Elizabethkingia Meningoseptica is a non-fermenting gram-negative organism commonly detected in soil and water but traditionally, rarely reported to be the causative agent of infections in humans,[3]. However, it has recently emerged as a cause of life-threatening infections especially in immunocompromised hosts. The genus is usually multi-drug resistant, exhibiting sensitivity to Minocycline but resistance to most beta lactams, beta lactams / beta lactam inhibitors, carbapenems and aminoglycosides,[4]. Most of the cases have been traced down to rubber stoppers used for milk bottles in neonatal meningitis, respiratory equipment, sink drains and water, [6, 7].

We present a unique case of community acquired Elizabethkingia Meningoseptica presenting with septic shock due to bacteremia and subclinical meningitis without alarm symptoms.

Case Description

A female patient in early 70s with a past medical history of marginal zone B cell lymphoma in remission (treated with 6 cycles of bendamustine and rituximab 1.5 years ago), autoimmune hemolytic anemia treated with splenectomy and hypogammaglobulinemia on monthly intravenous immunoglobulin (IVIG) therapy, disseminated zoster virus infection 3 months prior to presentation, postherpetic neuralgia, chronic diarrhea - secondary to IVIG therapy, presented to the emergency department (ED) with generalized weakness of 1 week duration. The patient was doing relatively well until she started to feel progressively weak to an extent where she did not have enough strength to ambulate and therefore called Emergency Medical Services (EMS). She was noted to be hypotensive with a systolic blood pressure of 60 by EMS. Denied any fever, chills, headaches, nausea, vomiting, photophobia, nuchal rigidity, abdominal pain, dysuria, frequency, cough, or shortness of breath.

On presentation in the ED, her blood pressure was 63/33 mmHg, heart rate was 129 beats per minute with temperature of 101.1oF. Initial laboratory testing was significant for leukocyte count, 21.27 K/uL with 93.9% neutrophilia; blood urea nitrogen, 63 mg/dL; creatinine, 2.9 mg/dL (increased from a baseline of 0.7 mg/dL); lactic acid, 8.0 mmol/L. Sepsis protocol was initiated, and she was administered 2 grams of aztreonam, 1 grams of vancomycin, 2-liter bolus of lactated ringers and continuous norepinephrine infusion. She was admitted to the Intensive Care Unit (ICU) with a diagnosis of septic shock.

Her two initial sets of blood cultures sent from the ED grew Elizabethkingia Meningoseptica. Urine culture was positive for Klebsiella. She was initially treated with Meropenem, which was switched to Meropenem/Vaborbactam 2 grams Intravenously (IV) every 12 hours 1 day later when the sensitivity report showed resistance to meropenem. The final sensitivity report resulted 3 days later that showed sensitivity to ciprofloxacin (S <=0.25), Piperacillin/Tazobactam (S <= 8) and TMP/SMX (S 1/19).

A transthoracic echocardiogram performed on day 2 of hospitalization showed no valvular vegetations with an ejection fraction of 15%, severely decreased left ventricular systolic function, grade II diastolic dysfunction, mild mitral regurgitation, mild tricuspid regurgitation, mild pulmonic regurgitation, mild aortic stenosis, and multiple left ventricular wall motion abnormalities. Transesophageal echocardiogram performed on day 8 of admission revealed EF of 35-40% with no evidence of valvular vegetations. Global systolic LV function was moderately to severely decreased. A cardiac catheterization was scheduled as outpatient. A whole-body nuclear scan was performed on Day 9 as blood cultures remained persistently positive that showed focal uptake in Left proximal greater trochanter region. Follow up Magnetic Resonance Imaging showed trochanteric bursitis without osteomyelitis, however clinically trochanter bursa was unremarkable. Patient’s blood lactate and hemodynamic status gradually improved, and she was tapered off pressors on Day 9.

Blood cultures remained persistently positive until day 14 of the hospitalization. Antibiotics regimen was changed in accordance with their sensitivities as shown in Table 1 and Table 2. On day 11, patient complained of diffuse headache without any fever, chills, nausea, vomiting, photophobia, or nuchal rigidity. Patient was alert and oriented to name, place, and time without any focal neurological deficits. As no focal source of infection was identified at that time, a diagnostic lumbar puncture was performed. Cerebrospinal Fluid (CSF) appearance was slightly cloudy. CSF studies were consistent with bacterial meningitis with glucose of 14 mg/dL, total nucleated cells 830 (lymphocytes 4%, neutrophils 92%, monocytes 4%), protein 90 mg/dL, Red Blood Cells 260, and lactate dehydrogenase 61. CSF culture grew Elizabethkingia Meningoseptica resistant to Aztreonam, Cefepime, Ceftriaxone and Meropenem. Additional sensitivities were run for vancomycin and Daptomycin with MIC of 16 and > 256 respectively.

Blood cultures collected from day 14 showed no growth and remained negative on the subsequently from days 15 to 19. The patient was discharged on day 23 on the final antibiotic regimen of Levofloxacin 750 mg IV every 24 hours, Minocycline 100 mg IV every 12 hours, and Rifampin 600 mg IV every 24 hours for a total duration of four weeks from the first negative blood culture. Acyclovir 400 mg orally every 12 hours was continued for antiviral prophylaxis due to patient's immunocompromised status.

Table 1: Blood Culture growth and sensitivities in MIC (Minimum Inhibitory Concentration) chronologically by hospital days.

Table 2: Antibiotic Regimen – Day of hospitalization and antibiotics regimen.