Microbiology Case Study: A 74 Year Old Female with Right Knee Swelling

Case History

A 74 year old female presented to the ED with a chief complaint of fever, right knee swelling and pain for three days. Past medical history was significant for a right total knee arthroplasty approximately 5 months prior, with no significant complications. Physical exam revealed the patient to be febrile (103 degrees Fahrenheit), a swollen right knee that was warm to the touch and erythema surrounding the surgical incision site. Routine labs were obtained while in the ED which revealed a leukocytosis with an elevated ESR and CRP. Imaging was ordered and showed a large joint effusion of the right knee with intact hardware. Arthrocentesis was performed which returned 80 cc of cloudy yellow fluid with no crystals identified by light microscopy, a nucleated cell count of 169,200/cmm of which 97% were neutrophils.

Laboratory Identification

The primary gram stain was reported as polys and gram negative bacilli present. Cultures revealed a pure moderate growth on sheep blood and chocolate agar with no growth on the MacConkey agar. Colony morphology on the sheep blood agar was smooth, gray with no hemolysis appreciated. The key biochemical and physiologic characteristics of the isolate included: positivity for indole, nitrate reduction, catalase, ornithine decarboxylase, and fermentation of mannitol and sucrose; negativity for urea and maltose fermentation.  The isolate was identified by MALDI-TOF as Pasteurella multocida. Upon further questioning, the patient admitted to living with two indoor cats but denied any recent history of bites or scratches.

pastmulti1
Image 1. Chocolate agar with smooth gray colonies.

Discussion

Pasteurella multocida is a non-motile, oxidase positive, small -gram negative bacilli capable of fermenting glucose. This organism is part of the normal flora of the gastrointestinal tract and nasopharynx of wild and domestic animals. Humans who have extensive exposure to animals may be found to have Pasteurella multocida as part of their upper respiratory tract flora. With no significant virulence factors, this organism is often viewed as an opportunistic pathogen which requires mechanical disruption of anatomic barriers as occurs with bite and scratch wounds from cats and dogs. Though most infections are associated with bites or scratched from animals, infection can occur with non-bite exposure to animals. The typical disease caused by Pasteurella multocida is a focal soft tissue infection following a bite or scratch. However, chronic respiratory infections in patients with preexisting chronic lung disease and heavy animal exposure, and bacteremia with metastatic abscess formation have been documented.

Biochemical characteristics can be utilized in identifying the different Pasteurella species. The key biochemical and physiologic characteristics for Pasteurella multocida include: positivity for indole, nitrate reduction, catalase, ornithine decarboxylase, and fermentation of mannitol and sucrose; negativity for urea and maltose fermentation.

The vast majority of these organisms are susceptible to penicillin, thus susceptibility testing is generally unnecessary. Additionally, soft tissue infections caused by animal bites are frequently polymicrobial and warrant use of therapeutics with a broader spectrum. However, should the need arise to perform susceptibility testing, the Clinical and Laboratory Standards Institute (CLSI) does provide break points for Pasteurella multocida.

References

  1. Forbes BA, Sahm DF, Weissfeld AS. Bailey & Scott’s Diagnostic Microbiology. Mosby; 2007.
  2. Koneman EW. Koneman’s Color Atlas and Textbook of Diagnostic Microbiology. Lippincott Williams & Wilkins; 2006.

 

-Justin Rueckert, DO is a 2nd year anatomic and clinical pathology resident at the University of Vermont Medical Center.

Wojewoda-small

-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.

 

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