Raoultella planticola bacteremia following consumption of...

Can J Infect Dis Med Microbiol Vol 25 July/August 2014 e83

PW Lam, IE Salit. Raoultella planticola bacteremia following consumption of seafood. Can J Infect Dis Med Microbiol 2014;25(4):e83-e84.

Raoultella planticola is a Gram-negative bacillus commonly found in water, soil and aquatic environments. There have only been 16 cases of R planticola infection documented in the literature to date. R planti-cola possesses the ability to convert histidine to histamine and can produce symptoms of scombroid poisoning when poorly prepared sea-food is consumed in large amounts. The present report describes a case involving a 56-year-old woman who presented with R planticola bacte-remia and symptoms consistent with cholangitis four days after con-suming a seafood salad containing squid and octopus. She was successfully treated with intravenous ceftriaxone followed by oral cip-rofloxacin. Recent chemotherapy, proton pump inhibitor use and altered biliary flow secondary to hepatic metastases may have been contributing factors to the pathogenesis of disease.

Key Words: Bacteremia; Cholangitis; Raoultella planticola; Seafood

Une bactériémie à Raoultella planticola après la consommation de fruits de mer

La Raoultella planticola est un bacille à Gram négatif qu’on trouve sou-vent dans l’eau, la terre et les milieux aquatiques. Seulement 16 cas d’infection à R planticola ont été répertoriés dans les publications jusqu’à présent. Le R planticola peut convertir l’histidine en histamine et produire des symptômes de scombroïdose après la consommation de grandes quantités de fruits de mer mal préparés. Le présent rapport décrit le cas d’une femme de 56 ans qui a consulté à cause d’une bacté-riémie à R planticola et de symptômes évocateurs d’une cholangite quatre jours après avoir consommé une salade de fruits de mer con-tenant du calmar et de la pieuvre. Elle a été traitée avec succès au moyen de ceftriaxone par voie intraveineuse suivie de ciprofloxacine par voie orale. Une récente chimiothérapie, la prise d’inhibiteurs de la pompe à protons et une perturbation de l’écoulement biliaire secon-daire à des métastases hépatiques peuvent avoir contribué à la patho-genèse de la maladie.

Raoultella planticola bacteremia following consumption of seafood

Philip W Lam BScPhm MD1,2, Irving E Salit BSc FRCPC MD1,2

1Toronto General Hospital, University Health Network; 2University of Toronto, Toronto, OntarioCorrespondence: Dr Irving E Salit, Toronto General Hospital, 200 Elizabeth Street, 13 Eaton North – Room 215, Toronto, Ontario M5G 2C4.

Telephone 416-340-3697, fax 416-340-3357, e-mail [email protected]

CaSE PrESEntatIonA 56-year-old woman presented to hospital with a one-day history of fevers, chills, anorexia, fatigue and right upper quadrant abdominal pain. She had stage IV non-small cell lung cancer with bone and liver metastases, hypertension and remote cholecystectomy. She had completed her second cycle of pemetrexed chemotherapy two weeks before admission. Four days before onset of symptoms, she attended a wedding and consumed a seafood salad containing squid and octo-pus. Medications on admission consisted of esomeprazole 40 mg daily and hydrochlorothiazide 25 mg daily. Investigations revealed a white blood cell count of 3400 cells/µL (absolute neutrophil count of 1480 cells/µL), elevated liver enzyme levels (alanine aminotransfer-ase 505 U/L, aspartate aminotransferase 306 U/L, alkaline phosphat-ase 259 U/L) and total bilirubin level (78 µmol/L). A computed tomography scan and ultrasound of the abdomen revealed multiple liver metastases with no evidence of intrahepatic or extrahepatic bile duct dilation. She was treated empirically with ceftriaxone and metronidazole. Two peripheral blood cultures were drawn before starting empirical therapy.

DIagnoSISBoth blood cultures grew bacteria identified as belonging to the genus Raoultella using the VITEK MS (bioMérieux, France) matrix-assisted laser desorption/ionization – time-of-flight mass spectrometry tech-nique. The bacteria were further identified as Raoultella planticola using the VITEK-2 (bioMérieux) automated bacterial identification system. The isolate was resistant to ampicillin and trimethoprim/sulfamethoxazole and susceptible to amoxicillin/clavulanic acid, ceftriaxone, ciprofloxacin, gentamicin, tobramycin and piperacillin/tazobactam (Table 1). Based on her clinical presentation and labora-tory results, a diagnosis of cholangitis was suspected but abdominal

imaging did not demonstrate biliary abnormalities. She was success-fully treated with ceftriaxone intravenously for three days followed by oral ciprofloxacin for an additional seven days. Definitive imaging of the biliary tract was not obtained because the patient’s symptoms and laboratory abnormalities improved with antibiotic therapy. She was discharged home eight days after admission.

DISCUSSIonR planticola is an encapsulated, aerobic, nonmotile, Gram-negative bacillus commonly found in water, soil and aquatic environments. Infections in humans have been rarely reported. R planticola is a diffi-cult organism to isolate in the laboratory and has been commonly been mistaken for Klebsiella species.

R planticola (along with Raoultella ornithinolytica) possesses the abil-ity to convert histidine to histamine via decarboxylation. This can lead to scombroid poisoning when there is consumption of poorly refrigerated histidine-containing seafood (not only scombroid fish) (1). The bacterial conversion of histidine to histamine results in symp-toms that include the acute onset of facial flushing, nausea, vomiting, diarrhea, hives and generalized pruritis that subsides in a few hours.

To date, 16 cases of R planticola human infection have been reported in the literature. Initially described in patients with sepsis (2), infection has since been described in a variety of settings. In 2012, Olson et al (3) published a case of cystitis caused by R planticola and, within the article, summarized 10 previous cases of R planticola infec-tion. Since this publication, five additional cases of R planticola infec-tion have been reported (4-7). Of the 16 cases, three cases occurred after surgical interventions (open reduction and internal fixation for tibial fracture, mitral valve replacement, coronary artery bypass graft), two cases followed skin trauma, and two cases after endoscopic retro-grade cholangiopancreatography (ERCP).

case report

Lam and Salit

Can J Infect Dis Med Microbiol Vol 25 July/August 2014e84

R planticola bacteremia may occur following consumption of sea-food. Puerta-Fernandez et al (5) described a 63-year-old man with abdominal pain and fever after consuming poorly prepared fish. Blood cultures grew a cephalosporin-susceptible R planticola and the patient was treated with 10 days of intravenous cefotaxime (5). Neither our patient nor the aforementioned case report exhibited signs of scombroid-like poisoning.

In contrast to this previously reported case (5), our patient had several risk factors that may have increased the likelihood of developing R planticola bacteremia. First, our patient had received chemotherapy two weeks before presentation. Of the 16 documented infections, an underlying malignancy was present in five cases (4,7-9), two of which had received recent chemotherapy (7,8). Although our patient did not have febrile neutropenia, the history of receiving pemetrexed chemotherapy likely contributed to the bacteremia, either by myelosuppression or via disruption of gastrointestinal mucosa. Hematological and gastrointestinal toxicities are common adverse effects associated with pemetrexed monotherapy in non-small cell lung cancer (10). Our patient had a more delayed onset of symptoms (three days) compared with the previous seafood-related case (5), in which the patient became symptomatic within hours of ingestion. This may be explained by a smaller number of ingested bacteria.

Second, our patient was taking esomeprazole before admission. Concomitant use of proton pump inhibitors has been associated with an increased risk of bacterial gastroenteritis as a result of the increased survival of enteric pathogens in the less acidic environment (11). The combination of immunosuppression with a proton pump inhibitor may have predisposed this patient to clinically significant disease in what may have been self-limiting illness in a healthy individual. There were no documented cases of R planticola infection in others who had con-sumed the seafood at the wedding.

The presence of Charcot’s triad suggested cholangitis. The two previous cases of R planticola cholangitis reported in the literature occurred post-ERCP (4,9). Our patient did not undergo recent ERCP; thus, other factors played a role in the probable biliary tract infection. We hypothesize that the patient acquired the bacteria from seafood consumption. The bacteria were able to colonize the biliary tract sec-ondary to altered biliary flow due to hepatic metastases and immuno-suppression from the pemetrexed. Alternatively, the ingested R planticola led to portal pyemia and bacteremia. Although pemetrexed can cause elevated liver transaminase levels, the time course of enzyme elevation and normalization with antibiotic therapy was not in keep-ing with a drug-induced etiology.

The susceptibility pattern of R planticola isolated from this patient was similar to previous case reports. However, multidrug-resistant strains of R planticola have been isolated from both patients (7,8) and the environment (12). Given the ubiquity of these bacteria in the environment, R planticola may be an important reservoir for anti-microbial resistance genes and may facilitate the acquisition of multi-drug resistance in pathogenic organisms through chromosomal and plasmid-mediated mechanisms.

SUMMary We present a case of R planticola bacteremia following recent seafood consumption. The clinical presentation was consistent with chol-angitis and, in contrast to previous case reports, was not associated with recent ERCP. Immunosuppression, proton pump inhibitor use and altered biliary flow secondary to hepatic metastases may have been contributing factors to the pathogenesis of disease.

rEfErEnCES1. Kanki M, Yoda T, Tsukamoto T, Shibata T. Klebsiella pneumoniae

produces no histamine: Raoultella planticola and Raoultella ornithinolytica strains are histamine producers. Appl Environ Microbiol 2002;68:3462-6.

2. Freney J, Fleurette J, Gruer LD, Desmonceaux M, Gavini F, Leclerc H. Klebsiella trevisanii colonisation and septicaemia. Lancet 1984;1:909.

3. Olson DS Jr, Asare K, Lyons M, Hofinger DM. A novel case of Raoultella planticola urinary tract infection. Infection 2013;41:259-61.

4. Hu AY, Leslie KA, Baskette J, Elsayed S. Raoultella planticola bacteraemia. J Med Microbiol 2012;61(Pt 10):1488-9.

5. Puerta-Fernandez S, Miralles-Linares F, Sanchez-Simonet MV, Bernal-Lopez MR, Gomez-Huelgas R. Raoultella planticola bacteraemia secondary to gastroenteritis. Clin Microbiol Infect 2013;19:E236-7.

6. Teo I, Wild J, Ray S, Chadwick D. A rare case of cholecystitis caused by Raoultella planticola. Case Rep Med 2012;2012:601641.

7. Tseng SP, Wang JT, Liang CY, Lee PS, Chen YC, Lu PL. First report of bla(IMP-8) in Raoultella planticola. Antimicrob Agents Chemother 2014;58:593-5.

8. Castanheira M, Deshpande LM, DiPersio JR, Kang J, Weinstein MP, Jones RN. First descriptions of blaKPC in Raoultella spp. (R. planticola and R. ornithinolytica): Report from the SENTRY Antimicrobial Surveillance Program. J Clin Microbiol 2009;47:4129-30.

9. Yokota K, Gomi H, Miura Y, Sugano K, Morisawa Y. Cholangitis with septic shock caused by Raoultella planticola. J Med Microbiol 2012;61(Pt 3):446-9.

10. Ciuleanu T, Brodowicz T, Zielinski C, et al. Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small-cell lung cancer: A randomised, double-blind, phase 3 study. Lancet 2009;374:1432-40.

11. Garcia Rodriguez LA, Ruigomez A, Panes J. Use of acid-suppressing drugs and the risk of bacterial gastroenteritis. Clin Gastroenterol Hepatol 2007;5:1418-23.

12. Koc S, Kabatas B, Icgen B. Multidrug and heavy metal-resistant Raoultella planticola isolated from surface water. Bull Environ Contam Toxicol 2013;91:177-83.

TabLe 1In vitro susceptibility profile of the Raoultella planticola isolate using VITeK-2*antimicrobial agent MIC (mg/L)Ampicillin 16Amoxicillin/clavulanic acid ≤2Ceftriaxone ≤1Ciprofloxacin ≤0.25Gentamicin ≤1Tobramycin ≤1Piperacillin/tazobactam ≤4Trimethroprim/sulfamethoxazole ≥16/304*bioMérieux, France. MIC Minimum inhibitory concentration

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