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  Table of Contents    
CASE REPORT  
Year : 2017  |  Volume : 60  |  Issue : 3  |  Page : 427-429
Nonpigmented strain of Chromobacterium violaceum causing neonatal septicemia: A rare case report


1 Department of Microbiology, Hi-Tech Medical College and Hospital, Rourkela, Odisha, India
2 Department of Microbiology, Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha, India
3 S.V.P. Post Graduate Institute of Paediatrics, Cuttack, Odisha, India

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Date of Web Publication22-Sep-2017
 

   Abstract 

Human infection caused by Chromobacterium violaceum is rare but has got high fatality in septicemia. Nonpigmented strains of C. violaceum have been found similar in pathogenicity to pigmented strains. Pigment production is not an exclusive character of the genus Chromobacterium because around 9%–11% strains of C. violaceum are nonpigmented. Herewith, we report a nonpigmented strain of C. violaceum from a case of neonatal septicemia that was successfully treated with gentamicin plus imipenem.

Keywords: Chromobacterium violaceum, neonatal septicemia, nonpigmented strain

How to cite this article:
Tiwari S, Pattanaik S, Beriha SS. Nonpigmented strain of Chromobacterium violaceum causing neonatal septicemia: A rare case report. Indian J Pathol Microbiol 2017;60:427-9

How to cite this URL:
Tiwari S, Pattanaik S, Beriha SS. Nonpigmented strain of Chromobacterium violaceum causing neonatal septicemia: A rare case report. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Dec 8];60:427-9. Available from: http://www.ijpmonline.org/text.asp?2017/60/3/427/215386



   Introduction Top


Human infections with Chromobacterium violaceum are rare and have a very high fatality rate, especially if associated with septicemia. It most commonly inhabits soil and stagnant water in tropical and subtropical regions but is not part of normal human flora.[1]C. violaceum usually produces a violet-colored nondiffusible pigment known as violacein, which is soluble in ethanol and insoluble in water and chloroform.[2] However, infections caused by nonpigmented strains are described rarely. C. violaceum was first identified in 1881, and its pathogenic potential was first described by Woolley in 1905, who isolated it from a fatal infection in buffalo in the Philippines. The first documented case of C. violaceum in human was described in 1927 in Malaysia by J.E. Lessler. Since then, there have been more than 160 human cases reported in India, Srilanka, Southeast Asia, Hongkong, Australia, Brazil, United States, etc.[2] It is facultative anaerobic, motile, Gram-negative curved rod which is fermentative and positive for catalase and oxidase reaction. Both pigmented and nonpigmented strains exist, though nonpigmented strains are rare.[3] Herewith, we are reporting a nonpigmented strain of C. violaceum from a case of neonatal septicemia. To the best of our knowledge, after web search of medical literature, we found that this is the first documented case from India.


   Case Report Top


A 16-day-old male infant was admitted to our hospital with chief complaint of high-grade fever (102°F) and fast breathing for the past 4 days. He had also history of loose motion and few skin lesions looking like pustules on the chest for the past 2 days. On examination, other findings such as respiratory rate 74/min, pulse rate 142/min, and respiratory system showed bilateral crepitations. On per abdominal examination, central nervous system and cardiovascular system were within normal limits. Relevant laboratory parameters include hemoglobin - 10 g%, total leukocyte count - 16,000/cmm, neutrophil - 82%, lymphocyte - 14%, eosinophil - 2%, monocyte - 2%, basophil - 0%, and erythrocyte sedimentation rate - 42 mm after first hour. Chest X-ray showed bilateral infiltrates. Ultrasound abdomen was normal. Blood was collected with complete aseptic precaution into aerobic and anaerobic pediatric blood culture bottle (BacT/ALERT/3D; bioMerieux, Marcy l'Etoile, France). The patient was then started empirically with gentamicin plus vancomycin. Aerobic culture bottle showed positive sign of growth within 16 h. The broth was then subcultured on 5% sheep blood agar and MacConkey agar. After overnight incubation, MacConkey agar showed nonlactose fermenting translucent colony which was 1–2 mm in diameter, smooth surface, and nonpigmented [Figure 1]. Blood agar plate also showed similar colony morphology and nonpigmented. Gram stain was done from both the culture plates, and it was Gram-negative bacilli. It was motile by hanging drop method. The routine biochemical test was done, and it was catalase and oxidase positive, nitrate reduced to nitrite, glucose fermented with the production of acid but did not ferment lactose and mannitol. On triple sugar iron agar, it showed K/A without H2S production. Urea was not hydrolyzed and citrate not utilized. Further identification was done by VITEK-2 (fully automated identification system) using GN-25 card (bioMerieux, Marcy l'Etoile, France). It was identified as C. violaceum with 99% probability. There was no growth in anaerobic blood culture bottle even after 7 days of anaerobic incubation. The isolate was found to be sensitive to gentamicin, amikacin, ciprofloxacin, imipenem, piperacillin-tazobactam, and resistant to cefotaxime, ceftriaxone, cefepime, and ampicillin. Therapy was changed to gentamicin 4 mg/kg/dose daily and imipenem 25 mg/kg/dose 8 hourly for 10 days. Pus sample was also collected from pustule on the chest with complete aseptic precaution and inoculated on 5% sheep blood agar and MacConkey agar. Similar colony morphology without pigment production was seen as in the case of blood. It was also processed by VITEK-2 and identified as C. violaceum with 98% probability using GN-25 card. Isolation of nonpigmented strain of C. violaceum from both the clinical samples (blood and pus) confirmed its pathogenic role. The patient responded well to antibiotic therapy. Skin lesion was subsided after 10 days of therapy. Blood sample was again taken for culture, 7 days after the completion of therapy, and there was no growth. The patient is doing well during follow-up.
Figure 1: Nonpigmented colony of Chromobacterium violaceum on MacConkey agar

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   Discussion Top


C. violaceum most commonly inhabits soil and stagnant water. Infection caused by C. violaceum in human being is very rare and has high fatality rate, especially if associated with septicemia. Till now, more than 160 patients infected with C. violaceum have been reported worldwide. Apart from the Indian subcontinent, the majority of the cases have been reported from Southeast Asia, South America, Australia, and the Southeastern United States.[4] Till now, around 13 cases have been reported from India including the present case [Table 1]. Very few nonpigmented strains of C. violaceum causing human infection have been reported in medical literature.[3] To the best of our knowledge, this one is the first documented case of nonpigmented strain of C. violaceum causing neonatal septicemia. C. violaceum infection is acquired mostly through exposure of broken skin coming in contact with contaminated soil and water. Infection is very rare through ingestion of contaminated water but suspected in patients with diarrhea as the only clinical presentation.[5] Unusual routes of exposure include scuba diving or near drowning and following surgical procedures.[4] In our case, there is no history of loose motion; only relevant clinical features are high-grade fever, tachypnea, and pustules on the chest. The patient belongs to rural area, so there might be chance of entry of organism through skin contact of contaminated soil or water.
Table 1: Cases of C. violaceum with their salient features reported from India

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C. violaceum septicemia occurs most commonly in patients with chronic granulomatous disease, neutrophil dysfunction, and severe polymorphonuclear G6 PD deficiency. In these conditions, neutrophils and monocytes lack the ability to produce oxygen metabolites required to kill phagocytosed bacteria, which makes the patient more susceptible to develop septicemia and dissemination of infection to various internal organs.[6]

Diagnosis of C. violaceum requires a high index of suspicion and isolation of the organism from clinical specimen. Growth occurs on ordinary supplied culture media and produces nondiffusible pigment called violacein. Diagnosis of C. violaceum is very difficult in case of about 9%–11% where they do not produce pigment.[6],[7] Pathogenicity of C. violaceum does not depend on pigment production. This is not an essential or exclusive character of the genus Chromobacterium.[8] Nonpigmented strains of C. violaceum either reported as laboratory contaminants or wrongly identified as members of genus Aeromonas, Pseudomonas, Vibrio, Flavobacterium, etc., because of similarity in their biochemical properties.[9]

C. violaceum is generally considered to be of low virulence, but septicemia is usually fatal if not treated promptly. Antimicrobial susceptibility data on C. violaceum are very much limited because of rare isolation of this pathogen from clinical specimen. Results of antimicrobial susceptibility testing also vary in different clinical settings. The Clinical Laboratory Standard Institute has not yet established a zone diameter for resistance and susceptibility associated with minimum inhibitory concentration breakpoints.[6] They are extremely resistant to penicillins and cephalosporins and susceptible to fluoroquinolones, carbapenems, aminoglycosides, chloramphenicol, tetracycline, and cotrimoxazole.[10] In our case, the patient was successfully treated with gentamicin and imipenem.

C. violaceum is very uncommon but emergent infection after global climatic change. Only few cases have been reported from India, and to the best of our knowledge, we think that this is the first documented case of nonpigmented strain of C. violaceum causing neonatal septicemia. Due to its rarity, there are no set guidelines on the management of such a rare infection. A high degree of clinical suspicion and appropriate antimicrobial therapy for adequate duration at the earliest stage is best strategy for successful therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Ma T, Shi W, Cheng J, Zhang JK, Hu LF, Ye Y, et al. Chromobacterium violaceum in China: Three case reports and literature reviews. Afr J Microbiol Res 2011;5:3096-102.  Back to cited text no. 1
    
2.
Ray P, Sharma J, Marak RS, Singhi S, Taneja N, Garg RK, et al. Chromobacterium violaceum septicaemia from North India. Indian J Med Res 2004;120:523-6.  Back to cited text no. 2
[PUBMED]    
3.
Bosch FJ, Badenhorst L, Le Roux JA, Louw VJ. Successful treatment of Chromobacterium violaceum sepsis in South Africa. J Med Microbiol 2008;57(Pt 10):1293-5.  Back to cited text no. 3
    
4.
Karthik R, Pancharatnam P, Balaji V. Fatal Chromobacterium violaceum septicemia in a South Indian adult. J Infect Dev Ctries 2012;6:751-5.  Back to cited text no. 4
[PUBMED]    
5.
Manjunath M. Fatal septicaemia due to Chromobacterium violaceum. West Indian Med J 2007;56:380-1.  Back to cited text no. 5
[PUBMED]    
6.
Yang CH, Li YH. Chromobacterium violaceum infection: A clinical review of an important but neglected infection. J Chin Med Assoc 2011;74:435-41.  Back to cited text no. 6
    
7.
Swain B, Otta S, Sahu KK, Panda K, Rout S. Urinary tract infection by Chromobacterium violaceum. J Clin Diagn Res 2014;8:DD01-2.  Back to cited text no. 7
[PUBMED]    
8.
Sivendra R, Tan SH. Pathogenicity of nonpigmented cultures of Chromobacterium violaceum. J Clin Microbiol 1977;5:514-6.  Back to cited text no. 8
    
9.
Sivendra R, Lo HS, Lim KT. Identification of Chromobacterium violaceum: Pigmented and non-pigmented strains. J Gen Microbiol 1975;90:21-31.  Back to cited text no. 9
    
10.
Vijayan AP, Anand MR, Remesh P. Chromobacterium violaceum sepsis in an infant. Indian Pediatr 2009;46:721-2.  Back to cited text no. 10
    

Top
Correspondence Address:
Shreekant Tiwari
S.O Quarter No. 1 S.C.B Medical College Campus, Ranihat Medical Road, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_479_16

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