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Pneumonia Due to Pandoraea Apista After Evacuation of Traumatic Intracranial Hematomas:A Case Report and Literature Review

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Pneumonia Due to Pandoraea Apista After Evacuation of Traumatic Intracranial Hematomas:A Case Report and Literature Review Lin et al. BMC Infectious Diseases (2019) 19:869 https://doi.org/10.1186/s12879-019-4420-6 CASE REPORT Open Access Pneumonia due to Pandoraea Apista after evacuation of traumatic intracranial hematomas:a case report and literature review Chuanzhong Lin1,2, Ning Luo1, Qiang Xu2, Jianjun Zhang3, Mengting Cai4, Guanhao Zheng5 and Ping Yang2* Abstract Background: Pandoraea species is a newly described genus, which is multidrug resistant and difficult to identify. Clinical isolates are mostly cultured from cystic fibrosis (CF) patients. CF is a rare disease in China, which makes Pandoraea a total stranger to Chinese physicians. Pandoraea genus is reported as an emerging pathogen in CF patients in most cases. However, there are few pieces of evidence that confirm Pandoraea can be more virulent in non-CF patients. The pathogenicity of Pandoraea genus is poorly understood, as well as its treatment. The incidence of Pandoraea induced infection in non-CF patients may be underestimated and it’s important to identify and understand these organisms. Case presentation: We report a 44-years-old man who suffered from pneumonia and died eventually. Before his condition deteriorated, a Gram-negative bacilli was cultured from his sputum and identified as Pandoraea Apista by matrix-assisted laser desorption ionization–time-of-flight mass spectrometry (MALDI-TOF MS). Conclusion: Pandoraea spp. is an emerging opportunistic pathogen. The incidences of Pandoraea related infection in non-CF patients may be underestimated due to the difficulty of identification. All strains of Pandoraea show multi-drug resistance and highly variable susceptibility. To better treatment, species-level identification and antibiotic susceptibility test are necessary. Keywords: Pandoraea Apista, Brain trauma, Pneumonia, Pathogenicity, Susceptibility Background of antibiotics, which makes the treatment of Pandoraea Pandoraea species were first described by Coenye et al. related infections more complicated. Pandoraea is rarely in 2000 [1], which had been isolated from both environ- found in non-CF patients, due to different lung environ- mental and human clinical samples, mostly from cystic ments and misidentification. We report a case of pneumo- fibrosis (CF) patients. They may contribute to the lung nia caused by Pandoraea Apista after the evacuation of function decline in CF patients. Some of these organisms traumatic intracranial hematomas and review the available are capable of causing bacteremia in both CF and non-CF literature concerning Pandoraea species to a better patients. And yet, with limited evidence presented, the understanding. pathogenicity of Pandoraea remains poorly understood. Besides, it is difficult to differentiate Pandoraea species from some other species, such as Burkholderia or Ralsto- Case presentation nia [2]. Furthermore, these bacteria are resistant to a lot A 44-year-old man was transferred to the emergency in- tensive care unit (EICU) of The First Affiliated Hospital of Zhejiang University, Hangzhou, China, on November * Correspondence: [email protected] 25, 2018, due to multiple injuries and coma after a brain 2Department of Pharmacy, The First Affiliated Hospital of Medicine School, Zhejiang University, Hangzhou, China injury. Five days earlier, he accidentally fell from a height Full list of author information is available at the end of the article of about 7 m and immediately fell into a coma. Removal © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lin et al. BMC Infectious Diseases (2019) 19:869 Page 2 of 9 of traumatic intracranial hematoma and decompressive hsCRP was 194.4 mg/L. CT scan (Fig. 2) confirmed new craniectomy were performed on November 20, 2018, infections in his right lung. The sputum culture result was and November 24, 2018. And antimicrobial treatment reconsidered, and the microbiologist of our hospital con- had been given before he was admitted to our hospital. firmed that Pandoraea Apista was the only germ grow in On the day of admission, physical examination showed the media. After a review of some case report concerning a low-grade fever of 37.6 °C, a blood pressure of 165/79 Pandoraea species, meropenem was altered by imipenem mmHg and a Glasgow Coma Score of 1 + T + 1. Labora- (1 g IV, 6 hourly) on day 12. Nonetheless, his condition tory examination detected an elevated white blood cell got worse and the relatives of him asked for a “Do Not At- count (17.1 × 10E9/L with 90.6% neutrophils) and hyper- tempt Resuscitation”. He died on day 14 with cardiac re- sensitive C-reactive protein (hsCRP) of 209.70 mg/L. spiratory arrest and multiple organ failure. Procalcitonin (PCT) was 0.38 ng/ml in the meantime. With tracheal intubation and ventilator-assisted ventila- Discussion and conclusion tion were given, blood gas values were as follows: pO2, The timeline of our case-patient is summarized in Table 1. 117 mmHg; pCO2, 31.4 mmHg. After two sets of blood Pandoraea species is a strange genus to both clinicians culture were taken, an antibiotic regimen included mer- and microbiologists in China. It is reasonable to believe openem (2 g IV, 8 hourly) and vancomycin (1million IU that Pandoraea apista might not the responsible pathogen IV 12 hourly) was given. A lung computed tomography at the time of admission. But the using of broad-spectrum (CT) scan was performed on day 3 (Fig. 1) and found antibiotics promoted the growth of Pandoraea apista, patchy consolidation in left inferior lobar. It was consid- which lead to the right pneumonia and a worsening con- ered as traumatic wet lung and/or lung infection. On dition of this patient. To better understand Pandoraea day 7, blood culture showed no bacteria growth, the species and its pathogenicity, we present a review from lit- hsCRP decreased to 6.7 mg/L, PCT was 0.12 ng/ml, but erature reported before November 31, 2018. the white blood cells were still elevated (12.3 × 10E9/L with 89.5% neutrophils). A large amount of Gram- Microbiology, distribution, and identification negative rod from the sputum specimen taken at day 5, Pandoraea species belongs to the β-subclass of the Pro- which identified as Pandoraea Apista by MALDI-TOF teobacteria, which contains a group of Gram-negative MS, was reported at day 8, with no antimicrobial suscep- bacilli that are aerobic or facultative anaerobic (e.g. P. tibility test results. The antibiotic regimen remained un- pnomenusa reported by Ambrose et al. [3]), do not form changed because of lack of knowledge about this genus spores, do not reduce nitrate, do not ferment lactose, and and the infection of this patient seemed to be getting rely on flagellar movement. Growth is observed at 30 °C better. However, hsCRP and PCT increased progressively and 37 °C. Catalase activity is variable [4], along with lack after that. It became more and more difficult to maintain of saccharolytic activity, and mostly are o-nitrophenyl-β- his blood pressure and oxygen saturation. On day 11, the D-galactopyranoside (ONPG) negative [1, 2]. Fig. 1 Lung CT scan on November 27, 2018. Lung CT taken on day 3 shows patchy consolidation in left inferior lobar Lin et al. BMC Infectious Diseases (2019) 19:869 Page 3 of 9 Fig. 2 Lung CT scan on January 4, 2019. Lung CT taken on day 11 shows patchy consolidation in both lungs It presently comprises five species that have been iso- acid analysis may be useful [1, 2], and yet cellular fatty lated from human clinical specimens (P. apista, P. pulmo- acid-deficient isolate has been reported [15]. Genus- nicola, P. pnomenusa, P. sputorum, and P. norimbergensis) specific PCR assays and the sequences of 16S rRNA [1, 32] [1], five named non-clinical species (P. thiooxydans [5],P. and gyrB [33] genes have proven to be reliable but may oxalativorans [6], P. faecigallinarum [6],P.vervacti[6], have some limitation in differentiating the Pandoraea spe- and P. terrae [4]) that have been isolated only from non- cies [15, 29]. More recently, several studies have reported clinical origin and at least four unnamed genomospecies good results in using MALDI-TOF MS for the identifica- [1, 7]. The main sources of Pandoraea species in the envir- tion of Pandoraea species [16–18, 20]. MALDI-TOF MS onment including soil, animal feces, water, and even pow- is a quick, easy and practical, high throughput analytic dered milk [8]. The clinical species were mainly isolated method that relies on a comparison between the mass from respiratory specimens of cystic fibrosis (CF) patients spectrum of the isolate and the mass spectra in available [1, 3, 7, 9–24]. To date, cases of Pandoraea species caused databases. But Pandoraea species are rare in clinical iso- colonization or infection have been reported all over the lates. With less information contributed by Pandoraea world, including USA [1, 7, 12, 25], Denmark [1, 10, 26], species in the database used might limit the discriminatory Germany [13], France [18, 19], Ireland [26], Argentina [20, power of this method. Misidentification in strains-level 24], Spain [16, 17, 27, 28], Australia [3, 14, 15], Canada [1], has been reported [3]. MALDI-TOF MS is a promising UK [1, 9, 22], China [29], Belgium [1], Brazil [1], Sweden [1] approach, but more specific information is needed to up- (See at Fig. 3). Most cases occurred in Europe, America, date its database for accurate confirmation of bacteria that and Australia, which was consistent with the epidemiology is less common.
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