bacillus cereus necrotizing pneumonia in a patient with
TRANSCRIPT
101
□ CASE REPORT □
Bacillus cereus Necrotizing Pneumonia in a Patientwith Nephrotic Syndrome
Jun Miyata 1, Sadatomo Tasaka 1, Masaki Miyazaki 1, Syuichi Yoshida 1, Katsuhiko Naoki 1,
Koichi Sayama 1, Koichiro Asano 1, Hiroshi Fujiwara 2, Kiyofumi Ohkusu 3,
Naoki Hasegawa 2 and Tomoko Betsuyaku 1
Abstract
Bacillus cereus (B. cereus) is a Gram-positive rod that is widely distributed in the environment and can be
a cause of food poisoning. We herein present a case of B. cereus necrotizing pneumonia in a patient with
nephrotic syndrome under corticosteroid treatment after developing transient gastroenteritis symptoms. B.cereus was isolated from bronchial lavage fluid and transbronchial biopsy specimens. A multiplex polymerase
chain reaction analysis of the toxin genes revealed a strain possessing enterotoxicity. The patient recovered
after one week of intravenous meropenem followed by a combination of oral moxifloxacin and clindamycin.
B. cereus is a pathogen that causes necrotizing pneumonia in immunocompromised hosts.
Key words: Bacillus cereus, necrotizing pneumonia, nephrotic syndrome, corticosteroid, hypogammaglobu-
linemia
(Intern Med 52: 101-104, 2013)(DOI: 10.2169/internalmedicine.52.7282)
Introduction
Bacillus cereus (B. cereus) is a Gram-positive, aerobic-to-
facultative, spore-forming rod that is widely distributed in
the environment (1). Although it is well known as a cause
of food poisoning (2), the clinical relevance of B. cereus is
often disregarded. When isolated from clinical specimens, it
is usually considered a culture contaminant. However, severe
hematogenous infections caused by B. cereus have been re-
ported, especially in drug addicts, premature neonates and
patients with severe underlying diseases or compromised im-
munity (3). B. cereus rarely causes lower respiratory tract
infections, although most reported cases of B. cereus pneu-
monia involve fatal outcomes despite intensive antibiotic
therapy.
We herein describe a case of B. cereus necrotizing pneu-
monia in an immunocompromised patient with nephrotic
syndrome under treatment with high-dose corticosteroids.
The definitive diagnosis of B. cereus pneumonia was made
based on cultures of bronchial lavage fluid and transbron-
chial lung biopsy specimens.
Case Report
A 43-year-old man presented with a 3-month history of
progressive edema in both lower extremities and the face.
On examination, his urinary protein level was 6.0 g/day and
his serum albumin level was 1.1 g/dL. His renal function
was mildly impaired (estimated glomerular filtration rate:
61.1 mL/min/1.73 m2) and hypogammaglobulinemia (immu-
noglobulin G (IgG): 224 mg/dL, immunoglobulin A (IgA):
322 mg/dL and immunoglobulin M (IgM): 58 mg/dL) was
present. After obtaining the results of a renal biopsy, the pa-
tient was diagnosed with minimal change nephrotic syn-
drome. Following three days of pulsed steroid therapy with
500 mg/day of methylprednisolone, oral prednisolone (PSL)
was administered at a dose of 50 mg/day. Diarrhea and
1Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Japan, 2Center for Infectious Diseases and In-
fection Control, Keio University School of Medicine, Japan and 3Department of Microbiology, Regeneration and Advanced Medical Science,
Gifu University Graduate School of Medicine, Japan
Received for publication January 10, 2012; Accepted for publication June 11, 2012
Correspondence to Dr. Sadatomo Tasaka, [email protected]
Intern Med 52: 101-104, 2013 DOI: 10.2169/internalmedicine.52.7282
102
Figure 1. Chest radiograph performed on day 22 showing infiltrates in the left lower lung field.
Figure 2. (A) Chest radiograph performed on day 46 showing infiltrates with cavitations in the left lower lung field. (B) Chest computed tomography performed on day 46 showing a cavity with a thick, irregular wall surrounded by consolidation in the left lower lobe, indicating the development of necrotizing pneumonia.
vomiting were noted on day 2 of oral steroid therapy; how-
ever, there were no symptoms suggestive of sepsis. As the
patient’s proteinuria and hypoalbuminemia gradually im-
proved, the dose of PSL was reduced to 40 mg/day on day
43 from the start of PSL treatment.
On day 22, chest roentgenogram (Fig. 1) showed infil-
trates in the left lower lung field. Due to the absence of fe-
ver, cough or sputum and normal physical examination find-
ings, no antibiotics were administered. On day 46, chest
roentgenogram (Fig. 2A) and chest computed tomography
(CT) (Fig. 2B) revealed a cavitary lesion surrounded by in-
filtrates in the left lower lung lobe. On day 47, broncho-
scopic examinations were performed, followed by antibiotic
therapy with intravenous meropenem (2.0 g/day). No patho-
genic organisms were identified by sputum cultures. Seven
days later, B. cereus was isolated from the bronchial lavage
fluid and transbronchial lung biopsy specimens. After under-
going eight days of intravenous meropenem treatment, the
patient received 400 mg/day of moxifloxacin and 900 mg/
day of clindamycin orally for 15 days. Chest roentgenogram
and chest CT performed three months after discharge
showed a reduction in the size of the cavity.
To identify B. cereus toxin genes, we performed multiplex
polymerase chain reaction (PCR). The strain isolated from
our patient exhibited the presence of nhe and cesB and the
absence of nblA, hblC, hblD, cap, cya, lef, pag and Ba813,
which indicates that the strain possessed strong cytotoxity
among the various strains of B. cereus (4) and was different
from outbreak strains (5).
Discussion
B. cereus plays a well-known pathogenic role in food poi-
soning. It leads to toxin-mediated (6, 7), self-limited illness
characterized by emetic or diarrheal syndromes. Systemic or
localized infections encompass bacteremia (8), endocardi-
tis (9), meningitis (10) and pneumonia (11-23). In this re-
port, we described a case of B. cereus necrotizing pneumo-
nia in a patient with nephrotic syndrome under treatment
with high-dose corticosteroids. Previously reported cases of
B. cereus pneumonia in adults are summarized in Table.
Most of these cases occurred in patients with hematological
disorders (e.g., leukemia and aplastic anemia) or alcohol
abuse; however, four lethal cases of B. cereus pneumonia in
immunocompetent welders and metalworkers have been re-
cently reported (12, 15). Our patient was not neutropenic,
although he could have been immunocompromised owing to
hypogammaglobulinemia and the use of corticosteroids.
B. cereus is generally considered to be a saprophytic con-
taminant when isolated from clinical samples. Therefore, de-
tection of the microorganism in multiple samples is neces-
sary to make a definitive diagnosis of B. cereus pneumonia.
In the present case, the pathogenic role of B. cereus in
pneumonia was indicated because the bacteria were isolated
from two different specimens that were sampled aseptically.
However, the two specimens were obtained with the same
Intern Med 52: 101-104, 2013 DOI: 10.2169/internalmedicine.52.7282
103
Tab
le.
Clin
ical
Cha
ract
eris
tics
, Treat
men
t an
d O
utco
me
of 1
6 Pat
ients
of B
. cer
eus P
neum
onia
in Adu
lts
Patie
ntA
ge/S
exR
isk
fact
orSe
ptic
emia
Neu
trope
nia
Rad
iogr
aphi
c ch
arac
teris
tics
Trea
tmen
tO
utco
me
Ref
eren
ce1
NA
none
NA
NA
NA
NA
died
232
52/M
acut
e le
ukem
iaye
sye
sin
filtra
te, e
ffus
ion
Abx
(pen
icill
in, m
ethi
cilli
n, g
enta
mic
in)
died
223
63/M
acut
e le
ukem
iaye
sye
sin
filtra
teA
bx (o
xaci
llin,
car
beni
cilli
n, g
enta
mic
in)
died
214
29/M
leuk
emia
noye
sin
filtra
te, c
avita
tion,
eff
usio
nA
bx (p
enic
illin
, cef
alot
in, c
arbe
nici
llin)
, pne
umoc
ente
sis
reco
vere
d20
560
/Mal
coho
l abu
seno
noin
filtra
te, c
avita
tion,
eff
usio
nA
bx (p
enic
illin
, chl
oram
phen
icol
), lu
ng re
sect
ion
reco
vere
d19
618
/Mal
coho
l abu
seno
noin
filtra
te, p
neum
otho
rax,
eff
usio
nA
bx (t
obra
myc
in, c
efam
ando
le, c
efal
otin
, clin
dam
ycin
,er
ythr
omyc
in, a
mpi
cilli
n), t
hora
cost
omy,
rese
ctio
nre
cove
red
18
754
/Mle
ukem
iaye
sye
sin
filtra
te, c
avita
tion
Abx
(mox
alac
tam
, naf
cilli
n, to
bram
ycin
)re
cove
red
178
21/M
bron
chie
ctas
isN
AN
Ain
filtra
teA
bx (a
zloc
illin
, gen
tam
icin
, cip
roflo
xaci
n)re
cove
red
169
46/M
none
(wel
der)
yes
noin
filtra
teA
bx (c
ipro
floxa
cin,
cef
otax
ime)
died
1510
41/M
none
(wel
der)
yes
noin
filtra
te, e
ffus
ion
Abx
(am
pici
llin-
sulb
acta
m, e
ryth
rom
ycin
, clin
dam
ycin
, van
com
ycin
)di
ed15
1152
/Fap
last
ic a
nem
iaye
sye
sin
filtra
teA
bx (p
iper
acill
in-s
ulba
ctam
, van
com
ycin
, im
ipen
em)
died
1412
37/F
leuk
emia
yes
yes
infil
trate
, eff
usio
nA
bx (c
efep
ime,
am
ikac
in, v
anco
myc
in)
died
1313
39/M
none
(met
al w
orke
r)ye
sno
infil
trate
Abx
(azi
thro
myc
in, v
anco
myc
in, c
efep
ime)
died
1214
56/M
none
(met
al w
orke
r)ye
sno
infil
trate
Abx
(cef
triax
one,
levo
floxa
cin)
died
1215
60/M
acut
e le
ukem
iaye
sye
sin
filtra
te, n
odul
eA
bx (c
efep
ime,
pan
ipen
em/b
etam
ipro
n, a
mik
acin
)di
ed11
1643
/Mne
phro
tic sy
ndro
me
nono
infil
trate
, cav
itatio
nA
bx (m
erop
enem
, mox
iflox
acin
, clin
dam
ycin
)re
cove
red
Pres
ent c
ase
NA
: not
ava
ilabl
e, A
bx: a
ntib
iotic
s
bronchoscope and the possibility for contamination cannot
be ruled out.
As in most of the reported cases of B. cereus pulmonary
infection, we were unable to identify the route of the infec-
tion (18). We observed no respiratory symptoms such as
cough, hemoptysis or chest pain, whereas gastrointestinal
symptoms (diarrhea and emesis) were present. Therefore, in
the present case, it was indicated that the B. cereus pulmo-
nary infection might have resulted from transient bacteremia
from a gastrointestinal infection.
B. cereus produces β-lactamase and is therefore resistant
to penicillin and cephalosporins (1). B. cereus is usually sus-
ceptible to clindamycin, vancomycin, fluoroquinolones,
carbapenems and aminoglycosides. After isolating B. cereus,
we changed the antibiotics to a combination of clindamycin
and moxifloxacin, which was effective.
A multiplex PCR analysis revealed that the strain of B.cereus isolated from our patient was different from outbreak
strains possessing Ba813 (5). The present strain, which was
positive for nhe and ces and negative for hbl, possesses
strong cytotoxic capacity and accounts for 28.6% of B.cereus strains (4). These results are compatible with the de-
velopment of necrotizing pneumonia in our patient and did
not present a life-threatening condition.
In summary, this is a rare case of B. cereus necrotizing
pneumonia in a patient with nephrotic syndrome. The pre-
sent case indicates the importance of performing a broncho-
scopic assessment of lung infiltrates, especially in immuno-
compromised hosts, even if the inflammatory reaction is not
significant.
The authors state that they have no Conflict of Interest (COI).
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