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CASE REPORT  
Year : 2015  |  Volume : 58  |  Issue : 3  |  Page : 395-397
Uncommon pathogen: Serious manifestation: A rare case of Achromobacter xylosoxidans septic arthritis in immunocompetetant patient


1 Department of Microbiology, Head of Department, Pediatrics, Bharati Vidyapeeth Deemed University and Medical College, Pune, Maharashtra, India
2 Department of Medical Director, Head of Department, Pediatrics, Bharati Vidyapeeth Deemed University and Medical College, Pune, Maharashtra, India

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Date of Web Publication14-Aug-2015
 

   Abstract 

Achromobacter xylosoxidans is a rare opportunistic Gram-negative bacilli and rarer etiology of septic arthritis. We present here the first Indian case of septic arthritis due to A. xylosoxidans in 11-month-old male child confirmed by 16S rRNA sequencing. The child was admitted as suspected case of septic arthritis and underwent arthrotomy. Drained pus revealed Gram-negative bacilli, identified as Serratia odorifera by API (bioMérieux, Marcy l'Ιtoile, France), later subjected to VITEK 2 (bioMérieux, Marcy l'Ιtoile, France) identification revealing it to be A. xylosoxidans. It being a rare etiology of septic arthritis confirmation was done with 16S rRNA Sequencing.

Keywords: 16S rRNA sequencing, Achromobacter xylosoxidans, septic arthritis

How to cite this article:
Suryavanshi KT, Lalwani SK. Uncommon pathogen: Serious manifestation: A rare case of Achromobacter xylosoxidans septic arthritis in immunocompetetant patient. Indian J Pathol Microbiol 2015;58:395-7

How to cite this URL:
Suryavanshi KT, Lalwani SK. Uncommon pathogen: Serious manifestation: A rare case of Achromobacter xylosoxidans septic arthritis in immunocompetetant patient. Indian J Pathol Microbiol [serial online] 2015 [cited 2022 Jan 22];58:395-7. Available from: https://www.ijpmonline.org/text.asp?2015/58/3/395/162929



   Introduction Top


Achromobacter xylosoxidans is a non-fermenting Gram-negative bacilli. Being closely associated with Alcaligenes species was also called as Alcaligenes xylosoxidance. [1] First identified, and described by Yabuchi and Ohyama in 1971 from 7 cases of chronic otitis media, belongs to family Alcaligenaceae and genus Achromobacter[1],[2] with two subspecies namely, xylosoxidans, denitrificans. [3] It is an uncommon opportunistic pathogen of low virulence. However, has the potential to cause invasive infections in immunocompromised patient, e.g., meningitis, empyema, pulmonary abscess, peritonitis, urinary tract infections, prosthetic valve endocarditis, chronic otitis media, keratitis, osteomyelitis, endophthalmitis, septic arthritis. [3] Nevertheless bone involvement is very rarely reported; worldwide only five cases of calcaneal osteomyelitis are present in literature [4] and septic arthritis never reported from India. We report this first Indian case to emphasize its importance as invasive pathogen with high morbidity even in an immunocompetent patient. Plasmid mediated resistance was one of the cause of beta-lactamase resistance making it multidrug-resistant organism. [5] Many cases are misidentified due to biochemical similarities with Pseudomonas species [6] correct identification with earlier treatment remains a prerequisite for a successful outcome in the patient. [5]


   Case Report Top


One month and 11 days the old child was presented with complaints of restriction of movements of the left leg since 1 month. The child was born full term normal vaginal delivery, with no history of birth trauma. Mother's antenatal history was uneventful. Before admitting to our hospital child, was treated at two other hospitals. On day 3 of life, the child developed bilateral bronchopneumonia suspected to be milk aspiration pneumonia and treated with antibiotics (no documents with parents) for 5 days. Since day 18 of life, decreased movements of the left leg and crying on left leg movement were noticed. The child was hospitalized at other hospital and underwent USG hip, showing small effusion of hip joint, s/o septic arthritis. X-ray left hip (AP and Lat) showed no bony abnormality. Patient's immunization history comprised of, Bacille Calmette-Guérin and oral polio vaccine. Initial haemogram findings were, Hb -12.9 g%, total leukocyte count -12,500/mm 3 , neutrophils -27%, lymphocytes -67%, monocytes -3%, eosinophils -3%, platelet count -4.7/mm 3 , Sr. potassium -5.3 meq/l, Sr sodium -132 meq/l, C-reactive protein -39 mg/dl, random blood glucose level -98 mg/dl. The child was negative for HIV and HbsAg.

The child received treatment at outside for 10 days with intravenous (IV) ceftriaxone, and injection ampiclox, relieving symptoms initially, following relapse of symptoms, was brought to our hospital, where repeat USG of left hip confirmed the finding of septic arthritis and X-ray pelvis with both the hips was s/o small cortical erosion involving upper end of left femur. The child underwent emergency arthrotomy at our hospital. Moreover, about 8 cc pus was drained. Child started on with IV ceftriaxone (100 mg/kg/day b.d) and IV vancomycin (60 mg/kg/day qid).

Drained pus was sent for microbiology workup, showed moderate number of polymorphonuclear cells and few Gram-negative bacilli in Gram stain. The culture was positive for Gram-negative bacillus [Figure 1] which was identified by API-ID32 GN Kit (bioMérieux, Marcy l''toile, France) as S. odorifera. Biochemical reactions used were as follows. Triple sugar iron test-nonfermentative, citrate-positive, urease-negative, indol-negative. Carbohydrate fermentation (glucose-positive, lactose, sucrose, mannitol were negative) decarboxylase (lysine, ornithine) and arginine dihydrolase were negative. The Acidification of oxidative fermentative glucose, xylose is key characteristic can be used to differentiate it from other nonfermenters, in adjunct to decarboxylase test. [2],[5] The progressive pattern of disease and inconsistent biochemical reactions warranted further confirmation, so it was tested again by VITEK 2 System (bioMérieux, Marcy l''toile, France), which identified it as A. xylosoxidans. Although both this systems used for diagnosis are by bioMérieux they differ in technique and database used in the analysis as given in their product manuals. VITEK 2 Compact is automatic system utilizes established methods and newly developed substrate measuring carbon source utilization enzymatic activities. Gram-negative organism are identified using 47 biochemical tests in comparison to API which is a manual system, uses 32 number of biochemical reactions and turbidonephlometry method for identification of microorganism and limited data base to analyze the results explaining the discrepancy in results by this system. This was also reported by Padmaja et al. in a case of endocarditis due to A. xylosoxidans, where it was identified as nonfermenters by API 32 GN card and VITEK identified it as A. xylosoxidans. [7] So further Confirmation was done by16S rRNA sequencing at National Centre for Cell Sciences (NCCS) Pune, which is considerate as gold standard technique. Sequencing protocol followed at NCCS was as follows:
Figure 1: Achromobacter xylosoxidans pinpoint colonies on MacConkey agar


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Sequencing pure isolate(s) using multiple PCR primers in ABI 3730XL sequencing machine.



Primer used were as given:

  1. Primer 8F: Sequence (5′-3′)-AGAGTTTGATCCTGGCTCAG, Target Group-Universal,

    Reference-Turner et al.1999.
  2. Primer 907R: Sequence (5′-3′)-CCGTCAATTCMTTTRAGTTT, Target Group-Universal,

    Reference-Lane et al. 1991


Gene bank accession number (KJ620851). Antibiotic susceptibility was done with VITEK (AST N090), API and disk diffusion. The consistent result was seen in all 3 methods with isolate sensitive to amoxyclav, piperacillin tazobactam, imipenem, meropenem.

Hip spika and the pavlik splint were applied. Later on amoxyclav (40 mg/kg/day b.d) was added. As child improved clinically, hip spika was removed, and the child was discharged uneventfully. Sutures were removed, and the child was seen rapidly recovering. However, repeat X-ray showed persistent findings suggestive of subluxation, as sequelae of deep infection damaging the head of the femur resulting in small cortical erosion. The child was followed for relapse of symptoms on subsequent visits but was seen completely asymptomatic and was free of any deformity.


   Discussion Top


Achromobacter xylosoxidans is rarer etiology of septic arthritis in the pediatric patient. Commonest organisms involved are Staphylococcus aureus, Streptococcus spp., Haemophilus influenzae, Klingella klingae, Borrelia burgordferri,  Neisseria More Details gonorrhoeae. [8] The natural habitat is the aquatic environment, [1],[9] but it can be a normal part of the human gut. [1],[9] Source of acquisition, therefore, could be environmental or endogenous. In our case, as a child was hospitalized before present illness, where he was incompletely treated prolonging the illness, most probable etiological pathogenesis could be hospital acquired.

No documented cases of septic arthritis are available in India, but other commonest invasive manifestations of A. xylosoxidans are pneumonia, device related infections, primary uncomplicated bacteremia. [1] Eshwara et al. has reported first pancreatic pseudocyst report, and local wound infection of metastatic ductal carcinoma due to A. xylosoxidans[1] and perinephric abscess case is reported by Vinod et al., from India. [9] Only one documented case of septic arthritis is seen but in an immunocompromised patient. [10]

It is resistant to most of aminoglycosides and cephalosporin, but sensitive to piperacillin + tazobactam, imipenem, meropenem, cotrimoxazole. [3],[5],[11] Our isolate was sensitive to amoxyclav, piperacillin + tazobactam, imipenem, meropenem, ticarcillin + clavulanate, but was resistant to cefuroxime, cefepime, ticarcillin. Immunocompromised status and prolonged treatment with antibiotics are risk factors reported. [5]

It is commonly confused with other non-fermenters, which can affect the clinical management of patient substantially as most of the times they are considerate environmental contaminant. [1] Fermentation of xylose, glucose, and peritrichous flagella differentiates it from Pseudomonas[2],[3],[5],[9] and can be used for presumptive diagnosis in any laboratory set up along with decarboxylase test. The role of automation and molecular typing method plays a significant role and are essential for confirmation and non-fermenters isolated from deep infections should be subjected to these methods.


   Acknowledgements Top


We gratefully acknowledge the important contributions and guidance provided by Dr. M. S. Modak, HOD of Microbiology and the following members of NCCS CAMPUS, Pune for carrying out 16S rRNA sequencing. Dr. Yogesh Shouche (Principal Investigator), Dr. Ashish Polkade (Scientist 'B').

 
   References Top

1.
Eshwara VK, Mukhopadhyay C, Mohan S, Prakash R, Pai G. Two unique presentations of Achromobacter xylosoxidans infections in clinical settings. J Infect Dev Ctries 2011;5:138-41.  Back to cited text no. 1
    
2.
Yabuuchi E, Yano I, Goto S, Tanimura E, Shiito T, Ohyama A. Description of Achromobacter xylosoxidans Yabuuchi and Ohyama 1971. Int J Syst Evol Microbiol 1974;24:470-7.  Back to cited text no. 2
    
3.
Wellinghausen N, Wirths B, Poppert S. Fluorescence in situ hybridization for rapid identification of Achromobacter xylosoxidans and Alcaligenes faecalis recovered from cystic fibrosis patients. J Clin Microbiol 2006;44:3415-7.  Back to cited text no. 3
    
4.
Ozer K, Kankaya Y, Baris R, Bektas CI, Kocer U. Calcaneal osteomyelitis due to Achromobacter xylosoxidans: A case report. J Infect Chemother 2012;18:915-8.  Back to cited text no. 4
    
5.
Shie SS, Huang CT, Leu HS. Characteristics of Achromobacter xylosoxidans bacteremia in northern Taiwan. J Microbiol Immunol Infect 2005;38:277-82.  Back to cited text no. 5
    
6.
Claassen SL, Reese JM, Mysliwiec V, Mahlen SD. Achromobacter xylosoxidans infection presenting as a pulmonary nodule mimicking cancer. J Clin Microbiol 2011;49:2751-4.  Back to cited text no. 6
    
7.
Padmaja K, Lakshmi V, Rao MA, Mishra RC, Rosy C, Sritharan V. Prosthetic valve endocarditis with aortic root abscess due to Achromobacter xylosoxidans subsp denitrificans - A rare case report. Int J Infect Control 2013;9:1-5.  Back to cited text no. 7
    
8.
De Boeck H. Osteomyelitis and septic arthritis in children. Acta Orthop Belg 2005;71:505-15.  Back to cited text no. 8
    
9.
Vinod V, Kumar A, Sanjeevan KV, Dinesh KR, Karim S. Perinephric abscess due to Achromobacter xylosoxidans following de-roofing of renal cyst. Surg Infect (Larchmt). 2013;14:422-3.  Back to cited text no. 9
    
10.
San Miguel VV, Lavery JP, York JC, Lisse JR. Achromobacter xylosoxidans septic arthritis in a patient with systemic lupus erythematosus. Arthritis Rheum 1991;34:1484-5.  Back to cited text no. 10
    
11.
Weitkamp JH, Tang YW, Haas DW, Midha NK, Crowe JE Jr. Recurrent Achromobacter xylosoxidans bacteremia associated with persistent lymph node infection in a patient with hyper-immunoglobulin M syndrome. Clin Infect Dis 2000;31:1183-7.  Back to cited text no. 11
    

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Correspondence Address:
Dr. Kalpana Tikaram Suryavanshi
Assistant Professor, Department of Microbiology, Bharati Vidyapeeth Deemed University and Medical College, Bharati Vidyapeeth Bhavan, LBS Road 13, Sadashiv Peth Next To Alka Talkies, Pune - 411 030, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.162929

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