Meningitis and Bacteremia Due to Neisseria cinerea following a Percutaneous Rhizotomy of the Trigeminal Ganglion

Abstract

e Neisseria cinerea is a human commensal. The first known case of meningitis and bacteremia due to Neisseria cinerea following percutaneous glycerol instillation of the trigeminal ganglion is reported. Conventional phenotypic methods and complete 16S RNA gene sequencing accurately identified the pathogen. Difficulties in differentiation from pathogenic neisseriae are discussed. CASE REPORTA 58-year-old male patient presented the day after a percutaneous glycerol rhizotomy of the trigeminal ganglion with fever (38.2°C), clinical signs of meningitis without new focal neurologic deficits, and a normal neurocognitive status.His personal history was remarkable for severe trigeminal neuralgia refractory to medical treatment and for diagnosis of primary progressive multiple sclerosis for 13 years without immunosuppressive treatment.His white blood cell count (18.9 G/liter; 90% neutrophils, no left shift) and his C-reactive protein level (189 mg/dl) were elevated. Two sets of blood cultures and a lumbar puncture were immediately performed, and empirical antibiotic treatment with intravenous (i.v.) ceftriaxone administered in two doses at 2 g per dose (2x2g) was started. The cerebrospinal fluid (CSF) sample showed 4,125 nuclear cells/l, with 89% polymorphonuclear neutrophils. Protein and glucose (GLU) levels were abnormal, with 1.32 g (normal, 0.15 to 0.45) of protein/liter and 0.29 mmol (normal, 2.2 to 3.9) of glucose/liter in the CSF. Gram staining of the CSF revealed Gram-labile cocci.A computed tomography (CT) scan showed a small amount of intracerebral air near the trigeminal ganglion, confirming accidental involvement of intracerebral structures during rhizotomy (Fig. 1A). Flucloxacillin (6x2g) was added to the regimen. Droplet isolation precautions were not considered necessary because the clinical picture was suggestive for iatrogenic complication and not for meningococcal meningitis (1, 2).The following day, Neisseria species, susceptible to penicillin, ampicillin, ceftriaxone, and ciprofloxacin, grew in one of two sets of blood cultures and the CSF cultures (Table 1). Flucloxacillin treatment was stopped, and ceftriaxone treatment was continued for 7 days in total, according to the recommended treatment duration for meningitis due to N. meningitidis (3). The patient recovered rapidly. After 1 week, he was asymptomatic, with normal blood values.The CSF isolate was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) analysis (MALDI BioTyper; Bruker Daltonik, Bremen, Germany) as Neisseria meningitidis, with a score of 1.82 (sufficient only for genus assignment). Neisseria cinerea was the third species proposed by MALDI-TOF MS, with a minimal difference in the score (1.81). The colony morphology turned out to show no pigmentation. API NH V3.0 (bioMérieux Suisse SA, Geneva, Switzerland) testing was performed, with a positive reaction only for ProA, consistent with N. cinerea, and negative test results for glucose (GLU), maltose (MAL), and ␥-glutamyl aminopeptidas...

Recurrent Neisseria cinerea bacteremia secondary to cardiovascular implantable electronic device infection

“…Although both diplococci, N. cinerea can be differentiated from N. gonorrhoeae due to its sensitivity to colistin and its ability to proliferate on Mueller-Hinton agar [8] . The widespread implementation of matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has improved the identification of Neisseria species but remains imperfect [9] , [10] .…”

“…While N. cinerea is generally considered a commensal organism, cases of invasive infection have been reported, primarily occurring in immunocompromised hosts. The spectrum of disease is broad and includes ocular infections in pediatric patients, particularly neonates [11] , [12] , [13] , pulmonary infection [14] , [15] , peritonitis in patients receiving peritoneal dialysis [16] , [17] , [18] , and bacteremia [4] , [6] , [10] , [15] , [19] , [20] , [21] , [22] . Infection of the central nervous system has been reported, although was probably due to direct inoculation in both cases [10] , [20] .…”

Neisseria Cinerea Bacteremia Secondary to a Retropharyngeal Abscess

“…The cases of Neisseria cinerea bacteremia include one case of posttraumatic meningitis with bacteremia, bacteremia in one post-splenectomy patient, one patient with AIDS, and one case of endocarditis in an intravenous drug user. Other cases of infections involving Neisseria cinerea include two patients with continuous ambulatory peritoneal dialysis (CAPD)associated peritonitis, two cases of pulmonary infections in immunosuppressed patients, one case of proctitis in a child, and several cases of purulent conjunctivitis in neonates [1][2][3][4][5].…”

“…Neisseria cinerea is a commensal bacteria of the human oropharynx, with low pathogenic potential, and very few reported cases of bacteremia [1]. Only a handful of case reports involving invasive N. cinerea infections are documented; and the affected patients had underlying comorbidities and immunosuppression [1][2][3][4].…”

“…Neisseria cinerea is a commensal bacteria of the human oropharynx, with low pathogenic potential, and very few reported cases of bacteremia [ 1 ]. Only a handful of case reports involving invasive N. cinerea infections are documented; and the affected patients had underlying comorbidities and immunosuppression [ 1 - 4 ]. Furthermore, retropharyngeal abscesses are rare in adults, and are usually attributable to local trauma, such as fishbone ingestion or instrumentation [ 5 , 6 ].…”