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  Table of Contents    
CASE REPORT  
Year : 2014  |  Volume : 57  |  Issue : 1  |  Page : 141-143
Blood stream infection by an emerging pathogen Oligella ureolytica in a cancer patient: Case report and review of literature


1 Department of Microbiology, Delhi State Cancer Institute, Dilshad Garden, Delhi, India
2 Department of Oncopathology, Delhi State Cancer Institute, Dilshad Garden, Delhi, India
3 Department of Clinical Oncology, Delhi State Cancer Institute, Dilshad Garden, Delhi, India

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Date of Web Publication17-Apr-2014
 

   Abstract 

Oligella ureolytica is an emerging bacteria rarely implicated as a human pathogen. It is infrequently recovered from clinical specimens probably because of inadequate processing of non-fermenting oxidase positive Gram negative bacilli. We present here a case of a 30 year old male suffering from right lung adenocarcinoma (moderately differentiated) with multiple abdominal lymph node metastasis with Syringohydromyelia whose blood culture yielded Oligella ureolytica in pure culture. Oligella ureolytica isolation in pure culture and the patient's response to targeted treatment supported that Oligella ureolytica was the true causative agent of the blood stream infection. Early suspicion, diagnosis and treatment with potent antibiotics are needed to prevent further complications resulting from infection with this emerging pathogen.

Keywords: Blood stream infections, Oligella ureolytica , immunocompromised

How to cite this article:
Baruah FK, Jain M, Lodha M, Grover RK. Blood stream infection by an emerging pathogen Oligella ureolytica in a cancer patient: Case report and review of literature. Indian J Pathol Microbiol 2014;57:141-3

How to cite this URL:
Baruah FK, Jain M, Lodha M, Grover RK. Blood stream infection by an emerging pathogen Oligella ureolytica in a cancer patient: Case report and review of literature. Indian J Pathol Microbiol [serial online] 2014 [cited 2019 Dec 7];57:141-3. Available from: http://www.ijpmonline.org/text.asp?2014/57/1/141/130928



   Introduction Top


Oligella ureolytica is an organism of low virulence and pathogenicity. The genus Oligella comprises of two species Oligella urethralis and Oligella ureolytica. Oligella ureolytica, known previously as CDC group IVe, is a Gram-negative, non-fermenting rod that is catalase and oxidase positive and is motile by peritrichous flagella. The rapidity of the urease reaction (within minutes after inoculation) is a distinctive feature. [1],[2]  Oligella urethralis Scientific Name Search  is a less common species. It differs from Oligella ureolytica in that it is nonmotile, urease-negative, does not convert nitrate to nitrite and is generally susceptible to most antibiotics including penicillin. [1]

We searched for relevant studies indexed in Pubmed and Google database for articles with words "Oligella ureolytica" and "Oligella-India". Based on available literature and to the best of our knowledge, we present the first case of blood stream infection caused by Oligella ureolytica in India.


   Case Report Top


The patient, a 30 year-old- male was admitted to our hospital with the chief complaints of abdominal distension, decreased urine output, inability to pass stool and flatus and headache for past five days. He was apparently well five days back when he developed abdominal distension and non passage of flatus and motion which was insidious in onset, gradually progressive, associated with multiple episodes of vomiting. No history of hematemesis, malena or passage of fresh blood in stool. Also no history of hematuria, increased frequency of urine or altered sensorium was given by the patient.

However he gives a positive history for incontinence of urine and stool, numbness and weakness in bilateral lower limbs along with seizures for the past two months. After two days of admission, the patient also developed fever.

The patient is a known case of right lung adenocarcinoma (moderately differentiated) with distant metastasis with Syringohydromyelia. No history of diabetes, hypertension, tuberculosis or past surgical intervention. He is a chronic bidi smoker, non alcoholic and non-vegetarian by diet.

On examination, the general condition was essentially normal except for increased body temperature and bilaterally enlarged axillary lymph nodes.The abdomen was grossly distended and bowel sounds decreased.

Hematological investigation revealed Hemoglobin: 10.9g/dl, total leukocyte count: 28.8 × 10 9 /L, platelet count: 68 × 10 9 /L, differential leukocyte count showed neutrophilic leucocytosis, serum total protein: 6.2g/dl, serum albumin: 3g/dl and serum globulin: 3.2g/dl. The chest X-ray showed right lung upper lobe opacity. CT guided FNAC and Endoscopic biopsy confirmed adenocarcinoma of the right lung. MRI of brain and spinal cord revealed multiple brain metastases with multiple site involvement. Venous Doppler of both lower limbs revealed chronic thrombus within bilateral femoral and popliteal veins, absence of blood flow in bilateral tibial veins and subcutaneous edema in left lower limb. A single blood culture sample was drawn and sent for culture due to the rising WBC count and high grade fever.

Blood culture was performed in BacT/Alert 3D (BioMe'rieux, Durham, North Carolina/USA). Ratio of blood to culture media volume was 1:10. Subcultures were performed in blood agar and MacConkey agar. After 48 hrs of incubation, non-lactose fermenting colonies in pure culture grew on MacConkey agar. On blood agar, the colonies were small, opaque and non-hemolytic. The organism was a Gram-negative bacillus which was oxidase-positive, nonfermentative and motile, and it rapidly hydrolysed urea. Identification of the isolate as Oligella ureolytia was confirmed by VITEK 2 compact system (BioMe'rieux, North Carolina/USA) with Gram negative GN REF21341 identification (GNID) card with 98% probability. By Kirby-Bauer disc diffusion method and following National Committee for Clinical Laboratory Standards guidelines, the organism was resistant to ampicillin, pipercillin, piperacillin/tazobactam, tobramycin, amikacin, ciprofloxacin, trimethoprim-sulfamethoxazole (TMP-SMX), ceftazidime, ceftriaxone and was susceptible to imipenem and meropenem. Urine and stool culture collected on this occasion remained negative.

The patient was empirically started on Injection (Inj.) ciprofloxacin 100 ml every 12 hourly intravenously (iv.) for 6 days, Inj. ceftriaxone 2 gm 12 hourly i.v. for 5 days, Inj. metronidazole 100 ml every 8 hourly i.v. for 5 days.However, the patient did not respond and continued to have fever and a rising WBC count. Inj. ceftriaxone was stopped on the 4 th day and Inj. amoxicillin and clavulanic acid 1.2 gm every 8 hourly i.v., and inj. meropenem 1 gm i.v. every 12 hourly were started. The patient became afebrile after three days and there was an improvement in his general condition too.


   Discussion Top


Oligella infection has rarely been reported in the literature. This may be due to misidentification of the organism or uncertainty of its pathogenicity. Oligella species have been implicated as a causative organism of urinary tract infection in patients with chronic indwelling catheters, found in the pleural fluid and decortication tissue of a child with chronic granulomatous disease and pneumonia. [2],[3] It has also been identified as a sporadic colonizer of respiratory tract in cystic fibrosis patients. [4] Baqi and Mazzuli reported isolation of Oligella ureolytica from cervical lymph node of a patient with Non-Hodgkin lymphoma. [5] According to literature, there are four reports of isolation of Oligella species from blood cultures as shown in [Table 1]. [6],[7],[8],[9]
Table 1: Reports of isolation of Oligella species from blood cultures

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In our lab, this organism is infrequently isolated and has never been isolated as a contaminant of blood culture bottles or any other sample. Oligella may be pathogenic in the face of malignancy as shown in the cases reported. [5],[6] Our patient's underlying lung adenocarcinoma with multiple abdominal lymph node involvement may have contributed to his infection. In the present case, Oligella ureolytica was the only organism isolated and the patient responded to targeted treatment, supporting that Oligella ureolytica was the true causative agent of the blood stream infection.

Infections due to Oligella appear to respond quickly to antibiotics. In the study by Baqi and Mazzulli, Rockhill and Lutwick and Manian, it was found that the isolate was susceptible to TMP-SMX. [5],[6],[7] However, Welch et al found that Oligella ureolytica was susceptible to aminoglycosides and cephalosporins but resistant to usual serum concentrations of ampicillin, chloramphenicol, erythromycin, penicillin G, tetracycline and TMP-SMX. [10] Lechner and Bruckner reported the isolate to be highly resistant to trimethoprim/sulfamethaxozole, imipenem, meropenem and ciprofloxacin. [8]

However, in vitro susceptibility testing may yield conflicting results. In this case, the organism was resistant to most antibiotics and was sensitive to imipenem and meropenem only by disc diffusion method. The condition of the patient improved following therapy with inj. amoxicillin/clavulanic acid and inj. meropenem. A second blood culture from the patient after a complete course of antibiotics remained sterile.

Almost all cases of Oligella ureolytica infection reported in the literature are from other countries. To the best of our knowledge, there has been no report from India. In conclusion, this case highlights the importance of Oligella ureolytica as a potential emerging pathogen, and utmost microbiological vigilance is required to identify this unusual agent of the disease. Early suspicion, diagnosis and treatment with potent antibiotics are needed to prevent further complications.

 
   References Top

1.Koneman EW. The nonfermentative gram-negative bacilli. In: Koneman EW, Allen SD, Janda WM, Schreckenberger PC, Winn WC, editors. Color Atlas and Textbook of Diagnostic Microbiology. 4 th ed. Philadelphia: JB Lippincott Co;1992. p. 215-7.  Back to cited text no. 1
    
2.McGowan JE Jr, Steinberg JP. Other gram-negative bacilli. In: Mandell GL, Douglas RG, Bennett JE, editors. Principles and Practice of Infectious Diseases. 4 th ed. New York: Churchill Livingstone;1995. p. 2106-17.  Back to cited text no. 2
    
3.Trotter JA, Kuhls TL, Pickett DA, Reyes de la Rocha S, WelchDF. Pneumonia caused by a newly recognized pseudomonad in a child with chronic granulomatous disease. J Clin Microbiol 1990;28:1120-4.  Back to cited text no. 3
    
4.Klinger JD, Thomassen MJ. Occurrence and antimicrobial susceptibility of gram-negative nonfermentative bacilli in cystic fibrosis patients. Diagn Microbiol Infect Dis1985;3:149-58.  Back to cited text no. 4
[PUBMED]    
5.Baqi M, Mazzulli T. Oligella infections: Case report and review of the literature. Can J Infect Dis1996;7:377-9.  Back to cited text no. 5
    
6.Rockhill RC, Lutwick LI. Group IVe-like gram-negative bacillemia in a patient with obstructive uropathy. J Clin Microbiol 1978;8: 108-9.  Back to cited text no. 6
[PUBMED]    
7.Manian FA. Bloodstream infection with Oligella ureolytica, Candida krusei, and Bacteroides species in a patient with AIDS. Clin Infect Dis 1993; 17:290-1.  Back to cited text no. 7
[PUBMED]    
8.Lechner A, Bruckner DA. Oligella ureolytica in Blood Culture: Contaminant or Infection? Eur J Clin Microbiol Infect Dis 2001; 20:142-3.  Back to cited text no. 8
    
9.Pugliese A, Pacris B, Schoch PE, Cunha BA. Oligella urethralis urosepsis. Clin Infect Dis 1993;17:1069-70.   Back to cited text no. 9
[PUBMED]    
10.Welch WD, Porschen RK, Luttrell B. Minimal inhibitory concentrations of 19 antimicrobial agents for 96 clinical isolates of group IVe bacteria. Antimicrob Agents Chemother 1983;24:432-3.  Back to cited text no. 10
[PUBMED]    

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Correspondence Address:
Frincy K Baruah
Department of Microbiology, Delhi State Cancer Institute, Dilshad Garden, Delhi - 110 095, H/N-160c, Pock-F, GTB Enclave, Nand Nagari, New Delhi - 110 093
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.130928

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    Tables

  [Table 1]

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