Pantoea Agglomerans as a Rare Cause of Catheter-related Infection in Hemodialysis Patients

Pantoea agglomerans has been reported in the literature as a source of bacteremia in humans (1, 2), and was rarely reported as a cause of peritonitis in patients with end-stage renal disease (ESRD) on peritoneal dialysis (PD) (3, 4). Two cases of catheter-related infections (CRI) caused by Pantoea agglomerans in hemodialysis patients are reported here. The first patient was a 56-year-old woman who commenced hemodialysis in March 2009. She was commenced on dialysis using a non-cuffed double-lumen internal jugular catheter; this was converted to a cuffed catheter in April 2009. In September 2010, she was admitted with high-grade fever during dialysis for two weeks. The first sample of blood culture with the blood drawn from the catheters grew Pantoea agglomerans (sensitivity to cefoperazone, cefuroxime [parenteral], gentamicin and bactrim). Physical examination revealed a displaced apex beat and a loud pansystolic murmur radiating to the axilla. There were no other signs of infective endocarditis. Her initial tests showed an Hb 7.5 g/dL, TWBC 11.8, platelets 262, CRP 22.74 mg/dL (<3.00). She was commenced on intravenous sulperazone 1 g bd. The catheter was removed, and she was dialyzed using the transposed left brachio-basillic fistula. Echocardiography revealed three small vegetations attached to the posterior mitral leaflet (PML) of the mitral valve. Subsequently, two more samples of blood cultures from the catheter and peripheral sites also grew Pantoea agglomerans. After discussion with our infectious disease specialist, she was treated with intravenous ciprofloxacin for four weeks, followed by oral ciprofloxacin for another two weeks. In December 2010, because of the persistent vegetations and fever, she was treated with intravenous ceftriazone 2 g od for another four weeks. The blood cultures became negative, and her CRP was normalized. She has severe mitral regurgitation as a result of the infective endocarditis. The second patient was a 39-year-old man with a history of ESRD and has been on hemodialysis (different dialysis center from the first patient) since July 2009. He was commenced on hemodialysis via a non-cuffed double lumen catheter, and a cuffed tunneled catheter was inserted in March 2010. He was admitted in December 2010 for CRI with fever during dialysis sessions. Physical examination was otherwise normal. Blood culture from the catheter grew Pantoea agglomerans. He was commenced on intravenous meropenam for two weeks, and he made a full recovery with no complication. Pantoea agglomerans is a Gram-negative bacillus, found in human and animal feces, plant and soils. Many human infections were related to plant thorn injuries. Contaminated blood products, intravenous fluids, total parenteral nutrition and anesthetic agents have also been linked to Pantoea infection (5). In the dialysis population, Pantoea agglomerans was reported to be a rare cause of peritonitis in patients on PD (3, 4). From the literature search, it has not been reported among hemodialysis patients using dialysis catheters. Our patients did not give a history of any penetrating trauma or any thorn injuries. It is possible that they might not recall such incidence. The first patient had a very complicated outcome, which resulted in severe infective endocarditis, and patient two escaped with an uneventful recovery. In conclusion, Pantoea agglomerans is a rare infection. However, in patients with ESRD with an in-situ catheter for dialysis, Pantoea agglomerans should be considered as a possible etiology of sepsis.