Portal de Periódicos da CAPES

POSTSURGICAL MENINGITIS CAUSED BY BORDETELLA BRONCHISEPTICA

2003; Lippincott Williams & Wilkins; Volume: 22; Issue: 4 Linguagem: Inglês

10.1097/01.inf.0000059766.51912.e8

1532-0987

Ozlem Belen, Joseph M. Campos, Philip H. Cogen, Barbara Jantausch,

Infectious Encephalopathies and Encephalitis

Bordetella bronchiseptica is a common commensal and respiratory pathogen in many wild and domestic animals, but it is a rare cause of human infection. There have been reports of human respiratory tract infection and bacteremia, occurring predominantly in immunocompromised patients and the elderly. We report a case of B. bronchiseptica postsurgical meningitis in an adolescent who had household pet contacts. Case report. A 17-year-old female adolescent with type II neurofibromatosis developed headache, nausea and vomiting 6 weeks after surgery to remove a left-sided acoustic neuroma. She denied any visual changes or fever. Medical history was remarkable for anorexia nervosa and past neurosurgical procedures to remove neurofibromas. The patient had a history of exposure to two dogs and one cat in her household. The cat slept in bed with the patient. At admission the patient had a temperature of 37.1°C, pulse of 80 beats/min, respiratory rate of 18/min and blood pressure of 90/56 mm Hg. Physical examination was significant for a fixed left pupil, left sided facial weakness, decreased strength of her left upper and lower extremities and normal gait. The computed tomography scan obtained on admission showed mild to moderate enlargement of the lateral, third and fourth ventricles without significant interval change in size. The patient was initially treated with ceftriaxone and vancomycin in preparation for right ventriculoperitoneal shunt placement for management of hydrocephalus, attributed to the post-operative failure of cerebrospinal fluid (CSF) absorption. A complete blood count at hospitalization revealed: white blood cell (WBC) count, 9.5 × 103 cells/mm3 (66% neutrophils, 29% lymphocytes, 5% monocytes); hemoglobin, 12.1 g/dl; and platelet count, 382 000/mm3. Analysis of CSF revealed WBC count, 20 cells/mm3 (66% lymphocytes, 20% monocytes, 9% neutrophils); glucose, 49 mg/dl; and protein, 25 mg/dl. A Gram-stained smear of CSF sediment revealed no organisms. Growth of a nonfermentative, Gram-negative organism was reported from the CSF on Day 2 of culture incubation. At that time the patient had low grade fever (38.4°C), and an erythematous, pruritic rash extended from the back of the right ear through the upper chest and abdomen, along the ventriculoperitoneal shunt track. The left-sided facial palsy persisted as well as the headaches and nausea. On the third hospital day, treatment with ceftazidime and tobramycin was initiated, and ceftriaxone was discontinued. On the fifth day of hospitalization, the organism from the initial CSF culture was identified as Bordetella bronchiseptica, and vancomycin was discontinued. The organism was susceptible in vitro to ceftazidime, trimethoprim-sulfamethoxazole and the aminoglycosides including gentamicin, tobramycin and amikacin; it was resistant to ceftriaxone, cefazolin, cefoxitin and cefuroxime. This susceptibility pattern is consistent with the Rapid Antibiogram national data. 1 The patient continued treatment with ceftazidime and tobramycin throughout her hospitalization. Her low grade temperature spikes subsided on Day 4 of hospitalization. A CSF specimen was sent on the third hospital day and had the following values: WBC count, 21 cells/mm3 (39% neutrophils, 58% lymphocytes); glucose, 43 mg/dl; and protein, 50 mg/dl. B. bronchiseptica was recovered from this CSF specimen. The patient improved clinically except for occasional complaints of mild headaches. Tobramycin was discontinued, and she was sent home on Hospital Day 8 to receive intravenous ceftazidime. She presented with lethargy and nausea 12 days after discharge and was readmitted for shunt failure and revision. CSF cultures were sterile. The patient completed a total 3-week course of intravenous ceftazidime for the B. bronchiseptica infection. Discussion.Bordetella pertussis and Bordetella parapertussis, the causative agents of whooping cough, are responsible for most of the important human infections caused by the genus. B. bronchiseptica is an obligately aerobic Gram-negative bacillus that grows readily on standard laboratory culture media. It tests positive for catalase, oxidase, citrate utilization, motility, urease and nitrate reduction. It is negative for indole production. Antimicrobial susceptibility patterns are similar to those expected from other nonfermentative, Gram-negative bacilli. 2 B. bronchiseptica is an important pathogen of domestic animals, causing kennel cough in dogs, atrophic rhinitis and pneumonia in pigs and pneumonia in cats. 2, 3 The infection is limited to the tracheobronchial tree and is characterized by adherence of the bacteria to the cilia and surface structures of respiratory epithelial cells. This results in mechanical blockage of the respiratory cilia and ultimately failure in clearing mucous secretions from the lower respiratory tract. B. bronchiseptica is capable of colonizing the human respiratory tract. 4 Human infections are reported only occasionally despite considerable exposure of humans to animal sources of this bacterium. B. bronchiseptica has been recovered primarily from immunocompromised patients. Several case reports of B. bronchiseptica infections in HIV patients have appeared in the literature. 5 Chang et al. 6 published the only prior report of B. bronchiseptica recovery from CSF. In that case a 9-year-old boy developed signs and symptoms of meningitis after repair of a posttraumatic orbital fracture. B. bronchiseptica was recovered from two CSF specimens. The patient was treated for 9 days with intravenous chloramphenicol and methicillin, followed by iv ampicillin for 2 weeks. The microbiologic characteristics of the organism recovered from our patient presented sufficient data for reliable identification. The antimicrobial susceptibility pattern of the isolate recovered is similar to other reports in the medical literature. 1, 2 Although contact with the household pets was considered to be a possible source for the infection, cultures from these animals were not obtained. B. bronchiseptica can be a true pathogen in CSF in an immunocompetent patient, especially in the setting of surgical manipulation. Our case extends the realm of this organism beyond the respiratory tract.