S1502 A Rare Case of Raoultella planticola-Associated Spontaneous Bacterial Peritonitis in a Patient With Decompensated Cirrhosis

Abstract

INTRODUCTION: Raoultella planticola (RP) is a rare human pathogen, the incidence and prevalence of which is likely underreported due to its frequent misidentification as a Klebsiella species. To our knowledge, three cases have been reported of RP causing peritoneal infections. We present a case of RP causing spontaneous bacterial peritonitis (SBP) in a patient with decompensated cirrhosis, the first case of RP infection in a patient with cirrhosis secondary to nonalcoholic steatohepatitis (NASH). CASE DESCRIPTION/METHODS: 53-year-old female patient with cirrhosis, presented with ascites and abdominal pain. Medical history is significant for multiple sclerosis, gastric bypass surgery, breast cancer status post lumpectomy, chemo and radiation 10 years prior, with recent diagnosis of cirrhosis due to NASH (biopsy confirmed). On presentation, the patient was afebrile, markedly hypotensive, hypokalemic, neutropenic (WBC 2.84), anemic, thrombocytopenic, and with lactic acidosis. CT scan was notable for cirrhotic morphology, known innumerable hepatic lesions (biopsy negative for malignancy), as well as large volume ascites with a nodular omentum. Patient underwent diagnostic and therapeutic paracentesis with removal of 4 liters of ascitic fluid. Fluid analysis revealed WBC count of 4,524 with 98% neutrophil predominance and a polymorphonuclear leukocyte count greater than 250. Cytology was negative for malignancy. The patient was started on metronidazole and fluoroquinolone based therapy and later switched to Vancomycin and Meropenem for broad spectrum coverage. Cultures from the ascitic fluid returned positive for RP. Antibiotics were narrowed to Aztreonam on day 4 to complete a 7-day course of treatment. Subsequent collection of ascitic fluid revealed 228 WBC per mcL and fluid differential of 16% neutrophils indicating good response to Aztreonam with resolution of SBP. DISCUSSION: RP is an extremely rare cause of SBP even in immunocompromised patients. Risk factors include heavy alcohol abuse, seafood consumption, diabetes, and chemotherapy. Our patient is unique in that she had clear evidence of RP in ascitic fluid and is the only documented cirrhotic patient with RP cultured in ascitic fluid with no known alcohol abuse history or history of peritoneal dialysis. Given that our patients peritoneal fluid was positive for RP alone, it is likely that the isolate was the pathogenic cause of SBP rather than a colonizing organism.