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CASE REPORT Table of Contents  
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Delftia acidovorans: An unusual pathogen from an adenocarcinoma lung patient with pleural effusion


1 Department of Microbiology, Homi Bhabha National Institute, ACTREC-Tata Memorial Centre, Navi Mumbai, India
2 Department of Microbiology, Homi Bhabha National Institute, TMH, Mumbai, Maharashtra, India
3 Department of Medical Oncology, Homi Bhabha National Institute, ACTREC-Tata Memorial Centre, Navi Mumbai, India
4 Department of Diagnostic and Interventional Radiology, Homi Bhabha National Institute, ACTREC-Tata Memorial Centre, Navi Mumbai, India

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Date of Submission01-Apr-2022
Date of Acceptance13-Jun-2022
Date of Web Publication01-Nov-2022
 

   Abstract 


Delftia acidovorans (D. acidovorans) is an aerobic, nonfermentative Gram-negative bacillus infrequently isolated from clinical specimens. The pathogenicity and clinical significance of the organism has not been ascertained due to uncommon clinical isolation and suspected low virulence. The organism has been reported to be inherently resistant to aminoglycoside group of drugs which remain as a widely used first-line drug of choice for febrile neutropenic patients. Hereby, we report a case of D. acidovorans-associated pleural effusion in a patient of metastatic adenocarcinoma diagnosed and treated timely and successfully with appropriate antibiotics.

Keywords: Adenocarcinoma lung, Delftia acidovorans, gentamicin, pathogen, pleural effusion


How to cite this URL:
Lall S, Bhat V, Biswas S, Joshi A, Janu A. Delftia acidovorans: An unusual pathogen from an adenocarcinoma lung patient with pleural effusion. J Global Infect Dis [Epub ahead of print] [cited 2022 Nov 28]. Available from: https://www.jgid.org/preprintarticle.asp?id=360045





   Introduction Top


Delftia acidovorans (D. acidovorans) is an aerobic, nonfermentative Gram-negative bacillus infrequently isolated from clinical specimens. It is usually considered an environmental contaminant and its role as a potential pathogen is yet to be established in spite of sporadic reports of its increasing association with various infections in both immunocompetent and immunocompromised individuals.[1] Laboratory identification of this organism up to the species level becomes very important because of its inherent resistance to gentamicin, a commonly used drug for empirical treatment of Gram-negative infections.[2] Hereby, we report a case of D. acidovorans-associated pleural effusion in a patient of metastatic adenocarcinoma diagnosed and treated successfully and timely with appropriate antibiotics.


   Case Report Top


A 35-year-old male smoker, alcoholic and having no family history of malignancy, presented with a history of cough for 2 months and gradually increasing shortness of breath for 1 month. There was no significant past history. On evaluation at a local health-care facility, chest X-ray revealed a massive right-sided pleural effusion. Contrast-enhanced computed tomography (CT) of the thorax was indicative of gross right pleural effusion with passive collapse of entire right bronchus and occlusion of lumen of proximal aspect suggestive of neoplastic etiology. The patient had undergone right intercostal drain insertion (ICD). Pleural fluid cytology was suggestive of malignant cells. Cellblock immunohistochemistry was positive for CK-T, thyroid transcription factor 1, napsin A, and carcino embryonic antigen and negative for CK20. On examination, at our outpatient department, the patient was afebrile with right infrascapular crepitations and right ICD in situ. A 3 cm × 3 cm mobile lymph node swelling was noted in the right axilla, and multiple subcentimetric lymph nodes were noted in the left supraclavicular fossa. The patient was admitted for supportive care. On admission, tablet erlotinib (tyrosine kinase inhibitor) was started on a compassionate basis along with cefoperazone–sulbactam sodium 3 g intravenously 12 hourly. The patient was tachypneic, and on respiratory system examination, there was reduced air entry in the right lower lobe. Laboratory evaluation was significant for WBC count of 12.38 × 10^ 9/L. Chest radiograph done on day 1 of admission showed middle and lower lobe consolidations along with right pleural effusion with ICD in situ [Figure 1]. On day 3 of admission, pleural fluid and ICD fluid both were sent for microbiological analysis. Gram stain for both samples revealed moderate pus cells, Gram-positive cocci, and Gram-negative bacilli. Enterococcus faecium (E.faecium) and Delftia acidovorans (D.acidovorans) were isolated on microbiological culture after 24 hours. E.faecium was susceptible to vancomycin,teicoplanin and linezolid by Kirby bauer disc diffusion method. D.acidovorans was susceptible to ciprofloxacin,levofloxacin,ceftazidime,cefoperazone sulbactam,piperacillin tazobactam and resistant to gentamicin by Vitek 2 compact system. On day 5, CT of the thorax, abdomen, and pelvis showed a malignant right middle lobe mass with metastatic involvement of bilateral lungs and right renal, mediastinal, and abdominal nodes. Moderate multiloculated right hydropneumothorax and mild thick septated organized fluid were noted in the right pleura with basal consolidation [Figure 2]. On day 6, linezolid 600 mg per oral B. D. was added. Axillary lymph node biopsy and pleural fluid cell blocks were consistent with metastatic adenocarcinoma. On day 9 of admission, injection carboplatin (chemotherapy) 450 mg was added. The patient showed improvement (breathlessness decreased, no fever, no other complaints, and vitals stable), tolerated treatment well, and got discharged after 12 days of admission under stable general condition on treatment with tablet ciprofloxacin 500 mg B. D, tablet linezolid 600 mg B. D, and tablet erlotinib 150 mg O. D and was planned for ICD removal which was done in follow-up OPD after 2 days of discharge.
Figure 1: Posteroanterior view of chest radiograph of October 7, 2020, showing ill-defined patchy densities in the right mid and lower zone with blunting of the right costophrenic angle and an opacity depicting ICD in situ. ICD: Intercostal drain insertion

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Figure 2: Mediastinal (a and b) and lung window (c) images. (a) Heterogeneously enhancing large lung mass (adenocarcinoma) is seen involving the right hilar region encasing the bronchus intermedius and pulmonary veins on the right side with multiple enlarged hilar and subcarinal lymph nodes. (b) Thick homogeneously enhancing pleural thickening seen involving the right hemithoracic cavity with ICD seen in situ suggests secondary infection or empyema formation. (c) Trapped air foci are seen within the right pleural cavity. ICD: Intercostal drain insertion

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   Discussion Top


Delftia (word Delftia refers to the city of Delft, where the type species were isolated and for the contribution of delft research groups in the role of bacteriology) acidovorans previously known as Comamonas acidovorans is a Gram-negative bacillus having straight to slightly curved rods which occur singly or in pairs.[1] It is a member of Pseudomonas ribosomal RNA homology 3 groups. It can be ubiquitously found in the environment (soil and water) and can be isolated from raw milk and animal infections.[3] The organism is able to survive in the biofilm formed in plumbing.[4]

The pathogenicity and clinical significance of the organism has not been ascertained due to uncommon clinical isolation and suspected low virulence. An extensive literature search has revealed that Delftia-associated infections have been sporadically reported both in immunocompetent and immunocompromised individuals (AIDS, hematological malignancy, solid organ malignancy, and intravenous drug abusers). Nosocomial pneumonia, catheter-related bloodstream infections, and infective endocarditis have been reported from immunocompromised individuals whereas empyema, bacteremia, peritonitis, keratitis, urinary tract infection (UTI), and ocular infections have been reported from immunocompetent individuals.[5],[6],[7],[8],[9],[10],[11],[12] Although the outcomes have been varied ranging from complete remission to death of the cases, establishing its pathogenicity still remains an area of concern considering its ubiquitous nature and infrequent isolation.

Microbiologically, the isolation of the organism was done on blood agar and MacConkey agar at 37°C. After a 24-h incubation period, nonfermenting motile Gram-negative, oxidase, and catalase-positive bacilli were grown. The colonies were identified by Vitek 2 compact system from bioMerieux system (99% probability) and also confirmed with standard biochemical tests. Minimum inhibitory concentration (MIC) determination for antibiotic susceptibility testing was also performed on Vitek 2 system. Identification of the colonies with orange indole reaction test was also performed. The colonies were plated on nutrient agar. With the addition of Kovac's reagent, the organism produces anthranilic acid using tryptophan leading to pumpkin orange color which is characteristic for the organism [Figure 3]. MIC breakpoints specific for this organism were not available in the Clinical and Laboratory Standards Institute 2020 M100 document and were interpreted as available for “other non-Enterobacterales” groups.
Figure 3: Culture of Delftia acidovorans on nutrient agar showing orange pumpkin-colored colonies after the addition of Kovac's reagent

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The clinical and radiological signs in the present case suggested of mass lesion leading to collapse of the right lobe. The tendency for D. acidovorans to form biofilm is the cause of establishment of its infection through invasive devices. The improvement of the patient with antibiotics and isolation of the organism twice (pleural fluid and ICD) led to confirmation of this case as Delftia-associated pleural infection. Strict infection control practices regarding care and maintenance of invasive devices which include appropriate handling, insertion, inspection, and preventive maintenance need to be implemented in immunocompromised group of population.

The organism isolated was found to be in vitro resistant to aminoglycosides which is a matter of concern as these drugs remain as a widely used choice for empirical treatment in febrile neutropenic patients. Furthermore, it emphasizes the need of accurate and timely laboratory identification and differentiation from Pseudomonas spp. and Comamonas spp. to aid in judicious selection of antibiotics as the organism is phenotypically similar to Pseudomonas spp., and Comamonas acidovorans, the differentiation being based on aminoglycoside susceptibility. Comamonas and Pseudomonas are sensitive to aminoglycosides whereas D. acidovorans is resistant.[13] Orange indole reaction can serve as an index source of suspicion where automated identification facility is not available.

In conclusion, this case emphasizes the emerging need of deciding on the clinical significance of these rarely isolated organisms as possible pathogens in immunocompromised hosts which remains largely unmet due to lack of extensive relevant published literature. Furthermore, this case highlights the issue of ICD drain as a probable source of infection which reinforces the need for cautious and judicious management along with correct infection control practices while using invasive devices in immunocompromised individuals. Prompt speciation can lead to timely and correct treatment in these patients, resulting in better clinical outcomes.

Declaration of patient consent

Waiver of the patient consent to participate and publicate has been approved by the institutional Ethics Committee (ECR/149/Inst/MH/2013/01/2021) as there was no direct contact with the patient and his family. Furthermore, name and initials of the patient will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wen A, Fegan M, Hayward C, Chakraborty S, Sly LI. Phylogenetic relationships among members of the Comamonadaceae, and description of Delftia acidovorans (den Dooren de Jong 1926 and Tamaoka et al. 1987) gen. nov., comb. nov. Int J Syst Bacteriol 1999;49 Pt 2:567-76.  Back to cited text no. 1
    
2.
Laffineur K, Janssens M, Charlier J, Avesani V, Wauters G, Delmée M. Biochemical and susceptibility tests useful for identification of nonfermenting Gram-negative rods. J Clin Microbiol 2002;40:1085-7.  Back to cited text no. 2
    
3.
Lipuma JJ, Currie BJ, Peacock SJ, Vandamme P, Whittier S. Burkholderia, Cupriavidus, Pandoraea, Stenotrophomonas, Ralstonia, Brevundimonas, Comamonas, Delftia, and Acidovorax. In: Versalovic J, et al., editors. Manual of Clinical Microbiology. 11th ed. Washington, DC: ASM Press; 2015. p. 791-812.  Back to cited text no. 3
    
4.
Mahmood S, Taylor KE, Overman TL, McCormick MI. Acute infective endocarditis caused by Delftia acidovorans, a rare pathogen complicating intravenous drug use. J Clin Microbiol 2012;50:3799-800.  Back to cited text no. 4
    
5.
Lang KJ, Chinzowu T, Cann KJ. Delftia acidovorans as an unusual causative organism in line-related sepsis. Indian J Microbiol 2012;52:102-3.  Back to cited text no. 5
    
6.
Chotikanatis K, Bäcker M, Rosas-Garcia G, Hammerschlag MR. Recurrent intravascular-catheter-related bacteremia caused by Delftia acidovorans in a hemodialysis patient. J Clin Microbiol 2011;49:3418-21.  Back to cited text no. 6
    
7.
Castagnola E, Conte M, Venzano P, Garaventa A, Viscoli C, Barretta MA, et al. Broviac catheter-related bacteraemias due to unusual pathogens in children with cancer: Case reports with literature review. J Infect 1997;34:215-8.  Back to cited text no. 7
    
8.
Kawamura I, Yagi T, Hatakeyama K, Ohkura T, Ohkusu K, Takahashi Y, et al. Recurrent vascular catheter-related bacteremia caused by Delftia acidovorans with different antimicrobial susceptibility profiles. J Infect Chemother 2011;17:111-3.  Back to cited text no. 8
    
9.
Khan S, Sistla S, Dhodapkar R, Parija SC. Fatal Delftia acidovorans infection in an immunocompetent patient with empyema. Asian Pac J Trop Biomed 2012;2:923-4.  Back to cited text no. 9
    
10.
Kam SK, Lee WS, Ou TY, Teng SO, Chen FL. Delftia acidovorans bacteremia associated with ascending urinary tract infections proved by molecular method. J Exp Clin Med 2012;4:180-2.  Back to cited text no. 10
    
11.
Bilgin H, Sarmis A, Tigen E, Soyletir G, Mulazimoglu L. Delftia acidovorans: A rare pathogen in immunocompetent and immunocompromised patients. Can J Infect Dis Med Microbiol 2015;26:277-9.  Back to cited text no. 11
    
12.
Kawamura I, Yagi T, Hatakeyama K, Ohkura T, Ohkusu K, Takahashi Y. Recurrent vascular catheter-related bacteremia caused by Delftia acidovorans with different antimicrobial susceptibility profiles. J Infect Chemoth 2011;17:111-3.  Back to cited text no. 12
    
13.
Horowitz H, Gilroy S, Feinstein S, Gilardi G. Endocarditis associated with Comamonas acidovorans. J Clin Microbiol 1990;28:143-5.  Back to cited text no. 13
    

Top
Correspondence Address:
Sujata Lall,
Department of Microbiology, Homi Bhabha National Institute, ACTREC-Tata Memorial Centre, Khargar, Navi Mumbai - 410 210, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgid.jgid_66_22



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