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Indian Pediatr 2009;46: 721-722 |
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Chromobacterium violaceum Sepsis in
an Infant |
AP Vijayan, MR Anand and Preetha Remesh
From the Department of Pediatrics, Malabar Institute of
Medical Sciences, Calicut, Kerala, India.
Correspondence to: AP Vijayan, Consultant Pediatrician,
Malabar Institute of Medical Sciences, Mini Bypass Road, Govindapuram P.O,
Calicut 673 016, Kerala, India.
Email: [email protected]
Manuscript received: May 6, 2008;
Initial review: June 5, 2008;
Accepted: September 19, 2008.
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Abstract
Chromobacterium violaceum is a rare pathogen that
can cause potentially fatal infections in humans. Till date, 150 cases
are reported worldwide including 7 from India. We report a 6 month old
infant who presented with high grade fever, respiratory distress and
multiple vesicular skin lesions. Chromobacterium violaceum was
isolated from blood, bone marrow aspirate and from skin lesions. Infant
responded to treatment with piperacillin and ciprofloxacin, and is doing
well on follow up.
Key words: Chromobacterium, violaceum, Infant, Sepsis.
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Chromobacterium violaceum is
a common inhabitant of water and soil. Occasionally, it can cause human
infections including septicemia, lung abscess, liver abscess, dental
abscess, skin infection, urinary tract infection and diarrhea.
Chromo-bacterium infections are notorious for their high mortality.
About 150 cases have been reported in world literature including 7 from
India(1) We report Chromobacterium violaceum sepsis in a six
month-old infant who was treated succesfully.
Case Report
A 6 month-old male infant was admitted with a short
history of fever, cough, breathing difficulty, loose stools and multiple
skin lesions. Three months prior to present admission, the infant was
admitted with high grade fever. On evaluation, he was found to have an
abscess in the right lobe of liver measuring 30×19×35 millimetres by CT
scan of the abdomen. This was aspirated under ultrasound guidance. Pus
culture grew Staphylococcus aureus and the infant was treated for
six weeks with cloxacillin. Follow up ultrasonogram of the liver done
twelve days later showed complete resolution. At initial assessment during
the present admission, infant was sick and febrile. The right upper arm
was swollen. Respiratory rate was 64 per minute and pulse rate was 130 per
minute. Violet colored vesicular skin lesions of varying size were present
over abdomen and both arms with an erythematous base. Some lesions had
necrotic center. Systemic examination revealed bilateral crepitations,
firm hepatomegaly (span 8 cm), and splenomegaly (4cm).
We made a provisional diagnosis of sepsis with
osteomyelitis. Pseudomonas sepsis was considered on account of the
distinctive skin lesions. Another possibility entertained was disseminated
varicella. After taking blood for routine investigations and culture,
empirical parenteral antibiotics were started (ceftazidime and cloxacillin).
Blood investigations revealed, hemoglobin of 9g/dL, white blood cell count
of 28.4×10 3/µL, with a differential
count of polymorphs 71% , lymphocytes 25% and monocytes of 4%. Erythrocyte
sedimentation rate was 50 mm at the end of first hour. Peripheral smear
revealed microcytic hypochromic anemia with neutrophilic leucocytosis.
Chest X-ray showed bilateral infiltrates consistent with
bronchopneumonia. Ultrasonogram of abdomen showed hepatosplenomegaly.
There were no focal lesions in the liver. Tzank smear
from vesicular lesions was negative for varicella. Bone marrow aspirate
showed myeloid hyperplasia with toxic granulation. Pus collected from the
skin pustule was inoculated on sheep blood agar and McConkey agar plates.
Blood and bone marrow aspirate were cultured by conventional method in two
bottles containing 45mL each of tryptone soy broth, and bile broth and
subcultures made on sheep blood agar and McConkey agar plates. Sheep blood
agar plates were incubated with 7 per cent CO 2
at 35ºC. All other media were incubated at 35ºC aerobically.
Chromobacterium
grew on sheep blood agar and McConkey agar plates from blood and pus with
characteristic violet colored colonies. The organism was a
facultatively anerobic (non-pigmented anaerobically), motile, Gram
negative rod. It was sensitive to ciprofloxacin, cefoperazone-sulbactam,
meropenem, piperacillin – tazobactam, amikacin, gentamicin, netilmicin and
tetracycline; and resistant to ceftazidime, cefepime, ampicillin and
cefazolin. In view of history of liver abscess and isolation of this rare
organism, infant was evaluated for underlying immunodeficiency. DNA PCR
was negative for HIV.
Total lymphocyte count, serum immunoglobulin, and G6PD
assay were normal. Leucocyte adhesion defect was ruled out with flow
cytometry. NBT stain showed normal neutrophilic function. Infant was
treated with ciprofloxacin and piperacillin for 21 days. The child
responded well to treatment and is doing well on follow up.
Discussion
Chromobacterium violaceum is acquired mostly
through exposure of broken skin to contaminated water and soil and rarely
through ingestion of contaminated water(1,3). Cases with G6PD deficiency
and chronic granulomatous disease are prone to develop this infection(3).
Most infections are reported in young population. Usual mode of
presentation includes fever and abscesses of skin and internal organs(1).
Isolated diarrhea and nasopharyngeal abscess are also reported(1,4).
Mortality rate in sepsis cases is reported to be as high as 57%.
Generally, the organism is susceptible to quino-lones
trimethoprim, sulfamethoxazole, tetracycline, chloramphenicol, cefepime
and imipenem. It is resistant to penicillins and narrow spectrum
cephalosporins. Susceptibility to third generation cephalosporins and
aminoglycosides is variable(3). This organism is described as one of the
emerging pathogens, and being potentially fatal, it is important to be
aware of this infection. Similarity of skin lesions of varicella and
Pseudomonas is noteworthy.
Acknowledgments
Mr Vishnu, Microbiologist for isolating the organism.
Contributors: APV admitted and managed the case.
MRA drafted the article with help of APV. PR critically evaluated the
manuscript. All authors were involved in search of literature.
Funding: None.
Competing interests: None stated.
References
1. Ray P, Sharma J, Marak RS, Singhi S, Taneja N , Garg
RK, et al. Chromobacterium violaceum septicemia from North
India. Indian J Med Res 2004;120: 523-526.
2. de Siqueira I C , Dias J, Ruf H, Ramos EA, Maciel
EA, Rolim A, et al. Chromobacterium violaceum in siblings,
Brazil. Emerg Infect Dis 2005; 11: 1443-1445.
3. Choon-yuk Chiang, Yuan-Ti Lee , Ken-Sen Liu, Ya-Li
Wang, Shih-Ming Tsao. Chromobacterium violaceum infection in
Taiwan: a case report and literature review. J Microbiol Immunol Infect
2007; 40: 272-275.
4. Shao PL, Hsueh PR, Chang YC, Lu CY, Lee PY, Lee CY, et al.
Chromobacterium violaceum infection in children: a case of fatal
septicemia with nasopharyngeal abscess and literature review. Pediatr
Infect Dis J 2002 ; 21: 707-709.
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