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LETTER TO EDITOR
Year : 2005  |  Volume : 53  |  Issue : 1  |  Page : 122-123

Meningitis due to Escherichia vulneris


Department of Microbiology, All India Institute of Medical Sciences, New Delhi - 110 029, India

Date of Acceptance23-Apr-2004

Correspondence Address:
Srujana Mohanty
Department of Microbiology, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.15082

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How to cite this article:
Mohanty S, Chandra SP, Dhawan B, Kapil A, Das BK. Meningitis due to Escherichia vulneris. Neurol India 2005;53:122-3

How to cite this URL:
Mohanty S, Chandra SP, Dhawan B, Kapil A, Das BK. Meningitis due to Escherichia vulneris. Neurol India [serial online] 2005 [cited 2019 Dec 7];53:122-3. Available from: http://www.neurologyindia.com/text.asp?2005/53/1/122/15082


Sir,

A right-handed 4-year-old girl presented with a history of trauma as a result of a fall from stairs. Clinical examination revealed an open injury over the left fronto-parietal region with brain herniation and cerebrospinal fluid (CSF) leak. Computed tomography scan showed a compound fracture of the left frontal bone extending to the parietal bone and orbit with an underlying contusion. An emergency surgery was performed with left frontal exploration, removal of loose bone fragments, wound debridement, evacuation of contusion and duraplasty. She was discharged on the 13th post-operative day with a Glasgow Coma Scale (GCS) of E4V4M5.

Two days after discharge, she presented with neck rigidity and purulent discharge from the operative scalp wound. She was febrile, emaciated and dehydrated, had a blood pressure of 100/80 mm Hg and a pulse rate of 100/min. GCS was E2V3M4. She had ptosis of left eye with synechiae formation, right-sided facial nerve paresis and paresis of the right upper and lower limbs. The wound site showed a copious CSF leak with flakes of purulent material.

Laboratory examination revealed hemoglobin 9.9 gm,/L, a white blood cell count of 7.4 x 109/L and platelet count of 110x109/L. Routine blood chemistry and coagulation tests were normal. Cerebrospinal fluid obtained by lumbar puncture revealed a raised leucocyte count of 2500/mm3, elevated protein level of 127 mg/dl and decreased glucose level of 39 mg/dl. The CSF along with the locally purulent material, blood and urine specimens of the patient were sent for culture and empiric therapy was started with parenteral ceftriaxone, amikacin and metronidazole. The CSF (both lumbar puncture and local discharge) culture yielded  Escherichia More Details vulneris identified by standard biochemical tests[1] and confirmed by API 20E test strips (Bio-Merieux, Marcy l' Etoile, France). The organism was a non-lactose fermenting, motile, gram-negative bacilli, catalase positive, oxidase negative, did not produce indole and did not decarboxylate ornithine. In a standard disk diffusion method,[2] the organism was susceptible to piperacillin, βlactam-β lactamase inhibitor combinations (piperacillin-tazobactam, cefoperazone-sulbactam, ticarcillin-clavulanic acid) and meropenem. The strain tested positive for the production of extended-spectrum-β lactamase.[2] Therapy was changed to parenteral piperacillin-tazobactam combination. However, the patient's clinical condition did not improve and subsequently therapy with parenteral meropenem was initiated. The patient started to improve neurologically (GCS = E4V5M6), however, the wound site failed to epithelialize. On the 25th day of admission, exploration of the scalp wound site was performed, the underlying necrotic bone fragments were removed and debridement done followed by primary dural closure. A rotation skin flap was utilized for primary skin closure. Antibiotics were continued postoperatively till the patient was discharged on the 35th day of hospitalization with a healthy wound.

In 1982, Brenner et al[3] classified Escherichia vulneris as a new species in the family Enterobacteriaceae on the basis of DNA relatedness studies and biochemical reactions. Most isolates of E. vulneris have been recovered from wounds (vulneris [Latin]: of a wound).[3],[4] However, it is questionable whether they are pathogenic or not, since they fail to produce infection in mice.[4] Reports of invasive infections due to E. vulneris are relatively few and include ostemyelitis,[5] urosepsis,[6] bacteremia[7] and septic shock.[8] No fatal cases have been reported so far. The majority of the patients were adults.[3],[4],[6],[8] A review of literature revealed no previous report of bacterial meningitis due to this organism.

In wounds with E. vulneris infection, co-infection with other bacteria has been observed which may have contributed to the extensive tissue injury seen in such cases.[4],[8] However, E. vulneris was the sole pathogen in cases of osteomyelitis,[5] urosepsis,[6] bacteremia[7] and in the present case of meningitis. Thus, E. vulneris may be a potential pathogen and more studies are needed to explore the virulent nature of the organism. Clinical isolates of E. vulneris are reportedly susceptible to commonly used antibiotics.[3],[4],[7] In contrast, the isolate infecting our patient was multidrug resistant, suggesting that the infection was nosocomial.

 
 » References Top

1.Altwegg M, Bockemühl H. Escherichia and Shigella. In: Topley & Wilson's Microbiology and Microbial Infections. Vol. 2, 9th Ed. Balows A, Duerden BI, editors. UK: Arnold; 1998. p. 935-65.  Back to cited text no. 1    
2.National Committee for Clinical Laboratory Standards, Performance standards for antimicrobial disk susceptibility testing; Twelfth informational supplement. Wayne PA: NCCLS; (M100-S12), 2002.  Back to cited text no. 2    
3.Brenner DJ, McWhorter AC, Knutsom JK. Steigerwalt AG. Escherichia vulneris: A new species of Enterobacteriaceae associated with human wounds. J Clin Microbiol 1982;15:1133-40.  Back to cited text no. 3    
4.Pien FD, Shrum S. Swenson JM, Hill BC, Thornsberry C, Farmer JJ III. Colonization of human wounds by Escherichia vulneris and Escherichia hermannii. J Clin Microbiol 1985;22:283-5.  Back to cited text no. 4    
5.Levine WN, Goldberg MJ. Escherichia vulneris osteomyelitis of the tibia caused by a wooden foreign body. Orthop Rev 1994;23:262-5.  Back to cited text no. 5  [PUBMED]  
6.Awsare SV, Lillo M. A case report of Escherichia vulneris urosepis. Rev Infect Dis 1991;13:1247-8.  Back to cited text no. 6  [PUBMED]  
7.Spaulding AC, Rothman AL. Escherichia vulneris as a cause of intravenous catheter-related bacteremia. Clin Infect Dis 1996;22:728-9.  Back to cited text no. 7  [PUBMED]  
8.Horii T, Suzuki Y, Kimura T, Kanno T, Maekawa M. Intravenous catheter-related septic shock caused by Staphylococcus sciuri and Escherichia vulneris. Scand J Infect Dis 2001;33:930-2.  Back to cited text no. 8  [PUBMED]  



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