This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrowReprints and Permissions
Right arrow Copyright Information
Right arrow Books from ASM Press
Right arrow MicrobeWorld
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pagani, L.
Right arrow Articles by Mian, P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pagani, L.
Right arrow Articles by Mian, P.

 Previous Article  |  Next Article 

Journal of Clinical Microbiology, May 2003, p. 2240-2241, Vol. 41, No. 5
0095-1137/03/$08.00+0     DOI: 10.1128/JCM.41.5.2240-2241.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.

CASE REPORT

Soft Tissue Infection and Bacteremia Caused by Shewanella putrefaciens

Leonardo Pagani,1* Adolf Lang,2 Claudio Vedovelli,1 Oswald Moling,1 Giovanni Rimenti,1 Raffaele Pristerà,1 and Peter Mian1

Division of Infectious Diseases,1 Laboratory of Clinical Microbiology and Virology, Bolzano Central Hospital, Bolzano, Italy2

Received 21 November 2002/ Returned for modification 19 January 2003/ Accepted 18 February 2003


arrow
ABSTRACT
 
Shewanella putrefaciens is as yet rarely responsible for clinical syndromes in humans. However, a case involving multiple organs in an elderly male under treatment with appropriate steroids confirms that attention should be devoted to unusual pathogens.


arrow
CASE REPORT
 
An 87-year-old Caucasian male who had come back a few days before from holidays on the Adriatic shore was admitted because of shivering, fever up to 39.8°C, and erysipelas of the left forearm. He complained of malaise, extreme weakness, and severe pain at the upper left extremity. No other relevant symptoms were present. There was a history of "rheumatic myalgia" (not well diagnosable) for which he was on long-term, low-dose methylprednisolone (4 mg once daily); he denied other previous illnesses of note and regular consumption of any drugs.

On exam, he presented as an obese man with a typical Cushing-like face and was febrile (39°C) but hemodynamically stable. A 1.5-cm-long cutaneous-subcutaneous wound was present on the skin near the left elbow, together with erysipelas affecting the whole left forearm. Small-bubbled rattling noises were heard at the level of the left pulmonary basis. In view of the fever, immediate blood (three sets each in aerobic and anaerobic bottles) (BD BACTEC, Benex Ltd., Shannon, Ireland), urine, and stool cultures were taken. Wound exudate was not cultured, nor was skin biopsy performed. Hematological investigations revealed a white cell count of 13.9 x 109/liter, a hemoglobin level of 14.0 g/dl, and a platelet count of 167 x 109/liter. C-reactive protein was at 13.5 mg/dl (normal range, 0 to 0.5 mg/dl), and the erythrocyte sedimentation rate was 37 mm (normal range, 0 to 10 mm). Chest X-ray film showed a segmental infiltrate in the left lower lobe very close to the diaphragm muscle and consistent with pneumonia. No sputum cultures were obtained, and the stable general conditions of the patient suggested delaying a bronchoscopy in order to recover lung aspirate. The patient was given empirical antimicrobial therapy with intravenous sulbactam-ampicillin and a protective dressing on the affected forearm. On the third day from admission and the start of the therapy, all six blood cultures became positive for Shewanella putrefaciens, whose antibiotic susceptibilities are shown in Table 1. Urine and stool cultures remained negative. At the same time, both a complete disappearance of fever and a remarkable improvement of the patient's clinical status were observed. A decision to perform either bronchoscopy or skin biopsy was definitively withdrawn. On the fifth day, antibiotic therapy was switched to ampicillin orally. Within a few days, the patient progressively regained complete function of the forearm, and any local sign of infection disappeared as well. C-reactive protein, as well as the white cell count and the erythrocyte sedimentation rate, returned to normal levels. A further chest radiography showed an almost complete normalization of the pulmonary picture. The patient was then discharged on the tenth day, still on treatment with ampicillin, which was definitively withdrawn four days later.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Antimicrobial susceptibility of an isolated Shewanella strain

Subcultured blood specimens were plated onto traditional blood agar and chocolate agar; on the former, incubated both in air and anaerobically at 37°C, small mucoid brown colonies became evident within 36 h. On a Gram stain, the isolate was found to be a gram-negative rod. Identification was initially performed with the VITEK II automated system (bioMérieux, Marcy l'Etoile, France), which evaluates 41 biochemical tests and which gave an excellent confidence level for the identification, and with the semiautomated Api ID 32 GN method (bioMérieux), which is based on 32 assimilation tests. This second assay offered a 96.5% probability for S. putrefaciens. Antimicrobial susceptibility determinations were automatically performed through the VITEK system, which yielded the MICs reported in Table 1; then, the Kirby-Bauer agar diffusion method was used as a confirmatory tool.

Both S. putrefaciens and Shewanella alga are uncommon as isolates from clinical syndromes, their natural habitats being all forms of water, fish, oily foodstuffs, and soils (2, 4, 11). Indeed, this is the first case, to our knowledge, of such isolates in Italy. Initially classified as Pseudomonas spp., their importance in human pathology has become evident in the last years as reports of different kinds of infection have increased (1, 5, 6, 9-12). Experimental works have allowed differentiation of these two pathogens on the basis of their genetics and metabolism, thus also allowing review of the previously published clinical experiences (7, 11). In light of these findings, and though a definitive taxonomy of the genus is still debated, microbiology diagnostic tools have become more refined and presently permit a distinction between the two species (6). In particular, based on the oxidation of various carbohydrates, Khashe and Janda distinguished two main biotypes of S. putrefaciens: biotype 1 produces acid from maltose, sucrose, and arabinose, whereas biotype 2 could be chiefly separated by the inability to oxidize maltose and sucrose (7). In contrast, S. alga strains do not oxidize these carbohydrates at all (7). Thus, this different utilization of carbohydrates, together with different growth at 42°C or in 6.5% NaCl and the production of a hemolytic substance, would make easier the separation of these species from one another (7). Moreover, it has been suggested that different tolerance to some antimicrobials seems to provide a reliable phenotypic characterization between them (11). However, it should be remarked that the chemosensitivity patterns of nonfermenter gram-negative rods in Italy are extremely variable with respect to carbapenems, and it is therefore not unusual to find isolates with great differences between each other in the MICs of imipenem and meropenem. In addition, the absolute rarity of such isolates makes the definition of a reference phenotype very difficult. S. alga appears to be more closely related to human illnesses than S. putrefaciens (7, 11). The reason for the difference in pathogenic potential, though still unclear, could lie in some hemolytic factors or exotoxins that are expressed by S. alga and not by S. putrefaciens; also, the different pattern of resistance to antimicrobials could explain, in part, such a difference (7). Nevertheless, S. putrefaciens also retains pathogenic potential, mainly under special environmental circumstances. Indeed, most of the reported infections pertained to contact with contaminated waters or injuries or occurrences in which integrity of the skin was compromised to some extent (3, 4, 9, 10, 12); this last issue encompasses also long-term catheters (1). In addition, isolation of S. putrefaciens occurred in polymicrobial infections (3).

In our opinion, this new case of infection and consequent bacteremia caused by S. putrefaciens strengthens the hypothesis that attention should always be extended also to unusual pathogens, especially under particular circumstances. Despite the relatively better sensitivity to antimicrobials of S. putrefaciens compared to S. alga, they both should probably be regarded as emerging opportunistic pathogens in taking care of immunosuppressed patients (8).


arrow
FOOTNOTES
 
* Corresponding author. Mailing address: Division of Infectious Diseases, Bolzano Central Hospital, Via L. Böhler, 5, 39100 Bolzano, Italy. Phone: 39-0471-908131. Fax: 39-0471-908552. E-mail: leonardo.pagani{at}asbz.it. Back


arrow
REFERENCES
 
    1
  1. Bhandari, S., T. L. T. Pan, J. Horvath, and D. Tiller. 2000. CAPD, swimming in Shewanella. Nephrol. Dial. Transplant. 15:1484-1485.[Free Full Text]
    2. 2
  2. Brink, A. J., A. van Straten, and A. J. van Rensburg. 1995. Shewanella (Pseudomonas) putrefaciens bacteremia. Clin. Infect. Dis. 20:1327-1332.[Medline]
    3. 3
  3. Butt, A. A., J. Figueroa, and D. H. Martin. 1997. Ocular infection caused by three unusual marine organisms. Clin. Infect. Dis. 24:740.[Medline]
    4. 4
  4. Chen, Y. S., Y. C. Liu, M. Y. Yen, J. H. Wang, J. H. Wang, S. R. Wann, and D. L. Cheng. 1997. Skin and soft-tissue manifestations of Shewanella putrefaciens infection. Clin. Infect. Dis. 25:225-229.[Medline]
    5. 5
  5. Dominguez, H., B. Fonnesbech Vogel, L. Gram, S. Hoffmann, and S. Schaebel. 1996. Shewanella alga bacteremia in two patients with lower leg ulcers. Clin. Infect. Dis. 22:1036-1039.[Medline]
    6. 6
  6. Iwata, M., K. Tateda, T. Matsumoto, N. Furuya, S. Mizuiri, and K. Yamaguchi. 1999. Primary Shewanella alga septicemia in a patient on hemodialysis. J. Clin. Microbiol. 37:2104-2105.[Abstract/Free Full Text]
    7. 7
  7. Khashe, S., and J. M. Janda. 1998. Biochemical and pathogenic properties of Shewanella alga and Shewanella putrefaciens. J. Clin. Microbiol. 36:783-787.[Abstract/Free Full Text]
    8. 8
  8. Krsnik, I., K. Arribalzaga, and J. Romanyk. 2002. Shewanella alga bacteremia and associated cellulitis in a patient with multiple myeloma. Haematologia 32:79-80.[CrossRef][Medline]
    9. 9
  9. Leong, J., M. Mirkazemi, and F. Kimble. 2000. Shewanella putrefaciens hand infection. Aust. N. Z. J. Surg. 70:816-817.[CrossRef][Medline]
    10. 10
  10. Papanaoum, K., G. Marshmann, L. A. Gordon, R. Lumb, and D. L. Gordon. 1998. Concurrent infection due to Shewanella putrefaciens and Mycobacterium marinum acquired at the beach. Australas. J. Dermatol. 39:92-95.[Medline]
    11. 11
  11. Vogel, B. F., K. Jorgensen, H. Christensen, J. Elmerdahl Olsen, and L. Gram. 1997. Differentiation of Shewanella putrefaciens and Shewanella alga on the basis of whole-cell protein profiles, ribotyping, phenotypic characterization, and 16S rRNA gene sequence analysis. Appl. Environ. Microbiol. 63:2189-2199.[Abstract]
    12. 12
  12. Yohe, S., J. T. Fishbain, and M. Andrew. 1997. Shewanella putrefaciens abscess of the lower extremity. J. Clin. Microbiol. 35:3393.

Journal of Clinical Microbiology, May 2003, p. 2240-2241, Vol. 41, No. 5
0095-1137/03/$08.00+0     DOI: 10.1128/JCM.41.5.2240-2241.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.



This article has been cited by other articles:

  • Richards, G. P., Watson, M. A., Crane, E. J. III, Burt, I. G., Bushek, D. (2008). Shewanella and Photobacterium spp. in Oysters and Seawater from the Delaware Bay. Appl. Environ. Microbiol. 74: 3323-3327 [Abstract] [Full Text]  
  • Botelho-Nevers, E., Gouriet, F., Rovery, C., Paris, P., Roux, V., Raoult, D., Brouqui, P. (2005). First Case of Osteomyelitis Due to Shewanella algae. J. Clin. Microbiol. 43: 5388-5390 [Abstract] [Full Text]  
  • Liu, Y., Gao, W., Wang, Y., Wu, L., Liu, X., Yan, T., Alm, E., Arkin, A., Thompson, D. K., Fields, M. W., Zhou, J. (2005). Transcriptome Analysis of Shewanella oneidensis MR-1 in Response to Elevated Salt Conditions. J. Bacteriol. 187: 2501-2507 [Abstract] [Full Text]  
  • Oliver, J. W. (2003). Ochrobactrum anthropi Misidentified as Shewanella putrefaciens. J. Clin. Microbiol. 41: 4486-4486 [Full Text]  

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrowReprints and Permissions
Right arrow Copyright Information
Right arrow Books from ASM Press
Right arrow MicrobeWorld
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pagani, L.
Right arrow Articles by Mian, P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pagani, L.
Right arrow Articles by Mian, P.

Copyright © 2009 by the American Society for Microbiology.   For an alternate route to Journals.ASM.org, visit: http://intl-journals.asm.org | More Info»