Achromobacter xylosoxidans (Alcali9,nes xylosoxidans subsp. xylosoxidans) is an aerobic gram·negative organism first described bl' Yabuuchi en Ohyama in ...
NETHERLANDS JOURNAL OF CRITICAL CARE
Figure 1: Tree·in·bud configuration caused by endobronchial spreading.
Figure ): severe necratizing pneumon ia wilh mulliple cavilations.
Figure 2: endobronchial pUS collections with hemorrhagic lesions, typical for S. aureus infect ion . 21
Case Report
We present a patiem with Achromobacter xylosoxidans bacceremia and recurrem sepsis
Achromobacter xylosoxidans bacteremia in a critically iII patient caused by ritual washing
due to rirual washing with weU-water.
Case Report. A 67-year aid Indonesian man with a medicaJ histery ofcolitis ulcerasa, treated with azathioprine, was admitred te the leu of an university hospital for respiratory insufficiency. Sepsis and tuberculous meningitis was diagnosed. He
MAW van lperen
I,
MA Schouten 2 , ARH van Zamen3
'D'partm, nt oflntensiu, Care, Riuierenland Hospital Tiel, The Nctherlands Gelderse Valiei Hospital, Ede, The Nctherlands 3Departm,nt oflntensiv, Care, Gelderse Vall,i Hospital , Ede , Th, Nctherlands 2 D'partm, nt of Microbiolo9Y,
Achromobacter xylosoxidans (Alcali9,nes xylosoxidans subsp. xylosoxidans) is an aerobic gram·negative organism first described bl' Yabuuchi en Ohyama in 1971. Achromobacter is aften found in aqueous environments and has been isolated in duck pond water, weil-water, swimming pools, distiJled water and chlorhexidin solutions [I-Z). It is resistam te most amimicrobial agents and causes infections in immunocompromised patients with underll'ing diseases like diabetes and malignancy (3). The most frequently encoumered infections are catheter-associated bacteremia and pneumonia, however surgical wound infections, meningitis, biliary tract infections , urinary tract infections and osteomyelitis have also been des cri bed [4J·
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was intubated, mechanicaJly ventilated and treated with isoniazide, rifampicine, p)'razinamide en dexamethasone. During the weaning-process Candida albicans and Pseudomonas aeru9inosa strains we re isolated from spurum and treatment with voriconazoI en ceftazidime was commenced. 111 cultures from bronchoalveolar lavage and perineum Achromobacter species was isolated. Subsequently contact isolation was instituted. After !Wo months the patiem was transferred te the IeU ofour hospita!. Neurological impairment and profound muscJe weakness was noted. No ancibiotics we re given except for the anti ruberculosis medication and there were na signs or symptoms ofinfection. Surveillance cultures were taken and from the nasal swab Achromobacter species was isolaced, sensitive ani)' te trimethoprim-sulfamethoxazo!. As it was considered to be colonizarion no antibiotic treatmenr was sraned and the patien[ was discharged te the generaJ ward. Few da)'s later he was readmitred te the Ieu for septic shock and respiratery insufficiency. Mechanical ventilation and treatment with ftuids and vasopressor was necessary. Imipenem was started empiricalIl'. Candida 9Iabrala was isolated from
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bronchoalveo lar lavage and voriconazol was added ra the antibiotics. The patient responded weil ra the treatment and recovered. Some weeks later th e patient developed high fever and blood cultures we re taken which yielded Athromobacter xylosoxidans subsp. xylosoxidans. Trimethoprim sulfamethoxazol therapy was statted based on susceptibiliry results of survei llance culrures. All intravasc ular lines were removed. Culrures were raken from the intravascular lines, sputum , urine and a decubital uker at the sacral region. Arhromobacter was isolated from the decubiral uJeer and from the tip of a peripheral
The patienrs clinical condition improved and he was discharged ra the general ward. One week late r the patient became septic again and died. Autopsy was not performed. Conclusion. This case report shows that rirual washing with weil-water mal' lead ra Achromobacter xylosoxidans bacterem ia and sepsis. In religion·dri"en riruals bl' padents or relatives involving liquid solutÎons we suggest to culture or heat sterili ze
these solutions before application as it may lead to colonization and exogenous infection.
inrravascular Line.
We noted that during visiting hoUts the famil)' was ritual washing the patient with weil-water from the parienrs hometown in Indonesia. In retrospect these washings had already statted at the universiry hospita!. Consent was obtained from the family to culrure thewater the)' used for these ritual washings. From this water Achromobacter xylosoxidans subsp. xy losoxidans was isolated. I6S rRNA sequenrion analysis was performed ofboth the Arhromobacter xylosoxidans strain isolated from the bl ood and the strain isolated from the weil-water and it showed 100% homology. Our hypothesis that the patient was colonized with Arhromobacter xylosoxidans due to ritual washin gs by relatives with conraminated water leading to bacteremia and recurrent sepsis seems hereb)' proven. Bath hospitals did not reveal culrures positive
for Arhrom obarter in other patienrs in the ICU.
The filmil)' was confronred with these findings but their falth in healing power ofthe
water was toO inrense to stop the rirual washings.
22
References
5pear JB, Fuhrer J, Kirby BD. Aehromobaeter xylosoxidans (Alealigenes xylosoxidan s
subsp. xylosoxidans) baeteremia associated with a well·water sou ree: case report and
review of the literature. J Clin Mierobiol '98 8;26:598'599.
van HalS, 5tark D, Marriott Det al. Aehromobader xylosoxidans subsp. xylosoxidan s
prosthetie aortie valve infeetive endocarditis and aortie root abscesses. JMed Mierobiol.
2008 Apr;57(Pt 4):525'7.
Ren·Wen Tsay, Li·Chen Lin. Chien·5hun Chiou et al. Alcaligenes xylosoxidans baderemia,
clinical features and microbiologieal eha raeteristies of isolates. J Microbiollmmunol
Infeel 2005;38:194'199.
Dugga n JM, Goldstein SJ, Chenoweth CE et al. Aehromobaeler xylosoxidans baeteremia:
report of four cases and review of the Jite,atu'e. Clin Infeel Dis 1996;23:569-576.
Case Report
Severe clozapine-induced cardiomyopathy in a schizophrenic patient related to smoking cessation and ciprofloxacin use RSchellaars , CJPW Keijsers 2, DHT Tjan" YG van der Meer3, ARH van Zanten I ' 1 Department oflntensive Care , Gelderse Va llei Hospital, Ede, The Netherlands
2 Department oflnternal Medicine, Geld erse Vallei Hospital , Ede, The Nctherlands
3 Department ofPharmacy. Gelderse Vallei Hospital , Ede, The Ncthrrlands
Introduction . Clozapine is frequently prescribed for therapy resistant psychoses in schi zop hren iaand low incidence oftardive dyskinesia and extrapyramidal side effects [1] . Clozapine depends malnly on cytochrome P4s0 IA2 (CYPIA2) for its metabolic clearance. CYPIA2 is inducible b)' smoking, and lower plasma concentrations of c10zapine are measured in smokers than in nonsmokers [2-3]. Smoking cessarion may increase c10zapine drug levels. After ciproftoxacin use also increased drug levels up to 3'% have been described due to inhibirion ofCYFrA2 [4]. We report a case of reversible cardiomyopath)' due to c10zapine in a schizophrenic pari ent. Case. A forry-)'ear-old schizophrenic patient presented with fever, farigue and dry cough for prolonged time. No prior ca rd iac history was known. Due to discomfott he quit heavy smoking two days earlier. He was on several psychiatric medications. Two months before ad miss ion c10zapine roomg bid was added. Seven days before admission c10zapine drug level s were normal i.e. 22 5 ~g/L (200-600 ~g/ L) . Physical examination revealed: temperarure 38.6 °C, heatt rate: 126 bpm, and blood press ure IOo/6smmHg. Cardiac and pulmonary auscultations were normal, Oxygen sarurario n was 950/0. Chest X-ral' revealed no abno rmalities. Laboratory findings showed: Hb 7.3 mmolil, MCV 76 ft, CR!' 179 mg/ L, CK 4s41U/L, Urea 10.6 mmolil and creatinine 122 mcmol/L. ECG showed supraventricular tachycardia. Spurum, blood and urine culrures were taken. Empirically, cefo taxim and ciproftoxacin we re prescribed for suspected CAP. Over 24 hours patient's condition deteriorated. Heatt rate increased to r60 bpm and bloo d pressure dropped to 90/60 mmH g. New findings were tachypnoea (301 min) and a dec rease in oxygen saturation (92%).Repeated chest X-ray showed no pul monary infiltrations, however heatt size had slightl)' increased. Patienr was admitted to the ICU, inrubated and tteated according the surviving sepsis guidelines for assumed pneumosepsis. One hour afrer ICU admission bradycard ia
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and pulseless electrical activit)' waS noted. Cardiopulmonary resuscitation was initiared and successfu!' A transthoracic echoca rdiography was performed and showed a low ejection fraction (
