Recurrent Cystitis Due to Raoultella planticola Infection

Abstract

To the Editor: Raoultella planticola is a bacterium, commonly found in plants, soil, and aquatic settings.1 It is a histamine-producing bacterium that can be found in scombroid fish, which can lead to clinical complications upon consumption if high levels of histamine are present.2 Histamine poisoning normally produce gastrointestinal symptoms such as nausea, vomiting, and diarrhea, as well as hives, itching, or red rashes.3 The usual incubation period for histamine poisoning can range from a few hours to 24 hours.3R. planticola specifically has been implicated in other clinical manifestations after consumption of seafood in the literature, however, very rarely in cystitis cases. In this present case, we present an R. planticola infection with recurrent symptoms indicating cystitis after consumption of seafood. A 56-year-old woman presented with a recurrent urinary tract infection (UTI) for a span of 4 months. Throughout the recurrent episodes of UTI, the patient had received 2 antibiotics—ciprofloxacin and bactrim—providing no relief. The chief complaint was a recurring UTI, and symptoms presented included burning on urination, blood in the urine, urinary frequency, and mild right flank pain. A unique characteristic to note in this present case is the history of urinary stress incontinence. The patient, along with her family, experienced episodes of nausea, vomiting, and diarrhea in August 2015 after consumption of seafood before the start of the UTIs. Symptoms among family members resolved themselves with the exception of the recurrent UTIs presented by the patient. The patient reported that she greatly enjoys seafood, which ultimately aided in the process of diagnosis. A urinalysis with culture was ordered to identify the bacteria and confirm the infection. The urinalysis identified an elevated level of white blood cells (>30/hpf) indicative of the recurrent UTI. The urine culture grew gram-negative rods that were later identified as R. planticola. After assessment, based on the clinical presentation and laboratory results, the patient was given a diagnosis of an acute cystitis with hematuria and foodborne illness as a result of R. planticola. The urine culture also tested for antimicrobial sensitivity, as indicated in Table 1. Given that the patient's previous therapy with ciprofloxacin and bactrim were ineffective, Rocephin of 2 g daily administered via intravenous (IV) route for 4 weeks was prescribed. Two sets of blood cultures, baseline and weekly chem 7, complete blood cell count with differential, and a computed tomography (CT) of the abdomen/pelvis with IV contrast were ordered. A blood culture was ordered to rule out hematogenous spread of the bacteria because the Raoutella sp. is known to cause bacteremia in some cases.4 Given that the patient had mild right flank pain, a CT was ordered to rule out possible pyelonephritis. Follow-up was set for 4 weeks. Upon return for follow-up, the patient reported no further urinary complaints and an overall improvement in health. Both blood cultures ordered were clear, and the CT of the abdomen/pelvis showed no obstructive uropathy, effectively ruling out pyelonephritis. At follow-up, IV Rocephin was discontinued, and the patient was discharged with symptoms resolved.TABLE 1: Antimicrobial Susceptibility Test in the Present CaseThe present case discussed was a 56-year-old patient with a diagnosis of acute cystitis with hematuria and foodborne illness caused by R. planticola. She experienced recurrent episodes of UTIs that therapy with ciprofloxacin and bactrim could not resolve. A unique aspect to this case is the presence of seafood consumption before the occurrence of the symptoms presented. R. planticola and R. ornithinolytica are the 2 histamine-producing strains in the Raoultella species, which are often isolated from raw fish and other fish products.2 The patient reported that her family experienced gastrointestinal symptoms after seafood consumption, which ultimately resolved. However, she experienced a recurrent UTI postexposure, which, upon further examinations, revealed an infection with R. planticola. Given the patient's history with urinary stress incontinence, it could have been associated with the manifestation of the targeted infection that led to acute cystitis. This is a unique case because there is not a substantial amount of literature on the association between R. planticola and cystitis. There have been other case reports of R. planticola infections with a range of clinical manifestations; however, its relation to cystitis has not been explored enough in the literature. This provides a new avenue of investigation to explore the full extent of clinical manifestations caused by an infection with R. planticola. Jazmin Brito, BS University of North Texas Health Science Center Fort Worth, TXNikhil K. Bhayani, MD, FIDSA Department of Adult Medicine at Texas Health Resources Arlington Memorial Hospital Arlington, TX [email protected]Richard Scriven, MD USMD Department of Surgery/Urology Division Arlington, TX