Case Presentation: A 65-year-old male presents to hospital with a 1-day history of confusion and fever. Past medical history is significant for heart failure requiring AICD, chronic kidney disease, type-2 diabetes mellitus, May-Thurner syndrome, and recent admission three weeks prior due to sepsis from streptococcus bacteremia requiring hemodialysis, with dialysis catheter removed before initial discharge. He presented in septic shock with a fever of 103 F, hypoxia, tachycardia and with hypotension requiring vasopressors. His physical exam and imaging were grossly unremarkable. Vancomycin and ceftriaxone were initiated. The patient had persistent fevers and after 48 hours blood cultures were positive for gram negative bacilli, with isolation of a Pantoea species in all blood culture sets. Sensitivities from cultures were unable to be obtained. Infectious disease was consulted. He was transitioned to cefepime with improvement of leukocytosis and fevers. Repeat blood cultures were negative for growth. The patient was discharged on oral levofloxacin 750mg daily for five days, having treatment for total of ten days. He was followed up by his primary care physician with resolution of his symptoms.
Discussion: Pantoea spp. are aerobic, gram-negative bacilli in the Enterobacteriaceae family frequently encountered in plant and soil debris. Historically, infections with Pantoea have been nosocomial; primarily with parenteral nutrition contamination, intravenous anesthetics, packed erythrocytes or, due to catheter-related infection. When community acquired, Pantoea most notably affects those with plant exposures or thorn injury in immunocompromised patients. Pantoea infection has been a well-known cause of neonatal sepsis due to the immunocompromised nature of prematurity. Conversely, there have been less than five cases of spontaneous Pantoea infection in otherwise healthy patients. This case poses inquiry as to whether previous treatment with hemodialysis requiring tunneled catheter may have predisposed the patient to infection with Pantoea. Furthermore, the patient’s history of diabetes may confer him to be considered immunosuppressed or predispose him for severe infection. Treatment of Pantoea infection usually confers recovery, aside from neonatal infections. Pantoea in-vitro sensitivities reflect a wide range of antibiotics including aminoglycosides, fluoroquinolones, broad-spectrum cephalosporins, carbapenems, trimethoprim/sulfamethoxazole, and piperacillin/tazobactam. In this case, treatment with cefepime until clearance of blood cultures followed by oral levofloxacin for a total of ten days resulted in patient recovery.
Conclusions: Human infections with Pantoea spp. are rare. Infections have been documented in cases of neonatal sepsis and are also associated with parenteral nutrition and penetrating injury from plant thorns or in patients who are immunocompromised. This report depicts a case of septic shock due to Pantoea spp., in an immunocompetent patient.