Elizabethkingia Meningoseptica sepsis Associated with COVID-19 Infection: An Emerging Nosocomial Pathogen

Abstract

Elizabethkingia meningoseptica is a multi-drug resistant, aerobic, gram-negative bacteria known for causing nosocomial infections and high mortality in critically ill patients. A 68-year-old male with a past medical history significant for hypertension and stroke presented to the emergency department with worsening cough and shortness of breath ten days after being diagnosed with Coronavirus Disease-2019 (COVID-19) infection. He also endorsed fatigue, fever, loss of smell, and diarrhea. He denied any chest pain, nausea and vomiting. On examination, he was febrile with a temperature of 102.2-degree Fahrenheit, heart rate of 145 beats/minute, blood pressure of 120/90 mm of Hg, respiratory rate of 24 breaths/minute, and oxygen saturation of 85% while breathing ambient air. Laboratory data revealed a leukocytosis of 12,000/μL, elevated serum creatinine of 1.38 mg/dL, D-dimer of 4.36 mg/L, C-reactive protein of 18 mg/dL and markedly elevated ferritin of 2500 ng/mL. Chest radiograph showed patchy bilateral alveolar infiltrates. His clinical presentation was consistent with severe COVID-19 infection causing acute respiratory distress syndrome. The patient was initiated on bi-level positive pressure ventilation, but his respiratory status continued to worsen, requiring intubation and mechanical ventilation. He was managed with low tidal volume ventilation and ARDS-network protocol. Treatment with remdesivir, dexamethasone, and convalescent plasma was initiated. On day 10 of admission patient developed fever, increasing oxygen requirement, and hypotension concerning for sepsis. Empiric treatment with vancomycin and piperacillin-tazobactam was started after obtaining blood cultures, which grew Elizabethkingia meningoseptica resistant to all beta-lactam antibiotics (penicillins and cephalosporins). Intravenous trimethoprimsulfamethoxazole was started but later switched to clindamycin due to electrolyte abnormalities. Therapy was continued for two weeks, and repeat blood cultures were sterile. His hospital course was complicated by prolonged ventilator weaning, acute kidney injury, and hospital-acquired pneumonia. He was successfully extubated to a high-flow nasal cannula after twenty days and is currently being managed for delirium. Elizabethkingia meningoseptica causes neonatal meningitis and nosocomial sepsis in older adults with underlying chronic comorbidities or immunocompromised status like an organ transplant receiving immunosuppressive therapy, uncontrolled diabetes mellitus, and end-stage renal disease. Mortality is high and ranges from 30%- 50%. It is usually resistant to beta-lactam antibiotics, carbapenems, and aminoglycosides. Some isolates have shown varying susceptibility to fluoroquinolones, trimethoprim-sulfamethoxazole, minocycline, and tigecycline. With the increasing use of steroids and prolonged critical illness in patients with COVID-19 infection, this emerging pathogen is a paramount health concern during the pandemic.