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Case Report Neisseria Cinerea Induced Available Online at http://www.recentscientific.com International Journal of CODEN: IJRSFP (USA) Recent Scientific International Journal of Recent Scientific Research Research Vol. 11, Issue, 01(A), pp. 36738-36740, January, 2019 ISSN: 0976-3031 DOI: 10.24327/IJRSR CASE REPORT NEISSERIA CINEREA INDUCED OSTEOMYELITIS Mansour Rami¹, Youssef Boutros¹, Fenianos Fady² and El Murr Tony3 ¹Department of Internal Medicine diseases, Faculty of Medical Sciences-LU, Beirut, Lebanon ²Department of Infectious Diseases, Medical Director of SZUMC affiliated with the Faculty of Medical Sciences –LU, Zgharta, Lebanon ³Division of Internal Medicine Diseases, Head of Medicine Department at MEIH-UH affiliated with the Faculty of Medical Sciences-LU, Bsalim, Lebanon DOI: http://dx.doi.org/10.24327/ijrsr.2020.1101.4985 ARTICLE INFO ABSTRACT Article History: We describe the first case of osteomyelitis due to invasive Neisseria Cinerea (N. cinerea) in a Lebanese University Medical Center. A previously healthy, well vaccinated 10-year-old female Received 13th October, 2019 presented for the first time to our hospital for fever and persistent left knee pain since two weeks. An Received in revised form 11th admission diagnosis of septic arthritis was retained and laboratory and radiologic tests were November, 2019 requested accordingly. Her chest X-ray was normal as well as her laboratory tests except for a Accepted 8th December, 2019 moderate leucopenia and high c-reactive protein (CRP) level. The synovial aspirate cultures from the Published online 28th January, 2020 left knee was negative but the blood and the bone marrow aspirate specimens yielded a pure growth of N. cinerea. Left knee magnetic resonance imaging (MRI) revealed a diffuse bone marrow disease Key Words: compatible with an infectious osteomyelitis. The patient has been well treated with intravenous (i.v.) Neisseria cinerea, osteomyelitis, ceftriaxone for twenty one days at hospital than by oral antibiotic for additional two months at home. pediatrics. Upon discharge from hospital, she was afebrile with a clear cut improvements in her clinical and biologic inflammatory signs and symptoms. This report is designed to show that N. cinerea is not only a commensal bacteria but is emerging again as a potential source of invasive spontaneous disease. Accurate differentiation of Neisseria spp. is mandatory due to serious medical, legal, and public health consequences. Copyright © Mansour Rami et al, 2020, this is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited. INTRODUCTION examination was normal except for mild right upper quadrant tenderness. An admission diagnosis of septic arthritis was It is the case of a ten year-old girl whom presented for the first retained and laboratory and radiologic tests were requested time to Saydet Zgharta-University Medical Center in Lebanon accordingly. for fever and persistent left knee knife-like pain, night sweats, weight loss and mild non specific abdominal discomfort since Laboratory tests revealed moderate leucopenia (WBC = 3.7 two weeks; she has no respiratory, neurologic or other gastro- G/liter; 44% neutrophils and 50% lymphocytes) and high CRP intestinal symptoms; she has been treated by unknown oral level at 33mg/dl. The rest of the complete blood count (CBC) antibiotic since one week; she has no previous medical history features were within normal range as well as urine analysis, and she has got her routine vaccinations on time according to Wright and Widal tests, cytomegalovirus (CMV) and Epstein- the lebanese national vaccination program. Barr virus (EBV) serology, Hepatitis A and B serology, human immunodeficiency virus (HIV) ELISA test and Physical examination revealed a well conscious but lethargic, antinuclear antibodies (ANA) serologic profile. Moreover, febrile child with polpypnea and tachycardia and a maintained Clostridium Difficile (C.difficile) toxin B was detected in the blood pressure (body temperature = 39°C, pulse rate = 110, stool. The synovial aspirate culture from the left knee was respiratory rate = 22, and blood pressure = 110/60mmHg). She negative but the blood and the bone marrow aspirate culture had mild edema over her left knee and difficulty moving it yielded a pure growth of N. cinerea that was thereafter because of pain. She had normal coloration of the skin and identified by matrix-assisted laser desorption ionization–time conjonctiva without any neck stiffness or palpable lymph of flight mass spectrometry (MALDI-TOF MS) analysis. The nodes. Cardiopulmonary auscultation was unremarkable as bone marrow aspirate and biopsy showed no abnormal well as her complete neurologic exam. Abdominopelvic cellularity or any evidence of malignant disease. The chest X- *Corresponding author: Mansour Rami Department of Internal Medicine diseases, Faculty of Medical Sciences-LU, Beirut, Lebanon International Journal of Recent Scientific Research Vol. 11, Issue, 01(A), pp. 36738-36740, January, 2019 ray was normal. Abdominal US and thoraco abdominopelvic oxidized to carbon dioxide making it weakly glucose-positive CTscan showed mild hepatoslenomegaly only. or glucose-negative bacteria (3). Also unlike N. gonorrhoeae, N. cinerea can grow on Mueller-Hinton agar and trypticase The patient was put first on empirical antibiotic treatment with soy agar, is sensitive to colistin and does not react with i.v. ceftriaxone (2grs/day). Oral vibramycin (200mgrs/day) antigonococcal protein I monoclonal antibodies and does not and rifadine (600mgrs/day) was added to cover a probable produce immunoglobulin A protease (1). brucella infection and then stopped when the corresponding test came negative. After left knee MRI revealed a diffuse However, N. cinerea species may be accurately identified by bone marrow disease compatible with an infectious recent techniques like the matrix assisted laser desorption osteomyelitis, antibiotic therapy was adjusted to i.v. ionization-time of flight mass spectrometry (MALDI-TOF ceftriaxone (2grs/day) and i.v. vancomycin (2grs/day). After MS) when the limited number of specific phenotypic and the antibiogram report showed a good sensitivity of the biochemical characteristics failed (4). isolated bacteria to ceftriaxone, vancomycine was then As was mentioned previously, invasive infections by stopped and the i.v. ceftriaxone (2grs/day) was continued N.cinerea are rarely reported in the literature (5); One case of alone for twenty one days at hospital. Oral metronidazole post-traumatic meningitis and bacteremia (6), four episodes of (2grs/day) was added for ten days to treat the associated bacteremia, two of these in immunocompromised patients and C.Difficile colitis. resulting in death (7,8), one case of endocarditis in an The fever has disappeared at day 16 following the initiation of intravenous drug user in 2003 (9), two cases of pulmonary ceftriaxone and patient was discharged home on oral infections in immunosuppressed patients (10,11), three amoxicillin/clavulanate (2000mgrs/day) for additional three episodes of continuous ambulatory peritoneal dialysis months. On her discharge day, the patient was quietly (CAPD)-associated peritonitis in two different patients asymptomatic, without fever or knee pain, with a nearly (12,13), one case of proctitis in a child that was initially normal CBC (WBC = 8.8 G/liter; 61% neutrophils and 34% misidentified as N.gonorrhoeae infection (14), and several lymphocytes) and lower CRP level at 8mg/dl. A follow up cases of purulent conjunctivitis in neonates have been visit and MRI has been scheduled at the end of the antibiotic described so far (15). course. In our report, osteomyelitis caused by N.cinerea is considered DISCUSSION the first invasive, non-iatrogenic and non post-traumatic infection described in a lebanese child. The diagnosis was Neisseria species exist as normal flora of the upper respiratory suspected on MRI and confirmed by the cultures taken from tract and genital tract. These commensal bacteria rarely cause blood and Bone marrow aspirate. However, the N.cinerea disease, but they have sporadically been implicated in strains was specifically identified using the MALDI-TOF MS meningitis, endocarditis, prosthetic valve infections, technique to avoid any misleading identification with other bacteremia, pneumonia, empyema, bacteriuria, osteomyelitis, Neisseria species. The patient’s osteomyelitis and bacteremia and occular infections. The main challenge for the clinical responded well to i.v. ceftriaxone followed by oral microbiologist is to identify different strains and to amoxicillin/clavulanate long term antibiotherapy with differentiate them from pathogenic species. (1) radiologic follow up at the end of the treatment. First described by von Lingelscheim in 1906, N. cinerea is CONCLUSIONS also a commensal bacteria grouped with the gram-negative, oxidase-positive, and catalase-positive diplococci. It has been Despite being rarely pathogenic, N.cinerea has received isolated from human oropharynx, urogenital and gastro- considerable attention in recent years because of many intestinal tract, conjonctiva and lymph nodes where it has low emerging invasive infections and its misidentification as pathogenic potential (2). It is usually misidentified repeatedly N.gonorrhoeae with traditional laboratory techniques. as Neisseria gonorrhoeae (N. gonorrhoeae) in some Therefore rapid diagnosis, close surveillance
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