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Enterobacter cloacae Sacroiliitis with Acute Respiratory Distress Syndrome in an Adolescent.

Kim JS, Ko JH, Lee S, Jeon SC, Oh SH - Infect Chemother (2015)

Bottom Line: Chest radiography and CT findings and a PaO2/FiO2 ratio <200 mmHg were suggestive of ARDS; the patient subsequently received ventilatory support and low-dose methylprednisolone infusions.Within one week, defervescence occurred, and the patient was able to breathe on his own.Following the timely recognition of, and therapeutic challenge to, ARDS, and after 6 weeks of parenteral antimicrobial therapy, the patient was discharged in good health with no complications.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics and Adolescent, Hanyang University College of Medicine, Seoul, Korea.

ABSTRACT
Enterobacter cloacae has emerged as an important nosocomial pathogen, but is rarely a cause of sacroiliitis. Herein, we present the first reported case of Enterobacter cloacae sacroiliitis associated with sepsis and acute respiratory distress syndrome (ARDS). A previously healthy 14-year-old boy presented with low-grade fever and pain in the left side of the hip that was aggravated by walking. Pelvic computed tomography (CT) showed normal findings, and the patient received supportive care for transient synovitis with no antibiotics. However, there was no clinical improvement. On the third day of hospitalization, magnetic resonance imaging of the hip revealed findings compatible with sacroiliitis, for which vancomycin and ceftriaxone were administered. The patient suddenly developed high fever with dyspnea. Chest radiography and CT findings and a PaO2/FiO2 ratio <200 mmHg were suggestive of ARDS; the patient subsequently received ventilatory support and low-dose methylprednisolone infusions. Within one week, defervescence occurred, and the patient was able to breathe on his own. Following the timely recognition of, and therapeutic challenge to, ARDS, and after 6 weeks of parenteral antimicrobial therapy, the patient was discharged in good health with no complications.

No MeSH data available.


Related in: MedlinePlus

Chest radiograph on the fourth hospital day showing bilateral lower lobe infiltrates (A). Chest computed tomography images on the third hospital day shows bilateral and symmetric compartmental consolidation in gravity-dependent areas of the lung compatible with acute respiratory distress syndrome (B).
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Figure 2: Chest radiograph on the fourth hospital day showing bilateral lower lobe infiltrates (A). Chest computed tomography images on the third hospital day shows bilateral and symmetric compartmental consolidation in gravity-dependent areas of the lung compatible with acute respiratory distress syndrome (B).

Mentions: A 14-year-old boy was admitted to the Department of Orthopedic Surgery with a 1-day history of fever and pain in the left side of the hip that was aggravated by walking. The patient denied any injuries, medical problems, intake of any medications, previous hospitalizations, or recent tours. His family history was unremarkable with respect to musculoskeletal disorders. Although his temperature was 38℃, he did not appear ill. Other observations were as follows: blood pressure, 110/70 mmHg; heart rate, 88/min; and respiratory rate, 22/min. He experienced tenderness over the lateral aspect of the left side of the hip, which was accentuated by flexion and external rotation. Initially, laboratory studies showed a hemoglobin level of 14.6 g/dL, a white blood cell (WBC) count of 6,400/mm3 with 79% neutrophils, platelet count of 176,000/mm3, erythrocyte sedimentation rate (ESR) of 12 mm/h, and C-reactive protein (CRP) level of 3.1 mg/dL (normal range, <0.3 mg/dL). Hip radiography and pelvic computed tomography (CT) revealed no abnormal findings. Initially, transient synovitis was considered, and antibiotics were therefore not prescribed. On the third hospital day, the body temperature had risen to 38.9℃, and physical examination revealed pain at the sacroiliac joint on the FABERE (flexion-abduction-external rotation-extension) test. A hip magnetic resonance imaging (MRI) scan showed synovitis and capsulitis of the left sacroiliac joint with extra-articular extension to the left iliacus muscle and iliac vessels, suggesting sacroiliitis (Fig. 1A). Empiric administration of vancomycin (4 g/day) and ceftriaxone (4 g/day) was initiated to treat the sacroiliitis. The patient was transferred to the Department of Pediatrics where his condition deteriorated rapidly, with his fever reaching 40.4℃ and respiratory rate being >40/min with difficulty breathing. An arterial blood gas analysis (ABGA) showed the following results: pH, 7.399; pCO2, 32.7 mmHg; PO2, 52.7 mmHg; and O2 Sat, 88%. Dyspnea and ABGA findings were initially improved with oxygen supply via a nasal cannula. The respiratory status, however, worsened the following day, as the ABGA showed a PaO2/FiO2 of 137 mmHg, chest radiographs began to show bilateral lower lobe infiltrates (Fig. 2A), and chest CT (Fig. 2B) showed bilateral and symmetric compartmental consolidation in gravity-dependent areas of the lung compatible with ARDS, which was not observed over the thorax on the abdominal CT image obtained on the first hospital day. The patient was moved to the intensive care unit (ICU) for synchronized intermittent mandatory ventilation with pressure support; the initial settings used were a tidal volume of 360 mL (6 mL/kg), FiO2 of 40%, and positive end-expiratory pressure (PEEP) of 12 cmH2O. WBC and platelet counts decreased to 2,400/mm3 with 79% neutrophils and 58,000/mm3, respectively, and ESR and CRP were increased to 40 mm/h and 13.8 mg/dL, respectively. Blood cultures, which were taken on the second hospital day, yielded E. cloacae which is susceptible to amikacin, aztreonam, ceftriaxone, ceftazidime, cefotaxime, ciprofloxacin, gentamicin, imipenem, piperacillin/tazobactam; intermittently resistant to cefuroxime; and resistant to amoxicillin/clavulanic acid, ampicillin, ampicillin/sulbactam, cephalothin, cefoxitin, and cefazolin. The antibiotic regimen was changed to ceftriaxone (4 g/day) and amikacin (1.5 g/day). Because of the rapid progression of ARDS, methylprednisolone (1 mg/kg) administration was initiated. By the fifth day, defervescence occurred and the need for ventilatory support was reduced. On the seventh day, the patient was breathing room air and the pain in the left side of the hip lessened dramatically; he was subsequently discharged from the ICU. A follow-up chest radiograph demonstrated marked improvement. Parenteral antimicrobial therapy was maintained for 6 weeks until CRP and ESR normalized, and low doses of methylprednisolone were administered and tapered over 19 days. A repeat hip MRI scan on the thirteenth hospital day showed improvement in extra-articular soft tissue inflammation but with aggravated subchondral inflammation (Fig. 1B). Repeat blood culture on the fourth hospital day grew no bacteria, and the patient was discharged on day 46 in good health without any complications. Serum immunoglobulin and complement levels were normal: IgG 890 mg/dL, IgA 83.3 mg/dL, IgM 86.3 mg/dL, C3 144.0 mg/dL, and C4 22.4 mg/dL, and no further tests for an immunologic disorder were pursued since the patient had shown marked improvement under treatment.


Enterobacter cloacae Sacroiliitis with Acute Respiratory Distress Syndrome in an Adolescent.

Kim JS, Ko JH, Lee S, Jeon SC, Oh SH - Infect Chemother (2015)

Chest radiograph on the fourth hospital day showing bilateral lower lobe infiltrates (A). Chest computed tomography images on the third hospital day shows bilateral and symmetric compartmental consolidation in gravity-dependent areas of the lung compatible with acute respiratory distress syndrome (B).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4495273&req=5

Figure 2: Chest radiograph on the fourth hospital day showing bilateral lower lobe infiltrates (A). Chest computed tomography images on the third hospital day shows bilateral and symmetric compartmental consolidation in gravity-dependent areas of the lung compatible with acute respiratory distress syndrome (B).
Mentions: A 14-year-old boy was admitted to the Department of Orthopedic Surgery with a 1-day history of fever and pain in the left side of the hip that was aggravated by walking. The patient denied any injuries, medical problems, intake of any medications, previous hospitalizations, or recent tours. His family history was unremarkable with respect to musculoskeletal disorders. Although his temperature was 38℃, he did not appear ill. Other observations were as follows: blood pressure, 110/70 mmHg; heart rate, 88/min; and respiratory rate, 22/min. He experienced tenderness over the lateral aspect of the left side of the hip, which was accentuated by flexion and external rotation. Initially, laboratory studies showed a hemoglobin level of 14.6 g/dL, a white blood cell (WBC) count of 6,400/mm3 with 79% neutrophils, platelet count of 176,000/mm3, erythrocyte sedimentation rate (ESR) of 12 mm/h, and C-reactive protein (CRP) level of 3.1 mg/dL (normal range, <0.3 mg/dL). Hip radiography and pelvic computed tomography (CT) revealed no abnormal findings. Initially, transient synovitis was considered, and antibiotics were therefore not prescribed. On the third hospital day, the body temperature had risen to 38.9℃, and physical examination revealed pain at the sacroiliac joint on the FABERE (flexion-abduction-external rotation-extension) test. A hip magnetic resonance imaging (MRI) scan showed synovitis and capsulitis of the left sacroiliac joint with extra-articular extension to the left iliacus muscle and iliac vessels, suggesting sacroiliitis (Fig. 1A). Empiric administration of vancomycin (4 g/day) and ceftriaxone (4 g/day) was initiated to treat the sacroiliitis. The patient was transferred to the Department of Pediatrics where his condition deteriorated rapidly, with his fever reaching 40.4℃ and respiratory rate being >40/min with difficulty breathing. An arterial blood gas analysis (ABGA) showed the following results: pH, 7.399; pCO2, 32.7 mmHg; PO2, 52.7 mmHg; and O2 Sat, 88%. Dyspnea and ABGA findings were initially improved with oxygen supply via a nasal cannula. The respiratory status, however, worsened the following day, as the ABGA showed a PaO2/FiO2 of 137 mmHg, chest radiographs began to show bilateral lower lobe infiltrates (Fig. 2A), and chest CT (Fig. 2B) showed bilateral and symmetric compartmental consolidation in gravity-dependent areas of the lung compatible with ARDS, which was not observed over the thorax on the abdominal CT image obtained on the first hospital day. The patient was moved to the intensive care unit (ICU) for synchronized intermittent mandatory ventilation with pressure support; the initial settings used were a tidal volume of 360 mL (6 mL/kg), FiO2 of 40%, and positive end-expiratory pressure (PEEP) of 12 cmH2O. WBC and platelet counts decreased to 2,400/mm3 with 79% neutrophils and 58,000/mm3, respectively, and ESR and CRP were increased to 40 mm/h and 13.8 mg/dL, respectively. Blood cultures, which were taken on the second hospital day, yielded E. cloacae which is susceptible to amikacin, aztreonam, ceftriaxone, ceftazidime, cefotaxime, ciprofloxacin, gentamicin, imipenem, piperacillin/tazobactam; intermittently resistant to cefuroxime; and resistant to amoxicillin/clavulanic acid, ampicillin, ampicillin/sulbactam, cephalothin, cefoxitin, and cefazolin. The antibiotic regimen was changed to ceftriaxone (4 g/day) and amikacin (1.5 g/day). Because of the rapid progression of ARDS, methylprednisolone (1 mg/kg) administration was initiated. By the fifth day, defervescence occurred and the need for ventilatory support was reduced. On the seventh day, the patient was breathing room air and the pain in the left side of the hip lessened dramatically; he was subsequently discharged from the ICU. A follow-up chest radiograph demonstrated marked improvement. Parenteral antimicrobial therapy was maintained for 6 weeks until CRP and ESR normalized, and low doses of methylprednisolone were administered and tapered over 19 days. A repeat hip MRI scan on the thirteenth hospital day showed improvement in extra-articular soft tissue inflammation but with aggravated subchondral inflammation (Fig. 1B). Repeat blood culture on the fourth hospital day grew no bacteria, and the patient was discharged on day 46 in good health without any complications. Serum immunoglobulin and complement levels were normal: IgG 890 mg/dL, IgA 83.3 mg/dL, IgM 86.3 mg/dL, C3 144.0 mg/dL, and C4 22.4 mg/dL, and no further tests for an immunologic disorder were pursued since the patient had shown marked improvement under treatment.

Bottom Line: Chest radiography and CT findings and a PaO2/FiO2 ratio <200 mmHg were suggestive of ARDS; the patient subsequently received ventilatory support and low-dose methylprednisolone infusions.Within one week, defervescence occurred, and the patient was able to breathe on his own.Following the timely recognition of, and therapeutic challenge to, ARDS, and after 6 weeks of parenteral antimicrobial therapy, the patient was discharged in good health with no complications.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics and Adolescent, Hanyang University College of Medicine, Seoul, Korea.

ABSTRACT
Enterobacter cloacae has emerged as an important nosocomial pathogen, but is rarely a cause of sacroiliitis. Herein, we present the first reported case of Enterobacter cloacae sacroiliitis associated with sepsis and acute respiratory distress syndrome (ARDS). A previously healthy 14-year-old boy presented with low-grade fever and pain in the left side of the hip that was aggravated by walking. Pelvic computed tomography (CT) showed normal findings, and the patient received supportive care for transient synovitis with no antibiotics. However, there was no clinical improvement. On the third day of hospitalization, magnetic resonance imaging of the hip revealed findings compatible with sacroiliitis, for which vancomycin and ceftriaxone were administered. The patient suddenly developed high fever with dyspnea. Chest radiography and CT findings and a PaO2/FiO2 ratio <200 mmHg were suggestive of ARDS; the patient subsequently received ventilatory support and low-dose methylprednisolone infusions. Within one week, defervescence occurred, and the patient was able to breathe on his own. Following the timely recognition of, and therapeutic challenge to, ARDS, and after 6 weeks of parenteral antimicrobial therapy, the patient was discharged in good health with no complications.

No MeSH data available.


Related in: MedlinePlus