Shelley Cypher Springer, MD, MBA, George
M. Johnson, MD, Department of Pediatrics, Medical University of South
Carolina, Charleston.
A full term, previously normal 2 1/2-month-old black boy was
transferred to our hospital from an outlying facility on hospital day 5 for
failure to thrive. Three weeks before transfer, the infant was hospitalized for
a diarrheal illness with fever. The baby received 3 days of ceftriaxone
empirically and was discharged home after the sepsis evaluation was negative.
Mild diarrhea and steady weight loss continued and the baby was readmitted.
Blood culture done on admission grew Flavobacterium meningosepticum,
an organism previously described as an uncommon cause of sepsis in neonates and
immunocompromised individuals. As it is water-borne, it has been associated
with infection via contaminated water. This organism is usually resistant to
antibiotics commonly used for empiric treatment. To our knowledge, this is the
first reported case of Flavobacterium bacteremia associated with a
prodromal and concurrent diarrheal illness. [South
Med J 92(2):225-227, 1999. ¿ 1999 Southern Medical Association]
Flavobacteria are genera of aerobic gram-negative bacilli
ubiquitous in environmental water and soil.[1]
Microbiologically, they are characterized as non-glucose-fermenting and
non-motile, catalase, and oxidase positive.[2]
Clinically, they are typically of low virulence and cause significant infection
primarily in immunocompromised hosts.[1]
The species Flavobacterium meningosepticum has been reported to cause
endocarditis,[3,4]
ophthalmologic infection,[5]
upper and lower respiratory infection,[2,6-9]
peritonitis,[1,10] and, most
commonly, neonatal meningitis.[10]
We have found no reports of severe intestinal infection associated with F
meningosepticum in the literature. We report a 2 1/2-month-old infant with
F meningosepticum sepsis and a preceding unresolved diarrheal illness.
The patient was a 2 1/2-month-old black boy who was
transferred to our tertiary care facility after 24 days of persistent diarrhea
and weight loss. He was born at term after an uncomplicated pregnancy; birth weight
was 7 lb, 3 oz (3,286 g). The baby went home on day-of-life (DOL) 3 with his
mother to the patient's maternal great-grandmother, who lived in sub-poverty
conditions in a rural area. At his 2-week checkup, he weighed 8 lb, 1 oz.
On DOL 54, the patient was hospitalized at the outlying hospital for a
diarrheal illness with fever. He was treated empirically with parenteral
ceftriaxone for 3 days. Blood and spinal fluid cultures grew no organisms,
while the stool culture grew Candida tropicalis. The baby was
discharged with a diagnosis of probable viral syndrome and, with his mother,
went to live in a suburban location. The diarrhea persisted and at his third
hospital follow-up visit on DOL 73, his weight had decreased to 7 lb, 8 oz. He
was admitted for failure to thrive.
Vital signs taken on admission were within normal limits. Physical
examination was significant only for cachexia. Complete blood count showed
total white blood cells 71,200 with 32 segmented forms and 39 immature ones.
Hemoglobin was 10.8 g/dL, hematocrit 29.1%, with 357,000 platelets. Abnormal
serum electrolytes included Na 128 mEq/L, CO2
20 mEq/L; arterial pH was 7.26. T4 and TSH were within normal limits. Urine
drug screen was negative. The baby was started on 22 cal/oz formula and intravenous
fluids at 14 mL/hr.
Over the next 2 days, the patient had a resting tachycardia and a poor suck;
stool output was 8 to 10 per day. Hemoglobin dropped to 9.2 g/dL, hematocrit to
25.8%. HIV-1 antibody screen on hospital day 2 was non-reactive. Stool culture
was preliminarily negative. The patient was transferred on hospital day 5 when
his weight continued to decrease. His medications at time of transfer were oral
nystatin and maintenance intravenous fluids.
Upon arrival to our facility, the patient's temperature was 99.6œF, heart rate was 160 beats/minute, respirations 40 breaths/minute, blood pressure 86/56 mm Hg, weight 3.4 kg (< 5%), height 53.5 cm (< 5%), head circumference 34.5 cm (< 5%). Physical examination was significant for a cachectic-appearing black male infant, alert, and age-appropriate with significant global hypotonia. Bilateral cheilitis was also noted, as was a II/VI non-radiating systolic ejection murmur heard best at the left sternal border. Abdomen was soft and protuberant, with palpable peristalsis. During the abdominal examination, watery stool with gross blood was evacuated through the anus. Peripheral perfusion was suggestive of compensated shock. Complete blood count showed total white blood cells 8,160 with 11 segmented forms and 9 bands. Hemoglobin was 7.44 g/dL, hematocrit 22.1%, platelets 152,000. Serum CO2 had decreased to 17