We report a case of a 68–year–old female with hypertension and osteoarthritis who presented with altered mental status and bilateral lower extremity cellulitis. Shortly after initial evaluation, the patient became non–responsive and exhibited horizontal gaze palsy, a left dilated non–reactive pupil, extensor Babinski response, and decerebrate posturing. Repeat head CT imaging, twenty hours after the initial scan, showed interval development of hydrocephalus. The patient was empirically started on vancomycin, ampicillin and ceftriaxone. On day two of admission, initial blood cultures, wound cultures and CSF cultures were positive for a Gram–negative bacillus identified as Elizabethkingia meningosepticum by Matrix Assisted Laser Desorption Ionizaton Time–Of–Flight (MALDI–TOF) Mass Spectrum and later confirmed by Microscan. The organism was susceptible to fluoroquinolones and trimethoprim–sulfamethoxazole, but resistant to aminoglycosides, imipenem and piperacillin–tazobactam. Her antimicrobial regimen was adjusted to rifampin, trimethoprim–sulfamethoxazole, minocycline, and levofloxacin, with an appropriate clinical response 24 hours after initiation of therapy. Her neurologic status progressively improved with increased responsiveness and spontaneous facial and limb movements. She was discharged to a long–term acute care hospital where she would continue receiving therapy for 6 weeks.
Elizabethkingia meningosepticum, previously classified under the genera Flavobacterium and Chryseobacterium, is a ubiquitous Gram–negative rod known to cause nosocomial outbreaks of meningitis in neonates as well as various infections in immunocompromised adults. The occurrence of E. meningosepticum meningitis in adults is rare, with only sixteen cases described worldwide. Fifteen of these patients had significant comorbidities such as malignancy and diabetes, or had undergone surgical instrumentation. This report illustrates three major points. First, E. meningosepticum is a virulent pathogen, not only in the immunocompromised, but also in immunocompetent patients. This patient had no history of diabetes, malignancy or recent hospitalization and a comprehensive evaluation for an underlying systemic disease was unremarkable. Second, clinical and laboratory manifestations of E. meningosepticum are not pathognomonic, and reliance on early microbiological diagnosis using automated technology such as MALDI–TOF, is essential in selecting appropriate therapy. Third, as an emerging multi–drug resistant pathogen, E. meningosepticum‘s antimicrobial susceptibilities have been inconsistent across reports. The available data suggest 80–91% of isolates are sensitive to trimethoprim–sulfamethoxazole, levofloxacin, and rifampin.
In the era of emerging multidrug–resistant pathogens, adopting new technology that allows rapid bacteriologic diagnosis is essential in ensuring appropriate treatment and averting negative outcomes.