, humidifiers, water containers, distilled water tanks, basins and thermometer probes. [3]

S. paucimobilis has recently gained importance in terms of hospital-acquired infections, being associated with bacteraemia/sepsis, pneumonia or peritonitis in patients with malignancies, immunosuppression or diabetes. [4] However, S. paucimobilis bacteraemia/sepsis in patients with ARF have not yet been reported.

We present a case diagnosed with bacteraemia of S. paucimobilis and shock developing in the presence of ARF carditis with CD3 (+) T-cell reduction. To the best of our knowledge, this is the first such report in the literature.

 ~ Case Report Top

A 13-year-old female patient was admitted with complaints of sore throat, mild fever, malaise and fatigue. She was in good general condition, conscious, cooperative and mildly dehydrated. Body temperature was 37.7°C, pulse rate 124 beats per minute, blood pressure 105/60 mmHg and respiratory rate 18 per minute. History revealed a severe episode of pneumonia and pleurisy requiring chest tube insertion, prolonged hospitalisation and intravenous antibiotics a year ago. The causative agent had not been identified and treated empirically with vancomycin and ceftriaxone. Electrocardiography was normal. Mild mediastinal expansion and cardiomegaly was observed on chest X-ray [Figure 1]. Echocardiography showed an ejection fraction of 68%, fractional shortening 34%, second-degree mitral and tricuspid regurgitation, mild aortic and pulmonic regurgitation. Pericardial echogenicity was increased with moderate fluid accumulation [Figure 2]. Biochemical analyses were as follows: White blood cell: 10700/mm 3 , haemoglobin: 9.7 g/dl, MCV: 80 fl, platelet: 491.000/mm 3 , ESR: 117 mm/h, CRP: 11.8 mg/dl and ASO: 769.00 IU/ml. Differential count showed 88% polymorphonuclear leukocytes, 10% lymphocytes and 2% monocytes; there were no atypical cells. Blood glucose, liver and kidney function tests, electrolytes, uric acid, LDH and lipid levels were normal, as were blood gas analysis, cardiac panel, ANA, anti-dsDNA,  Salmonella More Details and  Brucella More Details group agglutination tests and ferritin levels. Urinalysis was unremarkable. Three consecutive blood samples were obtained hourly for culture.
Figure 1: Posteroanterior chest X-ray showing mild cardiomegaly and mediastinal expansion

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Figure 2: Echocardiography showing second-degree mitral regurgitation and pericardial effusion of 10 mm around left ventricle

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As the patient had one major (carditis) and two minor criteria (elevated ESR, CRP and temperature) along with ASO elevation, a diagnosis of ARF carditis and pericardial effusion was made. For primary eradication of GAS, 1.200.000 units of benzathine penicillin were administered intramuscularly. As she was hypotensive, dopamine (5 mcg/kg/min), spironolactone (2 mg/kg/day), prednisolone (2 mg/kg/day) and ceftriaxone (75 mg/kg/day) were added.

On the third day of hospitalisation, her general condition suddenly deteriorated into a clinical picture of shock. The treatment plan was modified to include dopamine, dobutamine, norepinephrine and fluids.

In the fourth day, the general condition of the patient was slightly better. Gram-negative bacilli were isolated from all of the blood cultures taken at the time of admission.

S. paucimobilis was detected with standard aerobic and anaerobic blood culture media in automated blood culture systems (BacT/ALERT PF Plus, bioMérieux, France). Identification and antibiotic susceptibility testing of the isolate were done with the VITEK 2 Compact system (bioMérieux, France). The results were interpreted using Clinical and Laboratory Standards Institute (CLSI) standards. Sensitivity results were reported as sensitive or resistant based on CLSI criteria. The strain was found to be resistant to gentamicin, amikacin, sulbactam + ampicillin and sensitive to meropenem, ceftazidime and piperacillin. Accordingly, ceftriaxone was withdrawn and meropenem 60 mg/day was started. Immunoglobulins and lymphocyte panel were studied. As the percentage of CD3 (+) T cells were lower [Table 1], CD3 TRC complex chain was considered to be defective and 0.4 g/kg intravenous immunoglobulin was given.
Table 1: The percentages of CD3, CD4, CD8 T cells, CD4/CD8 T cell ratios and CD19 B cells in the patient

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The clinical status and biochemical analyses gradually improved after the fifth day; ESR dropped to 60 mm/h and CRP to 1.63 mg/dl. Control blood cultures were reported negative. She was discharged after 10 days of hospital stay with usual ARF outpatient treatment plan with oral prednisolone and subsequent acetyl salicylic acid. Three months after the discharge, her general condition was good, percentage of CD3 (+) T cells were normal, minimal aortic and mitral regurgitation was detected with echocardiography.

 ~ Discussion Top

Patients with ARF carditis are treated with steroids and subsequent acetyl salicylic acid. Changes in the cellular immune response, especially CD3 (+) T-cell reduction, have been reported in patients with ARF. [5] Our case was given steroids for severe ARF carditis and reduced numbers of CD3 (+) T-cell reduction was identified.

S. paucimobilis is an aerobic, non-fermentative Gram-negative bacillus with slow motility found commonly in nature, particularly in soil and drinking water. In the hospitals, it has been isolated in haemodialysis instruments, humidifiers, basins and thermometer probes. [2],[3] In a meta-analysis published by Ryan and Adley, bacteraemia/sepsis and peritonitis were reported as the most common clinical forms. [6]

The origin of nosocomial S. paucimobilis infection may be endogenous (colonisation secondary to the previous infection) or environmental (catheters, infected distilled water, haemodialysis fluids). [7] The fact that all of the blood samples obtained at admission was positive for S. paucimobilis in our case makes us consider that the organism had been endogenous, possibly secondary to pleurisy and chest tube insertion a year ago.

In another review of 16 cases of S. paucimobilis bacteraemia, the underlying diseases were reported as diabetes in 11.9%, immunosuppressive therapy in 40.5% and Malignancy in 57.1% of cases. [4] In our case, we consider that S. paucimobilis was present due to the previous pleural infection, and the suppression was removed with the steroid therapy causing CD3 (+) T-cell reduction leading to bacteraemia and shock.

S. paucimobilis is a bacterium with low virulence and a rare cause for life-threatening infections, possibly due to the lack of lipopolysaccharides in the cell wall, rendering it resistant to the effects of endotoxins. [8] S. paucimobilis is generally sensitive to imipenem, tetracycline, chloramphenicol, cotrimoxazole and carbapenem and aminoglycosides. Its sensitivity to third-generation cephalosporins and quinolones is variable. [9] Our case initially developed shock, but rapidly improved after the administration of meropenem.

To the best of our knowledge, this is the first case of coexisting ARF carditis, S. paucimobilis bacteraemia/sepsis and shock reported in the literature. In patients with ARF carditis, S. paucimobilis bacteraemia should be considered when sepsis and shock develop during corticosteroid therapy and antibiotic sensitivity should be assessed for appropriate treatment.

 ~ References Top

1.Stollerman GH. Rheumatic fever. Lancet 1997;349:935-42.  Back to cited text no. 1
2.Yabuuchi E, Yano I, Oyaizu H, Hashimoto Y, Ezaki T, Yammoto H. Proposals of Sphingomonas paucimobilis gen. nov. and comb. nov., Sphingomonas parapaucimobilis sp. nov., Sphingomonas yanoikuyae sp. nov., Sphingomonas adhaesiva sp. nov., Sphingomonas capsulata comb. nov., and two genospecies of the genus Sphingomonas. Microbiol Immunol 1990;34:99-119.  Back to cited text no. 2
3.Reina J, Bassa A, Llompart I, Portela D, Borrell N. Infections with Pseudomonas paucimobilis: Report of four cases and review. Rev Infect Dis 1991;13:1072-6.  Back to cited text no. 3
4.Lin JN, Lai CH, Chen YH, Lin HL, Huang CK, Chen WF, et al. Sphingomonas paucimobilis bacteremia in humans: 16 case reports and a literature review. J Microbiol Immunol Infect 2010;43:35-42.  Back to cited text no. 4
5.Zedan MM, el-Shennawy FA, Abou-Bakr HM, al-Basousy AM. Interleukin-2 in relation to T cell subpopulations in rheumatic heart disease. Arch Dis Child 1992;67:1373-5.  Back to cited text no. 5
6.Ryan MP, Adley CC. Sphingomonas paucimobilis: A persistent gram-negative nosocomial infectious organism. J Hosp Infect 2010;75:153-7.  Back to cited text no. 6
7.Holmes B, Owen RJ, Evans A, Malnick H, Willcox WR. Pseudomonas paucimobilis, a new species isolated from human clinical specimens, the hospital environment, and other sources. Int J Syst Bacteriol 1977;27:133-46.  Back to cited text no. 7
8.Kawasaki S, Moriguchi R, Sekiya K, Nakai T, Ono E, Kume K, et al. The cell envelope structure of the lipopolysaccharide-lacking gram-negative bacterium Sphingomonas paucimobilis. J Bacteriol 1994;176:284-90.  Back to cited text no. 8
9.Kuo IC, Lu PL, Lin WR, Lin CY, Chang YW, Chen TC, et al. Sphingomonas paucimobilis bacteraemia and septic arthritis in a diabetic patient presenting with septic pulmonary emboli. J Med Microbiol 2009;58:1259-63.  Back to cited text no. 9


  [Figure 1], [Figure 2]

  [Table 1]

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1 Prednisolone
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