Case of Catheter Sepsis with Ralstonia gilardii in a Child with Acute Lymphoblastic Leukemia

Abstract

Acute lymphoblastic leukemia was diagnosed in a 7-year-old girl. Two months after insertion of a central venous catheter, she developed fever and complained of headache and abdominal pain. Physical examination revealed no focus of infection. A gram-negative nonfermenting bacillus was recurrently cultured from blood. Extensive biochemical testing and 16S ribosomal DNA sequencing led to the identification of Ralstonia gilardii. CASE REPORTAcute lymphoblastic leukemia (ALL) was diagnosed in a 7-year-old girl in May 2000, and treatment was initiated according to the EORTC-CLCG-58951 protocol for children with very-low-risk ALL. The girl achieved hematologic remission after induction chemotherapy. A central venous catheter was inserted in June 2000. The girl tolerated the treatment uneventfully until September 2000, when, during a course of chemotherapy (high-dose methotrexate), she developed spiking fever as high as 40°C. She complained of headache and abdominal pain and vomited twice. Physical examination revealed no focus of infection. The leucocyte count was 5,800/ml, with an absolute neutrophil count of 4,760/ml and elevated C-reactive protein (87 mg/dl). The chemotherapy was stopped, and the girl was treated with intravenous (i.v.) ampicillin (100 mg/kg of body weight/day). One day later blood cultures grew gram-negative bacilli, and (i.v.) netromycin (7.5 mg/kg/day) treatment was added. The spiking fever disappeared and the girl's health improved.A gram-negative nonfermenting bacillus was isolated and found to be resistant to ampicillin, piperacillin, aztreonam, gentamicin, and tobramycin and susceptible to cefuroxime, ceftriaxone, ceftazidime, imipenem, co-trimoxazole, ofloxacin, and amikacin. The girl was treated as an outpatient with i.v. ceftriaxone (100 mg/kg/day) once daily for 4 more days. Thirtysix hours after the ceftriaxone treatment was stopped, she again developed spiking fever, and i.v. ceftriaxone (100 mg/kg/ day) was restarted in combination with i.v. amikacin (15 mg/ kg/day). Again, a gram-negative nonfermenting bacillus was cultured from blood. The girl showed an allergic reaction to ceftriaxone with rash and pruritus, and the ceftriaxone was replaced with i.v. ciprofloxacin (20 mg/kg/day). The spiking fever disappeared again, and amikacin and ciprofloxacin i.v. treatment was given for 7 more days. Blood cultures remained negative, and the central venous catheter was not removed. Three months later the intensive chemotherapy was completed and the girl was doing well. The catheter was removed on January 8 2001. No nonfermenting gram-negative bacilli were cultured from the tip.Discussion. The gram-negative bacillus was isolated in pure culture from all eight FAN aerobic blood cultures and from one of the eight BacT/Alert anaerobic cultures (Organon Teknika, Turnhout, Belgium), collected over a period of 10 days. Initial identification based on the API20NE system (bioMérieux, Marcy l'Etoile, France) yielded code 1000474, leading to an identification as Alcaligenes faecalis, Comamonas acidovorans ...

Fatal Infection Caused by Cupriavidus gilardii in a Child with Aplastic Anemia

“…To our knowledge, the presented case represents the first fatal infection caused by this organism. Intriguingly, our case of C. gilardii infection is quite similar to the case presented by Wauters et al (9). In both situations, the patients were young and immunocompromised.…”

“…Furthermore, C. gilardii has been identified in respiratory secretions of cystic fibrosis patients (2,3). The only reported clinical infection caused by C. gilardii was described by Wauters et al in 2001. In this case, the organism was the cause of catheter-related sepsis in a 7-year-old female patient with acute lymphoblastic leukemia (9).…”

“…The only reported clinical infection caused by C. gilardii was described by Wauters et al in 2001. In this case, the organism was the cause of catheter-related sepsis in a 7-year-old female patient with acute lymphoblastic leukemia (9). A bloodstream isolate from the patient was found to be resistant to ampicillin, piperacillin, aztreonam, gentamicin, and tobramycin and susceptible to cefuroxime, ceftriaxone, ceftazidime, imipenem, cotrimoxazole, ofloxacin, and amikacin.…”

“…The child was treated with intravenous ampicillin, netromycin, ceftriaxone, ciprofloxacin, and amikacin at different points in time based in part on the blood culture results and in part on the patient's response to therapy. After treatment, her sepsis resolved completely (9).…”

Classification of Ralstonia pickettii-like isolates from the environment and clinical samples as Ralstonia insidiosa sp. nov.

“…Strains of R. mannitolilytica (formerly known as 'Pseudomonas thomasii' and R. pickettii biovar 3) have also been isolated from various clinical sources, including nosocomial recurrent meningitis (Philips et al, 1972;De Baere et al, 2001;Vaneechoutte et al, 2001). R. gilardii, R. paucula and R. taiwanensis have been isolated both from human clinical samples and from the environment Vandamme et al, 1999;Chen et al, 2001;Wauters et al, 2001). Recent studies have demonstrated that R. pickettii, R. mannitolilytica, R. gilardii and R. taiwanensis can also be recovered from the respiratory tract of cystic fibrosis (CF) patients (Chen et al, 2001;Coenye et al, 2002a, b).…”