The Mysterious Visitor: A Chilling Encounter With Elizabethkingia Miricola

Document Type

Conference Proceeding

Publication Date

10-2024

Publication Title

Chest

Abstract

INTRODUCTION: Elizabethkingia species (spp.) were first discovered in the 1950s as culprits for causing septicemia and meningitis in infants1. While there is documentation on the pathogenicity of E. meningiosepticum and E. anopheles, reported cases of E. miricola are limited[2–5]. We present a case involving a patient with status epilepticus, acute interstitial edematous pancreatitis, refractory hypocalcemia, and pneumonia caused by E. miricola. CASE PRESENTATION: A forty-year-old woman with bipolar disorder and hypertension presented following two days of malaise and emesis. Initial testing demonstrated hypercalcemia at 15 mg/dL, pancreatic inflammation on abdominal and pelvic computed tomography (CTAP), and bilateral infiltrates on chest radiograph (CXR). She received ampicillin-sulbactam for aspiration pneumonia, zoledronic acid for hypercalcemia, and promethazine/diphenhydramine for nausea. Post-medication administration, she developed generalized tonic-clonic seizures. Brain magnetic resonance imaging (MRI) revealed possible posterior reversible encephalopathy. Lumbar puncture showed elevated protein with normal glucose. Levetiracetam was administered, and she was intubated for airway protection. Midazolam and propofol were started for analgosedation and she was transferred to our hospital for continuous electroencephalogram (EEG).Objective data at our facility: hypernatremia (146 mmol/ L), normal anion gap acidosis (bicarbonate: 15 mmol/L, chloride: 120 mmol/L), severe hypocalcemia (6 mg/dL), normocytic anemia (hemoglobin: 8.9 g/dL), elevated lipase (239 U/L), and AKI (creatinine: 1.64 mg/dL). CTAP showed pancreatitis, ileus and bibasilar opacities. EEG revealed severe bilateral encephalopathy. Echocardiography showed normal ejection fraction. Dopplers found DVTs. Despite antibiotic treatment, fevers persisted. Respiratory cultures from tracheal aspirate grew Methicillin-resistant Staphylococcus aureus (MRSA) and Elizabethkingia spp. leading to initiation of vancomycin, piperacillin-tazobactam and doxycycline. Further testing to identify alternative infectious etiologies were unrevealing as were hypercoagulable, hematologic, and rheumatologic workups. Chest computed tomography identified multifocal ground-glass opacities in the upper lobes. Bronchoscopy with bronchoalveolar lavage (BAL) of the right middle lobe revealed Elizabethkingia miricola. Susceptibility testing indicated resistance to piperacillin-tazobactam, tetracycline, cefepime, and sensitivity to ciprofloxacin, levofloxacin, and trimethoprim-sulfamethoxazole. Piperacillin-tazobactam was then switched to levofloxacin. Her status epilepticus was proposed to be iatrogenic due to promethazine and diphenhydramine reducing seizure threshold in the setting of hypocalcemia. Hypocalcemia, attributed to zoledronic acid administration in the background of vitamin D deficiency and pancreatitis, was treated with intravenous calcitriol, ergocalciferol, and intermittent calcium gluconate. Levofloxacin contributed to improvement in her secretion burden, and she was successfully extubated with improved encephalopathy. DISCUSSION: Elizabethkingia miricola has emerged as a nosocomial pathogen [6–9], associated with pulmonary manifestations such as bilateral ground-glass opacities, cystic fibrosis exacerbation [3], and pulmonary abscess [7]. Our case highlights the attribution of upper lobe predominant ground-glass opacities to E. miricola, substantiated by persistent fevers and heightened secretion burden despite treatment for MRSA pneumonia. Therapeutic challenges arise due to multidrug resistance, lacking a consensus on empiric antibiotic regimens 10. Some research studies demonstrate resistance to beta lactam, monobactam, vancomycin, carbapenems, and aminoglycosides, with variable susceptibility to minocycline, trimethoprim-sulfmethoxazole, piperacillin-tazobactam and levofloxacin [10–12]. In our case, BAL cultures indicated susceptibility and resistance as described above, consistent with prior studies. CONCLUSIONS: This case plays a crucial role in addressing the gap in documenting imaging characteristics, antibiotic susceptibilities, and management options for Elizabethkingia miricola

Volume

166

Issue

4 Suppl

First Page

A1210

Last Page

A1211

Comments

Chest 2024 Annual Meeting, October 6-9, 2024, Boston, MA

DOI

10.1016/j.chest.2024.06.790

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