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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 49-51

Febrile neutropenia: An unusual cause of Pantoea Agglomerans bacteremia in acute myeloid leukemia


1 Department of Hematology and BMT, HCG Cancer hospital, Bangalore, Karnataka, India
2 Department of Clinical Pharmacology, HCG Cancer hospital, Bangalore, Karnataka, India
3 Deparetment of Microbiology, HCG Cancer hospital, Bangalore, Karnataka, India
4 Department of Infectious disease, HCG Cancer hospital, Bangalore, Karnataka, India
5 Department of Radiation oncology, HCG Cancer hospital, Bangalore, Karnataka, India

Date of Submission12-Oct-2021
Date of Decision09-Feb-2022
Date of Acceptance07-Mar-2022
Date of Web Publication03-May-2022

Correspondence Address:
Dr. Sachin Suresh Jadhav
Departments of Haematology and BMT, HCG Cancer hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpo.jpo_8_22

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  Abstract 


We present a case of febrile neutropenia in a patient with acute myeloid leukemia caused by an uncommon bacterial species. The patient was treated with antibiotics for 14 days before being discharged. Pantoea agglomerans is a plant soil and water-dwelling agricultural organism. It is both a commensal and pathogen of animals and humans, according to earlier research. In conclusion, p. agglomerans should be considered a bacterial threat in cancer patients who are undergoing highly myelotoxic chemotherapy.

Keywords: Acute myeloid leukemia, febrile neutropenia, meropenem, pantoea agglomerans


How to cite this article:
Jadhav SS, Kumar JG, Tripathi P, Matani A, Ganesan SK, Vishnupriya, Panchal AC, H.Kaswala CK, Nishit, Koramati SL, Ajaikumar B S. Febrile neutropenia: An unusual cause of Pantoea Agglomerans bacteremia in acute myeloid leukemia. J Precis Oncol 2022;2:49-51

How to cite this URL:
Jadhav SS, Kumar JG, Tripathi P, Matani A, Ganesan SK, Vishnupriya, Panchal AC, H.Kaswala CK, Nishit, Koramati SL, Ajaikumar B S. Febrile neutropenia: An unusual cause of Pantoea Agglomerans bacteremia in acute myeloid leukemia. J Precis Oncol [serial online] 2022 [cited 2022 Aug 8];2:49-51. Available from: https://www.jprecisiononcology.com//text.asp?2022/2/1/49/344541




  Introduction Top


Pantoea agglomerans is a gram-negative aerobic bacillus that belongs to the family Enterobacteriaceae. It is primarily an environmental and agricultural organism that inhabits plants, soil, and water. This bacterium has been reported as both commensal and pathogen of animals and humans.[1] It is an opportunistic pathogen and very rarely causes disease in healthy individuals.[2] Human infections may be associated with trauma caused by penetration of vegetative material and also with secondary bacteremia or nosocomial infections that are related to medical equipment such as intravenous catheters or contaminated intravenous fluids and parenteral nutrition[2],[3],[4]. The most common infections caused by P. agglomerans are septic arthritis or synovitis, occupational respiratory infections and skin allergy, peritonitis, and bloodstream infection mostly known to affect elderly persons.[5] Although its transmission through contaminated medical equipment's causing secondary bacteremia or nosocomial infections, spontaneous infection in immunocompromised patients is very rarely seen or reported with p. agglomerans. In this case report, we describe a 40-year-old female with acute myeloid leukemia (AML) who was undergoing chemotherapy and developed a bloodstream infection with P. agglomerans.


  Case Report Top


A 40-year-old female patient presented to our hospital with complaints of easy fatigability, intermittent fever, toothache, and dyspnea on exertion. On evaluation, peripheral smear showed dimorphic anemia with marked leucopenia and thrombocytopenia for which the patient was advised a bone marrow examination. Bone marrow revealed 92% of blasts and flow cytometry report was positive for AML with minimal differentiation. Considering the reports, the patient was planned to undergo treatment for AML with induction treatment regimen containing (3 + 7 Regimen) 3 days-daunorubicin and 7 days cytarabine. On 6th day of induction chemotherapy, she had fever spikes. The African National Congress-48/cumm was discovered in the laboratory parameters during the complete blood count test. According to our department protocol, blood and urine cultures were sent before she began empirical antibiotic therapy with meropenem followed by colistin P. agglomerans had grown in blood cultures. Deescalation of the antibiotics to amikacin and meropenem was done on the basis of reported culture sensitivity reports [Figure 1]. The patient received a total of 7 days of amikacin and 14 days of meropenem. The patient was discharged on day 14 in stable hemodynamic condition.
Figure 1: Shows the growth of Pantoea agglomerans species in blood and its antibiotic sensitivity

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  Discussion Top


The genus Pantoea belongs to the family Enterobacteriaceae, contains different species such as P. agglomerans, Pantoea ananatis, Pseudoalteromonas citrea, Pantoea dispersa, Phyllorhiza punctata, Pantoea Stewartii, and Pergolato terrea. P. agglomerans was formerly known as Enterobacter agglomerans or still earlier as Erwinia herbicola.[6] Pantoea spp. is an opportunistic pathogen and rarely causes disease in healthy individuals. Infections caused by Pantoea spp. have been reported in samples obtained from cotton swabs, intra-arterial devices as well as plants and plant material.[7] Pantoea spp. When involved in a systemic infection, has a predilection for the lungs. Infections caused by P. agglomerans are usually associated with an identifiable exogenous source.[2] These organisms grow well at 4°C and most commonly cause septic arthritis or synovitis following a penetrating injury by vegetation. Organic materials such as plant thorn may penetrate the skin and remain embedded in the tissues and set up a chronic inflammatory process.[4],[8] According to the literature, Pantoea species has been isolated from wounds, abscess, bacteremia, pneumonia, urinary tract infection, septic arthritis, osteomyelitis, peritonitis, choledocholithiasis, dacryocystitis, and endophthalmitis.[9] The most common clinical implications of P. agglomerans involved in wound infections (35.7%), pneumonia (21.4%), and urinary tract infections (21.4%). There is a chance of infection in agricultural occupations due to trauma associated with vegetative material penetration. In hospital settings, cotton swabs are continuously used by nurses and physicians and have a chance to be contaminated in many ways which is yet another route through which the bacteria can cause infections. Previous reports also described that samples obtained from cotton swabs, plant materials, and intra-arterial devices contained P. agglomerans.,[7],[10] In few reports, P. agglomerans is described as an opportunistic pathogen in immunocompromised individuals. Immunocompromised hosts with underlying respiratory symptoms are at high risk for infection with P agglomerans.[6] Our patient was being treated with high-dose cytarabine, a potentially cytotoxic drug used in AML. This medication is known to cause severe myelotoxicity, which the patient experienced with a neutrophil count of 48/cumm. Our patient bloodstream infection is most likely caused by his immunocompromised state.


  Conclusion Top


Although P. agglomerans is observed in immunocompromised hosts, it is exceedingly unusual to see and report P. agglomerans as the predominant source of infection in such individuals. Patient taking high-dose myelotoxic chemotherapy is at high risk of contracting infections caused by uncommon organism such as P. agglomerans. In this group of individuals, it is critical to keep an eye out for infections caused by unusual organisms such as Pantoea.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gavini F, Mergaert J, Beji A, Mielcarek C, Izard D, Kersters K, et al. Transfer of Enterobacter agglomerans (Beijerinck 1888) Ewing and Fife 1972 to Pantoea gen. nov. as Pantoea agglomerans comb. nov. and description of Pantoea dispersa sp. nov. Int J Syst Bacteriol 1989;39:337-45.  Back to cited text no. 1
    
2.
Matsaniotis NS, Syriopoulou VP, Theodoridou MC, Tzanetou KG, Mostrou GI. Enterobacter sepsis in infants and children due to contaminated intravenous fluids. Infect Control 1984;5:471-7.  Back to cited text no. 2
    
3.
Liberto MC, Matera G, Puccio R, Lo Russo T, Colosimo E, Focà E. Six cases of sepsis caused by Pantoea agglomerans in a teaching hospital. New Microbiol 2009;32:119-23.  Back to cited text no. 3
    
4.
Cruz AT, Cazacu AC, Allen CH. Pantoea agglomerans, a plant pathogen causing human disease. J Clin Microbiol 2007;45:1989-92.  Back to cited text no. 4
    
5.
Habsah H, Zeehaida M, Van Rostenberghe H, Noraida R, Wan Pauzi WI, Fatimah I, et al. An outbreak of Pantoea spp. in a neonatal intensive care unit secondary to contaminated parenteral nutrition. J Hosp Infect 2005;61:213-8.  Back to cited text no. 5
    
6.
Flores Popoca EO, Miranda García M, Romero Figueroa S, Mendoza Medellín A, Sandoval Trujillo H, Silva Rojas HV, et al. Pantoea agglomerans in immunodeficient patients with different respiratory symptoms. ScientificWorldJournal 2012;2012:156827.  Back to cited text no. 6
    
7.
Sanders WE Jr., Sanders CC. Enterobacter spp.: Pathogens poised to flourish at the turn of the century. Clin Microbiol Rev 1997;10:220-41.  Back to cited text no. 7
    
8.
Jain S, Bohra I, Mahajan R, Jain S, Chugh TD. Pantoea agglomerans infection behaving like a tumor after plant thorn injury: An unusual presentation. Indian J Pathol Microbiol 2012;55:386-8.  Back to cited text no. 8
  [Full text]  
9.
Büyükcam A, Tuncer Ö, Gür D, Sancak B, Ceyhan M, Cengiz AB, et al. Clinical and microbiological characteristics of Pantoea agglomerans infection in children. J Infect Public Health 2018;11:304-9.  Back to cited text no. 9
    
10.
Delétoile A, Decré D, Courant S, Passet V, Audo J, Grimont P, et al. Phylogeny and identification of Pantoea species and typing of Pantoea agglomerans strains by multilocus gene sequencing. J Clin Microbiol 2009;47:300-10.  Back to cited text no. 10
    


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