PHILIPPINE CHILDREN’S MEDICAL CENTER

QUEZON AVENUE, QUEZON CITY

CASE REPORT

SPHINGOMONAS PAUCIMOBILIS GROWTH ON CEREBROSPINAL FLUID

CULTURE

FELICE ISABEL D.G. DE GUZMAN

FIRST YEAR RESIDENT

DR. KATHERINE BANZALI

SUPERVISING CONSULTANT

2019

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ABSTRACT

Sphingomonas paucimobilis, previously called Pseudomonas paucimobilis, is an

aerobic, non-fermentative, gram negative, non-spore-forming, motile bacillus with

polar flagellum and it typically produces yellow pigmented colonies on trypticase soy

agar plates supplemented with 5% sheep blood [1]. It includes four genera but it is

the genus S. paucimobilis that is regarded as the only representative of clinical

importance.

S. paucimobilis is widely distributed in the natural environment such as in soil and

water. S. paucimobilis has been shown to form biofilm in water piping and it has

been identified in ultrapure water in industrial systems, in the Space Shuttle water

system, in laboratory-base ultrapure water systems in hospital water and in dental

water [2]. This organism has been implicated to cause various community acquired

and nosocomial infections. Of which, bacteraemia/septicaemia (38%), peritonitis

(10%), and urinary tract infection (6%) comprise the most common types of

infections.

Sphingomonas paucimobilis is rarely isolated from cerebrospinal fluid as a cause of

central nervous system (CNS) infection. Currently, there are only 6 reported cases of

CNS infection worldwide that detected Sphingomonas paucimobilis on cerebrospinal

fluid culture. Of the 6 reported cases, four were adult (one from Malaysia, two from

the USA and one from United Kingdom), and two cases belonged to the pediatric

population (one from Turkey, another from Colombia) with no reported case in the

Philippines. All cases were treated with either a third generation Cephalosporin or

Carbapenem. All showed clinical improvement and all were eventually discharged

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except for one who died during the course of treatment. This case presents a 12-

year old Filipino male who presented with 3 weeks history of intermittent fever,

headache and behavioral changes with positive Sphingomonas paucimobilis growth

on CSF culture.

INTRODUCTION

CNS is protected by the blood-brain barrier (BBB), but is still highly vulnerable to

microbial invasion by extension from a contiguous focus, hematogenous

dissemination or less commonly, intraneural passage of organisms [3]. Central

nervous system infections are mainly due to a pathogen’s mucosal colonization,

bloodstream invasion, resultant subarachnoid space inflammation and ensuing

detrimental effects on blood-brain barrier permeability, intracranial pressure and

cerebral blood flow. Acquisition and eventual sequelae of CNS infections are dictated

by the interplay of the pathogen’s ability to evade host defenses and the host’s

immune status.

CNS infections can be caused by a variety of microorganisms. Causal agents are

commonly influenced by the patient’s age group, host’s immune status and the

epidemiology of the pathogen. In an 11-year study on four hundred five cases of

central nervous system infections on ages 3 months to 156 months from years 1987

to 1998 in Philippine Children's Medical Center (PCMC) published by Dr. Lilian Lee,

of the 7,906 admitted under Neurology service, 26% are CNS infections: 44%

bacterial, 30% secondary to tuberculous infections; 25% viral and 0.09% parasitic..

The most common causative bacteria of community-acquired bacterial meningitis in

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children aged 3 months and older are S. pneumoniae and N. meningitidis. The

remainder of cases are caused by group B streptococcus, Escherichia coli, non-

typeable H. influenzae, other Gram-negative bacilli, L. monocytogenes, and group A

streptococci.

Infection of the central nervous system is the most common cause of fever

associated with signs and symptoms of CNS disease in children [4]. Meningitis

involves primarily the meninges. The diagnosis of meningitis is mostly clinical but

can easily be confirmed with cerebrospinal fluid analysis via lumbar puncture once

meningitis is suspected. Regardless of etiology, it usually presents with the classical

triad of headache, neck stiffness, and unexplained fever. Other associated

symptoms may include nausea and vomiting, cranial nerve abnormalities, rash, and

seizure, while infants can also present with non-specific symptoms such as lethargy

and irritability [5].

The usual CSF findings in bacterial meningitis are white blood cell count (WBC) of

>1000mm3, neutrophilic predominance, elevated protein, and low glucose. However,

there have been reports shown in multiple studies where bacterial meningitis has no

CSF abnormalities [6]. Blood cultures should be performed in all patients with

suspected meningitis as blood cultures reveal the responsible bacteria in up to 80-

90% of cases of meningitis.

Testing of levels of acute phase reactants such as C-reactive protein, erythrocyte

sedimentation rate, and procalcitonin have shown benefit in differentiating bacterial

(usually elevated) from viral causes of meningitis.

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Once bacterial meningitis is considered, antibiotic therapy targeting the most usual

pathogens should be immediately initiated. Due of the efficacy of third-generation

cephalosporins in the therapy of meningitis caused by the most common CNS

infection pathogens (S. pneumoniae, N. meningitidis, and H. influenzae type b),

Cefotaxime (300 mg/kg/24 hours, given every 6 hours) or Ceftriaxone (100 mg/

kg/24 hours administered once per day or 50 mg/kg/dose, given every 12 hours)

should be used in initial empirical therapy. Patients allergic to β-lactam antibiotics

and >1 month of age can be treated with Chloramphenicol, 100 mg/kg/24 hours,

given every 6 hours. Another option for patients with allergy to β-lactam antibiotics is

a combination of Vancomycin and Rifampicin. Alternatively, patients can be

desensitized to the antibiotic.

If a patient is immunocompromised and Gram-negative bacterial meningitis is

suspected, initial therapy might include Ceftazidime and an Aminoglycoside or

Meropenem. Outcome is chiefly determined by the timely detection of the condition

and provision of antibiotics.

Empirical use of adjuvant dexamethasone (0.15 mg/kg/dose, 4 times a day) given before or

up to a maximum of 12 hours after the first dose of antibiotics and continued for 2 to 4 days

is currently recommended [7].

CASE REPORT

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This is a case of JB, a 12-year old male, Filipino, Roman Catholic, born in and

currently residing at Caloocan City, who came in with a chief complaint of intermittent

low-grade fever and behavioral changes of 3 weeks duration.

Patient was apparently well until three weeks prior to consult, patient developed

intermittent, undocumented fever which was associated with nonproductive cough.

Patient was given by his mother Paracetamol tablet, which he took on as needed

basis and provided temporary fever lysis. There was no associated colds, vomiting,

loose stools, seizure, loss of consciousness. After two days of persistent, intermittent

fever, patient consulted and was seen by a Pediatrician where complete blood count

(CBC) and urinalysis were done. CBC revealed increased WBC at 11.5 and

urinalysis result were 6-9/hpf WBC, 3-5 red blood cell (RBC), few epithelial cells and

moderate amorphous urates. Assessment that time was urinary tract infection.

Patient was prescribed with Amoxicillin Clavulanate syrup of unrecalled dosage

which he took for 7 days with good compliance. The patient was also given by his

mother unprescribed Lagundi capsules once daily, which provided resolution of

cough, however, despite intake of antibiotic, intermittent fever still persisted. There

was a reported family member who also had cough that time who lived with the

patient in the same household.

In the interim, patient still had intermittent undocumented fever but this time was

associated with decreased appetite, poor activity, undocumented weight loss and

irritability with localizing symptoms such as dizziness described as “parang umiikot

ang paligid” not associated with aggravating and relieving factors. During that time,

there was no noted decrease in sensorium, vomiting or focal neurologic deficit.

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Patient was still able to perform activities of daily living independently. There was

difficulty initiating sleep but was uninterrupted.

Two weeks prior to consult, patient was still febrile, now documented, with a

maximum temperature of 38C. fever was nonproductive cough, body malaise and

intermittent headache with pain scale of 5-7 in the visual pain scale, aggravated by

movement and relieved by sleep; frontal in location and squeezing in character. No

associated vomiting, changes in sensorium or neck rigidity noted. They consulted

with another Pediatrician who requested urinalysis revealing increased wbc.

Assessment again was urinary tract infection. Patient was prescribed with

Cefuroxime syrup of unrecalled dose which he only tolerated to take for 2 days due

to bad taste.

In the interim, patient still had intermittent fever, headache, difficulty initiating sleep,

body malaise, decreased appetite and activity and with recurrence of nonproductive

cough. Patient was also noted to be irritable, described by relatives as “mabilis

mainis, pasigaw sumagot”.

One week prior, patient still had intermittent fever, headache, nonproductive cough,

body malaise and generalized weakness with difficulty in ambulation. Patient

consulted at a private hospital and was subsequently admitted for 6 days. CBC and

urinalysis were done, revealing normal results. Chest roentgen revealed fibrotic

densities in the right upper lobe. Assessment was Pediatric Community Acquired

Pneumonia C and patient was treated with Cefuroxime intravenously for three days

and Clarithromycin syrup of unrecalled dosage and frequency. There was noted

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clinical improvement as patient’s fever lysed, with decreased episodes of coughing

with better sleep, activity and appetite with only intermittent headache and

generalized weakness. However, two days prior to consult, at his 4th hospital day,

patient had his first afebrile seizure. Semiology of the seizure was left versive gaze,

left head turning, tonic clonic flexion of upper extremities, and drooling, lasting for

one minute. Patient was given unrecalled IV medication which resolved the seizure.

Post-ictal, patient was drowsy and preferred to lie down. They were advised to

transfer to and be admitted at a tertiary private hospital for neurologic evaluation and

management. Upon transfer, patient had decreased sensorium with Glasgow Coma

Score of 12 (E4V4M4) with pertinent neurologic examination of left central facial

palsy positive Brudzinski and Kernig’s sign. Assessment at that time was Meningitis

probably Tuberculous. Cranial Computed Tomography scan done at that time

showed moderated communicating hydrocephalus, hence, Mannitol was started.

Lumbar tap was done revealing CSF wbc of 1 with 100% lymphocytes with low

protein (12.4 mg/dl, Normal value: 15-45 mg/dl) and decreased glucose. CSF Acid

Fast Bacilli, Phadebact, TB gene xpert, CALAS, India Ink and CSF gram stain and

culture were all negative. Chest roentgen done showed fibrotic changes in the right

upper lung field (fibrotic densities noted in the right upper lobe). Patient was

assessed as case of Meningitis Probably Tuberculous Stage 2 (TB stage with

lethargy with meningeal signs) and was started with quadruple TB treatment of

Isoniazid, Rifampicin, Ethambutol and Pyrazinamide. Patient was transferred to our

institution due to decreasing neurologic status.

Patient was born to a then 19 year old Gravida 1 Para 1 (1001) non-smoker and

non-alcoholic beverage drinker mother. Patient’s mother was cognizant of pregnancy

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at 5 months age of gestation as she had irregular menses. Ultrasound was done at 6

months age of gestation. She had regular pre-natal check-up with a private

obstetrician. which revealed normal results. She had no maternal illness and took

multivitamins, Ferrous Sulfate and Folic Acid. No exposure to radiation or anyone

with viral exanthem reported.

Patient was born full-term at a lying-in assisted by a midwife. There was no

premature rupture of membrane, prolonged labor or difficult delivery. Upon delivery,

there was no cord coil or meconium-stained amniotic fluid. Birth weight was

unrecalled. Patient had good cry, activity and color upon birth. Patient had urine

output and bowel movement within 24 hours after birth. Routine newborn care done.

Patient was given Hepatitis B and BCG vaccine. He was eventually discharged after

24 hours with his mother. Newborn screening and hearing screening were not done.

There was no family history of malignancy, infectious disease like tuberculosis or

chronic disease such as hypertension or diabetes. Immunization include one dose of

Bcg, 3 doses of Hepatitis B, 3 doses of Hib, 3 doses of Oral Polio, 3 doses of

Diphtheria, 1 dose of measles, 1 dose of Varicella and 1 dose of MMR. All vaccines

were administered at a local health center.

Patient was formula fed since birth. Complementary feeding started at 6 months of

age with mashed vegetables. Patient has no known allergy to food or medication. He

is not a picky eater and would eat meat, rice, vegetables and fish.

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Patient lives in a 3-storey concrete house with his mother, aunt and grandmother. He

had exposure to smoking but their house had good ventilation. Their drinking water

at home is distilled. Garbage in their community was collected regularly.

Patient was an academic achiever and was always a part of the top 10 students in

class. He has a group of friends whom he can share his problems with. He has not

experienced being bullied in school or online. He spends most of his free time at

home, using his mobile phone. He would occasionally go out and play sports with

friends. Patient reportedly has poor hygiene and would usually bathe once every 2

days.

Patient has had one girlfriend whom he broke up with since his mother did not allow

him to enter a romantic relationship as he was still young. He had no history of

suicidality or signs of depression such as depressed mood, loss of interest or

pleasure from previously enjoyed activities, recurring thoughts of death, feelings of

guilt, etc.

COURSE IN THE WARDS

On the day of admission, patient was assessed to have a Glasgow Coma Score

(GCS) of 10 (E1M5-6V3). Seen with the vitals of 110/70, heart rate of 102,

respiratory rate of 24, 02 sat of 98% at room air. He had anicteric sclerae, pink

palpebrae, no alar flaring, no tonsillar congestion, no cervical lymphadenopathy,

symmetric chest expansion, clear breath sounds, adynamic precordium, tachycardic

but with normal rhythm, no murmur, flabby, normoactive bowel sounds, soft, no

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cyanosis, full pulses, warm, capillary refill time <2 seconds. Neurological examination

revealed 3 mm pupils equally brisk reactive to light, there was left facial palsy, motor

5/5 on the right upper and lower extremities with 4/5 on the left upper and lower

extremities. Patient had reflexes of +2 on patellar, +3 on ankle, negative for Babinski

or clonus. Chest roentgen revealed suspicious densities on the right upper lobe.

There was increased white blood count noted on CBC at 16.2 with slight toxic

granules Arterial blood gas (ABG) result was normal. Urine analysis was negative

for infection. Gastric Aspirate day 1 and 2 revealed no acid fast bacilli. Mannitol,

Phenobarbital, and quadruple anti-TB regimen that were started from the previous

hospital were continued. Patient was hydrated with PNSS.

During admission, patient was worked up for CNS infection. Cranial CT scan

revealed the following findings: no infarcts, hemorrhages, masses or abnormal

enhancement. Mild-moderate communicating hydrocephalus with subependymal

effusion. Polysinus disease. Due to decreasing trend of the Glasgow Coma Scale

score of the patient, emergency ventriculoperitoneal shunt insertion was done on the

third hospital day. Intraoperative CSF analysis was requested and done. CSF

analysis sent for cell count, differential count, csf protein/sugar, afb, gram stain,

culture and sensitivity, CALAS, India ink and TB gene xpert done, which all revealed

negative results. Preoperative medication Oxacillin was given. Assessment at that

time was TB meningitis stage 3. Medications were continued.

Since admission, no recurrence of seizure noted. Patient also had increasing

appetite and activity. Although the ptosis and the left facial asymmetry persisted, he

became more conversant and was consistently oriented. However, on the 8 th hospital

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day, CSF culture and sensitivity revealed the following findings: Sphingomonas

paucimobilis sensitive to Cefepime, Meropenem, Gentamicin, Imipenem and

Amikacin.

Patient was referred back to infectious disease service and was started with

Meropemen 2G every 8 hours and Amikacin 1G once a day to complete for 3 weeks.

Blood culture and sensitivity turned negative after 5 days of incubation. Patient is

currently still at the ward with ongoing antibiotic treatment with improving appetite

and activity, and no recurrence of seizure.

DISCUSSION

Sphingomonas paucimobilis was first identified and described in 1977 by by Holmes

et al. S paucimobilis is an opportunistic pathogen with relatively low virulence likely

because of lack of typical gram-negative lipopolysaccharide cell membrane

component as well as lack of endotoxin activity. S. paucimobilis was originally

regarded as the only representative of the Sphingomonas genus to be of clinical

importance. However two other Sphingomonas spp. species – Sphingomonas

mucosissima and Sphingomonas adhesiva have recently been implicated in infection

[8].

This bacteria can be found in different environment such as bodies of water (e.g.

river water, undergroundwater, sea water), soil, and water reservoirs. In the hospital

setting, Sphingomonas can be isolated from indwelling catheters, sterile intravenous

fluid, nebulizer, ventilator, and hemodialysis device and from various clinical

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specimens. They have oligotrophic properties and can live in environments of very

low nutrient content.

S paucimobilis can cause a variety of infections in both healthy people and

immunocompromised hosts. Most S paucimobilis infections reported in the literature

were either hospital acquired or related to nosocomial outbreaks. Most of the

community-acquired infection presented with primary bacteremia and mainly

occurred in immunocompromised hosts.

S paucimobilis bacteremia had been reported mainly in patients with indwelling

devices or in immunocompromised host, especially those with neutropenia and

hematopoietic stem cell transplantation. A recent study by Lin et al. focused on S

paucimobilis bacteremia stated that the most common comorbidities were

malignancy (57.1%) and immunosuppressant use (40.5%). However, the most

common comorbidities of their own series were malignancy (56.3%) and diabetes

mellitus (31.3%). Multivariate logistic regression showed that community-acquired

infection, diabetes mellitus, and alcoholism were risk factors for primary bacteremia

of S paucimobilis infection.

In a literature review done by M.P. Ryan et al. wherein papers were searched online

containing discussion on S. paucimobilis infections from 1979 to December 2009,

they have concluded that the major conditions that are associated with S.

paucimobilis infection are bacteraemia/septicaemia and peritonitis. The breakdown

of conditions are as follows: twenty instances of bacteraemia/septicaemia (38%), five

instances of peritonitis (10%), three instances of urinary tract infection (UTI) (6%),

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and three instances of lung infection/pneumonia (6%). Other conditions include two

instances of leg ulcer (4%) and two instances of endophthalmitis (4%). One instance

of cervical adenitis (2%), one instance of bromhidrosis (2%) and single instances of

other unusual infections have also been reported. At that time, there was only one

reported case of meningitis in United Kingdom in whom Sphingomonas paucimobilis

was isolated from CSF. Presentation of CNS infection secondary to Sphingomonas

paucimobilis does not differ to the typical presentation of other bacterial causes of

meningitis.

Bacterial coinfection with tuberculous meningitis is uncommon but possible. In an

article published by Luis, Patricia et. al in Mexico on October 2017, they have

presented 4 cases of concurrent bacterial and tuberculous meningitis, with

streptococcus pneumoniae as the most frequent bacteria isolated. Such co-infection

was found to be increasingly associated with immunosuppressed patients e.g.

patients with HIV, type 2 diabetes, and myelodysplastic syndrome.

Of note, there are currently 6 known cases worldwide of CNS infection with isolated

Sphingomonas paucimobilis, none is currently reported in the Philippines. Of the 6

cases, 4 were adults (ages 31, 39, 39 and 50) and 2 were pediatric patients ages 3

and 14 years old. Of the six, five were immunocompetent and one was

immunocompromised, presenting with end-stage renal disease at the time when

CNS infection was detected.

Patient’s history of illness started 3 weeks prior to consult. His symptoms were

initially nonspecific, presenting as intermittent fever, nonproductive cough, decreased

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appetite and activity. This then was accompanied by localizing symptoms such as

dizziness, headache, behavioral changes and eventually, seizure. Of the reported

cases, almost half presented the illness acutely (as short as 2 days prior) and others

as long as 2 weeks to 2 months prior to consult. Our patient and all of 6 identified

cases had the classic triad of meningitis which are fever, headache and neck

stiffness.

On imaging, the patient’s CT scan showed mild to moderate communicating

hydrocephalus. Of the 6 patients with meningitis secondary to Sphingomonas, one

had hydrocephalus with cerebral edema, one had had T2 hyperintensities consistent

with ventriculitis, one only had nonspecific T2 signal increase on the frontal region,

two had normal cranial imaging and one had no imaging done.

The patient’s CSF analysis had normal (higher end of normal) CSF protein 0.60 g/L

but decreased CSF sugar 2.13 mmol/L. CSF also revealed lymphocytic

predominance. Results of CSF analysis of the six confirmed cases revealed that

three patients had increased CSF protein and decreased CSF sugar, one had both

CSF protein and sugar with decreased values, with two having normal CSF protein

and sugar. All patients had increased white blood cells in blood, with neutrophilic

predominance. All also had positive culture of Sphingomonas paucimobilis.

Although the patient’s work up only identified Sphingomonas paucimobilis and work-

up for meningitis secondary to tuberculosis (i.e. CSF TB gene xpert, sputum and csf

Acid Fast Bacilli, PPD) all turned out negative, his chest xray finding of fibrotic

changes in the righ upper lung, exposure to a family member with chronic cough

15
that had no TB work-up and clinical symptoms such as prolonged cough, fever,

nonspecific signs of decrease in appetite and weight loss, coupled with the CSF

finding of lymphocytic predominance, increased prevalence of tuberculosis in the

country and an imaging finding consistent with TB meningitis (i.e. hydrocephalus),

coverage for TB meningitis was also warranted. In the Philippines, in the study done

by Dr. Lilian Lee wherein 405 cases of TB meningitis that were seen at the Philippine

Children’s Medical Center from 1987 to 1998 was reviewed, the most common

neurological findings of TB meningitis that the patients presented were also

consistent with the presentation of bacterial meningitis. Such symptoms were altered

sensorium, neck rigidity, motor and cranial deficits. The study identified significant

predisposing factors to having the disease such as positive family history of TB and

the presence of pulmonary tuberculosis or primary complex. Of the 405 cases, none

turned out positive on smear or culture. Hence, there has been heavy reliance on

neuro-imaging to support the diagnosis of TB meningitis. Most common CT findings

of the studied patients seen in PCMC were the presence of the following: basal

exudate, hydrocephalus and chronic granulomatosis with caseation. Short course (6

months) triple anti-Koch's therapy was found to be adequate. The use of

corticosteroids is advantageous, especially in more serious cases of TB meningitis.

One identified risk factor in this patient’s case is poor hygiene. The patient was

reported to bathe at least once every two days and would sometimes emit an

odorous body scent. In a case report presented by Mancini, M. et al in Italy, they

presented a case of a 50-year old female that presented with bromhidrosis.

Bromhidrosis occurs secondary to excessive secretion from either apocrine or

eccrine glands that become malodorous on bacterial breakdown. A culture of the

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axillary smear revealed the presence of Sphingomonas paucimobilis. Bromhidrosis is

caused by the interaction of apocrine sweat and existing bacteria present on skin.

The condition is further aggravated by poor hygiene or underlying disorders

promoting bacterial overgrowth, including diabetes, intertrigo, erythrasma, and

obesity [9]

There are no standardized and recommended for therapies of S.paucimobilis

infections. Thus, antibiotic treatment rested on clinical experience. The duration of

the treatment was 7 – 13 days according to the clinical response of the patients.

Aminoglycoside plus a third-generation cephalosporin have been recommended as

suitable antibiotics for treatment of S paucimobilis infections. However, in a study by

Bayram, Nuri et al. wherein they analyzed 24 pediatric infections that tested positive

for S paucimobilis, the S.paucimobilis isolates in their study exhibited antibiotic

susceptibility trends that were different from those in other studies. Previous reports

suggested that third generation cephalosporins or aminoglycosides were best choice

of treatment of S.paucimobilis infections. However, 20% of the isolates in their study

were resistant to cefotaxime, and 13.6% were resistant to amikacin.

In a study done by Toh, Han-Siong et al. on risk factors associated with S

paucimobilis, they found that carbapenem still may still be a good treatment choice

because of its high susceptibility rate (94.5%) for S paucimobilis and because

susceptibility to the third-generation cephalosporins and fluoroquinolones varied.

There is no data available on combination therapy with two or more agents. These

differing results reinforce the need to treat these infections with individualized

antibiotic therapy, guided by the in vitro susceptibility of each clinical isolate.

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In adjunct to antibiotic treatment, the removal of infected catheters or medical

devices is indicated in many patients. The case for removal of such catheters and

devices has to be individualized, based on the need and utility of the catheter or

device and the risk of ongoing infection

Patient was initially treated with quadruple anti-tuberculosis therapy (Isoniazid,

Rifampicin, Pyrazinamide and Ethambutol), but was started on antibiotic Meropenem

upon release of CSF culture and sensitivity that revealed Sphingomonas

paucimobilis with sensitivity to Cefepime, Gentamicin, Imipenem, Meropenem,

Amikacin. All of the 6 patients mentioned above had positive csf culture for

Sphingomonas paucimobilis that were sensitive to Ceftriaxone, Meropenem and

Amikacin. They were treated with either Ceftriaxone or Meropenem. Of the 6

patients, one patient died, another one was discharged with mild ataxia on lower

limbs while the remaining four returned to their baseline condition.

Success of therapy is measured by clinical resolution of infection. Negative blood

cultures in bacteremic patients document bacteriologic cure. The need for repeat

cultures in patients who have responded well to therapy has not been studied for this

organism. There are no available vaccines for this organism and as with all other

infections, universal precautions must be followed.

Despite the probability of development of complications, the overall prognosis of S

paucimobilis infection is usually favorable. There was no statistical difference about

18
the development of complications between community-acquired and health care-

associated S paucimobilis infections.

Since initiation of treatment, patient has shown improving neurological status and is

currently undergoing rehabilitation. Patient had no episode of decrease in sensorium.

No recurrence of seizure noted with better appetite and activity. Repeat blood and

CSF culture were done at the 12 th day of giving of antibiotics, revealing negative

results for any microorganism. Plan was to continue Meropenem and Amikacin to

complete for three weeks.

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REFERENCES

[1] Holmes B, Owen RJ, Evans A, Malnick H, Wilcox WR. Pseudomonas

paucimobilis, a new species isolated from human clinical specimens, the
hospital environment and other sources. Int J Syst Bacteriol 1977;27: 133-
46

[2] Szymanska, J. 17 August 2013. Bacterial contamination of dental unit

waterlines. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613572/

[3] Varatharaj, A. 16 March 2016. The blood-brain barrier in systemic

inflammation. Retrieved from:
https://www.ncbi.nlm.nih.gov/pubmed/26995317

[4] Dorsett, M. 1 November 2017. Diagnosis and Treatment of Central

Nervous System Infections in the Emergency Department.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5082707/

[5] Ris, J. 22 November 1985. Bacterial meningitis despite normal CSF

findings. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/4057506

[6] Tacon, C. 12 September 2012. Diagnosis and Management of Bacterial

Meningitis in the Paediatric Population: A Review. Retrieved fromL
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461291/

[7] [Ryan, M. Sphingomonas paucimobilis. Retrieved from:

http://www.antimicrobe.org/b232.asp

[8] Semkova, K. 8 April 2015. Hyperhidrosis, bromhidrosis, and

chromhidrosis: Fold (intertriginous) dermatoses. Retrieved from:
https://www.ncbi.nlm.nih.gov/pubmed/26051066

9. Mancini, M. 6 July 2009. Bromhidrosis induced by Sphigomonas

paucimobilis: A Case Report. Retrieved from
https://journals.sagepub.com/doi/pdf/10.1177/039463200902200332

10. Lee, Lilian. Neurotuberculosis Among Filipino Children: An Eleven-year

Experience at the Philippine Children's Medical Center. Retrieved from:
http://citeseerx.ist.psu.edu/viewdoc/download?
doi=10.1.1.528.3246&rep=rep1&type=pdf

20
11. Ryan, M.P. “Sphingomonas paucimobilis: a persistent Gram-negative
nosocomial infectious organism.” ResearchGate. 30 April 2010,
https://www.researchgate.net/publication/43533822_Sphingomonas_pauci
mobilis_A_persistent_Gram-negative_nosocomial_infectious_organism.
Accessed 15 May 2019

12. Tai, Mei-Ling Sharon. “Sphingomonas Paucimobilis: An Unusual Cause

of Meningitis—Case Report”. 8 November 2013.
https://www.jstage.jst.go.jp/article/nmc/54/4/54_cr2012-0429/_pdf/-char/ja.
16 May 2019.

13. Bolen, Robert. “Sphingomonas paucimobilis meningitis and

ventriculitis in an immunocompromised host”. Journal of Neurological
Science. Accessed 27 October 2015. https://www.jns-
journal.com/article/S0022-510X(15)02497-1/fulltext. 14 May 2019.

14. Mehmood, Hassan. “A Rare Case of Sphingomonas paucimobilis

Meningitis in the Absence of Cerebrospinal Fluid Pleocytosis”. Sage
Journals. 31 January 2018.
https://journals.sagepub.com/doi/full/10.1177/2324709618756424.
Accessed 17 May 2019

15. Deveci, Nazli. “Sphingomonas paucimobilis: An Uncommon Cause of

Meningitis”. Sage Journals. 31 January 2018.
https://pdfs.semanticscholar.org/01e0/1ad3777891528507d9647375baa5
e62f3d52.pdf. Accessed 12 May 2019.

16. Luis, Patricia. “CNS Bacterial Coinfections: An Uncommon Association

of Tuberculous and Pyogenic Bacteria”. 31 October 2017. Austin Journal
of Clinical Neurology. Accessed 19 May 2019.

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