Serratia marcescens okozta csecsemőkori multiplex agytályogból való felépülés

Serratia marcescens okozta csecsemőkori multiplex agytályogból való felépülés Szerző:Fejes Melinda, Borbás Éva, Papp Attila, Velkey Imre, Székhelyi Zsuzsanna, Szűts Ágnes www.radiologia.hu

Serratia marcescens is a typical nosocomial Gram negative infective agent, which is a member of normal gut bacterium colonia. They are mobile aerobic bacteria from the Enterobacteriaceae family. There are three colonial and two pathogenic forms. Those predisposed to such infection include the young, immunodeficient, chronically ill, and post-surgical patients. Mortality rate is high (1). Case report Our male patient was born during the 34th gestational week; his birth weight was 2150 grams. There was polycythaemia in the first days, though partial blood exchange was not necessary. On the 7th day he had fever and short apnea. Serratia marcescens was cultured from the blood, targeted antibiotic treatment was started. Physical, neurological status and inflammatory parameters were normal at the time. Cranial ultrasound examination showed hyperreflectivity in the left thalamus, referring to a possible haemorrhagic or vascular abnormality (fig. 1. a, b).

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Figure 1. a) Sagittal and b) coronal cranial ultrasound examination showed hyperreflectivity in the left thalamus (4 mm diameter). On the 11th post-natal day focal convulsions were observed, antiepileptic therapy was introduced. Second cranial US showed frontal, left-sided large echo lucent circumscribed abnormality. The early thalamic hyperechogenicity regressed (fig. 2.). Mechanical ventilation was introduced due to respiratory insufficiency for some hours on that day.

Figure 2. Control cranial ultrasound showed frontal, left side large echolucent circumscribed abnormality (13×8 mm ). Cranial CTdemonstrated multiple abscesses and ventriculitis. Distended, torturous vasculature was detected, suggesting vasculitis or vascular abnormality (fig. 3.). Rapid progression with lack of inflammatory reactions was seen. Immune deficiency and cardiac disease were excluded.

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Figure 3. Supratentorial ventricle system is dilated in middle level. There are large abscecces on the left side frontal position and both side occipital position with 5-6 cm diameter. Cerebral vasculature is dilated and curved. We found the agent was resistant in vivo for ceftriaxon. Antibiotic was changed and intrathecal therapy introduced (table 1.;2.). Antibiotics/date 08. 09. H Ampicillin R Tobramycin Trimetha/sulfa S Cefuroxim R Cefotaxim S Amikacin S Ceftriaxon S Ampicillin/sulbac R tam Imipenem S Meropenem S Cefepine 1. Table. Serratia marcescens in vitro resistance. CSF: cerebrospinal fluid, H: haemoculture, R: resistent, S: sensitive, -:not investigated Excellent Chloramphenicol Trimetha/sulfa

Only inflammatory amikacin, ampicillin cefotaxim,ceftriaxo cefuroxim, meropen cefepine 2. Table. Liquor penetrations of antibiotics Surgical therapy included drainage of large abscesses with placement of an external ventricular shunt (fig. 4–6.). Unfortunately, the smaller abscesses ruptured into the ventricle. There were no detected bacteriae in the culture, but inflammatory signs and bacteriae were seen in the cerebrospinal fluid (CSF) three weeks after therapy.

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Figure 4., 5., 6. Drainage was done across larger abscesses. At this time the child frequently had epileptic seizures, demanding a complex antiepileptic therapy. Vascular malformations were not detected by cranial MRI-angioscan (fig. 7. a, b). Secondary hydrocephalus and closed 4th ventricle required ventriculoperitoneal shunt (fig. 8. a, b). After these surgical procedures and complex antibiotics administration for infections, the boy is in satisfactory physical condition. Treatment for West syndrome continues, as does the antiepileptic treatment monotherapy.

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Figure 7. a)-b). There was no vascular malformation on MR-angio scans.

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Figure 8. a)-b). IV. ventricle and aquaeductus Sylvii are cystic dilated on the axial CT scans. Unfortunately, the child suffers from severe mental retardation motor developmental delay at the age of nine (fig. 9.).

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Figure 9 a)-b). CT imagines of 8 year of age. Ventriculoperitoneal shunt is in a correct place, ventricule system is dilated and deformed. Discussion Cases of newborn bacterial meningitis are 1-8/1000. Risk factors are prematurity, maternal bacterial colonisation, premature rupture membrane for more than 18 hours, and fever during labor, chorioamnionitis, male gender, invasive monitoring resuscitation, and respiratory distress syndrome. The frequent agents are Gram negative bacteria like Escherichia coli, Klebsiella, Enterobacter and Serratia species (1). Serratia marcescens is a motile Gram negative aerobic bacteria. Serratia species are responsible for 1.4% of nosocomial bloodstream infections (2). Its speciality is coloured pigment production from deep purple to pink, but there is a non-pigmented form too (3). Polymerase chain reaction is the most frequently used test for isolation. There are two pathogenic and three colonisation forms. They are members of normal gut bacterial colony (4). Latency period of diseases of Serratia marcescens bacteria is generally about 3-10 days, but can also be longer. The sources of outbreaks are frequently the medical staff and the colonized /infected infants (5–7). Serratia marcescens pseudo-bacteriaemia is associated with contaminated instruments (8). Theccanat et al. detected meningitis in a 66 year-old male patient one month after ear operation (9). Serratia infections are of nosocomial origin in 80.4 %. The potential infective agent is mainly the hand of nursing staff, but this bacterium can live and survive in all places from soap dispenser to drugs (10, 11). Initial signs are apnea or septic shock. Normal cerebrospinal fluid examination may be seen in early stages. Meningitis develops in half of all Serratia marcescens infections with or without bacteriaemia, renal infections and subcutaneous inflammatory reactions. In certain cases vasculitis precedes ventriculitis, with the former allowing for diagnosis on imaging. Brain abscesses are rare but treatable complications in newborn age. Most of them could be classified under meningitis. Common agents are Proteus and Serratia species. Usually cerebral necrosis from bacteriaemia is prone to develop abscesses, but main cause is cerebral infarct after vasculitis. They are also related to hypoxic ischaemic lesion, periventricular haemorrhage, and septic shock in other cases. The abscess is usually large, not circumscribed, typically on frontal location. It begins on average at the age of nine days. Abscesses may cause seizures and other non-specific septic signs like developing high circumference of the heads. Aspiration of abscesses by neurosonography and systemic antibiotic treatment are recommended (12). Bacterial resistance against first-line third generation cephalosporins can form rapidly. Aminoglycosides, sulfonamid with trimethoxazol, imipenem, meropenem are effective in newborns (2). Also high dose combined therapy can be useful (7). After the CSF has become sterile, at least a three-week treatment is necessary (10). Serratia infections had very high mortality rate (about 25 %). Hydrocephalus internus followed by postmeningitic signs develop in 61% of ill babies. After brain abscesses, mental retardation was observed in two-thirds of patients and epilepsy in 60%. There was frequent hearing impairment and cerebral palsy (4, 12–14). Our case was typical. The disease, the rarity of the pathogen agent and its invasive features were the main causes to introduce our patient. Conclusion An increase in the incidence of Gram negative infections is probable at neonatal intensive centres, because more and more invasive procedures and plastic devices are put into practice. A full array of diagnostic modalities is present to diagnose the illness and follow its natural course or complications. These illnesses can be prevented with a good surveillance program, strict hygienic rules and outbreak investigations. During treatment, the pathogens can frequently develop resistance against cephalosporins, so they increase morbidity and mortality.

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Better recovery is expected from early, targeted-combined antibiotic treatment. References 1. Polin RA, Harris MC. Neonatal bacterial meningitis. Semin Neonatol 2001;6:157-72. 2. Basilio JA. Serratia. http://emedicine.medscape.com/article/228495-overview,2009.nov.4. 3. Campbell JR, Diacovo T, Baker C. Serratia meningitis in neonates. Pediatr Infect Dis J 1992;11;881-6. 4.Campbell JR, Zaccaria E, Mason EO, Baker CJ. Epidemiological analysis defining concurrent outbreaks of Serratia marcescens and methicillin-resistant Staphylococcus aureus in a neonatal intensive-care unit. Infection Controll and Hospital Epidemiology 1998;19(12):924-8. 5. Zavasky DM, Samore MH, Classen DC, Johnston BL, Brinton B, Mooney B, Burke JP. Concurrent Outbreaks of Serratia marcescens in Two Neonatal Intensive Care Units (NICUs). Antimicrob Agents Chemother 1999;(39):607. 6. Berger AA, Aspöck C, Mustafa S, Kohlhauser C, HirschlAM. Nosocomial Outbreak of Serratia marcescens in a Neonatal Intensive Care Unit.Infection Control and Hospital Epidemiology 2002;23(8):457-61. 7.Voelz A, Müller A, Gillen J, Le C, Dresbach T, Engellhart S, et et al. Outbreaks of Serratia marcescens in neonatal and pediatric intensive care units: clinical aspects, risk factors and management. Int J Hyg Environ Health 2010;213(2):79-87. Epub 2009 Sep 26. 8. Neal TJ, Corkill JE, Bennett KJ, Yoxall CW.Serratia marcescens pseudobacteraemia in neonates associated with a contaminated blood glucose/lactate analyzer confirmed by molecular typing. Journal of Hospital Infection 1999, 41(3) 219-22. 9. Theccanat G, Hirschfield L, Isenberg H. Serratia marcescens meningitis. J Clin Microbiology 1991;822-3. 10. Haddy RI, Mann BL, Nadkarni DD, et al. Nosocomial infection in the community hospital: severe infection due to Serratia species. J Fam Pract 1996;42:273-7. 11. Berthelot P, Grattard F, Amerger C, et al. Investigation of a nosocomial outbreak due to Serratia marcescens in a maternity hospital. Infection Control and Hosp Epid 1999;20(4):233-6. 12. Volpe JJ. Bacterial and fungal intracranial infections. In: Neurology of the newborn. 1995;730-61. 13. Aicardi J. Diseases of the nervous system in childhood. Cambridge Press ed. 1998;373-93. 14. Unhanand M, Mustafa MM, McCracken GH Jr, et al. Gram-negative enteric bacillary meningitis: a twenty-one-year experience. J Pediatr 1993;122(1):15-21. Absztrakt: BEVEZETÉS: A Serratia marcescens által okozott többszörös agytályog ritka betegség újszülöttekben. ESETISMERTETÉS: Közleményünkben bemutatjuk az első életnaptól polycytémiával és lázzal kezelt újszülött fiú esetét. A 11.életnapon konvulziók, meningitis és intracraniális ultrahang eltérés miatt koponya CT vizsgálatot végeztettünk. A CT felvételeken többszörös tályog ábrázolódott, ezért sebészeti beavatkozást, drenázst, majd agykamra shunt beültetést végeztek. Ebben az időszakban kombinált antiepileptikus kezelést igényelt a gyakori konvulziók kezelésére. A sebészeti beavatkozásokat és a komplex antibiotikus kezelést követően a fiú kielégítő fizikális állapotban volt két éves korban. Ekkor West szindrómával kezelték. Epilepsiája egy antiepileptikus gyógyszerrel egyensúlyban van. Jelenleg kilenc éves, szellemi és mozgássérült. KONKLÚZIÓ: E súlyos betegség kivédhető jó surveillance programmal és szigorú higiénés szabályokkal. A korai, célzottkombinált antibiotikus kezeléstől kedvezőbb kimenettel várható. Kulcsszavak: Serratia marcescens, ventriculitis, meningitis, epilepszia, újszülött Author: Melinda Fejes, Éva Borbás, Attila Papp, Imre Velkey, Zsuzsanna Székhelyi, Ágnes Szűts Abstract: INTRODUCTION: Multiple brain abscesses caused by Serratia marcescens is a rare disease in newborn infants. CASE REPORT: We are presenting a newborn baby boy registered with polycythaemia and fever in the first days of his life. On the 11th day due to convulsions, intracranial abnormality and meningitis cranial CT was needed and performed. On CT scans multiple abscesses were revealed and surgical therapy including drainage and ventricle shunt was done. This time he frequently had epileptic seizures demanding complex antiepileptic therapy. Following these surgical procedures and complex antibiotics administration the boy was in a proper physical condition in the age of two. The boy was treated with West syndrome. His epilepsy is in balance with only one antiepileptic drug. He has mental and motor delay in the age of nine. CONCLUSION: This kind of serious illnesses can be prevented with a good surveillance program and strict hygienic rules. Better recovery is expected from early, targeted-combined antibiotic treatment. Keywords: Serratia marcescens, ventriculitis, meningitis, epilepsy, newborn Szerző munkahelye: Borsod A.Z. Megyei Kórház, H-3526 Miskolc, Szentpéteri kapu 72–76. Szerző e-mail címe: [email protected]

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Szerző levelezési címe: Borsod A.Z. Megyei Kórház, Koraszülött osztály, H-3526 Miskolc, Szentpéteri kapu 72–76.

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Serratia marcescens okozta csecsemőkori multiplex agytályogból való felépülés

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