Int.J.Curr.Microbiol.App.Sci (2018) 7(5): 48-53

International Journal of Current Microbiology and Applied Sciences ISSN: 2319-7706 Volume 7 Number 05 (2018) Journal homepage: http://www.ijcmas.com

Original Research Article https://doi.org/10.20546/ijcmas.2018.705.007

Emerging Pathogen: Algae causing Burn Wound Infection - Report of Two Cases from a Tertiary Care Center

Pratibha Shamanna*, Jayashree Ravindran, Jacinta Lalremruati and Muralidaran Sethumadavan

Department of Microbiology, St John’s Medical College, Bangalore, Karnataka, India

*Corresponding author

ABSTRACT

K e yw or ds

Emergin g pathogen, Shewanella algae Shewanella algae infections are rare in humans. Repeated isolation of the same organism from two different patients suffering from burn wound Article Info infection and successful treatment thereafter confirms the need of utmost

Accepted: microbiological vigilance to identify the unusual pathogen. 04 April 2018

Available Online: 10 May 2018 Introduction distributed in nature, with soil and water being their natural habitat. Initially they were Shewanella species are found throughout the considered to be colonisers or saprophytes world in marine environments, and most thriving on previously damaged tissue (Winn reported human infections occur in countries et al., 2006). in warm climates (Holt et al., 2005). Shewanella species have been implicated in Shewanella algae and Shewanella putrefaciens skin and soft tissue infections, bacteremia, are the two important species of Shewanella biliary tract infections, thoracic empyema, that are most frequently implicated in human endocarditis, dacrocystitis, intracranial infections, although more than 80% are caused abscess, arthritis, peritonitis, ventilator by S. algae (Tsai et al., 2008). S. algae was associated pneumonia, and ear infections (Tsai introduced as a new species in 1990 and has et al., 2008; Tan et al., 2008) Shewanella been most frequently associated with species is a saprophytic gram negative rod, infections of skin and soft tissues resulting belonging to family Vibrionaceae. It is from breaches in dermis, such as ulcers or frequently isolated from nonhuman sources following trauma (Tsai et al., 2008; Simidu et and is rarely considered pathogenic in al., 1990). Although S. algae has been humans. Shewanella species are widely reported to be the etiological agent of distinct

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Int.J.Curr.Microbiol.App.Sci (2018) 7(5): 48-53 human infections it is difficult to give clinical identified as S. algae based on Nitrate significance to the isolation of this micro- reduction, of maltose, mannitol, organism as it may be present as a coloniser or sucrose, arabinose, ribose, decarboxylation of a component of mixed bacterial flora (Renu Amino acids, arginine, lysine and ornithine, Goyal et al., 2011). Here we present two case hemolysis in 5% sheep bloodagar, growth on series in burns patients who were infected by Salmonella-Shigella agar(SS), growth at 42°C, S. algae during admission to burns ward at the growth in presence of 6.5% NaCl, gelatin same period of time. In the present study S. hydrolysis, DNAase production. Antibiotic algae was repeatedly isolated from same sensitivity testing was done using Kirby-bauer patients and the patients responded to the disc diffusion method following CLSI targeted treatment supporting that S. algae guidelines with Ampicillin, Amikacin, was the true pathogen. Gentamicin, Netilmicin, Cephalexin, Cefotaxime, Ceftazidime, Ciprofloxacin, Materials and Methods Cefoperazone + Sulbactam, Piperacillin + Tazobactam, Meropenem, Piperacillin, Wound swabs taken from raw burnt area sent Imipenem, Ertapenem and zone of inhibition to microbiology lab, were cultured on5% was measured and reported as sensitive or Sheep Blood agar, MacConkey agar and liquid resistant (NCCLS, 2003). In both of cases the Thioglycollate medium. Simultaneously isolates were identified as Shewanella algae Gram’s stain of the smear was made from based on the ability to produce mucoid wound swab to look for the presence of colonies with Beta-hemolysis on 5%sheep and tissue cells. The culture plates blood agar, growth at 42°C and in 6% NaCl, and thioglycollate broth after inoculation were inabililty to produce acid from maltose and incubated at 37°C for 18-24 hours. ability to reduce nitrite (Rajshree Patel et al., 2012). On Blood agar grey lytic colonies with red tan pigment was noticed after 24 hours of Case-1 incubation and on MacConkey agar, non- lactose fermenting colonies were seen. 22yr old male patient, cook by occupation Thioglycollate broth showed uniform with history of accidental thermal burns turbidity. Bacterial colony from BA and sustained 3 months back at his residence was MAwere tested for oxidase production by admitted to Victoria hospital and later referred strips impregnated with 1% tetra methyl to St John’s Hospital for further treatment and paraphenylenediamine dihydrochloride. The follow up, came with raw area involving face, colonies were oxidase positive.Oxidase neck, chest. positive colonies were further identified by grain stain, motility on mannitol motility On local examination: Post burns raw area (MM) medium. Urease on Christensen’s agar, with slough, granulation tissue along with Citrate utilization by Cimmon’s citrate agar, discharge was noticed involving mainly H2S production and differentiation between anterior chest, upper abdomen, right posterior fermenter and non-fermenter on Triple sugar chest, scalp area and bilateral medial aspect of agar slant (TSI) and for Indole forearm. There was restriction in lateral production. The organism was identified as shoulder abduction and neck movements. Also Shewanella species since this is the only non- grade III contracture of ear was observed. fermenter which produces H2S gas in TSI agar and is also oxidase positive (Winn et al., Investigations revealed Hb-10.6%, PCV- 2006). Shewanella species were further 33.20, S. Creatinine 0.1, B. Urea 181, 49

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Na/K/CL-35/4.6/100, and HIV and HBsAg Meropenem and Klebsiella species was status – Non reactive. resistant to all gram negative drugs. A provisional diagnosis of 15% thermal burns Wound swab taken from discharge site for with infection was made. Patient was taken for culture and sensitivity in Gram’s stain-showed 6% epifacial excision of left thigh 9% total numerous pus cells, numerous gram positive excision over abdomen with homograft and cocci in singles, pairs, clusters, numerous right thigh with autograft done. After a week gram negative bacilli. Wound swab culture homograft over left thigh was replaced with showed growth of Shewanella algae and autograft. Post operatively graft was taken up Staphylococcus aureus. well and child was advised discharge with regular follow up. Shewanella algae were sensitive to Pipercillin + Tazobactam, Piperacillin, Cefoperazone + Results and Discussion Salbactam, Gentamycin, Meropenem, intermediate to Amikacin. Staphylococcus Although pseudomonas aeruginosa is the most aureus was sensitive to Netilmicin, Amikacin, common oxidase positive non fermenter Tetracycline, Chloramphenicol, Erythromycin, isolated from clinical specimens, Shewanella Vancomycin, Teicoplanin. Repeat sample sent species has recently attracted attention of also grew Shewanella algae with same clinical microbiologists. Recognition of this sensitivity pattern. A provisional diagnosis rare organism has been hampered as the 22% burnswith S. algae infection was made. isolation of Shewanella species from clinical The patient underwent Split skin grafting samples has long been considered merely (SSG) in anterior chest and bilateral arm and colonization rather than active infective agent SSG on the back. Post operatively graft was (Mukhopadhyay et al., 2007). The organism healthy and patient advised for discharge and generally resides in marine and aquatic regular follow up. environment so the route of transmission in these cases in not clear. There have been only Case-2 four reports of isolation of Shewanella from India and these were from patients with An 8yr old female child came with alleged infective endocarditis, peritonitis, chronic history of flame burns, child clothes caught obstructive pulmonary disease respectively fire while playing near campfire. (Mukhopadhyay et al., 2007; Dhawan et al., 1998). Shewanella algae and Shewanella On local examination: 2°deep to 3° burns over putrefaciens are the two species of Shewanella the right thigh anterior aspect, left anterior that are most frequently implicated in human thigh, lateral aspect and left lower anterior infections. Among Shewanella species, S. algae trunk. causes 80% human infections (Khashe and Micheal, 1998). Investigations revealed: HB-9.7%, S.Creat- 0.6%, Na+ 128, K-3.6, CL-96, HIV, HBsAg- Important differential characteristics between Non -reactive. Wound swab taken from the two species include the ability of S. algae to discharge site on Gram’s stain-showed scanty produce mucoid colonies with β- heamolysis pus cells, scanty gram negative bacilli. Wound on 5% sheep blood agar, to grow at 42°c and in swab culture grew Shewanella algae and 6% NaCl and to reduce nitrate, and an inability Klebsiella species. Shewanella algae was to produce acid from maltose all of which are sensitive to Pipercillin + Tazobactam, in contrast to the characteristics of Shewanella Piperacillin, Cefoperazone + Salbactum, putrefaciens (Fig. 1–4). 50

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Fig.1 Blood agar showing lytic colonies with red tan pigment

Fig.2 MacConkey’s agar showing non-lactose fermenting colonies

Fig.3 Biochemical properties of Shewannella algae. a) Showing OF (oxidative fermentative media with 1% glucose), MM (mannitol motility media), TSI (triple sugar iron media), Indole, Citrate, Urease. b) Ornithine decarboxylase test with control

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Fig.4 DNase test with control

Automated identification systems fail to Shewanella algae are susceptible to differentiate between Shewanella agae and aminoglycosides, carbapenems, erythromycin, Shewanella putrefaciens, as S. algae is not in and quinolones with variable susceptibility to included in the databases of these systems. penicillin and cephalosporin. However rapid Presumably for this reason most Shewanella development of resistant to Imipenem and infections reported during recent years have Piperacillin + Tazobactam has been reported been attributed to Shewanella putrefaciens. (Ostwal et al., 2015).

However in studies where extensive phenotypic Though burn wound infections due to characterisation is performed most human Shewanella algae have been reported from infections are caused by Shewanella algae. As several countries, such reports from India are the two species have different pathogenic rare. The main reason for this is that in most of potential for humans, correct identification is the hospitals, all gram negative and oxidase important, and this is possible only in routine positive organisms are reported as clinical microbiology laboratories (Holt et al., Pseudomonas species and no further 2003). identification is done.

In present study also Shewanella algae was To conclude the isolation of Shewanella algae isolated in both the burn wound cases, as most from above two cases strengthens the common infection due to Shewanella species assumption that the organism should be are infections of skin and soft tissue and are regarded as a potential emerging pathogen. usually associated with breaches in the skin Utmost microbiological vigilance to diagnose such as ulcers or following trauma like in other the unusual pathogen will facilitate the studies. administration of appropriate treatment at the earliest thereby getting satisfactory clinical There are no standard guidelines for treatment response and prevention of further of Shewanella infection. In both of our cases the complications. organism was sensitive to Piperacillin, Piperacillin + Tazobactam, Meropenem and Acknowledgement Gentamicin, intermediate sensitive to Amikacin and resistant to other gram negative antibiotics. We acknowledge the sincere effort of our MSc Previously published studies reported that postgraduate student Jacinta Lalremruati, for

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Int.J.Curr.Microbiol.App.Sci (2018) 7(5): 48-53 her help in laboratory diagnosis. Also we Ostwal K, Shah P, Pathak S, Jadhav A, Shaikh acknowledge Department of Plastic Surgery for N, 2015. New enterant in the class of the clinical samples and necessary clinical data. uropathogens- Shewanella algae, Asian Journal of Medical Sciences. Jul-Aug References 6(4): 92-95. Rajshree Patel, Albin Abraham, Johnson Dhawan B, Chaudry R, Mishra BM and Thomas, Wanqing Zhi, Shadab Ahmed, Agarwal R.1998 Isolation of Shewanella Janice Verley. A Rare case of pneumonia putrefaciens from a Rheumatic Heart caused by Shewanella putrefaciens. Disease Patient with Infective Hindawi Publishing Corporation Case Endocarditis. J Clin Microbial. 36: 2394- Reports in Medicine. Volume 2012, 6. Article ID 597301, 3 pages Holt HM, Hansen BG, Brunn B. 2005. doi:10.1155/2012/597301. Shewanella algae and Shewanella Renu Goyal, Narinder Kaur, Rajeev Thakur. putrefaciens: clinical and microbiological 2011. Human soft tissue infection by the characteristics. Clin Microbial Infect. 11: emerging pathogen Shewanella algae, J 347-352. infect DevCtries. 5(4): 310-312. Holt HM, Sogaarrd P, Gahrn-Hansen B. Bruun. Simidu U, Ysukamoto K, Yasumoto T, Yotsu 2003. Shewanella alga and Shewanella M. 1990. of four marine putrefaciens: clinical and microbiological bacterial strains that produce tetradoxin. characteristics ClinMicrobiol Infect. 11: Int J SystBacteriol. 40: 331-336. 347-352. Tan CK, Lai CC, Kuar WK, Hsueh PR. 2008. Khashe S and Micheal JJ. 1998. Biochemical Purulent pericarditis with greenish and Pathogenic Properties of Shewanella pericardial effusion caused by Shewanella alga and Shewanella putrefaciens algae. J Clin Microbiol.46: 2817-2819. JClinMicrobiol. 36(3): 783-787. Tsai MS, You HL, Tang YF, Liu JW. Mukhopadhyay C, Chawla K, Sharma Y, Bairy Shewanella soft tissue infection: case I. 2007 First Report of Shewanella alga as report and literature review. International Emerging Infection in India: Two Cases. J Infect Dis 2008; 12: 119-124. Journal of Clinical and Diagnostic Winn W Jr, Allen S, Janda W, Koneman E, Research. Aug; 1(4): 293-295. Procop G, Schrenberger P, Woods G. NCCLS, Performance Standards for 2006. Koneman’s colour Atlas and Antimicrobial Disc Susceptibility Tests. textbook of Diagnostic microbiology. 6th Approved Standard. 8thed NCCLS ed. Lippincott Williams and Wilkins Document M2-A8 Wayne, Pa: NCCLS: (USA); Pp. 303-391. 2003.

How to cite this article:

Pratibha Shamanna, Jayashree Ravindran, Jacinta Lalremruati and Muralidaran Sethumadavan. 2018. Emerging Pathogen: Shewanella Algae causing Burn Wound Infection - Report of Two Cases from a Tertiary Care Center. Int.J.Curr.Microbiol.App.Sci. 7(05): 48-53. doi: https://doi.org/10.20546/ijcmas.2018.705.007

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