plesiomonas shigelloides septicemia and meningitis in a...
TRANSCRIPT
Plesiomonas shigelloidessepticemia and meningitis
in a neonate
JULIAN D EASON MBBS MRCP (UK), DONLIM PEACOCK MBCHB FRCPC
Plesiomonas shigelloides was originally isolated in 1947 by
Ferguson and Henderson (1) who noted certain antigenic
similarities between it and Shigella. The organism was desig-
nated C27 and considered a member of the family Enterobacte-
riaceae. It was later called Aeromonas. The genus Plesiomonas
currently resides in the family Vibrionaceae. P shigelloides is a
facultatively anaerobic, Gram-negative, oxidase-positive, motile
rod. It is readily isolated on enteric media as a lactose nonfer-
menter. The primary natural reservoirs are soil, surface water
and fish, especially shellfish such as oysters (2). Infections
with P shigelloides often cause gastroenteritis, but it has been
associated with septicemia, cellulitis, arthritis, cholecystitis,
osteomyelitis and meningitis (3,4). Most infections with this
organism have been described in Japan (where a great deal of
shellfish is eaten), in the Indian subcontinent and in Africa.
The vast majority of Caucasians infected with this bacterium
have been travellers to high risk areas or those who have
recently eaten raw shellfish. A case of P shigelloides sepsis in
a neonate with complications of endophthalmitis and multifo-
cal intracerebral abscesses is described. To the best of our
knowledge this is the first reported case of neonatal P shigel-
loides infection in Canada.
CASE PRESENTATIONA male was born to a healthy mother whose membranes
were artificially ruptured 16 h before delivery. Delivery was
induced at 36 weeks because of a previous intrauterine death
at 38 weeks. The Apgar scores were 8 at 1 min and 9 at 5 mins,
and the baby weighed 3410 g (90th percentile).
The mother had intermittent diarrhea throughout her preg-
CASE REPORT
Special Care Nursery, British Columbia’s Children’s Hospital, Vancouver, British Columbia
Correspondence: Dr Julian D Eason, Department of Paediatrics, Jersey General Hospital, St Helier, Jersey JE3 1LD. Telephone 01 534 59000,
fax 01534 59805, e-mail [email protected]
Received for publication January 22, 1996. Accepted May 24, 1996
JD EASON, D PEACOCK. Plesiomonas shigelloides septicemia and meningitis in a neonate. Can J Infect Dis1996;7(6):380-382. A newborn infant is described who presented with septicemia and meningoencephalitis caused by
Plesiomonas shigelloides, a Gram-negative rod belonging to the family Vibrionaceae. This appears to be the firstdocumented case in a neonate in Canada. Despite prompt treatment with appropriate antibiotics, he developed
endophthalmitis and lytic brain lesions.
Key Words: Endophthalmitis, Meningitis, Neonate, Plesiomonas shigelloides
Septicémie et méningite à Plesiomonas shigelloides chez un nouveau-né
RÉSUMÉ : On décrit ici le cas d’un nouveau-né atteint de septicémie et de méningite à Plesiomonas shigelloides, bacille
gram-négatif appartenant au genre Vibrio. Il s’agirait du premier cas documenté d’infection de ce type au Canada. Malgré
l’instauration rapide de l’antibiothérapie nécessaire, l’enfant a développé une endophtalmie et des lésions cérébraleslytiques.
380 CAN J INFECT DIS VOL 7 NO 6 NOVEMBER/DECEMBER 1996
EASON.CHPMon Dec 02 16:24:46 1996
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nancy that was attributed to iron prescribed for anemia. Two
weeks before the induction of labour following a regular sushi
dinner, her diarrhea became worse, and she required intrave-
nous rehydration in an emergency room. This worsening of the
diarrhea lasted for 10 days. At that time the iron was still
thought to be the cause of the bowel problems.
During the first day of life, the baby was a little restless and
fed poorly. At 24 h of age he was febrile at 37.7°C, with a
vasculitic type rash on his back. A blood culture and complete
blood count were taken, and treatment started with intravenous
ampicillin (100 mg/kg/day) and gentamicin (5 mg/kg/day). The
total leukocyte count was 6.69×109/L with 0.97×109/L granu-
locytes and 0.25 bands with a platelet count of 192×109/L.
Within an hour he became irritable and hypertonic. A lumbar
puncture was performed to complete the sepsis work-up. Cefo-
taxime (150 mg/kg/day) treatment was commenced immediately
after the cerebrospinal fluid (CSF) was taken. CSF contained
6600×106/L leukocytes (97% granulocytes), 2600×106/L red
blood cells and a protein concentration of 2.92g/L. CSF Gram
stain showed abundant Gram-negative rods. A repeat blood
count at that time revealed progressive neutropenia and throm-
bocytopenia (21×109/L). A Gram-negative bacterium with coli-
form morphology was detected in a blood culture (Bactec 9240
medium, Becton Dickinson Diagnostic Instruments Systems,
Maryland). In addition CSF yielded the same bacterium, which
was oxidase-positive. The organism was presumptively iden-
tified as P shigelloides on the basis of a biochemical assess-
ment with a replica plating technique. Further assessment
with the API 20E identification system (Bio Mérieux, Missouri)
confirmed the speciation. Susceptibility to cefotaxime, ceftriax-
one, cotrimoxazole and gentamicin was established, with re-
sistance to ampicillin. Treatment was continued with
cefotaxime and gentamicin. A fecal culture taken from the
mother three days postpartum failed to grow any pathogens,
and this assessment included a direct search for P shigel-
loides.
At 26 h of age the baby had repeated seizure activity and
required treatment with phenobarbitone, phenytoin and loraz-
epam. Mechanical ventilation was required. Clinical examina-
tion of the pupils revealed a white opacity on the right side.
Ophthalmic examination the following day confirmed the
presence of endophthalmitis with purulent exudate coating
the anterior of the lens and iris. A cranial ultrasound on day 2
revealed multiple focal areas of increased echogenicity in the
frontal lobes and cerebellar folia. Subsequent computed to-
mography (CT) scans on day 4 revealed white matter edema,
and on day 21 revealed multifocal intracerebral cystic and
solid lesions (Figure 1). At one month of age a ventriculoperi-
toneal shunt was inserted for relief of obstructive hydrocepha-
lus, and a 5×5 cm frontal lobe abscess was drained. Micro-
scopic examination of the abscess material demonstrated
necrotic brain tissue. No bacteria were seen, and subsequently
there was no growth on culture. Antibiotic treatment was
continued for a total of six weeks. The child survived to
discharge at the age of two months with signs of severe neuro-
logical damage. Ophthalmic infection resolved, but examina-
tion at three months revealed a vitreous condensation over the
optic nerve head.
Figure 1) Computed tomogram of the cranium: large frontal and multifocal intracerebral abscesses in a neonate infected with Plesimonas shigelloides
CAN J INFECT DIS VOL 7 NO 6 NOVEMBER/DECEMBER 1996 381
P shigelloides septicemia and meningitis
EASON.CHPMon Dec 02 16:24:54 1996
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DISCUSSIONPlesiomonas is a rare cause of neonatal sepsis and menin-
gitis with high morbidity and mortality. To the best of our
knowledge only 10 other cases have been reported (4-13). The
probable source of infection in this case was the intestinal
infection of the mother. The baby acquired the organism peri-
natally rather than in utero, given the time of onset of symp-
toms. This neonate never had diarrhea. Plesiomonas infection
causing gastroenteritis in adults is well described and is usu-
ally a self-limiting diarrheal illness (14). A total of 24 such
cases were reported in British Columbia in 1994 (15).
P shigelloides may be resistant to ampicillin but is uni-
formly susceptible to third-generation cephalosporins, particu-
larly cefotaxime (10,11,16). Five of the 10 previously described
cases received cefotaxime as one of their antibiotics; four
survived and three had no sequelae. Among the five patients
who did not receive cefotaxime, there was only one survivor,
a child who was treated with penicillin G and gentamicin and
suffered no sequelae (7). The others received either a combi-
nation of ampicillin and an aminoglycoside, or rifampicin.
P shigelloides in the present case was resistant to ampicillin.
Cefotaxime was added as soon as meningitis was sus-
pected.
Endophthalmitis caused by P shigelloides was previously
described in one case, but it was acquired with a penetrating
fishhook injury and necessitated enucleation (17). It seems
that this is a most unusual localization of neonatal bacterial
infection, but it is consistent with a high bacterial load in the
bloodstream, as indicated by the early onset of vasculitic rash
and thrombocytopenia in the present case. Infection resolved
without intraocular administration of antibiotics. Brain ab-
scesses are an unusual complication of meningitis and multi-
ple abscesses even more so. We attributed this complication to
vasculitis leading to thrombosis and cerebral infarction (18).
Gram-negative organisms most often cause necrotizing cere-
britis and abscesses, particularly Proteus, Escherichia and
Citrobacter species (18,19). Necrotizing ependymitis and the
subsequent formation of synechiae are thought to account for
noncommunicating hydrocephalus and the formation of mul-
tiloculated intraventricular cysts seen in this patient.
For an organism that is often described as a sporadic cause
of a self-limiting diarrheal illness, plesiomonas must be re-
garded as highly virulent in the neonate.
ACKNOWLEDGEMENTS: We thank Dr David Scheifele and Dr Nevio
Cimolai for their help in compiling this report.
REFERENCES1. Ferguson WW, Henderson ND. Description of strain C27: A
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2. Scholfield G. Emerging food-borne pathogens and theirsignificance in chilled foods. J Appl Bacteriol 1992;72:267-73.
3. Zeaur R, Akbar A, Bradford AK. Prevalence of Plesiomonasshigelloides among diarrhoeal patients in Bangladesh.Eur J Epidemiol 1992;8:753-6.
4. Fujita K, Shirai M, Ishioka T, Kakuya F. Neonatal Plesiomonasshigelloides septicaemia and meningitis: A case review. ActaPaediatr Jpn 1994;36:450-2.
5. Appelbaum PC, Bowen AJ, Adhikari M, et al. Neonatal septicemiaand meningitis due to Aeromonas shigelloides. J Pediatr1978;92:676-7.
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9. Pathak A, Custer JR, Levy J. Neonatal septicemia and meningitisdue to Plesiomonas shigelloides. Pediatrics 1983;71:389-91.
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11. Waeker NJ, Davis CE, Bernsrein G, Spector SA. Plesiomonasshigelloides septicemia and meningitis in a newborn. PediatrInfect Dis J 1988;7:877-9.
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13. Terpeluk C, Goldmann A, Bartmann P, Pohlandt F. Plesiomonasshigelloides sepsis and meningoencephalitis in a neonate.Eur J Pediatr 1992;151:499-501.
14. Brendan RA, Miller MA, Janda JM. Clinical disease spectrum andpathogenic factors associated with Plesiomonas shigelloidesinfections in humans. Rev Infect Dis 1988;10:303-16.
15. Annual Report of the Provincial Laboratory. Victoria: BC Centrefor Disease Control, 1994.
16. Kain KC, Kelly MT. Antimicrobial susceptibility of Plesiomonasshigelloides from patients with diarrhea. Antimicrob AgentsChemother 1989;33:1609-10.
17. Cohen KL, Holyk PR, McCarthy LR, Peiffer RL. Aeromonashydrophila and Plesiomonas shigelloides enopthalmitis.Am J Opthalmol 1983;96:403-4.
18. Brown LW, Zimmerman RA, Bilaniuk LT. Polycystic braindisease complicating neonatal meningitis: Documentation ofevolution by computed tomography. J Pediatr 1979;5:757-9.
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382 CAN J INFECT DIS VOL 7 NO 6 NOVEMBER/DECEMBER 1996
Eason and Peacock
EASON.CHPMon Dec 02 16:24:56 1996
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