Year : 2022 | Volume
: 10 | Issue : 2 | Page : 80--82
A case of scrub typhus meningoencephalitis complicated by a rare pathogen Leclercia adecarboxylata
Sanjay K Sahu1, Surya N Mishra2, Seba R Biswal1, Hari K P Yerru1, Chinmay K Behera1,
1 Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Microbiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
Surya N Mishra
Department of Microbiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha
Leclercia adecarboxylata is Gram-negative bacteria and belongs to the family Enterobacteriaceae, which is motile and is considered as a commensal in normal gut flora. It causes opportunistic infection in immunocompromised hosts but also has been isolated from pus, blood, urine, and sputum of immunocompetent hosts. It is often found to be a part of polymicrobial infection indicating synergistic effect, enhancing its virulence. Rarely, it has been isolated from the cerebrospinal fluid of a child, and its coinfection with scrub typhus has hardly been reported. Because of significant morbidity and mortality associated with nosocomial infections, microbiologists and clinicians should be aware of such unusual pathogens such as L. adecarboxylata. Though most L. adecarboxylata isolates are sensitive to many of the antibiotics, their coexistence with multidrug resistant organisms could result in the transmission of resistance elements.
|How to cite this article:|
Sahu SK, Mishra SN, Biswal SR, Yerru HK, Behera CK. A case of scrub typhus meningoencephalitis complicated by a rare pathogen Leclercia adecarboxylata.D Y Patil J Health Sci 2022;10:80-82
|How to cite this URL:|
Sahu SK, Mishra SN, Biswal SR, Yerru HK, Behera CK. A case of scrub typhus meningoencephalitis complicated by a rare pathogen Leclercia adecarboxylata. D Y Patil J Health Sci [serial online] 2022 [cited 2023 Jan 29 ];10:80-82
Available from: http://www.dypatiljhs.com/text.asp?2022/10/2/80/361365
Leclercia adecarboxylata is associated with a spectrum of infection solely or with other infectious agents in both immunocompetent and immunocompromised hosts necessitating increased awareness among clinicians.
Scrub typhus is an emerging childhood infection in many parts of the globe caused by Orientia tsutsugamushi, sometimes causing life-threatening complications.Leclercia adecarboxylata, a motile Gram-negative bacilli isolated in 1962, is considered as a commensal in normal gut flora. Previously, it is thought to cause opportunistic infection in immunocompromised patients but cases from immunocompetent patients are also being reported. Mostly the organism has been isolated from pus, blood, urine, and sputum. On extensive search of literature, no reports of the organism being isolated from the cerebrospinal fluid (CSF) have been reported in children. We are herewith reporting the case of a 10-month-old child diagnosed as suffering from scrub typhus meningoencephalitis complicated by an additional infection with L. adecarboxylata.
A 10-month-old male child was admitted to our hospital presenting with fever for 7 days and one episode of seizure. On examination, the child was febrile, irritable, pale, and had tachycardia. Anterior fontanelle was pulsatile and at level. Hepatosplenomegaly was present with no other systemic findings. He was admitted with a provisional diagnosis of meningitis. The child was started on injection ceftriaxone with other supportive measures. On investigation, a total leukocyte count (TLC) was 26,620/mm3, hemoglobin was 11.4 g/dL, platelet was 130000/mm3, C-reactive protein (CRP) was found to be 64.76 mg/dL, whereas serum sodium was 135 mmol/L and serum potassium was 4.2 mmol/L. The value of serum urea and creatinine was found to be normal, but liver function revealed transaminitis. Urine test was normal, malaria parasite and dengue test were negative, but scrub typhus IgM was positive. The kit that was used was manufactured by INBIOS kit (In BiOS International, Inc., Seattle, USA), which shows 99.9% sensitivity and 99.15% specificity. The optical density value was found to be of >0.5 at 450 nm. The CSF collected by a lumber puncture following all standard precaution and taking proper consent from the relatives of the patient was immediately transported to the Central Laboratory of KIMS (PBMH) for further processing. CSF analysis revealed 43 cells, 93% lymphocyte, glucose 51.2 mg/dL, and protein 47.1 mg/dL. Gram stain of CSF revealed occasional polymorphs and no organisms. Blood and urine culture sent initially were sterile. Accordingly, he was provisionally diagnosed as a case of scrub typhus meningoencephalitis, and doxycycline was added. There were no further seizures, but fever persisted beyond 72 h of starting of doxycycline. The CSF sample was immediately streaked on chocolate agar, 5% sheep blood agar, and was incubated in a CO2 incubator at 37°C. The sample was also streaked on MacConkey agar and was kept for overnight aerobic incubation in an ordinary incubator at 37°C. After overnight incubation, the plates were studied for the growth pattern inside a biosafety cabinet (type IIA). The growth on 5% sheep blood agar showed tiny, moist, and nonhemolytic colonies, and MacConkey’s agar showed pink lactose-fermenting colonies. The chocolate agar showed the growth of very tiny, grayish colonies. Representative colonies from all the culture plates showed the presence of gram-negative bacilli, which were then loaded into the fully automated VITEK-2 instrument for identification and sensitivity pattern with a minimum inhibitory concentration value using N-280 card. The organism was identified as L. adecarboxylata sensitive to tigecycline, amikacin, amoxycillin/clavulanic acid, cefepime, cefoperazone/sulbactam, colistin, ertapenem, gentamycin, imipenem, and meropenem. It showed resistant pattern to trimethoprim/sulfamethoxazole, ampicillin, ceftriaxone, and cefuroxime, whereas it showed intermediate pattern to piperacillin/tazobactam and ciprofloxacin.
After observing the antibiotic sensitivity pattern, ceftriaxone was stopped and meropenem was started along with doxycycline. The child improved and became afebrile after next 48 h. By day 7, CRP became negative, and TLC and platelet count became normal, so meropenem was continued for 14 days and doxycycline for 10 days. The child was discharged in an hemodynamically stable condition and was kept on regular follow-up.
L. adecarboxylata belongs to the Enterobacteriaceae family and shows phenotypic resemblance with Escherichia coli. It is a Gram-negative bacillus, which is motile and shows aerobic growth pattern. It was first described by Leclerc in 1962 and is ubiquitously distributed in nature. The distribution of this bacteria is considered as universal and is found in a variety of foods, water, and animals (snails and slugs). The organism also exists as a commensal in the gut. Pathogenicity of this organism has been reported only in a few cases so far, thus emphasizing its nature as an opportunistic agent.L. adecarboxylata has been isolated from the pediatric age group of patients, mostly from immunosuppressed children with acute lymphoblastic leukemia, acute kidney injury, with centrally placed catheters. It is also isolated from some cases of bacteremia-associated late-onset sepsis in the preterm infant and in children with folliculitis, musculoskeletal infection, diarrhea, peritonitis, and cholecystitis.,,
After extensive search of literatures, it was found that L. adecarboxylata had a predilection for infections of skin in immune-competent patients exposed to marine or water environments. In another study, Hess et al. have described a slow-growing abscess in the heel of a healthy swimmer after swimming in a public pool. Another case report states that a man has suffered from cellulitis caused by L. adecarboxylata after cleaning up floodwater in his basement after Hurricane Irene.
L. adecarboxylata may be a cause of mono-microbial infections in immune-competent hosts, but it is often found to be a part of polymicrobial infection. It indicates that the presence of other pathogens in polymicrobial infection has some synergistic effect, enhancing its virulence. However no evidence on scrub typhus meningoencephalitis complicated by L. adecarboxylata has been reported in the literature, and this is the maiden instance of the organism being isolated from the CSF of a child. Because of increasing reports of infection, this bacterium that previously had minimal recognition is now gaining importance needing awareness among clinicians.
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