© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Transplant Infectious Disease, ISSN 1398-2273

Case report

Acute prostatitis caused by Raoultella planticola in a renal transplant recipient: a novel case M. Koukoulaki, A. Bakalis, V. Kalatzis, E. Belesiotou, V. Papastamopoulos, A. Skoutelis, S. Drakopoulos. Acute prostatitis caused by Raoultella planticola in a renal transplant recipient: a novel case. Transpl Infect Dis 2014: 16: 461–464. All rights reserved Abstract: We present a unique case of acute bacterial prostatitis caused by a very rare human pathogen, Raoultella planticola, in a renal allograft recipient 3.5 months post transplantation. Only a few cases of human infection by this pathogen have been reported worldwide. The present study reports the case of a 67-year-old man who was admitted to our transplant unit 3.5 months post transplantation with fever, dysuria, suprapubic pain, symptoms and signs of acute prostatitis, and elevated markers of inflammation and prostate-specific antigen. R. planticola was isolated in the urine culture. The patient was treated with ciprofloxacin (based on the antibiogram) and had a full recovery, with satisfactory renal function. To the best of our knowledge, this is not only the first reported case of R. planticola prostatitis, but also the first report of such an infection in a solid organ transplant recipient or in a patient on immunosuppressive medication.

M. Koukoulaki1, A. Bakalis1, V. Kalatzis1, E. Belesiotou2, V. Papastamopoulos3, A. Skoutelis3, S. Drakopoulos1 1

First Department of Surgery and Transplant Unit, Evangelismos General Hospital, Athens, Greece, 2 Department of Microbiology, Evangelismos General Hospital, Athens, Greece, 3Fifth Department of Internal Medicine – Infectious Diseases, Evangelismos General Hospital, Athens, Greece Key words: acute prostatitis; renal transplantation; immunosuppression; gram-negative bacteria; Raoultella planticola Correspondence to: Maria Koukoulaki, First Department of Surgery and Transplant Unit, Evangelismos General Hospital, 45-47 Ispilantou Street, Athens 10676, Greece Tel: 00302107233422 Fax: 00302107233421 E-mail: [email protected]

Received 9 December 2013, accepted for publication 14 December 2013 DOI: 10.1111/tid.12213 Transpl Infect Dis 2014: 16: 461–464

Infections are one of the major causes of morbidity and mortality after solid organ transplantation and the second greatest cause of mortality in patients with functioning grafts. Common opportunistic organisms are usually responsible, but occasionally rare environmental pathogens. Raoultella planticola is a gramnegative aerobic, oxidase-negative, catalase-positive, non-motile, and capsulated rod of the Enterobacteriaceae family. R. planticola is facultatively anaerobic, having both a respiratory and a fermentative type of metabolism, and is recovered from water, soil, plants, and occasionally from mammalian mucosae, including human specimens. R. planticola was renamed in 2001, replacing the former term Klebsiella planticola, based on 16S rRNA and rpoB gene sequencing (1, 2). Only 14 cases of human infection by R. planticola have been

reported previously, none of which were in a transplant patient (Table 1) (3–14). We present the first reported case, to our knowledge, of R. planticola infection in a solid organ transplant (SOT) recipient, as well as the first reported case of prostatitis caused by this pathogen.

Case presentation A 67-year-old man, recipient of a renal allograft from a deceased organ donor, was admitted in our transplant unit 3.5 months after transplantation, with abdominal and suprapubic pain, chills, rigors, fever, dysuria, urge to urinate, and pain during urination. He denied consumption of any suspicious food or water of unknown

461

Koukoulaki et al: Raoultella planticola prostatitis

Reported cases of Raoultella planticola infection

Case’s Author (reference)

Country

Age in years, Gender

Freney et al. (3)

France

47 M

Bacteremia

Mitral valve replacement

Freney et al. (4)

France

69 N/A

Bacteremia

Mitral valve replacement

Ceftriaxone, tobramycin

Recovered

Freney et al. (4)

France

57 N/A

Bacteremia

Post coronary artery bypass graft

Ceftriaxone

Recovered

Alves et al. (5)

Brazil

45 M

Pancreatitis

None

Imipenem, amikacin

Recovered

Castanheira et al. (6)

USA

83 F

Bacteremia

N/A

None

Died

Castanheira et al. (6)

USA

64 M

Bacteremia

N/A

Doxycycline

Died

O’Connell et al. (7)

Ireland

30 M

Cellulitis

Injury from hammer

Benzylpenicillin, flucloxacillin clindamycin, ciprofloxacin

Recovered

Wolcott and Dowd (8)

USA

66 M

Surgical site infection

Open reduction internal fixation

Ertapenem

Recovered

Yokota et al. (9)

Japan

65 M

Cholangitis, bacteremia

ERCP

Meropenem, piperacillin/ tazobactam

Recovered

Kim et al. (10)

Korea

66 M

Necrotizing fasciitis

Abdominal trauma

Ceftriaxone, levofloxacin, tigecycline

Recovered

Teo et al. (11)

UK

62 F

Cholecystitis

None

Co-Amoxiclav + surgery

Recovered

Olson et al. (12)

USA

89 M

Cystitis

None

Ciprofloxacin

Recovered

Hu et al. (13)

Canada

59 M

Bacteremia

ERCP

Piperacillin/tazobactam

Recovered

Puerta-Fernandez et al. (14)

Spain

60 M

Bacteremia, gastroenteritis

None/Ate fish

Piperacillin/tazobactam, cefotaxime

Recovered

Koukoulaki et al. (Current report)

Greece

67 M

Prostatitis, cystitis

Renal transplant

Ciprofloxacin

Recovered

Clinical infective episode

Invasive procedure

Treatment

Outcome

Cefotaxime, tobramycin

Recovered

M, male; N/A, not available; F, female; ERCP, endoscopic retrograde cholangeo-pancreatography.

Table 1

origin, or any work with animals, outside occupation, travel or vacation for himself, or family members. In addition, no other family member suffered from similar symptoms. The patient had a history of immunoglobulin-A nephropathy, diagnosed 8 years before transplantation, which had led to end-stage renal disease requiring hemodialysis for 2 years. His past medical history included hypertension, dyslipidemia, and mild left atrial and ventricular dilatation. He was treated with a triple immunosuppressive regimen including tacrolimus, mycophenolate mofetil, and prednisolone. Physical examination revealed fever of 38.4°C, normal breath sounds, normal bowel sounds without tenderness, a smooth distended bladder, and no peripheral edema. Blood pressure was slightly elevated at 145/80 mmHg. Rectal exam revealed a tender prostate that was enlarged and boggy. Laboratory tests showed elevated white blood cells 19,300 mm3 with 87.5% neutrophils, C-reactive protein 13.4 mg/dL, and serum creatinine 2.19 mg/dL. The

462

urine dipstick and urinalysis showed white blood cells (40–50), and bacteriuria/pyuria. Prostate-specific antigen (PSA) was elevated at 19.7 ng/mL, while in prior testing it was 2.1 ng/mL. The ultrasound revealed a renal graft at the right iliac fossa with good size (11.75 cm), mild dilatation of the pelvicalyceal system, and thickening of urothelium. The diameter of upper ureter was approximately 6 mm, resistance index was measured at 105 colony-forming units/mL). The biochemical identification

Transplant Infectious Disease 2014: 16: 461–464

Koukoulaki et al: Raoultella planticola prostatitis

Antibiogram of the urine cultures: Raoultella planticola (>105 cfu/mL)

Antibiotic

MIC

Sensitivity (S) or Resistance (R)

Amikacin

≤2

S

Ampicillin

16

R

Amoxicillin/clavulanic acid

≤2

S

Ceftazidime

≤1

S

Ciprofloxacin

≤0.25

S

Cefoxitin

≤4

S

Cefotaxime

≤1

S

Nitrofurantoin

≤16

S

Gentamicin

≤1

S

Imipenem

≤0.25

S

Cephalothin

≤2

S

Nalidixic acid

≤2

S

Ofloxacin