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CASE REPORT
Year : 2022  |  Volume : 21  |  Issue : 3  |  Page : 299-300  

Steroid and sphingomonas


1 Assistant Professor, Department of General Medicine, All India Institute of Medical Science, Raipur, Chhattisgarh, India
2 Professor, Department of General Medicine, All India Institute of Medical Science, Raipur, Chhattisgarh, India
3 Associate Professor, Department of General Medicine, All India Institute of Medical Science, Raipur, Chhattisgarh, India
4 Intern, Department of General Medicine, All India Institute of Medical Science, Raipur, Chhattisgarh, India

Date of Submission11-Jun-2021
Date of Decision25-Dec-2021
Date of Acceptance03-Jan-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Pankaj Kumar Kannauje
Department of General Medicine, All India Institute of Medical Science, Room No D1-413, 4th Floor, D Block, Gate No 4, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_120_21

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   Abstract 


Sphingomonas paucimobilis is a Gram-negative bacteria identified as a rare infectious agent, more commonly seen among immune-compromised hosts. Infections include bacteremia, septicemia leading to septic shock, bone and soft-tissue infections such as septic arthritis, osteomyelitis, infection of shunts, and implantable devices. Although the organism has been reported to have low pathogenicity, infections in the immune compromised can be devastating leading to even death.

   Abstract in French 

Résumé
Sphingomonas paucimobilis est une bactérie Gram-négative identifiée comme un agent infectieux rare, plus fréquemment observé chez les hôtes immunodéprimés. Les infections comprenaient la bactériémie, la septicémie entraînant un choc septique, les infections des os et des tissus mous telles que l'arthrite septique, l'ostéomyélite, l'infection des shunts et des dispositifs implantables. Bien que l'organisme ait été signalé comme ayant une faible pathogénicité, les infections chez les personnes immunodéprimées peuvent être dévastatrices et même entraîner la mort.
Mots clés: Sphingomonas, stéroïdes, antibiotiques

Keywords: Antibiotics, Sphingomonas, steroids


How to cite this article:
Kannauje PK, Pandit VR, Wasnik PN, Venkat N. Steroid and sphingomonas. Ann Afr Med 2022;21:299-300

How to cite this URL:
Kannauje PK, Pandit VR, Wasnik PN, Venkat N. Steroid and sphingomonas. Ann Afr Med [serial online] 2022 [cited 2022 Nov 29];21:299-300. Available from: https://www.annalsafrmed.org/text.asp?2022/21/3/299/356824




   Introduction Top


The bacterium infects any age group, from neonates to adults, with reports of deaths in both demographic age groups. Given that it is both community (soil and water borne) and nosocomial derived, widespread antibiotic resistance poses a challenge in the treatment of this infection.[1] We are reporting this interesting case because the early suspicion of cortisol insufficiency was made in view of nonimprovement of blood pressure with adequate hydration. Hence, the catch in this case report is that early institution of steroid leads to increased peripheral circulation, along with antibiotics improving the outcome of the patient.


   Case Report Top


A 65-year-old male, who is a known case of chronic obstructive lung disease (COLD), presented to the medicine outpatient department with complaints of multiple episodes of loose stools with blood for 3 days, undocumented fever for 1 day, and a single episode of vomiting.

On physical examination, the patient appeared ill, compos mentis, with a falling blood pressure (66/48 mmHg on admission), tachycardia, tachypnea, and fall in saturation (86% on room air). General examination revealed pale, cold, and clammy peripheries with delayed skin pinch test and dried mucus membranes. Radial pulse on palpation was feeble. Auscultation over regions of lung fields revealed bilateral rhonchi which corroborated with the history of COLD.

A provisional diagnosis of acute gastroenteritis with mild-moderate dehydration and hypovolemic/septic shock was made. The patient was started on adequate fluid therapy and oxygen supplementation. He was nebulized with salbutamol four times a day and budesonide twice a day.

Complete blood counts revealed hemoglobin of 11.1 g%, total leukocyte count of 24,500 cells/cu mm with neutrophilic predominance (87%), and a platelet count of 325,000/ml. His random blood sugar was 8 mmol/l, serum creatinine 0.9 mg/dL, blood urea 9 mmol/l, serum sodium 138 mmol/l, serum potassium 3.9 mmol/l, and serum chloride 96 mmol/l. Liver function tests were normal. Blood culture and sensitivity report tested positive for Sphingomonas paucimobilis which was sensitive to amikacin, cefepime, ceftriaxone, ciprofloxacin, gentamicin, levofloxacin, meropenem, and tobramycin.

Based on blood culture and sensitivity report, the patient was started on ceftriaxone. Following this, patients' vitals stabilized briefly on the 2ndday.

However, despite ongoing fluid therapy, the patient's blood pressure showed constant fluctuations. Serum cortisol levels were tested at 8 AM (normal reference level: 6.7–22.6 μg/dL) and 4 PM (<10 μg/dL) with a patient value of 5.8 μg/dL suggestive of adrenal insufficiency. The patient was injected with hydrocortisone loading dose of 100 mg than 50 mg qid for 2 days under bilateral limb blood pressure monitoring and showed drastic recovery. Following a symptom-free interval, the patient was discharged.


   Discussion Top


S. paucimobilis, the main pathogenic species of the Sphingomonas genus, is a yellow-pigmented, glucose nonfermenting, aerobic, weakly oxidase-positive Gram-negative bacilli. The organism can be isolated from a range of clinical specimens including blood, sputum, urine, and cerebrospinal fluid.[1]

Blood culture showing positive reports on admission (<48 h) of this case suggests the likelihood of a community-acquired infection. Community spread of the organism occurs both via soil and water. Hospital setting for infection arises from implantation of indwelling catheter, sterile intravenous fluid, contaminated tap and distilled water, ventilator, nebulizer, and hemodialysis devices.

The organism is known to infect immunocompromised patients more.[2] This could be the consequence of interplay between host immunity and the low virulence of the organism owing to the absence of lipopolysaccharide component and endotoxin activity.

However, reports of infection from immune-competent hosts are also emerging, as can be seen in our case.[3] Among the comorbidities that provide a fertile soil for the organism to flourish, common causes include diabetes mellitus, malignancy, liver cirrhosis and alcoholism, end-stage renal disease, acquired immunodeficiency syndrome, and chronic obstructive pulmonary disease as seen in our case. Once the infection takes root in the background of such comorbidities, they can result in bacteria, catheter-related sepsis, meningitis, peritonitis, adenitis, cutaneous infections, septic arthritis, osteomyelitis, endophthalmitis, visceral abscess, and as in our patient, diarrheal diseases.[1] Infections causing death have been reported in two cases, one adult patient and one in a premature neonate.[2],[4]

Owing to chromosomally encoded beta-lactamase production, this organism is resistant to penicillin, piperacillin, colistin, cefoperazone, ceftazidime, and first-generation cephalosporins.[5] Good response has been noted with third-generation cephalosporins, aminoglycosides, and carbapenems.[5] This needs to be borne in mind while treating this infection with a battery of antibiotics. Studies have shown widespread resistance to antibiotics including amikacin, ceftazidime, cefoxitin, cefotaxime, and fluoroquinolones.[5] Currently, in the absence of specific antibiotic guidelines in the treatment of S. paucimobilis, culture and sensitivity profiles are used to guide treatment with regard to choice of antibiotics. In this case, the patient responded to ceftriaxone and steroid for suspected adrenal insufficiency.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Smalley DL, Hansen VR, Baselski VS. Susceptibility of Pseudomonas paucimobilis to 24 antimicrobial agents. Antimicrob Agents Chemother 1983;23:161-2.  Back to cited text no. 1
    
2.
Hardjo Lugito NP, Cucunawangsih, Kurniawan A. A lethal case of Sphingomonas paucimobilis bacteremia in an immunocompromised patient. Case Rep Infect Dis 2016;2016:3294639.  Back to cited text no. 2
    
3.
Pascale R, Russo E, Esposito I, Leone S, Esposito S. Sphingomonas paucimobilis osteomyelitis in an immunocompetent patient. A rare case report and literature review. New Microbiol 2013;36:423-6.  Back to cited text no. 3
    
4.
Mutlu M, Bayramoglu G, Yilmaz G, Saygin B, Aslan Y. Outbreak of Sphingomonas paucimobilis septicemia in a neonatal intensive care unit. Indian Pediatr 2011;48:723-5.  Back to cited text no. 4
    
5.
Cheong HS, Wi YM, Moon SY, Kang CI, Son JS, Ko KS, et al. Clinical features and treatment outcomes of infections caused by Sphingomonas paucimobilis. Infect Control Hosp Epidemiol 2008;29:990-2.  Back to cited text no. 5
    




 

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