Case Presentation: A 30 year-old female with a history of B-cell acute lymphoblastic leukemia with central nervous system involvement presented with fever, chills, and tachycardia six days after completion of scheduled intrathecal and systemic chemotherapy. Three weeks prior, an intraventricular catheter for administration of intrathecal chemotherapy had been placed without complications. Following the most recent chemotherapy cycle, the patient was discharged with an absolute neutrophil count (ANC) < 200 cells/µL and planned administration of pegfilgrastim, however, she was unable to obtain the medication due to cost. On admission, she was febrile to 104.1°F with a benign physical exam and white cell count of < 0.1 K/µL. Chest radiograph was negative. Following collection of blood and urine cultures, she was started on vancomycin, cefepime, and pegfilgrastim. She clinically improved on this regimen. Blood cultures revealed gram-positive cocci in pairs, later identified as Rothia mucilaginosa susceptible to vancomycin and ceftriaxone. Infectious disease was consulted and advised switching cefepime to ceftriaxone which was subsequently switched back after the patient became febrile again. A multidisciplinary discussion concluded that the intraventricular catheter should be removed as it was thought to serve as a possible nidus for the infection. After removal, the patient continued to receive vancomycin and cefepime for a total of two weeks. By the time of discharge, all repeat blood cultures were negative and her ANC had returned to normal range.
Discussion: Rothia mucilaginosa is a gram-positive coccus found commensally in the oral cavity that can cause dental caries in the immunocompetent host, but may result in severely invasive disease in the immunocompromised. Traditionally, neutropenic fever has been most commonly associated with gram-negative bacteria such as Escherichia coli, Klebsiella species, and Pseudomonas aeruginosa , as well as certain fungi. Here, we present a less common case of neutropenic fever caused by Rothia mucilaginosa sepsis, with a recently placed intraventricular catheter system as a potential nidus. Not only does this highlight an interesting causal organism, but it also underscores the importance of ensuring that neutropenic patients have access to appropriate preventative treatment following chemotherapy.
Conclusions: This case presents a patient with neutropenic fever due to Rothia mucilaginosa sepsis following systemic and intrathecal chemotherapy. Clinicians should be aware that Rothia species is a less common but increasingly relevant cause of systemic infection in immunocompromised patients. In this case, the patient’s sepsis was successfully treated with vancomycin, cefepime, pegfilgrastim, and removal of her intraventricular catheter.