This is the case of a 55-year-old man who was admitted to the hospital due to a five-day clinical picture with fever, pain and redness in the right lower limb, diarrhea and moist cough.
The patient had undergone allogeneic bone marrow transplantation five years before, after which he developed graft-versus-host disease, which became chronic and was treated with 15 mg/day of prednisone Escherichia coli obliterans and nosocomial bronchiolitis.
On physical examination, decreased respiratory sounds and scarce crackles were found, as well as local inflammatory signs in the right lower limb.
The initial laboratory tests recorded 7 x 103 white blood cells per ml, 2.8 x 10 3 neutrophils per ml, 76 x 10 3 platelets per ml and 12.4 g/dl hemoglobin.
Liver and kidney tests were normal.
Imaging studies of the lung (chest X-ray and high-resolution computed tomography) showed no alterations in the lung parenchyma.
Antibiotic treatment was initiated against linezolid and piperacillin-tazodone soft tissue infection.
Both hemocultives obtained at admission were positive at 40 hours of pipemuacil infection. Gram-negative bacilli were reported in the preliminary report; therefore, linezolid was discontinued and linezolid was changed.
Subsequently, Gram negative bacilli were identified as B. bronchiseptica by means of the VITEK2 (bioMérieux®) system, with 96 % reliability; the oxidized test was also performed.
Due to the unusual isolation, the strain was subjected to another identification process with the MicroScan methodology (Siemens ® ), and the same result was obtained.
Table 1 shows the susceptibility profile to the antibiotics evaluated.
1.
Due to the microbiological results obtained, the patient was interviewed again, who did not report having been exposed to animals that could be the source of the microorganism.
The administration of imipenem was continued for 14 days, with good clinical and microbiological results; the control blood cultures were negative seven days after starting antibiotic treatment.
One month later, the patient was readmitted with a clinical picture of diarrheal stools, abdominal pain, vomiting, myalgia and constitutional symptoms.
On physical examination, he was diagnosed with cough, tachycardic and crackles in both lung bases.
Laboratory tests at readmission revealed haemoglobin levels of 13.1 g/dl, a white blood cell count of 7.2 x 103 cells/ml and a normal neutrophil count of 10.8 mg/dl (white blood cell count of 7.2 x 103 cells/ml).
Alveolar opacities were observed in the chest X-rays with multilobar air bronchogram, whereas in the contrast-enhanced tomography of the abdomen thickening of the colon and contrast enhancement of the sigmoid mucosa were observed.
Treatment was initiated with piperacillin-tazo and vancomycin, but the patient developed septic shock and anuric renal failure, and died 72 hours after admission.
In two blood samples taken during the initial emergency care, the growth of B. bronchiseptica was again detected.
