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Ewingella americana: an emerging true pathogen.
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MedLine Citation:
PMID:  22762003     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Infections caused by Ewingella americana have been rarely reported in the literature. Most of the cases that have been reported were among the immunocompromised patients. We report a case of E. americana causing osteomyelitis and septic arthritis of the shoulder joint in a previous intravenous drug abuser. The causative pathogen was identified by synovial fluid analysis and culture.
Authors:
Syed Hassan; Syed Amer; Chetan Mittal; Rishi Sharma
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Publication Detail:
Type:  Journal Article     Date:  2012-06-14
Journal Detail:
Title:  Case reports in infectious diseases     Volume:  2012     ISSN:  2090-6633     ISO Abbreviation:  Case Rep Infect Dis     Publication Date:  2012  
Date Detail:
Created Date:  2012-07-04     Completed Date:  2012-08-23     Revised Date:  2013-04-01    
Medline Journal Info:
Nlm Unique ID:  101573243     Medline TA:  Case Rep Infect Dis     Country:  Egypt    
Other Details:
Languages:  eng     Pagination:  730720     Citation Subset:  -    
Affiliation:
Division of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA.
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Journal Information
Journal ID (nlm-ta): Case Rep Infect Dis
Journal ID (iso-abbrev): Case Rep Infect Dis
Journal ID (publisher-id): CRIM.ID
ISSN: 2090-6625
ISSN: 2090-6633
Publisher: Hindawi Publishing Corporation
Article Information
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Copyright © 2012 Syed Hassan et al.
open-access:
Received Day: 28 Month: 3 Year: 2012
Accepted Day: 9 Month: 5 Year: 2012
Print publication date: Year: 2012
Electronic publication date: Day: 14 Month: 6 Year: 2012
Volume: 2012E-location ID: 730720
ID: 3384899
PubMed Id: 22762003
DOI: 10.1155/2012/730720

Ewingella Americana: An Emerging True Pathogen
Syed HassanI1*
Syed AmerI1
Chetan MittalI1
Rishi SharmaI1
Division of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
Correspondence: *Syed Hassan: shassan2@hfhs.org
[other] Academic Editors: L. M. Bush and B. Moreira

1. Introduction

Ewingella americana is a rare gram negative, lactose fermenting, oxidase negative, catalase positive, indole negative, facultative anaerobic bacillus first described from clinical specimens in 1983 by Grimont et al. [1], as a new group in the Enterobacteriaceae family. It rarely causes human infections and has been identified from various clinical samples including sputum [2], conjunctiva [3, 4], blood [58], wound [9], and peritoneal dialysate [10]. Interestingly, it has also been isolated from the intestinal contents of snails and slugs [11], fresh nutria carcasses [12], vacuum packaged meat [13], and mushrooms [14] as well.

This case report is the first clinical description of E. americana causing osteomyelitis and septic arthritis of the shoulder joint.


2. Case Report

A 50-year-old male was admitted to the hospital, with gradual onset of pain and swelling in the right shoulder since 4 days. He denied fever, chills, or rigors. His past medical history was significant for hypertension and intravenous drug abuse. His last use of heroin was 2 months ago with an unsterilized needle contaminated by saliva, in the right arm. Physical examination revealed limited range of motion of right shoulder secondary to pain. Radiograph of the right shoulder was suggestive of osteomyelitis. A computed topographic scan of the shoulder revealed multifocal, intraarticular abscess formation involving the right upper extremity. It also showed erosion of the humeral head and the glenohumeral joint, consistent with septic arthritis (Figure 1). Arthrocentesis was done, and the cell count of the synovial fluid showed white blood cell count of 9.4 × 109/L (90% neutrophils, 1% bands). Cultures of the synovial fluid grew Ewingella americana. The antimicrobial susceptibility test carried out by disk diffusion method showed susceptibility to amikacin, ampicillin, cefazolin, gentamicin, piperacillin tazobactam, tobramycin, and trimethoprim sulfamethoxazole while was resistant to ciprofloxacin.

The patient was started on ceftriaxone 2 gm intravenous every 24 hours. He continued to improve and was discharged home to complete 6 weeks of intravenous antibiotic therapy. He was followed 4 weeks later in the outpatient clinic and showed resolution of infection which was confirmed both clinically and by imaging. The antibiotic course was completed with no complications.


3. Discussion

Clinical infections due to E. americana have been reported to cause peritonitis [10], conjunctivitis [3, 4], bacteremia [8], and pneumonia [2, 15]. Colonization in wound [9] and sputum [2] were also reported in patients without causing clinical infection. Sepsis [58] and even death from Waterhouse-Friderichsen syndrome due to E. Americana [16] has also been reported.

E. Americana is seen in patients who were immunosuppressed due to diabetes mellitus [5], bone marrow transplantation, chemotherapy [7], end stage renal disease [10], and use of mercaptopurine [15]. Although, a few cases of E. americana have been reported earlier causing conjunctivitis [3, 4] and Waterhouse-Friderichsen syndrome [16] in previously healthy individuals, this is the first case of osteomyelitis involving the joint due to intravenous drug abuse. Based on this observation, clinicians may want to consider Ewingella Americana as an emerging true pathogen.

Since little information exists on the ecological niche of this organism, in our case we speculate on the source of contamination as saliva from the patient's mouth. Kati et al. [10] proposed domestic water to be a source of infection in peritonitis of a patient undergoing peritoneal dialysis. A contaminated ice bath was identified as the probable source in an outbreak of E. americana bacteremia, in patients who had undergone cardiovascular or peripheral vascular surgery [8]. Maertens et al. [7] speculated on inadequate hand hygiene as the source of infection. E. americana is an organism without nutritional needs that can survive in water and citrate solution and preferably grows at 4°C.

The only risk factor in our patient was that he was an intravenous drug abuser while using unsterilized needles for his heroin injections; he might have inoculated the pathogen into his blood causing transient blood stream infection which ultimately seeded into his shoulder joint.

To our knowledge, this case is the first report of osteomyelitis and septic arthritis caused by E. americana infection. Earlier reports suggested E. americana causing infections in immunocompetent host; however, in our case the infections were certainly favored by intravenous injections with contaminated material.


Consent

Informed consent is obtained from the patient for publication of this paper.


References
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2. Ryoo NH,Ha JS,Jeon DS,Kim JR,Kim HC. A case of pneumonia caused by Ewingella Americana in a patient with chronic renal failureJournal of Korean Medical ScienceYear: 20052011431452-s2.0-1484431731515716620
3. Da Costa PS,Tostes MM,de Carvalho Valle LM. A case of keratoconjunctivitis due to Ewingella Americana and a review of unusual organisms causing external eye infectionsThe Brazilian Journal of Infectious DiseasesYear: 2000452622672-s2.0-003429333511063558
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8. Pien FD,Bruce AE. Nosocomial Ewingella americana bacteremia in an intensive care unitArchives of Internal MedicineYear: 198614611111122-s2.0-00225884463942442
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12. Lyon WJ,Milliet JB. Microbial flora associated with Louisiana processed frozen and fresh nutria (Myocastor coypus) carcassesJournal of Food ScienceYear: 2000656104110452-s2.0-0033758598
13. Helps CR,Harbour DA,Corry JEL. PCR-based 16S ribosomal DNA detection technique for Clostridium estertheticum causing spoilage in vacuum-packed chill-stored beefInternational Journal of Food MicrobiologyYear: 1999521-257652-s2.0-003285128210573392
14. Reyes JE,Venturini ME,Oria R,Blanco D. Prevalence of Ewingella americana in retail fresh cultivated mushrooms (Agaricus bisporus, Lentinula edodes and Pleurotus ostreatus) in Zaragoza (Spain)FEMS Microbiology EcologyYear: 20044732912962-s2.0-154230148219712317
15. Pound MW,Tart SB,Okoye O. Multidrug-resistant Ewingella Americana: a case report and review of the literatureAnnals of PharmacotherapyYear: 20074112206620702-s2.0-3684900904517956962
16. Tsokos M. Fatal Waterhouse-Friderichsen syndrome due to Ewingella Americana infectionAmerican Journal of Forensic Medicine and PathologyYear: 200324141442-s2.0-003737282912604997

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