Burkholderia Cepacia Infection in an Immunocompetent Patient Following Pancreaticoduodenectomy

Infectious complications impart increased morbidity and mortality following surgery and are common in patients undergoing pancreatectomy. Most infections following pancreatectomy are polymicrobial in nature, with the most common organisms cultured from intra-abdominal abscesses being gram-negative bacteria. Gram-negative Burkholderia cepacia, on the other hand, is extremely rare. Burkholderia cepacia most commonly affects immunocompromised patients, especially those with cystic fibrosis (CF) or those undergoing lung transplantation. Unfortunately, through many different mechanisms, B. cepacia is a highly resistant organism to many commonly used antibiotics. Further, B. cepacia has rarely been described in immunocompetent patients, and most antibiotic regimens are extrapolated from CF patients. Herein, we describe a systemic infection of Burkholderia cepacia in an immunocompetent patient following pancreaticoduodenectomy. A previously healthy 32-year-old woman presented to her primary care provider, following multiple emergency department visits with recurrent episodes of epigastric and right upper quadrant pain. Her workup included an ultrasound revealing cholelithiasis. With recurrent symptomatology, she underwent a computed tomography (CT) scan which revealed a large pancreatic head mass. An esophagogastroduodenoscopy with endoscopic ultrasound was performed for better characterization. Endoscopic imaging was most consistent with solid pseudopapillary tumor (SPT) of the pancreas which was confirmed with biopsy of the lesion. After discussion with the patient, she chose to undergo pancreaticoduodenectomy for her newly diagnosed SPT. The patient was taken to the operating room (OR) and underwent pancreaticoduodenectomy with Roux-en-Y reconstruction. On postoperative day (POD) #2, the patient was noted to have a large volume of bilious output from her surgical drain, as well as increasing tachycardia and an overall feeling of malaise. Further, she was noted to be febrile to 38.6°C. Given the worsening physiologic parameters and large volume bilious output, the patient was returned urgently to the operating room for concern of anastomotic dehiscence. Immediately prior to return to the OR, the patient’s blood was cultured, and broadspectrum antibiotics were initiated. In the operating room, bilious succus was encountered and partial dehiscence of the pancreatojejunostomy was identified. This was repaired with a red inkwell pancreatojejunostomy. The abdomen was copiously irrigated and the patient was returned to the intensive care unit (ICU). Following the OR, the patient was continued on piperacillin-tazobactam, vancomycin, and fluconazole for broad antibiotic coverage. A blood culture that was obtained prior to return to the OR grew Burkholderia cepacia (Figure 1A). The patient’s antibiotic regimen was then changed to piperacillin-tazobactam, fluconazole, and levofloxacin with discontinuation of vancomycin, given the absence of gram-positive organisms. The patient developed a moderate-sized pleural effusion on POD #6 from her original operation (POD #4 from return to OR) which was evacuated by tube thoracostomy. The pleural fluid was cultured and grew a second species of B. cepacia (Figure 1B). A CT scan obtained for continued fevers and leukocytoses revealed multiple complex fluid collections