Letter to the Editor
Gemella haemolysans meningitis
Meningitis por Gemella haemolysans
Bartolome Gomez Arroyo, Emilio Cendejas Bueno, María Pilar Romero-Gómez
Corresponding author
Servicio de Microbiología, Hospital Universitario La Paz, Madrid, Spain
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Therefore, early and accurate identification of the causative microorganism is of utmost importance, especially in patients with comorbidities that can make them susceptible to infection by atypical organisms.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a patient who came to the emergency department with persistent severe headache, low-grade fever, and vomiting. As a history of interest, a clivus chordoma stood out, for which he underwent four surgical interventions and two radiation therapy cycles without achieving focus control. Prior to this episode, he underwent treatment with ampicillin, meropenem and linezolid for signs of acute bacterial meningitis with negative cultures in another hospital from which he was discharged 9 days before with oral moxifloxacin (500<span class="elsevierStyleHsp" style=""></span>mg/day). In the emergency department, he had a GCS: 15/15; BP 150/91<span class="elsevierStyleHsp" style=""></span>mmHg; HR 101<span class="elsevierStyleHsp" style=""></span>bpm and a SaO<span class="elsevierStyleInf">2</span> of 94%. A non-contrast head CT scan was performed, showing no changes compared to the one performed 2 months earlier. Laboratory tests showed 22,000<span class="elsevierStyleHsp" style=""></span>leuc/μl (neutrophils 88%), CRP 5.5<span class="elsevierStyleHsp" style=""></span>mg/L and elevated transaminases (ALT: 120<span class="elsevierStyleHsp" style=""></span>IU/L; GGT: 237<span class="elsevierStyleHsp" style=""></span>IU/L). The CSF biochemical study showed a glucose <1<span class="elsevierStyleHsp" style=""></span>mg/dL, protein 516<span class="elsevierStyleHsp" style=""></span>mg/dL, 9.16<span class="elsevierStyleHsp" style=""></span>lactate<span class="elsevierStyleHsp" style=""></span>mmol/dL and 1270<span class="elsevierStyleHsp" style=""></span>cells/mL (97% neutrophils). Given the suspicion of bacterial meningitis, empirical treatment with vancomycin (1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h) and meropenem (2<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h IV) was started.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient required admission to the ICU with the need for orotracheal intubation. The antibiotic treatment was readjusted to ampicillin (2<span class="elsevierStyleHsp" style=""></span>g/4<span class="elsevierStyleHsp" style=""></span>h IV), amikacin (1500<span class="elsevierStyleHsp" style=""></span>mg/day IV), meropenem (2<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h) and linezolid (600<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Blood and CSF samples were submitted and processed according to standard procedures. Gram-negative diplococci and a large number of polymorphonuclear leukocytes were observed on the CSF Gram staining (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A <span class="elsevierStyleItalic">Multiplex PCR</span> with the <span class="elsevierStyleItalic">FilmArray®ME Panel</span> system gave a negative result. Growth was observed after 18<span class="elsevierStyleHsp" style=""></span>h of incubation, identifying the isolate as <span class="elsevierStyleItalic">Gemella haemolysans</span> by MALDI-TOF mass spectrometry.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">After 8 days in the ICU, the patient was transferred to internal medicine.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">G. haemolysans</span> is a facultative anaerobic gram-positive coccus that can be gram-variable. It is a commensal microorganism that causes infections in immunocompromised patients or with pathologies such as valvular disease, tumours or after invasive procedures. It has been sporadically described as an aetiological agent in entities such as infective endocarditis, central nervous system infections, eye infections, spondylodiscitis, osteomyelitis or pyothorax.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It is resistant to cotrimoxazole and is usually sensitive to beta-lactams, glycopeptides, and linezolid.</p><p id="par0035" class="elsevierStylePara elsevierViewall">There are currently eight documented cases of <span class="elsevierStyleItalic">G. haemolysans meningitis.</span> In three cases, it developed a few hours after a neurosurgical intervention with a buccal and upper respiratory mucosa approach.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> The solution of continuity in the meninges could act as a gateway for <span class="elsevierStyleItalic">G. haemolysans</span> (traumatic inoculation or residual CSF fistula). In the fourth case, the meningeal continuity solution was the consequence of a bone splinter secondary to a dural osteoma.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In two other cases the gateway was not clear. In a 17-month-old patient with complex congenital heart disease, the authors speculate that prolonged hospital stay and instrumentation played a role in the pathogenesis of infection.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In a patient with chronic obstructive pulmonary disease, diabetes mellitus and a drinking habit,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> the condition could be explained by the fact that these pathologies lead to cilia dysfunction, colonisation, infectious exacerbations, and multiple antibiotic treatments that alter the usual microbiota.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Regarding the only immunocompetent case, the gateway could be the oral mucosa. The patient developed bacteraemia secondary to poor oral hygiene which led to the settlement of <span class="elsevierStyleItalic">G. haemolysans</span> in meninges, clivus and probably in the lungs.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In contrast to the acute onset in the other cases, this was subacute.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In most cases, the identification of isolates was carried out using biochemical methods.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> In one case, universal PCR and 16s rRNA sequencing were performed due to culture sterility.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> In our case, the MALDI-TOF method, a fast, reliable, simple and easy-to-interpret technique was used for its identification.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Cases with resistance to penicillins, cephalosporins and levofloxacin have been published.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Our isolates were sensitive to penicillins, cephalosporins, carbapenems, vancomycin and clindamycin but showed resistance to levofloxacin and moxifloxacin. This resistance to quinolones occurs in at least two strains described.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The sensitivity to beta-lactams and glycopeptides described in most strains, including our case, means that this microorganism is covered by the empirical treatments recommended for healthcare-associated meningitis, which improves the vital prognosis. No cases of treatment failure are described. Most patients were treated with at least one beta-lactam agent, except for one case of allergy which was treated with chloramphenicol and sulphadiazine.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, the introduction of tools such as MALDI-TOF allows rapid and reliable identification of this rare microorganism in healthcare-associated meningitis, which mainly affects surgical and immunocompromised patients and whose genus and species identification leads to effective targeted treatment.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gomez Arroyo B, Cendejas Bueno E, Romero-Gómez MP. Meningitis por <span class="elsevierStyleItalic">Gemella haemolysans</span>. Med Clin (Barc). 2021;157:e347–e348.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 500 "Ancho" => 905 "Tamanyo" => 39584 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intraleukocytic gram-negative diplococci can be observed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Meningitis due to <span class="elsevierStyleItalic">Gemella haemolysans</span> in a pediatric case" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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