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. Microbiologically, they are characterized as non-glucose-fermenting and non-motile, catalase, and oxidase positive. Clinically, they are typically of low virulence and cause significant infection primarily in immunocompromised hosts. The species Flavobacterium meningosepticum has been reported to cause endocarditis,[3,4] ophthalmologic infection, upper and lower respiratory infection,[2,6-9] peritonitis,[1,10] and, most commonly, neonatal meningitis. 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