Abstract
BackgroundInfections with multidrug-resistant organisms (MDRO) pose a serious threat to patients with dysregulated immunity such as in hemophagocytic lymphohistiocytosis (HLH), but such infections have rarely been comprehensively characterized. Here, we present a fatal case of HLH secondary to cytomegalovirus (CMV) infection complicated by both anti-viral drug resistance and sepsis from multiple MDROs including pandrug-resistant superbug bacteria.Case presentationA previously healthy, six-year-old boy presented with a 45-day history of fever prior to a diagnosis of hemophagocytic lymphohistiocytosis and hemorrhagic colitis, both associated with CMV. On hospital admission, the patient was found to be colonized with multiple, multidrug-resistant (MDR) bacteria including vancomycin-resistant enterococci (VRE) and carbapenamase-producing organisms (CPO). He eventually developed respiratory, urine and bloodstream infections with highly drug-resistant, including pandrug-resistant bacteria, which could not be controlled by antibiotic treatment. Antiviral therapy also failed to contain his CMV infection and the patient succumbed to overwhelming bacterial and viral infection. Whole genome sequencing (WGS) of the MDR bacteria and metagenomic analysis of his blood sample revealed an unusual accumulation of a wide range of antimicrobial resistance mechanisms in a single patient, including antiviral resistance to ganciclovir, and resistance mechanisms to all currently available antibiotics.ConclusionsThe case highlights both the risk of acquiring MDR superbugs and the severity of these infections in HLH patients.
Highlights
Infections with multidrug-resistant organisms (MDRO) pose a serious threat to patients with dysregulated immunity such as in hemophagocytic lymphohistiocytosis (HLH), but such infections have rarely been comprehensively characterized
Hemophagocytic lymphohistiocytosis (HLH) is a potentially life-threatening condition characterized by overactivation of lymphocytes and macrophages that results in dysregulation of inflammatory responses [3]
While these factors likely put HLH patients at high risk of infection with MDROs, no such reports has been published to date and the clinical course of such infections in these patients remains unknown
Summary
Antimicrobial resistance (AMR) is one of the most important public health challenges of current times as the burden of infectious diseases with multidrug-resistant organisms (MDRO) is increasing at an alarming rate. For HLH, his treatment was escalated to increasing doses of dexamethasone, intravenous immunoglobulin (IVIG) and cyclosporine Microbiological findings during this time were remarkable for multiple cultures positive for MDROs. The first was a positive blood culture on PICU day 5 with an extensively drug resistant, carbapenemase-producing E. coli, which prompted the addition of colistin to his antimicrobial treatment (Fig. 1). AMK amikacin, AMC amoxicillin-clavulanic acid, AMP ampicillin, SAM ampicillin-sulbactam, AZM azithromycin, ATM aztreonam, CFZ cefazolin, CFL cephalexin, FEP cefepime, CTX cefotaxime, FOX cefoxitin, CAZ ceftazidime, CZA ceftazidime-avibactam, C/T ceftolozane-tazobactam, CRO ceftriaxone, CXM cefuroxime, LEX cephalexin, CEF cephalothin, CHL chloramphenicol, CIP ciprofloxacin, CLR clarithromycin, CLI clindamycin, CST colistin, DOX doxycycline, ETP ertapenem, ERY erythromycin, FOF fosfomycin, GEN gentamicin, GENS gentamicin synergy, IPM imipenem, KAN kanamycin, LVX levofloxacin, LZD linezolid, MEM meropenem, NIT nitrofurantoin, OXA oxacillin, PEN penicillin, PIP piperacillin, TZP piperacillin-tazobactam, STR streptomycin, TET tetracycline, TGC tigecycline, TMP trimethoprim, SXT trimethoprim-sulfamethoxazole, VAN vancomycin *Bacterial whole genome sequencing (WGS) was performed as described in the supplemental methods and data were analyzed as described previously [4]. The patient passed away on PICU day 20 from multiorgan failure associated with sepsis with highly drug-resistant bacteria
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