Plesiomonas shigelloides septicemia and meningitis in a neonatedownloads.hindawi.com/journals/cjidmm/1996/404780.pdf · 2019-08-01 · toms. This neonate never had diarrhea. Plesiomonas

Plesiomonas shigelloidessepticemia and meningitis

in a neonate

JULIAN D EASON MBBS MRCP (UK), DONLIM PEACOCK MBCHB FRCPC

Plesiomonas shigelloides was originally isolated in 1947 by

Ferguson and Henderson (1) who noted certain antigenic

similarities between it and Shigella. The organism was desig-

nated C27 and considered a member of the family Enterobacte-

riaceae. It was later called Aeromonas. The genus Plesiomonas

currently resides in the family Vibrionaceae. P shigelloides is a

facultatively anaerobic, Gram-negative, oxidase-positive, motile

rod. It is readily isolated on enteric media as a lactose nonfer-

menter. The primary natural reservoirs are soil, surface water

and fish, especially shellfish such as oysters (2). Infections

with P shigelloides often cause gastroenteritis, but it has been

associated with septicemia, cellulitis, arthritis, cholecystitis,

osteomyelitis and meningitis (3,4). Most infections with this

organism have been described in Japan (where a great deal of

shellfish is eaten), in the Indian subcontinent and in Africa.

The vast majority of Caucasians infected with this bacterium

have been travellers to high risk areas or those who have

recently eaten raw shellfish. A case of P shigelloides sepsis in

a neonate with complications of endophthalmitis and multifo-

cal intracerebral abscesses is described. To the best of our

knowledge this is the first reported case of neonatal P shigel-

loides infection in Canada.

CASE PRESENTATIONA male was born to a healthy mother whose membranes

were artificially ruptured 16 h before delivery. Delivery was

induced at 36 weeks because of a previous intrauterine death

at 38 weeks. The Apgar scores were 8 at 1 min and 9 at 5 mins,

and the baby weighed 3410 g (90th percentile).

The mother had intermittent diarrhea throughout her preg-

CASE REPORT

Special Care Nursery, British Columbia’s Children’s Hospital, Vancouver, British Columbia

Correspondence: Dr Julian D Eason, Department of Paediatrics, Jersey General Hospital, St Helier, Jersey JE3 1LD. Telephone 01 534 59000,

fax 01534 59805, e-mail [email protected]

Received for publication January 22, 1996. Accepted May 24, 1996

JD EASON, D PEACOCK. Plesiomonas shigelloides septicemia and meningitis in a neonate. Can J Infect Dis1996;7(6):380-382. A newborn infant is described who presented with septicemia and meningoencephalitis caused by

Plesiomonas shigelloides, a Gram-negative rod belonging to the family Vibrionaceae. This appears to be the firstdocumented case in a neonate in Canada. Despite prompt treatment with appropriate antibiotics, he developed

endophthalmitis and lytic brain lesions.

Key Words: Endophthalmitis, Meningitis, Neonate, Plesiomonas shigelloides

Septicémie et méningite à Plesiomonas shigelloides chez un nouveau-né

RÉSUMÉ : On décrit ici le cas d’un nouveau-né atteint de septicémie et de méningite à Plesiomonas shigelloides, bacille

gram-négatif appartenant au genre Vibrio. Il s’agirait du premier cas documenté d’infection de ce type au Canada. Malgré

l’instauration rapide de l’antibiothérapie nécessaire, l’enfant a développé une endophtalmie et des lésions cérébraleslytiques.

380 CAN J INFECT DIS VOL 7 NO 6 NOVEMBER/DECEMBER 1996

EASON.CHPMon Dec 02 16:24:46 1996

Color profile: DisabledComposite Default screen

nancy that was attributed to iron prescribed for anemia. Two

weeks before the induction of labour following a regular sushi

dinner, her diarrhea became worse, and she required intrave-

nous rehydration in an emergency room. This worsening of the

diarrhea lasted for 10 days. At that time the iron was still

thought to be the cause of the bowel problems.

During the first day of life, the baby was a little restless and

fed poorly. At 24 h of age he was febrile at 37.7°C, with a

vasculitic type rash on his back. A blood culture and complete

blood count were taken, and treatment started with intravenous

ampicillin (100 mg/kg/day) and gentamicin (5 mg/kg/day). The

total leukocyte count was 6.69×109/L with 0.97×109/L granu-

locytes and 0.25 bands with a platelet count of 192×109/L.

Within an hour he became irritable and hypertonic. A lumbar

puncture was performed to complete the sepsis work-up. Cefo-

taxime (150 mg/kg/day) treatment was commenced immediately

after the cerebrospinal fluid (CSF) was taken. CSF contained

6600×106/L leukocytes (97% granulocytes), 2600×106/L red

blood cells and a protein concentration of 2.92g/L. CSF Gram

stain showed abundant Gram-negative rods. A repeat blood

count at that time revealed progressive neutropenia and throm-

bocytopenia (21×109/L). A Gram-negative bacterium with coli-

form morphology was detected in a blood culture (Bactec 9240

medium, Becton Dickinson Diagnostic Instruments Systems,

Maryland). In addition CSF yielded the same bacterium, which

was oxidase-positive. The organism was presumptively iden-

tified as P shigelloides on the basis of a biochemical assess-

ment with a replica plating technique. Further assessment

with the API 20E identification system (Bio Mérieux, Missouri)

confirmed the speciation. Susceptibility to cefotaxime, ceftriax-

one, cotrimoxazole and gentamicin was established, with re-

sistance to ampicillin. Treatment was continued with

cefotaxime and gentamicin. A fecal culture taken from the

mother three days postpartum failed to grow any pathogens,

and this assessment included a direct search for P shigel-

loides.

At 26 h of age the baby had repeated seizure activity and

required treatment with phenobarbitone, phenytoin and loraz-

epam. Mechanical ventilation was required. Clinical examina-

tion of the pupils revealed a white opacity on the right side.

Ophthalmic examination the following day confirmed the

presence of endophthalmitis with purulent exudate coating

the anterior of the lens and iris. A cranial ultrasound on day 2

revealed multiple focal areas of increased echogenicity in the

frontal lobes and cerebellar folia. Subsequent computed to-

mography (CT) scans on day 4 revealed white matter edema,

and on day 21 revealed multifocal intracerebral cystic and

solid lesions (Figure 1). At one month of age a ventriculoperi-

toneal shunt was inserted for relief of obstructive hydrocepha-

lus, and a 5×5 cm frontal lobe abscess was drained. Micro-

scopic examination of the abscess material demonstrated

necrotic brain tissue. No bacteria were seen, and subsequently

there was no growth on culture. Antibiotic treatment was

continued for a total of six weeks. The child survived to

discharge at the age of two months with signs of severe neuro-

logical damage. Ophthalmic infection resolved, but examina-

tion at three months revealed a vitreous condensation over the

optic nerve head.

Figure 1) Computed tomogram of the cranium: large frontal and multifocal intracerebral abscesses in a neonate infected with Plesimonas shigelloides

CAN J INFECT DIS VOL 7 NO 6 NOVEMBER/DECEMBER 1996 381

P shigelloides septicemia and meningitis



DISCUSSIONPlesiomonas is a rare cause of neonatal sepsis and menin-

gitis with high morbidity and mortality. To the best of our

knowledge only 10 other cases have been reported (4-13). The

probable source of infection in this case was the intestinal

infection of the mother. The baby acquired the organism peri-

natally rather than in utero, given the time of onset of symp-

toms. This neonate never had diarrhea. Plesiomonas infection

causing gastroenteritis in adults is well described and is usu-

ally a self-limiting diarrheal illness (14). A total of 24 such

cases were reported in British Columbia in 1994 (15).

P shigelloides may be resistant to ampicillin but is uni-

formly susceptible to third-generation cephalosporins, particu-

larly cefotaxime (10,11,16). Five of the 10 previously described

cases received cefotaxime as one of their antibiotics; four

survived and three had no sequelae. Among the five patients

who did not receive cefotaxime, there was only one survivor,

a child who was treated with penicillin G and gentamicin and

suffered no sequelae (7). The others received either a combi-

nation of ampicillin and an aminoglycoside, or rifampicin.

P shigelloides in the present case was resistant to ampicillin.

Cefotaxime was added as soon as meningitis was sus-

pected.

Endophthalmitis caused by P shigelloides was previously

described in one case, but it was acquired with a penetrating

fishhook injury and necessitated enucleation (17). It seems

that this is a most unusual localization of neonatal bacterial

infection, but it is consistent with a high bacterial load in the

bloodstream, as indicated by the early onset of vasculitic rash

and thrombocytopenia in the present case. Infection resolved

without intraocular administration of antibiotics. Brain ab-

scesses are an unusual complication of meningitis and multi-

ple abscesses even more so. We attributed this complication to

vasculitis leading to thrombosis and cerebral infarction (18).

Gram-negative organisms most often cause necrotizing cere-

britis and abscesses, particularly Proteus, Escherichia and

Citrobacter species (18,19). Necrotizing ependymitis and the

subsequent formation of synechiae are thought to account for

noncommunicating hydrocephalus and the formation of mul-

tiloculated intraventricular cysts seen in this patient.

For an organism that is often described as a sporadic cause

of a self-limiting diarrheal illness, plesiomonas must be re-

garded as highly virulent in the neonate.

ACKNOWLEDGEMENTS: We thank Dr David Scheifele and Dr Nevio

Cimolai for their help in compiling this report.

REFERENCES1. Ferguson WW, Henderson ND. Description of strain C27: A

motile organism with the major antigen of Shigella sonneiphase 1. J Bacteriol 1947;54:179-81.

2. Scholfield G. Emerging food-borne pathogens and theirsignificance in chilled foods. J Appl Bacteriol 1992;72:267-73.

3. Zeaur R, Akbar A, Bradford AK. Prevalence of Plesiomonasshigelloides among diarrhoeal patients in Bangladesh.Eur J Epidemiol 1992;8:753-6.

4. Fujita K, Shirai M, Ishioka T, Kakuya F. Neonatal Plesiomonasshigelloides septicaemia and meningitis: A case review. ActaPaediatr Jpn 1994;36:450-2.

5. Appelbaum PC, Bowen AJ, Adhikari M, et al. Neonatal septicemiaand meningitis due to Aeromonas shigelloides. J Pediatr1978;92:676-7.

6. Dahm LJ, Weinberg AG. Plesiomonas (Aeromonas) shigelloidesmeningitis in a neonate. South Med J 1980;73:393-4.

7. Su S, Ee CK. Plesiomonas shigelloides meningitis in a newborn.J Singapore Paediatr Soc 1981;23:156-8.

8. Dudley AG, Mays W, Sale L. Plesiomonas (Aeromonas)shigelloides meningitis in a neonate: A case report. J Med AssocGa 1982;71:775-6.

9. Pathak A, Custer JR, Levy J. Neonatal septicemia and meningitisdue to Plesiomonas shigelloides. Pediatrics 1983;71:389-91.

10. Matsumoto K, Nakanishi Y, Suzuki H, et al. Plesiomonasshigelloides meningitis in a neonate. J Jpn Assoc Infect Dis1986;60:798.

11. Waeker NJ, Davis CE, Bernsrein G, Spector SA. Plesiomonasshigelloides septicemia and meningitis in a newborn. PediatrInfect Dis J 1988;7:877-9.

12. Billiet J, Kuypers S, Van Lierde J, Verhaegen J. Plesiomonasshigelloides meningitis. Report of a case and review of theliterature. J Infect 1989;19:267-71.

13. Terpeluk C, Goldmann A, Bartmann P, Pohlandt F. Plesiomonasshigelloides sepsis and meningoencephalitis in a neonate.Eur J Pediatr 1992;151:499-501.

14. Brendan RA, Miller MA, Janda JM. Clinical disease spectrum andpathogenic factors associated with Plesiomonas shigelloidesinfections in humans. Rev Infect Dis 1988;10:303-16.

15. Annual Report of the Provincial Laboratory. Victoria: BC Centrefor Disease Control, 1994.

16. Kain KC, Kelly MT. Antimicrobial susceptibility of Plesiomonasshigelloides from patients with diarrhea. Antimicrob AgentsChemother 1989;33:1609-10.

17. Cohen KL, Holyk PR, McCarthy LR, Peiffer RL. Aeromonashydrophila and Plesiomonas shigelloides enopthalmitis.Am J Opthalmol 1983;96:403-4.

18. Brown LW, Zimmerman RA, Bilaniuk LT. Polycystic braindisease complicating neonatal meningitis: Documentation ofevolution by computed tomography. J Pediatr 1979;5:757-9.

19. Cussen LJ, Ryan GB. Hemorrhagic cerebral necrosis in neonatalinfants with enterobacterial meningitis. J Pediatr 1967;71:771-6.

382 CAN J INFECT DIS VOL 7 NO 6 NOVEMBER/DECEMBER 1996

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Plesiomonas shigelloides septicemia and meningitis in a neonatedownloads.hindawi.com/journals/cjidmm/1996/404780.pdf · 2019-08-01 · toms. This neonate never had diarrhea. Plesiomonas