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Morganella Morganii in Sinonasal Region: a Rare Case Report

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Morganella Morganii in Sinonasal Region: a Rare Case Report JCEI / Yazıcı et al. M. morganii in sinonasal region 2013; 4 (3): 383-386383 Journal of Clinical and Experimental Investigations doi: 10.5799/ahinjs.01.2013.03.0309 CASE REPORT / OLGU SUNUMU Morganella morganii in sinonasal region: A rare case report Sinonazal bölgede Morganella morganii: Nadir bir olgu sunumu Haşmet Yazıcı1, Sedat Doğan1, İlknur Haberal Can2, Yusuf Baygit3, Alicem Tekin4 ABSTRACT ÖZET Morganella morganii is a gram negative pathogen and Morganella morganii, özellikle immunsupresif, uzun dö- may cause potentially lethal disease especially in patients nem idrar yolu kateteri kullanan kişilerde ölümcül hasta- with underlying or immunosuppressive disease. It is com- lıklara yol açabilen Gram-negatif fırsatçı bir patojendir. monly found in long-term urinary catheter used and im- Sıklıkla üriner sistem enfeksiyonlarına yol açmasına rağ- mune system deficiency patients as nosocomial disease. men kas-iskelet sistemi, santral sinir sistemi ve cilt enfek- Involving other systems such as skin, skeletal system siyonlarına da sebep olabilmektedir. Sporadik enfeksiyon and central nervous system can be seen too. Sporadic olguları nadir olmakla birlikte AİDS, zehirlenmeler ve yılan occurrence is rare and can be seen in any system by vari- ısırmaları ile birlikte görülebilmektedir. Sino-kutanöz fistül, ous causes like AIDS, snake bites and poisoning. In this preseptal selülit ve oro-maksiller fistül gelişimi görülen, 58 case we present sporadic Morganella morganii infection yaşındaki diabetik erkek hastada yapılan tetkikler sonucu on sinonasal region with the presence of sinusitis, sino- M morganii enfeksiyonu saptandı. Hastaya fronto-etmoi- cutaneous fistula, preseptal cellulitis and hard palate de- dektomi ve mediyal maksillektomi yapıldı. İki hafta uygu- fect on 58 year old male diabetic patient. Microbiological lanan medikal tedavi sonucu genel durumu düzeldi. Bu assessment from open wound and sinuses were reported olgu, araştırmalarımıza göre sinonazal bölgede ilk kez as Morganella morganii. To our knowledge, this is the first görülen M. morganii enfeksiyonu olup tanı, tedavi ve klinik case of sino-nasal Morganella morganii infection with si- yönleriyle tartışılmıştır. no-cutaneous fistula, preseptal cellulitis and maxillofacial Anahtar kelimeler: Morganella morganii, sinonazal fistül, bone destruction. J Clin Exp Invest 2013; 4 (3): 383-386 preseptal selülit, kemik defekti Key words: Morganella Morganii, sino-nasal fistula, pre- septal cellulitis, bone destruction INTRODUCTION sporins, but they are susceptible to cefepime, imi- penem, meropenem, piperacillin, aminoglycosides, Morganella morganii is a member of Proteae which and fluoroquinolones. Improper antibiotic therapy is included in Enterobacteriaceae family [1]. M. may lead to delay on diagnosis and it is a predis- morganii is a Gram-negative opportunistic bacillus posing factor for infection process. In uncomplicat- which is usually found in the environment and in the ed cases mono therapy is usually enough. Combi- intestinal tracts of humans, mammals, and reptiles nation therapy with two antibiotics (based on sus- as normal flora. It has two subgroups named mor- ceptibility of organism) is preferred for complicated ganii and sibonii. They can cause wound infections, cases and immune compromised patients. Surgical urinary infections usually on patient who have uro- therapy is indicated for treating underlying disease. lithiasis, pneumonia, skeletal infections and central nervous system disease [2-4]. Appropriate antibi- otic therapy is important for the best treatment of CASE the disease. Usually they are naturally resistant to A fifty eight-year-old male diabetic patient attended many beta-lactam antibiotics and may be resistant ear-nose-throat clinic with complaints of purulent to ceftazidime and other third generation cephalo- drainage, hyperemia and swelling on the right side 1 Mardin General Hospital, Department of Ear-Nose-Throat Diseases, Mardin, Turkey 2 Fulya Acıbadem Private Hospital, Department of Ear-Nose-Throat Diseases, İstanbul, Turkey 3 Mardin Park Private Hospital, Department of Ear-Nose-Throat Diseases, Mardin, Turkey 4 Dicle University, Regional Blood Center, Microbiology Laboratory, Diyarbakır, Turkey Correspondence: Yusuf Baygit, Mardin Park Private Hospital, Department of Ear-Nose-Throat Diseases, Mardin, Turkey Email: [email protected] Received: 15.08.2012, Accepted: 23.03.2013 J Clin Exp InvestCopyright © JCEI / Journal of Clinical www.jceionline.organd Experimental Investigations 2013, AllVol rights 4, No reserved 3, September 2013 384 Yazıcı et al. M. morganii in sinonasal region of face (Figure 1). Patient had received ten days used for the quality control of antimicrobial suscepti- of amoxicillin-clavulanic acid therapy. Leukocyto- bility testing. M. morganii was observed on cultures sis and hyperglycemia were detected on labora- taken from granulation tissue. tory investigation. Dark colored granulation tissue Meticulous insulin therapy for regulation of di- was seen with anterior rhinoscopy. On CT scan abetes and I.V. meronem 3x1 gr, amikacin 1x1 gr there were mucosal thicknesses on right maxillary, for 15 days, amphotericin B 1x50 mg were started. ethmoid, sphenoid and frontal sinuses (Figure 2). Fistulizated wound was healed by daily surgical Furthermore erosive abscess formation with a size debridement and dressing with riphocin and acid of 3x1.5 cm on periorbital area and inflammatory borique solution. After two week sino-cutaneous thickness on optic nerve and retro-orbital fat tissue fistula healed. Preseptal cellulite and sinusitis re- were detected. There was no intracranial involve- gressed and general condition of patient improved. ment. Endoscopic sinus surgery was performed. However diabetic control couldn’t be obtained and Right middle concha was necrotic and adhered to patient was referred to endocrine service. During septum. Nasal cavity was full of dark colored gran- follow up period patient’s blood glucose control ulation tissue and lamina papyracea was eroded. couldn’t be obtained and after 13 days patient died There were fistulas at the base of maxillary sinus from sepsis. opening into oral cavity and at the anterior part of maxillary sinus. Fronto-maxilla-ethmoidectomy and DISCUSSION medial maxillectomy were performed. All granula- tion tissue was removed and send for microbiologi- Morganella is a Gram-negative opportunistic bacil- cal assessment. lus which is a member of Enterobacteriaceae fam- ily [1]. In 1906, Morgan described a non-lactose- fermenting organism as a different pathogen while studying the etiology of summer infantile diarrhea [6]. After then, in 1919 Winslow named this patho- gen as Bacillus morganii for the production of indole and the fermentation of carbonhydrates and non- ability of liquefaction of gelatin [7]. For a long time, Morganella was known as a type of Proteus and called as Proteus morganii. In 1978 Brenner et al. and in 1985 Farmer et al. showed that Morganella is a different organism from Proteus [8]. Identification of M. morganii is made by recovery of small, oxi- dase-negative, catalase and indole positive Gram- negative rod on 5% sheep blood agar or EMB agar. M. morganii ferments glucose and mannose but not lactose. M. morganii is motile, facultative anaerobic and non-encapsulated, and it hydrolyzes urea and reduces nitrates. Figure 1. Patient’s picture Immunosuppressive treatment, poison con- tamination, history of surgery, advanced age, uro- In microbiology laboratory, the granulation tis- lithiasis, improper antibiotic therapy and AIDS are sue specimen was inoculated onto 5% sheep blood the risk factors for M. morganii infections [9]. Most agar and Eosin-Methylen Blue agar (EMB) (Merck common clinical presentations are wound infection KGaA, Darmstadt, Germany) media plates. Then, and urinary tract infection [2]. Furthermore M. mor- these media plates were aerobically incubated at ganii can cause perinatal infections, late-onset neo- 35 ± 2°C for 18-24 hours. Identification of Gram- natal infections, fatal necrotizing fasciitis, skeletal negative isolate was performed by using conven- infections and central nervous system infections tional methods. Antimicrobial susceptibility testing [3,4]. In this case, presence of DM and improper of isolate was determined by measuring the diam- antibiotic therapy were the risk factors that we found eter of inhibition zone around the antibiotic discs for M. morganii infection. There were sinusitis and with using the Kirby-Bauer’s disc diffusion method bone defects at anterior, inferior part of maxilla and according to the Clinical and Laboratory Standards lamina papyracea. In the literature, no bone defect Institute susceptibility interpretive breakpoints [5]. caused by Morganella infection was reported in si- Escherichia coli ATCC 25922 reference strain was nonasal region. J Clin Exp Invest www.jceionline.org Vol 4, No 3, September 2013 Yazıcı et al. M. morganii in sinonasal region 385 Figure 2. Preoperative Computed Tomography image Treatment should be done by medically and sinonasal region with uncommon features of this in- surgically if needed. First of all, due to the opportu- fection like bone destruction, sino-cutaneous fistula nistic character of M. morganii, underlying disease and preseptal cellulitis. must be treated. Uncomplicated and early diag- nosed infections can be treated with mono antibiotic REFERENCES therapy. Choice of antibiotic treatment is very im- 1. O’Hara CM, Brenner FW, Miller JM. Classification, portant because
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