|Year : 2015 | Volume
| Issue : 1 | Page : 72-74
A case report of nonhealing leg ulcer infected with Stenotrophomonas maltophilia in an immunocompetent patient in a Tertiary Care Hospital of Eastern India
Kalidas Rit1, Rajdeep Saha2, Parthasarathi Chakrabarty1, Bipasa Chakraborty1
1 Department of Microbiology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of Microbiology, National Medical College, Kolkata, West Bengal, India
|Date of Web Publication||14-Jan-2015|
Dr. Kalidas Rit
Department of Microbiology, Institute of Post-Graduate Medical Education and Research, 70 B T.C. Mukherjee Street, Rishra, Hooghly, West Bengal
Source of Support: None, Conflict of Interest: None
Stenotrophomonas maltophilia is an aerobic, motile Gram-negative, nonfermentative bacillus considered as an opportunistic pathogen causing infection typically in individuals with immunosuppression, organ transplantation and malignancies. Contaminated water or medical devices in the hospital environment are the primary causes of infection. Here, we report a case of nonhealing leg ulcer infected with S. maltophilia in an immunocompetent individual.
Keywords: Immunocompetent, nonfermentative, nonhealing ulcer, opportunistic
|How to cite this article:|
Rit K, Saha R, Chakrabarty P, Chakraborty B. A case report of nonhealing leg ulcer infected with Stenotrophomonas maltophilia in an immunocompetent patient in a Tertiary Care Hospital of Eastern India. CHRISMED J Health Res 2015;2:72-4
|How to cite this URL:|
Rit K, Saha R, Chakrabarty P, Chakraborty B. A case report of nonhealing leg ulcer infected with Stenotrophomonas maltophilia in an immunocompetent patient in a Tertiary Care Hospital of Eastern India. CHRISMED J Health Res [serial online] 2015 [cited 2020 Jun 5];2:72-4. Available from: http://www.cjhr.org/text.asp?2015/2/1/72/149353
| Introduction|| |
Stenotrophomonas maltophilia is an opportunistic pathogen that is acquired from the environment.  They belong to the non-fluorescent group of Pseudomonas group of bacteria and frequently colonize various fluids in hospital settings, such as nebulizers, water baths, dialysis machines, and intravenous fluids. Infections due to S. maltophilia are commonly seen in immunocompromised patients especially in cases of prolonged hospital stay, indwelling devices, exposure to broad-spectrum antimicrobials, neutropenia for long duration, mucositis, and total parenteral nutrition.  Infections caused by S. maltophilia are linked with high mortality rate. 
| Case Report|| |
A 62-year-old male patient presented to the Dermatology Outpatient Department with a nonhealing ulcer on the upper part of right lower leg [Figure 1]. The ulcer was present for 6 months with a history of waxing and waning with much-increased discharge for last 1 month. There was no history of hospitalization in a recent past. The routine laboratory investigations revealed slight elevation of liver enzymes. All other parameters were within normal range. Tests for tuberculosis, malaria, HIV I, and HIV II were normal. Plain X-ray of ulcer area revealed no bony involvement. The patient performed a computed tomography angiography of the peripheral blood vessels that exhibited moderate degree of atherosclerotic changes in the abdominal aorta, celiac trunk, renal arteries bilaterally, and common iliac arteries. Subsequently, the patient got admitted in our tertiary care setup. Histopathological examination of biopsy material obtained from ulcer revealed invasion of viable tissue by Gram-negative rods and polymorphonuclear leucocyte response. After the admission, a consultation was made on 2 nd hospitalization day for wound debridement and obtaining of wound specimen for bacterial culture and antibiogram. The wound was thoroughly cleaned and irrigated by using 0.85% sterile sodium chloride (Nacl) solution. After repeat irrigation, the specimen was collected with a sterile culture swab and immediately sent to Microbiology Department for further processing. The specimen was seeded on selective MacConkey agar, blood agar, and brain heart infusion broth (Hi Media, Mumbai) followed by incubation at 37°C for 24 h. Gram-stained smear from smooth, glistening and pale yellowish colonies from MacConkey agar [Figure 2] showed Gram-negative bacilli. Biochemical tests were performed to identify the bacteria at the species level, and the growth was identified as S. maltophilia. After thorough debridement, the wound area was cleaned with 0.8% sterile Nacl solution. Then the wound area was irrigated with 1% hydrogen peroxide solution. After repeat washing, the wound area was irrigated with 10% povidone-iodine solution followed by application of nonadherent dressing. The organism isolated from the ulcer was sensitive to cotrimoxazole and levofloxacin [Figure 3]. Therefore, high dose of cotrimoxazole was started, and the ulcer showed sign of healing [Figure 4]. Ultimately, the patient recovered completely and discharged from the hospital.
| Discussion|| |
Stenotrophomonas maltophilia is an opportunistic pathogen that can survive in almost all humid environments, including water, soil, and plants. S. maltophilia causes a wide spectrum of infections, namely bacteremia, endocarditis and respiratory tract infections particularly in patients with prolonged hospitalization, especially in Intensive Care Unit (ICU), with prosthesis like bladder catheter, the use of broad-spectrum antibiotics, and immunodeficiency.  The management of patients suffering from chronic ulcers represents a significant problem for its high frequency of complexity. There are several reported cases of S. maltophilia infection in the literature in immunocompromised patients. ,, But in our case, no such predisposing factors were found, and the patient was immunocompetent.
Skin and soft tissue infections caused by S. maltophilia are becoming an increasingly recognized entity. Cutaneous manifestation includes primary cellulitis, gangrenous cellulitis, soft tissue necrosis, ecthyma gangrenosum, and infected mucocutaneous ulcer.  The other infections caused by S. maltophilia include bacteremia, endocarditis, and respiratory tract infections, especially in patients with cystic fibrosis, urinary tract infections usually secondary to urinary tract surgery or instrumentation, meningitis, ophthalmologic infections, skin and soft tissue infection and uncommonly, bone and joint infections.  A multicenter hospital-based study conducted in USA reported S. maltophilia as being among the 11 most frequently recovered organisms. 
The routes of spread include hematogenous seeding and direct inoculation through mucocutaneous surfaces. In our case the infection was probably acquired from the community as the patient had no history of exposure to the hospital environment. Our case is a unique one because it is the second type of such case reported from our institution and also probably from India. The first being was reported by Nag et al. from our institution. 
The incidence of S. maltophilia hospital acquired infections is on the rise, particularly in the immunocompromised patients and cases of community-acquired S. maltophilia infections have also been reported.  The transmission of S. maltophilia to susceptible individuals may occur through direct contact with the source. The hands of healthcare personnel have been reported to transmit nosocomial S. maltophilia infection in the ICU.  Trends of increasing resistance to antimicrobials such as cotrimoxazole and ticarcillin-clavulanic acid have been reported.  But in our case, the isolate was susceptible to cotrimoxazole and patient recovered completely with cotrimoxazole therapy.
Stenotrophomonas maltophilia is an emerging multidrug-resistant pathogen. The increasing incidence of nosocomial and community-acquired S. maltophilia infections are of particular concern for immunocompromised individuals, as this bacterial pathogen is associated with significant morbidity and mortality. The possibility of undiagnosed and refractory mucocutaneous infection needs urgent attention.
| References|| |
Denton M, Kerr KG. Microbiological and clinical aspects of infection associated with Stenotrophomonas maltophilia
. Clin Microbiol Rev 1998;11:57-80.
VanCouwenberghe CJ, Farver TB, Cohen SH. Risk factors associated with isolation of Stenotrophomonas
in clinical specimens. Infect Control Hosp Epidemiol 1997;18:316-21.
Morrison AJ Jr, Hoffmann KK, Wenzel RP. Associated mortality and clinical characteristics of nosocomial Pseudomonas maltophilia
in a university hospital. J Clin Microbiol 1986;24:52-5.
Moser C, Jønsson V, Thomsen K, Albrectsen J, Hansen MM, Prag J. Subcutaneous lesions and bacteraemia due to Stenotrophomonas maltophilia
in three leukaemic patients with neutropenia. Br J Dermatol 1997;136:949-52.
Vartivarian SE, Papadakis KA, Palacios JA, Manning JT Jr, Anaissie EJ. Mucocutaneous and soft tissue infections caused by Xanthomonas maltophilia
. A new spectrum. Ann Intern Med 1994;121:969-73.
Sakhnini E, Weissmann A, Oren I. Fulminant Stenotrophomonas maltophilia
soft tissue infection in immunocompromised patients: An outbreak transmitted via tap water. Am J Med Sci 2002;323:269-72.
Lockhart SR, Abramson MA, Beekmann SE, Gallagher G, Riedel S, Diekema DJ, et al
. Antimicrobial resistance among Gram-negative bacilli causing infections in intensive care unit patients in the United States between 1993 and 2004. J Clin Microbiol 2007;45:3352-9.
Nag F, De A, Banerjee K, Chatterjee G. Non healing leg ulcer infected with Stenotrophomonas maltophilia
: First reported case from India. Int Wound J 2013;10:356-8.
Nseir S, Di Pompeo C, Brisson H, Dewavrin F, Tissier S, Diarra M, et al
. Intensive care unit-acquired Stenotrophomonas maltophilia
: Incidence, risk factors, and outcome. Crit Care 2006;10:R143.
Wu H, Wang JT, Shiau YR, Wang HY, Lauderdale TL, Chang SC, et al
. A multicenter surveillance of antimicrobial resistance on Stenotrophomonas maltophilia
in Taiwan. J Microbiol Immunol Infect 2012;45:120-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]