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• W2749142196 abstract "Shewanella putrefaciens, a gram-negative bacillus, ubiquitous in marine environments, is an opportunistic agent reported to cause rare human infection, most commonly in patients who are immunocompromised or who have a preexisting soft tissue defect. We present an immunocompetent, 40-year-old woman with a soft tissue infection of the left palm caused by S. putrefaciens. The patient’s infection was complicated by the presence of retained foreign bodies, seashell fragments, from a traumatic fall. Following appropriate evaluation and surgical treatment, our patient experienced a successful outcome with no recurrence of infection or deficit in the affected hand. This case report complements the growing literature regarding morbidity attributed to S. putrefaciens infection. Shewanella putrefaciens, a gram-negative bacillus, ubiquitous in marine environments, is an opportunistic agent reported to cause rare human infection, most commonly in patients who are immunocompromised or who have a preexisting soft tissue defect. We present an immunocompetent, 40-year-old woman with a soft tissue infection of the left palm caused by S. putrefaciens. The patient’s infection was complicated by the presence of retained foreign bodies, seashell fragments, from a traumatic fall. Following appropriate evaluation and surgical treatment, our patient experienced a successful outcome with no recurrence of infection or deficit in the affected hand. This case report complements the growing literature regarding morbidity attributed to S. putrefaciens infection. The presence of Shewanella putrefaciens has been frequently demonstrated in all forms of water, fish, and marine environments.1Khashe S. Janda J.M. Biochemical and pathogenic properties of Shewanella alga and Shewanella putrefaciens.J Clin Microbiol. 1998; 36: 783-787PubMed Google Scholar, 2Holt H.M. Gahrn-Hansen B. Bruun B. Shewanella algae and Shewanella putrefaciens: clinical and microbiological characteristics.Clin Microbiol Infect. 2005; 11: 347-352Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar Most reports of infection with S. putrefaciens cite soft tissue involvement manifesting as abscesses, cellulitis, or infected leg ulcers, often originating after marine exposure in patients with ulceration of the lower extremities, burn wounds, or lower limb trauma.3Chen Y.S. Liu Y.C. Yen M.Y. et al.Skin and soft-tissue manifestations of Shewanella putrefaciens infection.Clin Infect Dis. 1997; 25: 225-229Crossref PubMed Scopus (101) Google Scholar This chronic necrotic or compromised tissue serves as a site for opportunistic bacterial growth and infection. The main phenotypic characteristic of the Shewanella genus is production of large amounts of hydrogen sulfide gas on triple sugar iron agar slants. It was previously believed that the majority of Shewanella infections are caused by S. putrefaciens, a gram-negative, motile, saprophytic, oxidative, and facultative nonoxidative bacillus. This genetically heterogeneous species has varying levels of cytosine and guanine content. After Shewanella algae was recovered from red algae in the early 1990s, it was realized that this distinct species had been erroneously considered a variant of S. putrefaciens.4Tsai M.S. You H.L. Tang Y.F. Liu J.W. Shewanella soft tissue infection: case report and literature review.Int J Infect Dis. 2008; 12: e119-e124Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar As a result, literature reviewing Shewanella infections published before the early 1990s has understandably unreliable data regarding speciation. Literature reviews now attribute greater than 90% of Shewanella infections to S. algae, suggesting that previous cases had been incorrectly identifying S. putrefaciens.5Janda J. Shewanella: a marine pathogen as an emerging cause of human disease.Clin Microbiol Newsl. 2014; 36: 25-29Abstract Full Text Full Text PDF Scopus (54) Google Scholar Whether or not these species have differing prognoses or treatment approaches is yet to be determined. We present a case of a monomicrobial S. putrefaciens infection of the hand in an immunocompetent patient. The purpose of this report is to highlight the possibility of Shewanella infections regardless of immune status and to stress the importance of adequate treatment of all open wounds in which foreign bodies may be present. A 40-year-old previously healthy right-handed woman presented to the emergency department with erythema and swelling of her left hand 1 day after a fall on a rock while kayaking on the shore of Connecticut. Hours after sustaining the open laceration to her left palm, she received irrigation and wound closure without antibiotic therapy at a local emergency department. During the following 24-hour period, she experienced worsening erythema, swelling, and pain in her left palm, leading her to seek medical attention upon return to her home in Washington, DC. She had a temperature of 35.5°C, heart rate of 56 beats/minute and blood pressure of 124/69 mm Hg upon admission. Physical examination of her left upper extremity revealed a laceration of the volar aspect of the left hand between the third and the fourth web spaces with swelling and erythema that was minimally painful to palpation and without fluctuance, purulence, or foul smell. The patient’s laboratory levels were significant for leukocytosis (13.2 K/μL) and an elevated serum C-reactive protein (44.90 mg/L). Owing to worsening symptoms in the setting of a recent exposure to unknown saltwater flora, the infectious disease service was consulted, wound cultures were obtained, and the patient was treated empirically for gram-positive, gram-negative, and anaerobic bacteria, a regimen consisting of intravenous piperacillin/tazobactam (3.375 g every 6 hours), vancomycin (1 g every 12 hours), and ciprofloxacin (400 mg every 12 hours). Radiographs of the left hand revealed a triangular radiopaque body possibly representing a foreign body within the soft tissues over the fourth metacarpophalangeal joint (Fig. 1). Within 12 hours of admission, erythema and swelling of the patient’s left hand had decreased, and her digital range of motion had improved. Thirty-six hours after admission and initiation of antibiotics, she had made no further clinical progress and was reporting increased pain in the hand. A small purulent area at the proximal aspect of her laceration had also begun to develop. The patient was taken to the operating room for incision and drainage. Investigation of the wound resulted in retrieval of 2 foreign bodies, later determined to be seashell fragments (Fig. 2). All infected material was debrided. The distal infected wound was irrigated and closed loosely. The following day, the patient returned to the operating room for a repeat incision and drainage to ensure complete removal of necrotic or foreign material. Initial cultures from the wound grew S. putrefaciens. The organism was sensitive to first-, second-, and third-generation cephalosporins, gentamicin, imipenem, and trimethoprim/sulfamethoxazole but was resistant to aztreonam. No other organisms were isolated from the wound. Per the infectious disease consultant’s recommendation, the patient was discharged 48 hours later on a new antibiotic regimen of ciprofloxacin 250 mg orally twice per day for 2 weeks and doxycycline 100 mg orally twice per day for 2 weeks. The Shewanella genus contains multiple human pathogens with unknown clinical differences. Table 1 outlines the points of phenotypic differentiation between S. putrefaciens and the more common S. algae.2Holt H.M. Gahrn-Hansen B. Bruun B. Shewanella algae and Shewanella putrefaciens: clinical and microbiological characteristics.Clin Microbiol Infect. 2005; 11: 347-352Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar Although it remains unclear, characteristics such as utilization of hemolysins, the capacity to adhere to epithelial cells, production of exotoxins and a biofilm, and the ability to withstand cold temperatures have been proposed as potential virulence factors of S. putrefaciens.6Bulut C. Ertem G. Gokcek C. Tulek N. Bayar M. Karakoc E. A rare cause of wound infection: Shewanella putrefaciens.Scand J Infect Dis. 2004; 36: 692-694Crossref PubMed Scopus (30) Google ScholarTable 1Summary of Biochemical Characteristics of Shewanella Algae and Shewanella Putrefaciens, Review of Previous StudiesReprinted with permission from Holt HM, Gahrn-Hansen B, Bruun B. Shewanella algae and Shewanella putrefaciens: clinical and microbiological characteristics. Clin Microbiol Infect. 2005;11(5):347–352.2Holt H.M. Gahrn-Hansen B. Bruun B. Shewanella algae and Shewanella putrefaciens: clinical and microbiological characteristics.Clin Microbiol Infect. 2005; 11: 347-352Abstract Full Text Full Text PDF PubMed Scopus (186) Google ScholarCharacteristicsS. algae∗Parentheses indicate weak result; ± indicates variable results.S. putrefaciens∗Parentheses indicate weak result; ± indicates variable results.Oxidase++Catalase++Indole production––Arginine dihydrolase––Lysine decarboxylase––Ortnithine decarboxylase++H2S production++Urea hydrolysis––Gelatine hydrolysis++DNA hydrolysis++Nitrate reduction++Nitrite reduction+–Acid production from Arabinose–± Ribose(+)± Glucose(+)± Fructose(+)± Mannitol–– Lactose–– Maltose–± Sucrose–±Growth 4°C–+ 42°C+– NaCl 6%–6.5% weight/volume+– Hemolysis (sheep blood, 48 h)+– Mucoid colony consistency+–∗ Parentheses indicate weak result; ± indicates variable results. Open table in a new tab Several documented reports of human infections and bacteremia from S. putrefaciens exist, although many accounts lack appropriate identification of Shewanella species or occur as polymicrobial infections, often in an immunocompromised host or in a host with a preexisting chronic ulcer.7Brink A.J. van Straten A. van Rensburg A.J. Shewanella (Pseudomonas) putrefaciens bacteremia.Clin Infect Dis. 1995; 20: 1327-1332Crossref PubMed Scopus (105) Google Scholar, 8Pagani L. Lang A. Vedovelli C. et al.Soft tissue infection and bacteremia caused by Shewanella putrefaciens.J Clin Microbiol. 2003; 41: 2240-2241Crossref PubMed Scopus (85) Google Scholar, 9Leong J. Mirkazemi M. Kimble F. Shewanella putrefaciens hand infection.Aust N Z J Surg. 2000; 70: 816-817Crossref PubMed Scopus (26) Google Scholar, 10Fluke E. Carayannopoulos N. Lindsey R. Pyogenic flexor tenosynovitis caused by Shewanella algae.J Hand Surg Am. 2016; 41: e203-e206Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 11Prinja A. Singh J. Davis N. Urwin G. A rare cause of wound infection after an open fracture: Shewanella putrefaciens.BMJ Case Rep. 2013; 2013Crossref PubMed Scopus (6) Google Scholar In a recent review of 260 case reports, 11% of patients were deemed immunocompromised secondary to disease or medical treatment such as neutropenia, human immunodeficiency virus, chemotherapy, and steroid use, whereas 68% of patients had an underlying medical condition such as chronic ear infection, hepatobiliary disease, heart failure, and hypertension. The remaining 21% of patients had no underlying issues, similar to our patient. However, 53% of bacterial cultures were polymicrobial, and the remaining monomicrobial cases were not speciated.12Vignier N. Barreau M. Olive C. et al.Human infection with Shewanella putrefaciens and S. algae: report of 16 cases in Martinique and review of the literature.Am J Trop Med Hyg. 2013; 89: 151-156Crossref PubMed Scopus (81) Google Scholar Assuming 10% of Shewanella infections are S. putrefaciens as previously discussed, it is likely that less than 1% of the cases reviewed were truly similar to our patient. This case is unique in that the patient was a healthy 40-year-old woman with no chronic medical conditions or comorbidities who suffered a monomicrobial infection of isolated S. putrefaciens in her upper extremity. The existence of foreign bodies in the wound likely contributed to the duration of the infection as well as to the lack of improvement with antibiotic therapy. After effective debridement and foreign body removal, the patient’s full recovery strongly suggests the role of the seashell fragments as the nidus for the prolonged infection. Hand infections may be particularly devastating to function. The first reported case of flexor tenosynovitis by a Shewanella species was documented in 2016. The patient had been exposed to saltwater flora via a fish hook injury to the right ring finger, and a superficial area of necrosis developed within 48 hours. The patient also presented with all 4 Kanavel signs and was taken to the operating room for treatment. Shewanella algae and Proteus vulgaris were isolated and the patient was discharged on levofloxacin.10Fluke E. Carayannopoulos N. Lindsey R. Pyogenic flexor tenosynovitis caused by Shewanella algae.J Hand Surg Am. 2016; 41: e203-e206Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar These cases confirm that Shewanella species should be considered in wounds exposed to saltwater regardless of immune status. A polymicrobial flexor tenosynovitis case differs from our monomicrobial soft tissue infection, yet the treatments were nearly identical. Both infections were successfully treated with fluoroquinolones, but it is unclear if these species will consistently have similar susceptibilities and treatments. Our patient could have been treated with a first-generation cephalosporin, yet we deferred to the infectious disease team owing to lack of experience with the pathogen. Shewanella species frequently show resistance to penicillins that are given for routine soft tissue infections, highlighting the importance of pathogen identification and susceptibilities.11Prinja A. Singh J. Davis N. Urwin G. A rare cause of wound infection after an open fracture: Shewanella putrefaciens.BMJ Case Rep. 2013; 2013Crossref PubMed Scopus (6) Google Scholar Fortunately, treatment for this bacterium is relatively straightforward once an antibiotic susceptibility profile has been determined; most are susceptible to third-generation cephalosporins, piperacillin, ciprofloxacin, and gentamicin.12Vignier N. Barreau M. Olive C. et al.Human infection with Shewanella putrefaciens and S. algae: report of 16 cases in Martinique and review of the literature.Am J Trop Med Hyg. 2013; 89: 151-156Crossref PubMed Scopus (81) Google Scholar Studies have not stratified susceptibilities by species, and our pathogen’s susceptibility to first- and second-generation cephalosporins suggests a potential treatment difference between S. algae and S. putrefaciens. Although medical management is necessary, our case demonstrates that antibiotic choice alone is inadequate if a nidus of infection has not been surgically removed from the wound. Although rare in incidence, soft tissue infections from S. putrefaciens can even progress to septicemia and mortality with limited case study reviews demonstrating a mortality rate of 7.4%.4Tsai M.S. You H.L. Tang Y.F. Liu J.W. Shewanella soft tissue infection: case report and literature review.Int J Infect Dis. 2008; 12: e119-e124Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The devastating outcomes that can occur as a result of S. putrefaciens soft tissue infections highlight the importance of early and thorough cleaning of all wounds sustained in marine environments, the appropriate consideration and cultures of Shewanella species and susceptibility in wounds, and the additional clinical suspicion in immunocompromised patients or patients with chronic cutaneous ulcers who will be exposed to marine environments." @default.
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• W2749142196 title "Palmar Soft Tissue Infection From Shewanella putrefaciens" @default.
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