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Kulkarni Acute pediatric bacterial meningitis due to the rare isolate, Pseudomonas putida

aftereffects of the meningitis in the survivors following diagnosed as meningitis with status epileptics with
the hospital discharge approaches 20%. [2,3] Risks of the lower respiratory tract infection. Cerebrospinal
long-term disabling secondary results were highest in fluid (CSF) analysis showed a normal white blood
low-income countries, where the burden of bacterial cell count (0.4 cells/cumm and lymphocytes 100%),
meningitis is the greatest. Most of these reported normal proteins (26.6 mg/dL) and elevated sugar
results could have been averted by vaccination with levels (112.7 mg/dL).
Hib, pneumococcal, and meningococcal vaccines.
[3]
Hence early diagnosis and appropriate management Gram stain did not show any organism and pus cells.
of children with meningitis is critical as it can be difficult However, CSF culture grew Gram-negative organism
to diagnose as the symptoms and signs are often which on further biochemical evaluation was identical
nonspecific especially in young children. [2] to Alcaligenes fecalis. The organism was later on
identified as Pseudomonas putida with automated
CASE REPORT identification system, VITEK 2 (BIOMERIEUX, USA).
®
A 5-year-old girl, a known case of opsomyclonus The patient was treated initially with injection of
syndrome and is therefore being treated for this piperacillin with tazobactum, vancomycin, meropenem,
autoimmune condition with steroids for the past 2 acyclovir and maintenance IV fluids. In addition to
years, she was referred Lotus hospital on March 3th, this, she received injection phenytoin followed by
2015, with the symptoms of fever, vomitings (7-8 phenobarbitone and anticerebral edema measures;
episodes) and reduced appetite for the last 48 h and computed tomography scan of the brain was normal.
altered sensorium for the last 24 h. She had the past As per the clinical findings, a possibility of severe
history of ataxia. On assessment, the growth and sepsis with septic shock was considered. Her 2D
the development were appropriate for her age. Her ECHO was done and showed normal heart with mild,
heart rate was 168/min, respiratory rate was 61/min, bilateral pleural effusion, inferior vena cava was non-
blood pressure (BP) was 77/38 mmHg. On physical collapsed and dilated. Her fluid bolus was optimized
examination, she had sunken eyes and wound over and she was commenced on the vasoactive agents
the knee. Her tongue appeared to be dry. Respiratory in view of refractory shock. C-reactive protein was
exam showed that she had tachypnea. Central elevated (46 mg/L).
nervous system examination showcased that she was
drowsy and Glasgow coma score (GCS) was E3V3M4 Pseudomonas putida displayed in vitro sensitivity to
and hypotonia was present in the lower limbs. Pupils amikacin, ciprofloxacin, levofloxacin and minocycline
were bilaterally equal and reacting to the light. On and moderately sensitivity to gentamicin and cefepime.
abdominal exam, abdomen was distended. In view It was totally resistant to piperacillin and tazobactum,
of the poor GCS, she was intubated and mechanical cefoperazone and sulbactum, cotrimoxazole, doripenem
ventilator support was continued. Her blood gases and tigeycycline. Hence the antibiotics were change to
were monitored regularly. amikacin. Gradually her hemodynamics improved with
the reversal of shock state.
Her complete blood picture was normocytic and
normochromic. The cell counts and erythrocyte Her chest X-ray showed the right lower lobe
sedimentation rate were within normal limits consolidation. She was extubated after 6 days and
except neutrpohils (neutrophilia) and platelets received chest physiotherapy. On the day of discharge,
(thrombocytosis). Blood urea nitrogen, serum calcium, March 26th, 2015, her BP was 110/54 mmHg, and
serum creatinine (1.2 mg/dL) and serum electrolytes oxygen saturation was 98% and all organ systems
were out of range. Her serum glutamic oxaloacetic examinations were normal.
transaminase was 152 IU/L and her test results for
malarial antigen were negative. Her blood ammonia DISCUSSION
was within normal range. Complete urine examination
showcased 10 pus cells/high power field whereas the Acute bacterial meningitis (ABM) is the dangerous
culture results showed that she was sterile. Routine disease if found in young children and has a high
examination of her stool was negative. Blood cultures rate of fatality and risk of neurological handicaps.
[4]
were negative for bacterial growth. Oxygen saturation In the developed countries, N.meningitidis and
was 55%. Ultrasonography of the abdomen showed S.pneumoniae are the most prevalent cause of the
[2]
mild ascitis and her fundus examination was normal. acute bacterial meningitis whereas H.influenzae,
N.meningitidis and S.pneumoniae are responsible for
In view of the history and clinical features, she was ABM in the developing countries. [4,5]
216 Neuroimmunology and Neuroinflammation ¦ Volume 3 ¦ September 26, 2016