Published online: 2019-09-26 Case Report Morganella morganii, subspecies morganii, biogroup A: An unusual causative pathogen of brain abscess Asha B Patil, Shobha D Nadagir, Lakshminarayana SA1, Syeda Fasiha M Department of Microbiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, 1Sree Gokulam Medical College, Kerala, India ABSTRACT Morganella morganii is a gram negative aerobe , found often as intestinal commensal. It is commonly implicated in Urinary tract infections and pyogenic infections, but rarely causes CNS infections especially brain abscess. There are very few published reports of Morganella morganii as a causative pathogen in brain abscess. High index of suspicion of this pathogen is important in cases of brain abscess secondary to otogenic infections. This paper reports an unusual case of Morganella morganii, subspecies morganii, biogroup A Brain abscess .The paper also reviews other infections caused by Morganell morganii. Key words: Brain abscess, Chronic Suppurative Otitis Media, Morganella morganii Introduction and power had decreased on the left side. Meningeal signs were present. There was a past history of ear The hospital incidence of brain abscess is reported to discharge intermittently since the last six years, and he be 8.4% cases per year. Congenital heart disease and was probably on antibiotic treatment, details of which Chronic Suppurative Otitis Media (CSOM) are the most could not be obtained. Based on the clinical findings and common predisposing factors accounting for 72% of the a CT scan report he was provisionally diagnosed with cases.[1] Morganella morganii is a gram-negative aerobe, brain abscess and meningitis. The abscess was situated belonging to the Enterobacteriaceae family, normally in the right temporoparietal region. found in soil, water, and fecal flora. Central Nervous System (CNS) infections due to Morganella Morganii are Right parietotemporal burr hole evacuation was extremely rare.[2] We report a case of brain abscess caused performed. The pus sample from the abscess was collected by the Morganella morganii subspecies, morganii biogroup intraoperatively and sent to the microbiology laboratory. A, following CSOM. The sample was purulent, and was processed as follows: Gram stain Case Report The gram stain revealed a few pus cells and Gram-negative coccobacilli; a preliminary report was given. The sample A 12-year-old male patient presented with fever, was cultured on to Chocolate agar and MacConkeys agar, headache, and ear discharge for 20 days. There was one inoculated in thioglycolate broth and incubated overnight episode of vomiting. There was no history of convulsions. at 370C aerobically. Based on the routine biochemical tests On CNS examination, he was conscious, but disoriented, the isolate was identified as Tribe proteae Genus Proteus, left-sided seventh nerve palsy was present, and tone Providencia, and Morganella. Decarboxylase tests and Access this article online Trehalose fermentation were done for speciation and the Quick Response Code: isolate was identified as Morganella morganii, subspecies Website: morganii. It was further identified as biogroup A, as it was www.ruralneuropractice.com resistant to tetracycline.[3] DOI: Antibiotic susceptibility was performed by using the 10.4103/0976-3147.102631 disk diffusion method and interpreted as per Clinical Address for correspondence: Dr. Asha Patil, c/o Dr Ravindra Eligar, S-1, 2nd floor, D Block, Revankar Complex, Court Circle, Hubli, Karnataka, India. E-mail:[email protected] 370 Journal of Neurosciences in Rural Practice | September - December 2012 | Vol 3 | Issue 3 Patil, et al.: Morganella morganii brain abscess Laboratory Standard Institute (CLSI) guidelines. The A Taiwanese study reported one case of M. morganii isolate was susceptible to Chloramphenicol, Ceftriaxone, brain abscess between 1992 and December 2002.[5] In a Cefotaxime, Cefepime, Ceftazidime, Cefoperazone, review of 107 cases between 1985 and December 2005 in Gentamicin, Amikacin, Ticarcillin, and Levofloxacin, Thailand, Proteus and Pseudomonas were reportedly and resistant to Ampicillin, and Ofloxacin. more common isolates among the gram-negative bacilli (GNB) accounting for 38.1 and 19.1%; there was only one Extended Spectrum Beta Lactamase (ESBL) and Amp case of M. morganii brain abscess in this review.[1] A case C-beta lactamase detection was done as per CLSI of frontal brain abscess caused by Morganella morganii guidelines, by phenotypic confirmatory disk diffusion was reported in 2006.[6] A rare case of multiple brain and cefoxitin disk diffusion test methods, respectively. abscesses after mastoiditis due to Morganella morganii, The isolate was negative for both. Apart from surgical secondary to otitis media, was reported in 2007.[7] evacuation, the patient was treated with amikacin, ceftriaxone, and metrnidazole and recovered at M. morganii was earlier designated as Proteus discharge. Ear discharge was not present at the time of morganii, now it is included as a separate genus in the admission as the patient was partially treated elsewhere. Enterobacteriaceae with one species morganii. The most Hence, the ear swab was not sent for microbiological recent, extensive, DNA–DNA hybridization studies investigations. have shown the existence of two subspecies: M. morganii subspecies morganii, with four biogroups and subspecies Discussion sibonii with three biogroups.[3] Despite the advent of modern neurosurgical techniques, It has been a well-known cause of urinary tract infection, antibiotics, and new powerful imaging techniques, brain wound infection, sepsis, and other extraintestinal abscess remains a potentially fatal central nervous system infections. It is commonly a part of polymicrobial infection Brain abscess is almost always secondary infection and can rarely cause fatalities in debilitated [2] to a focus of suppuration elsewhere in the body and patients. may develop either by a contiguous focus of infection, head trauma, or hematological spread from a distant The organism is usually susceptible to quinolones such focus.[4] Otogenic infections remain the important foci of as nalidixic acid, ciprofloxacin, aminoglycosides, such as, infection, especially among children, where they occur Gentamicin, Amikacin, Tobramycin, Chloramphenicol, [3] at a greater frequency. Furthermore, the similarity of Cotrimoxazole, Aztreonam, and other Carbapenems. the causative pathogens in CSOM and brain abscess In a brain abscess, the third generation Cephalosporins point toward the contiguous extension of infection like Cephotaxime and Ceftriaxone are generally adequate to the CNS. In CSOM, the most common location of therapy. Aminoglycosides and anti-pseudomonal the brain abscess is reported to be the cerebellum Penicillin are not good choices in the management of and temporal lobe (37.1% and 22.9%), respectively. brain abscess because of their limited penetration into [1] In the present case the abscess was situated in the the cerebrospinal fluid (CSF) and the abscess. They are temporoparietal lobe. The causative pathogen of bacterial also less active in acidic and anaerobic conditions.[2] brain abscess vary with the time period, geographic distribution, age, underlying medical and / or surgical Morganella morganii are resistant to Penicillins and condition, and mode of infection.[4] The polymicrobial many Cephalosporins through the formation of ESBL nature of the infection and lack of anaerobic culture and Amp C-beta lactamase production. Although it is facilities could also influence pathogen prevalence in common to find drug-resistant Morganella, there is no different hospitals. Apart from the anaerobic bacteria, evidence that strains of different biogroups differ in their the aerobic bacteria reported to cause brain abscess susceptibility patterns.[3] However, with an increase in are Staphylococcus aureus, Streptococcus pneumonia, beta lactamase-mediated resistance around the world Streptococcus pyogenes, Streptococcus viridians, Escherichia it may be quite possible that selection pressures may coli (E. coli), Proteus , Klebsiella, Citrobacter, Salmonella, lead to the dominance of the resistant subspecies and Enterobacter, Pseudomonas, Morganella, Haemophilus, biogroups in future. Furthermore, spread of these clones Corynebacterium, and the Enterococcus species.[1,4,5] CNS in the community poses a problem in the treatment of infections due to M. morganii are extremely rare, with common community-acquired infections like CSOM. In few published reports in the literature.[1,2,5-7] Nine cases the present case the isolate was susceptible to most of the of CNS infections caused by M .morganii were reported antibiotics tested and was not an ESBL or Amp C-beta before 1997, of which four had otogenic meningitis.[2] lactamase producer. Journal of Neurosciences in Rural Practice | September - December 2012 | Vol 3 | Issue 3 371 Patil, et al.: Morganella morganii brain abscess Conclusion 2. Chuang YC, Chang W, Huang CR, Chen H. Morganella morganii Central Nervous System Infection: Case Report and review. Infect Dis Clin Pract 1998;8:50-2. Morganella morganii is considered to be an opportunist 3. Chapter in a book: B. W Senior. Proteus. Morganella and Providencia. In: pathogen, and has been known to occur in both Colier L, Balows A, Sussman M, Brian ID, editors. Topley and Wilson’s, th community and nosocomial infections. Although Microbiology and Microbial infections, Systematic Bacteriology. 9 ed. London: Arnold Press; 1998. p. 1044-6. Morganella