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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~  References

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  Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 34  |  Issue : 4  |  Page : 544-547
 

Aeromonas hydrophila meningitis and fulminant sepsis in preterm newborn: A case report and review of literature


Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India

Date of Submission13-Mar-2016
Date of Acceptance16-Aug-2016
Date of Web Publication8-Dec-2016

Correspondence Address:
A Kali
Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.195383

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 ~ Abstract 

Neonatal meningitis is a lethal infection occurring in the 1st month of life. The risk of developing permanent neurological sequels is high among the neonates who survive. Bacterial pathogens are commonly associated with this condition. Aeromonas is a Gram-negative bacteria of aquatic habitat. Although isolation of Aeromonas species from neonates with blood stream infection is infrequently reported, neonatal meningitis caused by Aeromonas is exceedingly rare. We present a case of fulminant sepsis and meningitis caused by Aeromonas hydrophila in a preterm newborn male. The bacteria was isolated in culture from blood and cerebrospinal fluid. In spite of targeted antibiotics and supportive therapy, the baby failed to respond and died on the 12th day of life.


Keywords: Aeromonas hydrophila, meningitis, neonate, septicaemia


How to cite this article:
Kali A, Kalaivani R, Charles P, Seetha K S. Aeromonas hydrophila meningitis and fulminant sepsis in preterm newborn: A case report and review of literature. Indian J Med Microbiol 2016;34:544-7

How to cite this URL:
Kali A, Kalaivani R, Charles P, Seetha K S. Aeromonas hydrophila meningitis and fulminant sepsis in preterm newborn: A case report and review of literature. Indian J Med Microbiol [serial online] 2016 [cited 2017 Mar 26];34:544-7. Available from: http://www.ijmm.org/text.asp?2016/34/4/544/195383



 ~ Introduction Top


Meningitis is one of the most critical and life-threatening conditions among the spectrum of infections occurring in neonates. Not only it is associated with high morbidity and mortality but also the long-term neurological complications of meningitis are more frequent in neonatal period than in any other age groups.[1] The damage incurred is exceedingly high in several parts of the world where medical and diagnostic facilities are inadequate. As per current estimates, the mortality could be as high as 40–58% in developing countries.[2] Although immaturity of cellular and humoural immune system and deficient blood brain barrier are the factors contributing to the vulnerability of neonates to meningitis, prompt administration of appropriate antibiotic therapy is essential for a better treatment outcome. Meningitis is more common among babies with sepsis. In 10–30% cases of neonatal sepsis, meninges is also found to be involved in the infective process.[1] Moreover, the features of neonatal meningitis are often indistinguishable from that of sepsis. Both Gram-positive and Gram-negative bacterial pathogens are implicated in neonatal sepsis as well as meningitis. While Streptococcus agalactiae is the major pathogen in developed countries, Escherichia coli along with other Gram-negative enteric bacilli are found to have a causal association in the developing world.[2]Aeromonas hydrophila is a Gram-negative bacilli found in association with water systems. Although it has been reported to cause intestinal and extraintestinal infections in human, neonatal meningitis by A. hydrophila is remarkably rare. In this report, we describe a case of meningitis and fulminant sepsis caused by A. hydrophila in a preterm newborn.


 ~ Case Report Top


A 28-year primigravida female with dichorionic, diamniotic twin pregnancy at 30 weeks of gestation presented with preterm labour. Both the babies were delivered by vaginal delivery. Our patient was the first baby of the twins, a male newborn of 1.09 kg birth weight. The Apgar scores at 1 and 5 min after birth were 7/10 and 9/10, respectively. The baby was admitted to neonatal intensive care unit. Blood was sent for culture, and empirical antibiotic therapy (intravenous ampicillin and gentamicin), and inotropic agents were started. Although the initial chest X-ray had no features of hyaline membrane disease, the newborn had several episodes of apnoea lasting up to 15 s. He was given nebulisation with 3% NaCl, aminophylline and ventilatory support. The first blood culture was sterile, and C-reactive protein was nonreactive. However, the baby became lethargic with feeble cry and poor feeding on the 5th day of life. Although the baby had no temperature instability, he had episodes of apnoea, hypotension, bradycardia and seizures. Bulging of fontanelles, nuchal rigidity, focal neurological signs such as cranial nerve palsies, gaze deviation and hemiparesis were absent. Neonatal meningitis was suspected and cerebrospinal fluid (CSF), and blood samples were sent for culture. The haemogram displayed a drop in total leucocyte count from 3800/cmm at birth to 1700/cmm on day 5 of postnatal life. No cerebral malformation or intra/peri-ventricular haemorrhage were noted on cranial ultrasound. In view of possible meningitis and sepsis, antibiotics were changed to amikacin (18 mg/kg/dose q48 h) and piperacillin-tazobactam (100 mg/kg/dose q12 h) at meningitic doses along with anticonvulsants (phenobarbitone and phenytoin).

The CSF was straw colour and showed occasional lymphocytes and few red blood cells. The CSF protein 127 mg/dl and glucose 37 mg/dl. No organisms were seen in gram-stain. CSF culture grew Gram-negative bacilli which was oxidase positive and motile. It produced beta-haemolytic grey moist colonies on sheep blood agar, grey colonies on chocolate agar and nonlactose fermenter colonies on MacConkey's agar. Biochemical identification tests showed positive reaction for indole production, esculin hydrolysis, Voges–Proskauer test, arginine dihydrolase, lysine decarboxylase and nitrate reduction. Triple sugar iron agar had an alkaline slant, acid butt with hydrogen sulphide production. Glucose, sucrose, mannitol and maltose were fermented with gas. It was biochemically identified as A. hydrophila, and the same was confirmed by Vitek. Blood culture was flagged positive in BACTEC automated blood culture system after 18 h of incubation and the same organism was isolated from the blood. Antibiogram revealed that the isolate was sensitive to ceftriaxone, imipenem, meropenem, ciprofloxacin, amikacin and gentamicin and resistant to ampicillin and piperacillin-tazobactam.

Targeted antibiotic therapy with meropenem (40 mg/kg/dose q8 h) instituted from the 8th day. However, the condition deteriorated and the baby succumbed to death on the 12th postnatal day. We made an attempt to identify the source of infection. Blood and stool samples of the sibling twin, stool sample of the mother along with several environmental samples including apparatus and water sources in the neonatal intensive care unit such as distilled water plant, nebuliser and ventilator were screened by culture. However, A. hydrophila could not be recovered from these samples.


 ~ Discussion Top


Aeromonas species are oxidase positive motile Gram-negative bacilli with fermentative metabolism. It is ubiquitous in nature, especially in water ecosystems and soil. Human infections such as acute gastroenteritis, sepsis, endocarditis, myonecrosis and osteomyelitis by Aeromonas species have been reported in adults as well as in children.[3] However, its association with meningitis in neonate is rare. We found 15 reports of Aeromonas meningitis in 14 articles published in English language during literature search.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] Of these cases, seven were paediatric patients (including two neonates).[4],[7],[9],[15],[16],[17] With the exception of one case of meningitis associated with infection of ventriculoperitoneal shunt caused by A. caviae following meningomyelocele repair, all six cases reported isolation of Aeromonas species from both CSF and blood. Aeromonas meningitis in adults frequently found in patients with alcoholic hepatitis, cirrhosis, head trauma or patients who had undergone surgical procedures such as craniotomy, haemorrhoid ligation and splenectomy or medicinal leech therapy.[5], 8, [10],[11],[12] Cases of meningitis in infants and children were reported in association with sickle cell anaemia, beta-thalassemia and haemoglobin E.[7],[16],[17] In comparison to meningitis, bloodstream infection by Aeromonas species is not uncommon. Hepatobiliary diseases, haematological malignancies and anticancer therapy have been identified as predisposing factors in Aeromonas sepsis cases.[13] It is postulated that impaired reticuloendothelial function, immunosuppression along with medications toxic to intestinal epithelium may cause intestinal mucosal ulceration and increased permeability allowing entrance and subsistence of the organism in blood stream.[13] The postsurgical meningitis was considered to be iatrogenic and resulted from entry of the pathogen from the environment during surgery. It is probable that late onset neonatal and childhood sepsis and meningitis may also have an external source of infection. Pazzaglia et al. found contaminated hospital water supply was the source of Aeromonas outbreak in nursery and 55.6% of babies had asymptomatic intestinal colonisation.[18] The role of water as the source of infection has been documented in Aeromonas meningitis. Kumar et al. found unhygienic bottle feeding was associated with meningitis in a 4-month-old baby.[9] In another report, A. hydrophila was isolated from the well water of the patient's household.[15] However, there are little evidence to suggest such transmission in early onset neonatal sepsis and meningitis which occurs during the 1st week of life. Often the source of infection remains inapparent as in our case. We could not isolate the pathogen from environmental samples, from the mother and the sibling baby. Since asymptomatic intestinal carriage of Aeromonas is not uncommon in adult population, it is likely that the pathogen may colonise the mouth and skin of the newborn during the process of delivery and may manifests as watery diarrhoea, sepsis or meningitis in settings of impaired immunity and prematurity.[19],[20]

The findings of the present case and published reports suggest that the clinical and laboratory parameter of Aeromonas meningitis in neonates and children are not overtly distinguishable from that of bacterial meningitis. Most of these cases had a fever, lethargy, seizure and gaze deviation without any focal neurological signs.[9],[15] Watery diarrhoea, pneumonia, necrotizing fasciitis and maculopapular rash were also reported.[16],[17] Although nuchal rigidity was common in adults with Aeromonas meningitis, it has not been documented in neonate. This is in accordance with our findings. In our case, the baby had episodes of apnoea, bradycardia, hypotension and seizures. Diarrhoea, temperature instability, nuchal rigidity, bulging of fontanelles or focal signs were absent. Cranial ultrasound is an essential neuroimaging in neonatal meningitis. It is a common diagnostic modality in the initial evaluation of neonatal seizure as it can detect cerebral malformations, meningitic changes as well as its complications, such as hydrocephaly, cerebral oedema subdural effusion and abscess formation.[21] These ventricular and parenchymal brain lesions were absent in our patient at the time of initial diagnosis. Currently, there is inadequate information to associate these complications to Aeromonas meningitis in neonate. The laboratory parameters had considerable variation in different reports. Three authors found Gram-negative bacilli with neutrophilic pleocytosis, elevated CSF protein and low glucose.[7],[9],[15] However, the CSF was normal with negative gram stain in the present case and two other babies with Aeromonas meningitis.[16] These variations of CSF picture may be attributed to diverse factors related to the neonate, stage of disease and technique of CSF collection. Premature neonates often display higher CSF protein pertaining to the permeable nature of their developing blood-brain barrier.[22] Whereas significantly low glucose in CSF were common in traumatic tap in neonates.[22]

Among the seven reported case of Aeromonas meningitis in paediatric patients, five had an uneventful recovery.[4],[9],[15],[16] A third generation cephalosporin or carbapenem or chloramphenicol with or without aminoglycoside were used in these cases. In contrast, the other two babies who received penicillin and ampicillin succumbed to death.[7],[17] This is accordance with the resistance pattern of Aeromonas species which express a chromosomal beta-lactamase and exhibit high resistance to penicillins and first-generation cephalosporins. In contrast, carbapenems, fluoroquinolones, aminoglycosides and chloramphenicol have been found to exert in vitro antibacterial action against most Aeromonas strains and are considered appropriate for antibiotic therapy.[12] Although meropenem was initiated based on antibiotic susceptibility report, our patient developed catecholamine-resistant septic shock and multi-organ failure which ultimately resulted in death.


 ~ Conclusion Top


It is evident from the present case and published reports that Aeromonas species is an unusual pathogen in human, and it can cause life-threatening infections such as meningitis and sepsis in neonates. Although it may not always have a discernible source of infection, its isolation from hospital environment is of great health concern. In view of its distinct resistance pattern, there is a need to use antibiotics judiciously in both empirical and targeted therapy. Antibiotics such as penicillins and first-generation cephalosporins are to be avoided in empirical regimen for a suspected case of Aeromonas meningitis in neonate. Whereas, the targeted therapy should include antibiotics which can circumvent the specific resistance mechanisms of the isolate as reflected in its antibiogram.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ~ References Top

1.
Khalessi N, Afsharkhas L. Neonatal meningitis: Risk factors, causes, and neurologic complications. Iran J Child Neurol 2014;8:46-50.  Back to cited text no. 1
    
2.
Furyk JS, Swann O, Molyneux E. Systematic review: Neonatal meningitis in the developing world. Trop Med Int Health 2011;16:672-9.  Back to cited text no. 2
    
3.
Von Graevenitz A, Mensch AH. The genus aeromonas in human bacteriology report of 30 cases and review of the literature. N Engl J Med 1968;278:245-9.  Back to cited text no. 3
    
4.
den Butter CP, Mahieu LM. A neonate with a meningomyelocele complicated by Aeromonas caviae ventriculoperitoneal shunt infection. Acta Clin Belg 2013;68:380-1.  Back to cited text no. 4
    
5.
Ellison RT 3rd, Mostow SR. Pyogenic meningitis manifesting during therapy for Aeromonas hydrophila sepsis. Arch Intern Med 1984;144:2078-9.  Back to cited text no. 5
    
6.
Fratzia JD. Community-acquired Aeromonas hydrophila meningitis. Emerg Med 1993;5:251-3.  Back to cited text no. 6
    
7.
Freij BJ. Aeromonas: Biology of the organism and diseases in children. Pediatr Infect Dis 1984;3:164-75.  Back to cited text no. 7
    
8.
Jacob L, Carron DB, Haji TC, Roberts DW. An unusual case of pyogenic meningitis due to Aeromonas sobria. Br J Hosp Med 1988;39:449.  Back to cited text no. 8
    
9.
Kumar MR, Venkatesh VN, Sudhindra KS. Aeromonas species isolated from a case of meningitis. Indian J Pathol Microbiol 2014;57:521-2.  Back to cited text no. 9
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10.
Lin CS, Cheng SH. Aeromonas hydrophila sepsis presenting as meningitis and necrotizing fasciitis in a man with alcoholic liver cirrhosis. J Formos Med Assoc 1998;97:498-502.  Back to cited text no. 10
    
11.
Ouderkirk JP, Bekhor D, Turett GS, Murali R. Aeromonas meningitis complicating medicinal leech therapy. Clin Infect Dis 2004;38:e36-7.  Back to cited text no. 11
    
12.
Parras F, Díaz MD, Reina J, Moreno S, Guerrero C, Bouza E. Meningitis due to Aeromonas species: Case report and review. Clin Infect Dis 1993;17:1058-60.  Back to cited text no. 12
    
13.
Qadri SM, Gordon LP, Wende RD, Williams RP. Meningitis due to Aeromonas hydrophila. J Clin Microbiol 1976;3:102-4.  Back to cited text no. 13
    
14.
Salunke G, Namshikar V, Gaonkar R, Gaonkar T. A case of Aeromonas hydrophila meningitis in septic shock. Trop J Med Res 2015;18:54-7.  Back to cited text no. 14
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Seetha KS, Jose BT, Jasthi A. Meningitis due to Aeromonas hydrophila. Indian J Med Microbiol 2004;22:191-2.  Back to cited text no. 15
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Sirinavin S, Likitnukul S, Lolekha S. Aeromonas septicemia in infants and children. Pediatr Infect Dis 1984;3:122-5.  Back to cited text no. 16
    
17.
Yadava R, Seeler RA, Kalelkar M, Royal JE. Fatal Aeromonas hydrophila sepsis and meningitis in a child with sickle cell anemia. Am J Dis Child 1979;133:753-4.  Back to cited text no. 17
    
18.
Pazzaglia G, Escalante JR, Sack RB, Rocca C, Benavides V. Transient intestinal colonization by multiple phenotypes of Aeromonas species during the first week of life. J Clin Microbiol 1990;28:1842-6.  Back to cited text no. 18
    
19.
Chaudhari T, Todd DA. Aeromonas hydrophila sepsis in a preterm neonate. Indian Pediatr 2009;46:913-4.  Back to cited text no. 19
    
20.
Igbinosa IH, Igumbor EU, Aghdasi F, Tom M, Okoh AI. Emerging Aeromonas species infections and their significance in public health. Scientific World Journal 2012;2012:625023.  Back to cited text no. 20
    
21.
Yikilmaz A, Taylor GA. Sonographic findings in bacterial meningitis in neonates and young infants. Pediatr Radiol 2008;38:129-37.  Back to cited text no. 21
    
22.
Majumdar A, Jana A, Jana A, Biswas S, Bhatacharyya S, Bannerjee S. Importance of normal values of CSF parameters in term versus preterm neonates. J Clin Neonatol 2013;2:166-8.  Back to cited text no. 22
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