Journal of Medical Microbiology (2013), 62, 935–939 DOI 10.1099/jmm.0.

058669-0

Case Report Yokenella regensburgei infection in India mimicking

enteric fever
Sarika Jain,1 Rajni Gaind,1 Kunj Bihari Gupta,1 Reetika Dawar,2
Deepak Kumar,1 Premila Paul,3 Raman Sardana2 and Manorama Deb1
Correspondence 1
Department of Microbiology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi
Rajni Gaind 110029, India
rgaind5@hotmail.com 2
Department of Microbiology, Indraprastha Apollo Hospitals, New Delhi 110076, India
3
Department of Paediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New
Delhi 110029, India

Yokenella regensburgei is an opportunistic human pathogen of the Enterobacteriaceae family

rarely reported to cause human infections. Here, we present a case report of Y. regensburgei
Received 2 February 2013 bacteraemia from India clinically resembling enteric fever in an apparently immunocompetent
Accepted 16 March 2013 paediatric patient.

Introduction lost his appetite. There was no history of diarrhoea,

Yokenella regensburgei is an opportunistic human pathogen
and is the only species of the genus Yokenella within the
family Enterobacteriaceae (Stock et al., 2004; Abbott &
Janda, 1994). Previously, it was known as ‘enteric group 45’
and it was later renamed ‘Koserella trabulsii’ by the Centers
for Disease Control and Prevention. The name Y.
regensburgei assigned in 1984 by Kosako et al. (1984) was
retained for this new genus and species. The epidemiolo-
gical and clinical significance of this organism is not
established. Y. regensburgei has been recovered from water
from wells, food material (namely salad) and the intestinal
tracts of insects and reptiles (Kosako et al., 1984). It is
rarely reported to cause human infections, with only
sporadic case reports available in the literature. It has been
isolated from humans, namely leg wound, blood, upper
respiratory tract, urine, faecal and synovial fluid samples
(Stock et al., 2004; Abbott & Janda, 1994; Kosako et al.,
1984; Hickman-Brenner et al., 1985; Yagüe Muñoz et al.,
1989). Biochemically, Y. regensburgei closely resembles
Hafnia alvei and Salmonella enterica (Stock et al., 2004);
however, DNA relatedness values and other studies have
revealed that they are distinct species (Kosako et al., 1984;
Hickman-Brenner et al., 1985).
Here, we present a case report of a bloodstream infection
due to Y. regensburgei from India.
Case report
A 5-year-old male child presented to the paediatric
outpatient department of Vardhman Mahavir Medical
College and Safdarjung Hospital in October 2012 with
continuous high-grade fever and chills that he had
experienced for 7 days. The child looked unwell and had
abdominal pain, cough, dysuria or urinary frequency on
admission. His body temperature was 101 uF and he had a
respiratory rate of 40 min21, blood pressure of 100/
70 mmHg and a pulse rate of 102 beats min21. A systemic
examination (respiratory, abdominal and neurological)
revealed nothing of note. There was no history of any
major illness in the past. The child was admitted and the
cause of his fever was investigated. Laboratory data showed
his haemoglobin level was 10.5 mg dl21 and his total
leukocyte count was 10 500 mml23. The widal and
typhidot tests were negative; a peripheral blood smear
and a rapid test for malarial antigen were also negative.
Urine culture showed no growth and an X-ray of the chest
was normal. Blood cultures were sent as enteric fever was
suspected. The first blood culture was negative after 48 h of
incubation, hence another blood culture was taken. Both
the blood cultures became positive, the first sample after
5 days and the second sample after 48 h of incubation. A
preliminary result of non-lactose-fermenting (pale
coloured) growth was reported to the clinician.
Identification and biochemical properties
Based on routine biochemical testing the organism was
found to be a motile bacterium which was weakly positive
for catalase, oxidase-negative and able to utilize citrate
(positive after 48 h) and had a triple sugar iron reaction of
K/A with gas (indole, H2S and urease not produced). The
non-lactose-fermenting organism was presumptively iden-
tified as Salmonella enterica serovar Paratyphi A (S.
Paratyphi). However, the organism failed to agglutinate
with Salmonella polyvalent O antisera. Since the identifica-
tion of the strain was not ascertained, it was confirmed using
the VITEK 2 compact automated system (bioMérieux Inc),

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S. Jain and others

and extensive biochemical tests were performed by Entero-
18R (Liofilchem). The results were ONPG-negative,
mannitol-positive, Vogues–Proskuer-negative and lysine-,
ornithine- and arginine decarboxylase-positive. The organ-
ism was unable to ferment sucrose, raffinose, inositol,
sorbitol and malonate. The aesculin and glycerol fermenta-
tion tests were performed manually and the results were
negative (Table 1). The identification of both isolates was
confirmed by VITEK 2 (bioMérieux) and Entero 18R as Y.
regensburgei.
Antimicrobial disc diffusion susceptibility test was per-
formed as per the Clinical and Laboratory Standards
Institute (CLSI) guidelines (CLSI, 2012) and the organism
was found to be sensitive to ampicillin, ceftazidime,
cefotaxime, gentamicin, amikacin, netilmycin, ciproflox-
acin, nalidixic acid, piperacillin–tazobactum and carbape-
nems, but was resistant to penicillin, cefoxitin and colistin.
MICs were performed using the Etest (AB BIODISK);
results are shown in Table 1.
Extended-spectrum beta-lactamase detection was carried out
by performing the double-disc diffusion test using cefotax-
ime and ceftazidime as per CLSI guidelines (CLSI, 2012);
results were negative. Due to cefoxitin resistance along with
susceptibility to third-generation cephalosporins, the isolate
was presumed to have a chromosomal AmpC enzyme. DNA
was extracted and PCR was performed using degenerate
primer pair P1 (GGATTCCGGGTATGGCSGTNGC) and P4
(TCCCAGCCTARYCCCTGRTACAT), as described by
Stock et al. (2004), to detect the presence of genes encoding
chromosomal and plasmid-mediated AmpC enzymes. A
750 bp amplification product for AmpC was obtained (Fig.
1) and was sequenced, and further nucleotide and deduced
amino acid sequences were analysed and compared with
sequences available in GenBank at the National Centre for
Biotechnology Information website (http://www.ncbi.nlm.
nih.gov/).
Based on the susceptibility report, the child was treated
with ciprofloxacin for 7 days. He responded clinically to
the treatment. The child remained afebrile and he was
discharged. No recurrence was reported on a follow-up 3
months later.
Discussion
The clinical significance of Y. regensburgei as a human
pathogen is not well described. This may be attributed to a

Table 1. Biochemical reactions and antibiogram of Y. regensburgei

R, Resistant; S, sensitive.

Biochemical test Result Antimicrobial tested Antibiogram (MIC in mg ml”1)

Indole production – Penicillin R (32.0)

H2S production – Ampicillin S (1.5)
Motility + Amoxicillin–clavulanate S
Adonitol – Erythromycin S
L-Arabinose + Ceftazidime S
D-Cellobiose + Ceftriaxone S (0.094)
ONPG + Cefoxitin R (12.0)
Voges–Proskauer test – Ciprofloxacin S (0.094)
D-Glucose + Nalidixic acid S (1.0)
D-Maltose + Gentamicin S
D-Mannitol + Amikacin S
Lactose – Netilmycin S
Citrate + Piperacillin–tazobactam S
Malonate – Imipenem S
Urease production – Ertapenem S (0.006)
D-Sorbitol – Meropenem S (0.032)
Sucrose – Colistin R (.32)
Glucose fermentation + Tigecycline S
Xylose +
Aesculin –
Lipase –
Lysine decarboxylase +
Ornithine decarboxylase +
Arginine decarboxylase –
L-Rhamnose +
Phenylalanine deaminase –
D-Raffinose –

936 Journal of Medical Microbiology 62


M Y C S
786 bp
700 bp
500 bp
Fig. 1. Gel image showing the PCR products of the ampC gene
isolated from the Y. regensburgei clinical isolate from the present
case study. Lanes: M, 100 bp biolink ladder; Y, Yokenella; C,
Citrobacter (positive control); S, S. Typhi Ty2 (negative control).
lack of resources in routine clinical laboratories for its
identification. Only five clinical cases of human infection
have been reported so far worldwide, to the best of our
knowledge (Table 2). Septic knee and transient bacteraemia
(Abbott & Janda, 1994), venous ulcer wound infection
(Fajardo Olivares et al., 2005), abdominal abscess and
septic shock (Fill & Stephens, 2010) and soft tissue
infection with bacteraemia (Lo et al., 2011) were the
clinical diagnoses among these cases, and in none of these
cases could the source of the infection be traced. An
association between Y. regensburgei infection and some
form of immune suppression has been observed in all these
reports, such as alcohol intake, chronic renal failure,
diabetes mellitus, adenocarcinoma and the use of steroids
and immunosuppressive agents. Furthermore, all cases
were reported in adults or elderly patients. Isolation of this
species from water from wells, insect intestines, human
upper respiratory tract, faeces and urine may suggest its
ability to survive in these locations; however, the source
and route of transmission is unclear (Kosako et al., 1984;
Hickman-Brenner et al., 1985).
The present case involved a paediatric patient who was
apparently immunocompetent. Undoubtedly, isolation of
Y. regensburgei in pure growth from two separate blood
culture samples on separate days implicates the plausible
pathogenic role of this organism, as was also recently
reported by Lo et al. (2011). The child had no other
localized signs of infection. In addition, the clinical
response to ciprofloxacin therapy also supports the
clinical relevance of this species. Similar success with
fluoroquinolone therapy has also been demonstrated in
two previous cases of transient bacteraemia and perimal-
leolar ulcer (Abbott & Janda, 1994; Fajardo Olivares et al.,
2005). The source of infection could not be traced. The
absence of similar symptoms amongst other family
members possibly excludes infection through contami-
nated food and water. History of recent animal contact
could not be ascertained.
http://jmm.sgmjournals.org
Yokenella regensburgei bacteraemia in a paediatric patient
The child presented with a clinical picture of enteric fever,
and phenotypically the organism was presumptively
identified as S. Paratyphi A. However, the unusual feature
was its susceptibility to nalidixic acid, while the majority of
both Salmonella enterica serovar Typhi (S. Typhi) and S.
Paratyphi A strains isolated in the Indian subcontinent are
currently nalidixic acid resistant (Gaind et al., 2006;
Raveendran et al., 2008). Important identification features
of the species Y. regensbergei that can distinguish it from
Salmonella and Hafnia alvei are results from the Simmons’
citrate assimilation test, a negative Voges–Proskauer
reaction and fermentation of melibiose, cellobiose and
glycerol (Hickman-Brenner et al., 1985).
The species appeared to be of low virulence as specific
treatment (ciprofloxacin) was initiated only after 8 days of
presentation when blood cultures revealed Y. regensburgei.
However, the child’s condition did not deteriorate during
this period and he recovered without any complications.
The organism was susceptible to a variety of antimicrobial
agents including fluoroquinolones and third-generation
cephalosporins, which are used to manage patient condi-
tions. The isolate was in vitro susceptible to ampicillin,
piperacillin, cephalosporins and carbapenems, as well as to a
beta-lactamase inhibitor combination (amoxicillin–clavula-
nate, piperacillin–tazobactam, cefoperazone–sulbactam),
quinolones and aminoglycosides. As reported previously,
the strain was resistant to penicillin, cefoxitin and colistin
(Hickman-Brenner et al., 1985; Richard, 1989). On
characterizing 10 strains of Y. regensburgei from various
clinical and environmental sources, Stock et al. (2004) found
that the species possesses AmpC genes, closely related to the
chromosomal AmpC of Enterobacter and Citrobacter species,
and expresses highly inducible and potent beta-lactamases,
and is therefore naturally resistant to a variety of first- and
second-generation cephalosporins and cefoxin, but is
relatively susceptible to third-generation cephalosporins
(Stock et al., 2004). However, using broth dilution, Stock
et al. (2004) have reported medium-dependent susceptibility
among several beta-lactams including narrow-spectrum
cephalosporins with IsoSensitest broth. In this report, the
MIC of amoxicillin ranged from 1 to 16 mg ml21. Our isolate
was susceptible to ampicillin with an MIC of 1.5 mg ml21
using the Etest. The colistin susceptibility test can be a useful
screening test for the identification of Y. regensburgei, as the
species is often resistant to colistin, while other
Enterobacteriaceae members are uniformly sensitive to
colistin, except the tribe Proteae and Serratia species.
To the best of our knowledge, this is the first report from
India of Y. regensburgei infection. Important highlights of
this case were the clinical resemblance to enteric fever and
presentation in a paediatric patient who had an apparent
immunocompetent status. Due to the lack of adequate
diagnostic facilities in the form of automated and extended
biochemical tests in many laboratories, this species may be
overlooked, and hence the true incidence of human
infection due to this species may not be known. Clinical
laboratories should, however, attempt to identify the
937
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S. Jain and others

Table 2. Review of Y. regensbergei infection cases reported worldwide

AMC, amoxicillin–clavulanate; GER, gastroesophageal reflux; DM, diabetes mellitus; PTZ, piperacillin–tazobactam; TMP–SMX, trimethoprim–sulfamethoxazole; 3GC, third-generation
cephalosporin; AG, aminoglycoside.

Reference Age (years)/ Geographical Probable risk factor Clinical specimen Clinical diagnosis Antimicrobials Treatment Outcome
gender region sensitive in vitro

Abbott & Janda 74/Male California Alcohol abuse Left knee wound Septic knee Not reported Amikacin Unknown
(1994)
Abbott & Janda 35/Female California Alcohol abuse, liver disease, Blood Transient Not reported Ciprofloxacin Discharged, no
(1994) pancreatitis bacteraemia follow-up
Fajardo Olivares 82/Male Spain Chronic renal failure, venous Wound Perimalleolar Unknown Ciprofloxacin Cured
et al. (2005) thrombosis ulcer
Lo et al. (2011) 42/Male Taiwan Type 2 DM, renal disease, Blood Cellulitis, sepsis PTZ, cefotaxime, AMC changed Cured
steroids, immunosuppressants gentamicin, to ceftriaxone
amikacin,
ciprofloxacin,
ertapenem,
TMP–SMX
Fill & Stephens 77/Male USA Oesophageal and renal Blood, Abdominal Septic shock, PTZ (MIC ,16), PTZ, Transferred, no
(2010) carcinoma, GER, DM aspirate, sputum abdominal levofloxacin levofloxacin follow-up
abscess, (MIC ,2),
pneumonia others (unknown)
Present case 5/Male India None Blood Enteric fever Ampicilin, AMC, Ciprofloxacin Cured
erythromycin, PTZ,
Journal of Medical Microbiology 62

3GC, ciprofloxacin,
AG, carbapenem

organism, as further reports will aid in establishing the
clinical and epidemiological significance of this rarely
reported member of Enterobacteriaceae.
References
Abbott, S. L. & Janda, J. M. (1994). Isolation of Yokenella regensburgei
(‘‘Koserella trabulsii’’) from a patient with transient bacteremia and
from a patient with a septic knee. J Clin Microbiol 32, 2854–2855.
CLSI (2012). Performance Standards for Antimicrobial Susceptibility
Testing; 22nd Informational Supplement M100–S22. Wayne, PA:
Clinical and Laboratory Standards Institute.
Fajardo Olivares, M., Blanco Palenciano, J., Márquez Laffón, I. &
Ruiz León, J. M. (2005). [Infección por Yokenella regensburgei en una
úlcera venosa perimaleolar]. Med Clin (Barc) 125, 358–359 (in
Spanish).
Fill, M. A. & Stephens, J. L. (2010). Abdominal abscess and septic
shock secondary to Yokenella regensburgei. Int J Infect Dis 9.
Gaind, R., Paglietti, B., Murgia, M., Dawar, R., Uzzau, S.,
Cappuccinelli, P., Deb, M., Aggarwal, P. & Rubino, S. (2006).
Molecular characterization of ciprofloxacin-resistant Salmonella
enterica serovar Typhi and Paratyphi A causing enteric fever in
India. J Antimicrob Chemother 58, 1139–1144.
http://jmm.sgmjournals.org
Yokenella regensburgei bacteraemia in a paediatric patient
Hickman-Brenner, F. W., Huntley-Carter, G. P., Fanning, G. R.,
Brenner, D. J. & Farmer, J. J., III (1985). Koserella trabulsii, a new
genus and species of Enterobacteriaceae formerly known as Enteric
Group 45. J Clin Microbiol 21, 39–42.
Kosako, Y., Sakazaki, R. & Yoshizaki, E. (1984). Yokenella
regensburgei gen. nov., sp. nov.: a new genus and species in the
family Enterobacteriaceae. Jpn J Med Sci Biol 37, 117–124.
Lo, Y. C., Chuang, Y. W. & Lin, Y. H. (2011). Yokenella regensburgei in
an immunocompromised host: a case report and review of the
literature. Infection 39, 485–488.
Raveendran, R., Wattal, C., Sharma, A., Oberoi, J. K., Prasad, K. J. &
Datta, S. (2008). High level ciprofloxacin resistance in Salmonella
enterica isolated from blood. Indian J Med Microbiol 26, 50–53.
Richard, C. (1989). [Nouvelles Enterobacteriaceae rencontrées en
bactériologie médicale: Moellerella wisconsensis, Koserella trabulsii,
Leclercia adecarboxylata, Escherichia fergusonii, Enterobacter asburiae,
Rahnella aquatilis]. Ann Biol Clin (Paris) 47, 231–236 (in French).
Stock, I., Sherwood, K. J. & Wiedemann, B. (2004). Antimicrobial
susceptibility patterns, beta-lactamases, and biochemical identifica-
tion of Yokenella regensburgei strains. Diagn Microbiol Infect Dis 48, 5–
15.
Yagüe Muñoz, A., Castro Castro, H. & Paredes Arranz, C. (1989).
[Aislamiento de Koserella trabulsii en muestras clı́nicas]. Enferm Infecc
Microbiol Clin 7, 393–394 (in Spanish).
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