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Abdominal necrotizing fasciitis due to Pasteurella multocida infection.

Background

Pasteurella multocida is a small gram-negative coccobacillus that exists as normal flora in the upper respiratory and gastrointestinal tracts of animals, most commonly domestic and wild cats and dogs. Pmultocida infection in humans is often associated with an animal bite, but infection without epidemiologic evidence of animal contact has been reported. (1-4)

Severe invasive infections and death due to Pasteurellosis are rarely described in the literature. (5) We report this case of necrotizing soft tissue infection and sepsis with cultures that grew Pasteurella multocida in a diabetic morbidly obese woman who resides in a house with many cats and dogs. She denied any bites from these animals.

Case presentation

A 53 year old female patient with a past medical history significant for morbid obesity and diabetes meilitus was being treated by her PCP for superficial cellulitis of her abdominal pannus and she was prescribed topical Mupirocin. There was no improvement in the panniculitis after a sufficient course of treatment. Subsequently, the patient was admitted to the hospital for more aggressive therapy with intravenous clindamycin. At that time she was found to have a superimposed fungal infection. Topical nystatin and oral fluconazole were added to her treatment regimen. After a few days, her condition improved so she was discharged home on clindamycin orally and nystatin cream.

Three months later the patient was brought to the emergency department by her family with confusion and tachypnea. On arrival her blood pressure was 96/62, heart rate 118/min, respiration 24/ min and oral temp 97F. Physical examination of the abdomen showed an inflamed pannus extending from the flank to the groin region on the left side with areas of necrosis and purulent drainage consistent with a necrotizing soft tissue infection. Lab studies showed acute kidney injury, lactic acidosis and severe leukocytosis. She was admitted to the intensive care unit with the diagnosis of sepsis due to necrotizing soft tissue infection. She was intubated and broad spectrum antibiotic therapy was initiated with tigecycline, cefepime, tobramycin and clindamycin. The patient was aggressively fluid resuscitated and pressor therapy was added later on. A surgical consult was obtained and the patient was subsequently taken to the operating room for aggressive debridement.

In the OR the patient was found to have necrotizing soft tissue involving the left abdominal wall that extended from the groin inferiorly to the midline medially. This involved the soft tissues to the level of the abdominal wall fascia. The patient underwent a debridement of the affected tissues and intraoperative cultures were obtained. The patient was returned to the ICU and was taken back to the OR on the next day for further debridement. All tissue was aggressively debrided from the left flank and groin to the anterior axillary line on the right and from the pubic symphysis inferiorly to the lateral costal margin superiorly. Wound vac therapy was initiated.

All cultures grew Pasteurella multocida, Acinetobacter, and anaerobic culture grew gram positive cocci. On further questioning of the patient's family, the patient was found to have multiple cats and dogs at home. We assumed that probably the patient was licked by one of her pets at the open sore on the skin of her abdomen. Her antibiotics were switched according to culture results to cefepime, ciprofloxacin and clindamycin. Although she showed some initial improvement with each debridement she remained persistently pressor dependent and febrile; also her last debridement didn't show any new necrosis (Figure 1), therefore, intravenous steroids were added with a temporary improvement in her vital signs. Despite this she deteriorated again and expired.

Discussion

P. moltocida is a widespread microorganism in the natural world. It is the primary pathogen involved in animal bite or scratch infections. Human infections typically occur after a bite or scratch from these animals. (3,6) However, there have been cases of Pasteurellosis that occurred without any animal exposure. (7,8)

Pasturella infections in humans are classified in one of three forms; with local skin and soft tissue infection at the site of contact with the animal being the most common, the patient usually presents with a purulent wound exudate or cellulitis. The most common complication here is abscess formation and tenosynovitis. The second most common form is respiratory infection which occurs primarily in individuals with an underlying chronic pulmonary disease. These patients may have only casual exposure to an animal. A severe systemic infection is the third and least common form of Pasteurellosis. (7-13) Life threatening infections are rare and typically occur in immunocompromised hosts such as pregnant women, neonates and individuals with chronic diseases. (14-17) The disease can present with osteomyelitis, arthritis, endocarditis, meningitis, peritonitis, pneumonia and sepsis. (1,2,5,7,8,13,18) Bacteremia typically develops within 3-5 days after exposure in predisposed people. Shock is seen in half of those with Pasteurella bacteremia. Mortality in this group of patients is in excess of 37%. (11)

Necrotizing fasciitis is a rapidly progressive infection of the soft tissue with secondary necrosis of the subcutaneous tissues that moves along the fascial planes. (19) Type I necrotizing fasciitis is usually polymicrobial while type II infection is usually related to group A hemolytic streptococci or Staphylococcus aureus. (20) P. moltocida as a cause of necrotizing fasciitis is extremely rare and to the best of our knowledge, there have only been three similar cases reported in the literature. (21-23) Of patients with necrotizing fasciitis, 20-40% are diabetic, (24-25) as was our patient. The reported mortality in patients with necrotizing fasciitis has ranged from 20% to as high as 80%. Among the variables that affect survival are the pathogens, patient characteristics, infection site, and speed of treatment. (26-27)

Pasteurella infections are treated empirically with Penicillin, ampicillin or a third/forth generation cephalosporin. (28-30) P. multocida is usually resistant to the oral first generation cephalosporins, so they should be avoided. Sensitivities should be done because there have been reports of rare resistant microorganisms producing lactamases. This type of resistance can be overcome by adding a beta lactamase inhibitor (i.e. sulbactam or clavulinic acid). Our patient was allergic to penicillin but had tolerated a cephalosporin in the past, and so she was given cefepime. Other alternatives for penicillin allergic patients are fluoroquinolones, tetracyclic trimethoprim-sulfamethoxazole and aztreonam. (11,31-35) Clindamycin has poor activity against P. multocida. There is limited data about using azithromycin in treating P. multocida infections. (38)

Conclusion

Septic shock and necrotizing fasciitis due to invasive Pasteurellosis are rarely seen. But, given their susceptibility to such infection because of their weakened immunity, all patients with chronic diseases should be warned that contact with pets can lead to this fatal outcome, even without being bitten or scratched, and they must be informed to go immediately to the hospital if they actually are bitten or scratched because empirical antibiotics should be started immediately to reduce the chance of complications. (36-37)

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Alaa Gabi, MD

Medical Resident PGY3, Dept of Internal Medicine, Marshall University School of Medicine

Rebecca Wolfer, MD

Associate Proffessor, Dept of Surgery, Marshall University School of Medicine

Elias Shattahi, MD

Assistant Professor of Infectious Diseases, Dept of Internal Medicine, Marshall University School of Medicine

Corresponding Author: Alaa Gabi, 12491 15th Street, Huntington, WV 25701. Email: gabiffllive.marsliall.edu
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Title Annotation:Case Report
Author:Gabi, Alaa; Wolfer, Rebecca; Shattahi, Elias
Publication:West Virginia Medical Journal
Article Type:Case study
Geographic Code:1USA
Date:Nov 1, 2014
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