Necrotizing Fasciitis and Septic Shock Related to the Uncommon Gram-Negative Pathogen Sphingobacterium multivorum

Abstract

We report the first case of necrotizing fasciitis due to the uncommon Gram-negative pathogen Sphingobacterium multivorum in an immunocompromised patient, who presented with septic shock. This case adds necrotizing fasciitis to the spectrum of S. multivorum-related infections and highlights the emergence of Gram-negative bacteria in severe soft tissue infections. CASE REPORTA 64-year-old woman was referred to our intensive care unit (ICU) for septic shock. Her medical history included rheumatoid arthritis that had been treated with long-term intermediate-dose corticosteroids (0.25 mg/kg of prednisone per day for more than 30 years), morbid obesity (body-mass index, 33.5 kg/m 2 ), type 2 diabetes mellitus, and coronary disease. Her current treatment included 15 mg prednisone per day, rosuvastatine, metformine, atenolol, perindopril, aspirin, and furosemide. Twenty-four hours after her dog scratched her right leg, she developed fever and leg pain. She presented at the emergency department 48 h after the injury; her central body temperature was 38.2°C, heart rate was 100 beats/min, blood pressure was 82/43 mmHg, and respiratory rate was 35/min. She was confused. Her skin was mottled from legs to abdominal wall. Her right leg was erythematous and tender to palpation with swelling. The rest of the examination was uninformative. Biological results were as follows: C-reactive protein, 583 mg/liter (normal value [N], Ͻ6 mg/ liter); leukocyte count, 12.2 ϫ 10 9 /liter; arterial lactate level, 7.9 mmol/liter (N, Ͻ2 mmol/liter); HCO 3 Ϫ level, 13.4 mmol/liter; creatininemia, 320 mol/liter; and creatinine phosphokinase level, 874 IU/liter (N, Ͻ200 IU/liter). She was transferred to our ICU, where broad-spectrum antibiotic therapy, consisting of amoxicillin-clavulanate, clindamycin, and gentamicin, was initiated along with fluid loading. The blood pressure remained low, and the patient became comatose. She required circulatory support with norepinephrine up to 2.9 g/kg/min, mechanical ventilation, and low-dose steroids. Her condition deteriorated in the first 48 h to multiple organ failure with acute anuric renal failure requiring renal replacement therapy and disseminated intravascular coagulation (platelet count was 41 ϫ 10 9 /liter and prothrombin rate was 51%, whereas initial values were normal). At the same time, the patient exhibited soft tissue necrosis of the right leg, prompting extensive surgical debridement. Surgical findings revealed a typical aspect of necrotizing fasciitis (NF), with gray necrotic tissues and lack of bleeding, that was subsequently confirmed by histological examination.Three blood cultures from samples taken before antibiotic treatment and surgery remained sterile. Gram-stained surgical samples (fascia and subcutaneous tissues) displayed polymorphic Gramnegative bacilli. Bacterial cultures of all five samples revealed yellowpigmented colonies of a single aerobic oxidase-positive Gramnegative bacillus (Fig. 1), growing after 18 h at 37°C on blood and chocolate agars but not Drigalski medium, which...

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