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  Table of Contents    
LETTER TO EDITOR  
Year : 2017  |  Volume : 60  |  Issue : 4  |  Page : 626-628
Elizabethkingia meningoseptica peritonitis in continuous ambulatory peritoneal dialysis patient: A rare case report with diagnostic challenges


1 Department of Microbiology, KG Hospital and Postgraduate Medical Institute, Coimbatore, Tamil Nadu, India
2 Department of Nephrology, KG Hospital and Postgraduate Medical Institute, Coimbatore, Tamil Nadu, India

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Date of Web Publication12-Jan-2018
 

How to cite this article:
Ranjan S, Veerappan I, Patil SP, Sethuraman R. Elizabethkingia meningoseptica peritonitis in continuous ambulatory peritoneal dialysis patient: A rare case report with diagnostic challenges. Indian J Pathol Microbiol 2017;60:626-8

How to cite this URL:
Ranjan S, Veerappan I, Patil SP, Sethuraman R. Elizabethkingia meningoseptica peritonitis in continuous ambulatory peritoneal dialysis patient: A rare case report with diagnostic challenges. Indian J Pathol Microbiol [serial online] 2017 [cited 2019 Jun 19];60:626-8. Available from: http://www.ijpmonline.org/text.asp?2017/60/4/626/222967




Editor,

Elizabethkingia meningoseptica originally named as Flavobacterium meningosepticum and later as Chryseobacterium meningosepticum is a nonfermentative Gram-negative bacillus (GNB) that is widely distributed in nature. It is ubiquitously found in freshwater, saltwater, plants, soil, and food products. E. meningoseptica survives in chlorine-treated municipal water. Colonized sink basins and taps, saline solutions, disinfectants, and medical devices such as feeding tubes, arterial catheters, respirators, intubation tubes, and incubators for newborns are potential reservoirs of infection in hospital settings.[1]

E. meningoseptica is a nonmotile, nonsporing, noncapsulated, catalase positive, oxidase positive, indole positive, nonfermentative, and obligate aerobe. It shows oxidative reaction in O-F glucose. It is negative for urease and nitrate.[2] It grows on enriched media only.[1] Difficulties in culture and misidentification on some automated laboratory platforms contribute to diagnostic challenge in cases with E. meningoseptica infection. However, with widespread use of matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF), mass spectrometry has resulted in improved and rapid identification of E. meningoseptica from clinical samples. Consequently, there is increased reporting of sporadic cases as well as outbreaks caused by E. meningoseptica all over the world.

Here, we present a case of peritonitis caused by E. meningoseptica in a continuous ambulatory peritoneal dialysis (CAPD) patient which presented diagnostic challenges due to its rarity and unusual growth pattern.

A 72-year-old male, a known case of type 2 diabetes mellitus for 25 years, systemic hypertension for 10 years, and chronic kidney disease stage 5 (diabetic nephropathy) on CAPD for 22 months, presented with abdominal pain, loose motion, and cloudy CAPD fluid. With a diagnosis of infective peritonitis, empirical antibiotic treatment through oral as well as intraperitoneal route was started. Total cell count of CAPD fluid was 12,500 cells/mm3. Gram-stain of CAPD fluid revealed numerous pus cells. However, Ziehl–Neelsen stain and fungal stain were negative. After 24 h of incubation, culture revealed pure and heavy growth of nonlactose fermenting (NLF), smooth colonies on MacConkey agar (MA) [Figure 1]a, and nonhemolytic smooth colonies on blood agar (BA) [Figure 2]a. Colony smear from both the plates showed Gram-negative bacilli [Figure 2]b. Identification and antibiotic sensitivity testing was done by VITEK-2 compact (BioMerieux) using GNB identification card (GN 21 341) and AST card (AST-N281), respectively. The organism was identified as E. meningoseptica which was resistant to all the antibiotics tested, except cefoperazone + sulbactam, ciprofloxacin, levofloxacin, minocycline, and co-trimoxazole.
Figure 1: Heavy growth of nonlactose fermenting colonies on MacConkey agar (a) 1st continuous ambulatory peritoneal dialysis fluid sample (b) 2nd continuous ambulatory peritoneal dialysis fluid sample

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Figure 2: (a) Nonhemolytic smooth colonies on blood agar (b) Gram's-stain of the colony, showing Gram-negative bacilli

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However, we requested for the second sample taking into account the rarity of published literature on E. meningoseptica in CAPD fluid. The same was received after 3 days. The second CAPD fluid sample also yielded heavy growth of NLF colonies on MA after 24 h of incubation [Figure 1]b. Identification and antibiotic sensitivity resulted in the same organism with the same sensitivity pattern. For further confirmation, the same was sent for identification by MALDI-TOF method. The later identified the isolate as E. meningoseptica with score value of 2.216.

As per se nsitivity report, he was started on injection cefoperazone + sulbactam along with tablet co-trimoxazole. Although abdominal pain relieved, he continued to have loose stools and cloudy CAPD fluid despite 10 days of antibiotic therapy. Repeat total cell count of CAPD fluid after antibiotic therapy was 2000 cells/mm3. Due to limited response to antibiotic therapy, CAPD catheter was removed and the patient was switched over to hemodialysis for 2 months. Injection cefoperazone + sulbactam 1.5 g twice daily was given for 5 days after CAPD catheter removal. Another 5 days of oral treatment with minocycline 100 g twice daily was given as an outpatient basis. His symptoms improved rapidly with catheter removal and subsequent antibiotics. Two months after catheter removal and subsequent treatment with antibiotics, the CAPD catheter was reinserted and CAPD was restarted successfully.

E. meningoseptica is an emerging pathogen which has been reported to cause meningitis, pneumonia, endocarditis, bacteremia, sepsis, wound, soft tissue, abdominal, respiratory and ocular infections, dialysis-associated peritonitis, and prosthesis-associated septic arthritis, especially in immune-deficient hosts. However, CAPD-associated peritonitis caused by E. meningoseptica has been reported in only two cases till date.[2],[3] This rarity imposed the first challenge to consider the Gram-negative bacilli as a pathogen in our case, when the growth from CAPD fluid sample was first identified as E. meningoseptica by VITEK 2.

After 24 h of incubation, the organism showed heavy growth on MA. However, usually, E. meningoseptica shows no growth to poor growth on MA.[2] Hence, heavy growth on MA in our case created another diagnostic dilemma. To overcome this situation, we requested for the second sample of CAPD fluid, which also showed the growth and VITEK-based identification of the same organism. Finally, we labeled E. meningoseptica as a pathogen for peritonitis in our case, after confirmation of the organism by MALDI-TOF, which is a more reliable technique.

On extensive PubMed-based search, we found that the growth of the organism on MA is strain dependent. In only one case report by Connell et al. and one case series by Chawla et al., E. meningosepticum has shown good growth on MA.[4],[5] Connell et al. cultured vitreous biopsy from an endophthalmitis patient which showed heavy growth of E. meningoseptica on MA and BA after 48 h of incubation.[4] Chawla et al. collected endotracheal aspirates from four patients in which culture on MA and sheep BA showed significant growth of pathogen (≥105 cfu/ml). The biochemical characterization and VITEK identification revealed that the isolate in all 4 cases was E. meningoseptica (99% probability).[5] Similarly, in our case also, E. meningoseptica showed rare phenomena of good growth on MA. This strain-dependent variability in growth pattern of E. meningoseptica could be related to variable virulence of the organism and, hence, rare clinical scenario like in our case.

In a recently reported case of E. menigoseptica peritonitis in CAPD patient, the prompt treatment with cefoperazone + sulbactam led to improvement of the patient.[2] However, in another case, reported by Wu et al., intravenous antibiotics with good in vitro activity against E. meningoseptica did not lead to any improvement in the patient.[3] Finally, with the removal of the catheter, signs and symptoms of peritonitis subsided.[3] Similarly, in our case, antibiotic therapy resulted in partial response as relief in only abdominal pain, and complete recovery was noted after removal of the catheter.

Multi-drug resistance nature of E. meningoseptica has led to a limited treatment option.[1] Studies have demonstrated chromosomal and plasmid-mediated resistance to many antimicrobials, including beta (β)-lactams. Three blaCME genes coding for extended-spectrum serine-β-lactamase and two metallo-β-lactamases conferring carbapenem resistance: BlaB and blaGOB has been documented earlier. Acquisition of blaKPC genes conferring further resistance has also been demonstrated. High level of resistance to the commonly used β-lactams may be the reason for the excess appearance of this organism in patients who had a history of preceding broad-spectrum antimicrobial drug therapy. In our case also, organism showed multi-drug resistance, being sensitive to cefoperazone + sulbactam, ciprofloxacin, levofloxacin, minocycline, and co-trimoxazole only. However, there was limited in vivo sensitivity to even these antibiotics resulting in partial clinical improvement of the patient.

E. meningoseptica is a rare but upcoming pathogen in CAPD fluid and, hence, must be kept in mind by the microbiologists. However, reconfirmation of the organism by processing repeat sample and identification by a more reliable technique like MALDI-TOF is advisable before labeling it as a pathogen. The rarity, variable growth pattern and multi-drug resistance can account for diagnostic and therapeutic challenges in cases of E. meningoseptica peritonitis in CAPD patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ratnamani MS, Rao R. Elizabethkingia meningoseptica: Emerging nosocomial pathogen in bedside hemodialysis patients. Indian J Crit Care Med 2013;17:304-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Khan ID, Lall M, Sen S, Ninawe SM, Chandola P. Multiresistant elizabethkingia meningoseptica infections in tertiary care. Med J Armed Forces India 2015;71:282-6.  Back to cited text no. 2
    
3.
Wu VC, Tsai TJ, Wang R, Hsueh PR. Peritonitis caused by chryseobacterium meningosepticum in a patient undergoing continuous ambulatory peritoneal dialysis. J Formos Med Assoc 2003;102:270-2.  Back to cited text no. 3
    
4.
Connell PP, Wickremasinghe S, Devi U, Waters MJ, Allen PJ. Self-induced elizabethkingia meningoseptica endophthalmitis: A case report. J Med Case Rep 2011;5:303.  Back to cited text no. 4
    
5.
Chawla K, Gopinathan A, Varma M, Mukhopadhyay C. Elizabethkingia meningoseptica outbreak in intensive care unit. J Glob Infect Dis 2015;7:43-4.  Back to cited text no. 5
    

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Correspondence Address:
Shikha Ranjan
Department of Microbiology, KG Hospital and Postgraduate Medical Institute, Coimbatore - 641 018, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_28_17

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