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Tumor abscess formation caused by Morganella morganii complicated with bacteremia in a patient with gastrointestinal stromal tumor
Clinics and Research in Hepatology and Gastroenterology (2012) 36, e29—e31
CASE REPORT
Tumor abscess formation caused by Morganella morganii complicated with bacteremia in a patient with gastrointestinal stromal tumor Hsuan-Wei Chen a, Te-Yu Lin b,∗ a
Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu, Taipei 114, Taiwan b Division of Infection Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan Available online 15 September 2011
Summary We report the case of a 22-year-old man who presented with a 3-day history of watery diarrhea, abdominal pain, and fever. An image of the abdomen showed a heterogeneously echogenic mass lesion in the pelvis. The results of the blood cultures performed on admission showed the presence of Morganella morganii. Computed tomography-guided tube drainage was performed, and a culture of the drained abscess fluid yielded M. morganii growth. Exploratory laparotomy with segmental resection of the jejunum and excision of the tumor was performed. Pathological examination showed a gastrointestinal stromal tumor (GIST). A GIST abscess caused by M. morganii was diagnosed on the basis of radiological, microbiological, and histopathological findings. The possibility of an infected GIST should be considered during the differential diagnosis of patients with suspected abdominal neoplasm and bacteremia. © 2011 Elsevier Masson SAS. All rights reserved.
Introduction Morganella morganii is a facultative anaerobic gramnegative rod found in the intestines and feces of humans, dogs, and other mammals. It is known to cause wound infections and opportunistic infections in the respiratory, hepatobiliary, and urinary tracts, and in wound infections [1]. Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract
[2]. GISTs are generally incidentally discovered, although they may present symptoms, including bleeding, obstruction, abdominal pain, nausea, and vomiting. Cases where GIST abscesses are complicated with bacteremia have rarely been reported in the literature. Here, we present a unique case of GIST abscess formation complicated with M. morganii bacteremia in a 22-year-old man, which was successfully treated using flomoxef and surgical intervention.
Case report ∗ Corresponding author. Tel.: +886 2 87927257; fax: +886 2 87927258. E-mail address: [email protected] (T.-Y. Lin).
A previously healthy 22-year-old man presented to our emergency department with watery diarrhea, abdominal pain, and fever of 3-day duration. His initial vital signs were
2210-7401/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.clinre.2011.08.004
e30
H.-W. Chen, T.-Y. Lin
Figure 1 A. Abdominal computed tomography (CT) image showed a lobulated mass lesion (size approximately 8.9 × 7.6 × 8.0 cm) with an irregular wall and low-attenuated areas over the rectovesical pouch. B. A gross mass lesion (diameter approximately 5 cm) arising from the jejunum (100 cm distal to Treitz ligament). C. Spindle cell proliferation with low mitotic count in the tissues of the jejunum (hematoxylin and eosin staining; original magnification, × 100).
as follows: blood pressure, 120/80 mmHg; pulse rate, 96 beats/min; respiratory rate, 15/min; and body temperature, 38.6 ◦ C. Physical examination revealed tenderness over the lower abdominal region. Laboratory tests showed elevation in the white blood cell count (15800 cps/uL) and C-reactive protein level (10.86 mg/dL). Abdominal sonography showed a heterogeneously echogenic mass lesion (size, 9.1 × 8.2 × 6.2 cm) in the pelvis. An abdominal computed tomography (CT) image showed a lobulated lesion with an irregular wall and low-attenuated areas (Fig. 1A). A culture of 2 separate peripheral blood samples obtained on the day of admission yielded non-lactose-fermenting gramnegative bacillus within 48 h of incubation. The organism was identified as M. morganii (susceptible to amikacin, gentamicin, ciprofloxacin, ceftriaxone, ceftazidime, cefipime, and imipenem) by using a VITEK 2 system. Intravenous flomoxef was administered every 8 hours. CT-guided tube insertion was performed on the 9th day for draining turbid bloody fluid from the abscess. A culture of this fluid also showed M. morganii growth. The patient’s fever subsided after fluid drainage and antibiotics treatment. Diagnostic laparoscopy along with a biopsy was performed on the 14th day. The pathological findings were suggestive of GIST. Exploratory laparotomy with segmental resection of the jejunum and excision of the tumor was performed on the 28th day. Gross examination showed a mass lesion (diameter, approximately 5 cm) arising from the jejunum (100 cm distal to the Treitz ligament) (Fig. 1B). Pathological examination showed that the excised specimen was a low-risk GIST (Fig. 1C). The patient had an uneventful recovery after surgical intervention and 2-months of medical treatment.
Discussion M. morganii is the only species in the genus Morganella that belongs to the tribe Proteeae of the Enterobacteriaceae family. It has been reported to cause pneumonia, empyema, pyomyositis, endophthalmitis, wound infection, urinary tract infection, and biliary tract infection [3]. The risk factors for M. morganii bacteremia are old age and underlying comorbidity, including solid tumors, diabetes, chronic renal failure, hypertension, and non-neoplastic hepatobiliary disease. Among M. morganii bacteremia in solid tumors, renal or bladder tumor accounts for the most cases, followed by hepatobiliary and gastrointestinal tract tumors [4]. Here, we report a unique case of bacteremia caused by M. morganii in a patient with GIST. Over 90% of GISTs occur in adults over 40 years of age (median age, 63 years) [5]. The most common locations of GISTs are the stomach (50—60%) and small intestine (30—40%), followed by the colon and rectum (5—10%), and esophagus (5%). The most commonly reported clinical symptoms are bleeding and obstruction [6]. Other manifestations include abdominal pain, nausea, and anorexia [7]. In the present case, the GIST was located in the small intestine and presented all the typical symptoms. Our patient’s age was lesser than those of patients described in previous reports of such cases. Our patient initially presented with fever, abdominal pain, and leukocytosis. An abdominal CT image showed a lobulated lesion with an irregular wall and low-attenuated areas, revealing an intra-abdominal abscess. CT-guided tube drainage was performed, and a culture of the drained
GIST abscess with Morganella morganii bacteremia fluid yielded the same species obtained on blood culture. A GIST abscess formation caused by M. morganii complicated with bacteremia can be summarized as follows: M. morganii is a part of the normal flora of the colon. GISTs tend to disrupt gastrointestinal mucosal integrity, thereby forming a conduit through which colonizing bacteria can gain access to the circulation. Thus, the GIST formed a necrotic tumor mass, which was a result of M. morganii clustering, followed by secondary seeding into the systemic circulation because of altered physiological structure and abundant blood supply to the tumors. Cases of GIST abscess complicated with bacteremia are rare. This case report reinforces that an infected GIST should be considered during differential diagnosis for patients with suspected abdominal neoplasm and bacteremia. Radiological, microbiological, and histopathological examinations are important to verify the pathogen and neoplasm. Adequate antibiotic treatment and surgical intervention are required for successfully treating patients with a GIST abscess and bacteremia.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Funding: none. Ethical approval: not required.
e31
References [1] O’Hara CM, Brenner FW, Miller JM. Classification, identification, and clinical significance of Proteus, Providencia, and Morganella. Clin Microbiol Rev 2000;13(4): 534—46. [2] Miettinen M, Lasota J. Gastrointestinal stromal tumorsdefinition, clinical, histological, immunohistochemical and molecular genetic features and differential diagnosis. Virchows Arch 2001;438(1):1—12. [3] Kim BN, Kim NJ, Kim MN, Kim YS, Woo JH, Ryu J. Bacteremia due to tribe Proteeae: a review of 132 cases during a decade (1991—2000). Scand J Infect Dis 2003;35(2):98— 103. [4] Lee IK, Liu JW. Clinical characteristics and risk factors for mortality in Morganella morganii bacteremia. J Microbiol Immunol Infect 2006;39(4):328—34. [5] Goettsch WG, Bos SD, Breekveldt-Postma N, Casparie M, Herings RM, Hogendoorn PC. Incidence of gastrointestinal stromal tumours is underestimated: Results of a nation-wide study. Eur J Cancer 2005;41(18):2868—72. [6] Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 2002;33(5):459—65. [7] DeMatteo R, Lewis J, Leung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg 2000;231(1):51—8.
CASE REPORT
Tumor abscess formation caused by Morganella morganii complicated with bacteremia in a patient with gastrointestinal stromal tumor Hsuan-Wei Chen a, Te-Yu Lin b,∗ a
Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Kung Road, Neihu, Taipei 114, Taiwan b Division of Infection Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan Available online 15 September 2011
Summary We report the case of a 22-year-old man who presented with a 3-day history of watery diarrhea, abdominal pain, and fever. An image of the abdomen showed a heterogeneously echogenic mass lesion in the pelvis. The results of the blood cultures performed on admission showed the presence of Morganella morganii. Computed tomography-guided tube drainage was performed, and a culture of the drained abscess fluid yielded M. morganii growth. Exploratory laparotomy with segmental resection of the jejunum and excision of the tumor was performed. Pathological examination showed a gastrointestinal stromal tumor (GIST). A GIST abscess caused by M. morganii was diagnosed on the basis of radiological, microbiological, and histopathological findings. The possibility of an infected GIST should be considered during the differential diagnosis of patients with suspected abdominal neoplasm and bacteremia. © 2011 Elsevier Masson SAS. All rights reserved.
Introduction Morganella morganii is a facultative anaerobic gramnegative rod found in the intestines and feces of humans, dogs, and other mammals. It is known to cause wound infections and opportunistic infections in the respiratory, hepatobiliary, and urinary tracts, and in wound infections [1]. Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract
[2]. GISTs are generally incidentally discovered, although they may present symptoms, including bleeding, obstruction, abdominal pain, nausea, and vomiting. Cases where GIST abscesses are complicated with bacteremia have rarely been reported in the literature. Here, we present a unique case of GIST abscess formation complicated with M. morganii bacteremia in a 22-year-old man, which was successfully treated using flomoxef and surgical intervention.
Case report ∗ Corresponding author. Tel.: +886 2 87927257; fax: +886 2 87927258. E-mail address: [email protected] (T.-Y. Lin).
A previously healthy 22-year-old man presented to our emergency department with watery diarrhea, abdominal pain, and fever of 3-day duration. His initial vital signs were
2210-7401/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.clinre.2011.08.004
e30
H.-W. Chen, T.-Y. Lin
Figure 1 A. Abdominal computed tomography (CT) image showed a lobulated mass lesion (size approximately 8.9 × 7.6 × 8.0 cm) with an irregular wall and low-attenuated areas over the rectovesical pouch. B. A gross mass lesion (diameter approximately 5 cm) arising from the jejunum (100 cm distal to Treitz ligament). C. Spindle cell proliferation with low mitotic count in the tissues of the jejunum (hematoxylin and eosin staining; original magnification, × 100).
as follows: blood pressure, 120/80 mmHg; pulse rate, 96 beats/min; respiratory rate, 15/min; and body temperature, 38.6 ◦ C. Physical examination revealed tenderness over the lower abdominal region. Laboratory tests showed elevation in the white blood cell count (15800 cps/uL) and C-reactive protein level (10.86 mg/dL). Abdominal sonography showed a heterogeneously echogenic mass lesion (size, 9.1 × 8.2 × 6.2 cm) in the pelvis. An abdominal computed tomography (CT) image showed a lobulated lesion with an irregular wall and low-attenuated areas (Fig. 1A). A culture of 2 separate peripheral blood samples obtained on the day of admission yielded non-lactose-fermenting gramnegative bacillus within 48 h of incubation. The organism was identified as M. morganii (susceptible to amikacin, gentamicin, ciprofloxacin, ceftriaxone, ceftazidime, cefipime, and imipenem) by using a VITEK 2 system. Intravenous flomoxef was administered every 8 hours. CT-guided tube insertion was performed on the 9th day for draining turbid bloody fluid from the abscess. A culture of this fluid also showed M. morganii growth. The patient’s fever subsided after fluid drainage and antibiotics treatment. Diagnostic laparoscopy along with a biopsy was performed on the 14th day. The pathological findings were suggestive of GIST. Exploratory laparotomy with segmental resection of the jejunum and excision of the tumor was performed on the 28th day. Gross examination showed a mass lesion (diameter, approximately 5 cm) arising from the jejunum (100 cm distal to the Treitz ligament) (Fig. 1B). Pathological examination showed that the excised specimen was a low-risk GIST (Fig. 1C). The patient had an uneventful recovery after surgical intervention and 2-months of medical treatment.
Discussion M. morganii is the only species in the genus Morganella that belongs to the tribe Proteeae of the Enterobacteriaceae family. It has been reported to cause pneumonia, empyema, pyomyositis, endophthalmitis, wound infection, urinary tract infection, and biliary tract infection [3]. The risk factors for M. morganii bacteremia are old age and underlying comorbidity, including solid tumors, diabetes, chronic renal failure, hypertension, and non-neoplastic hepatobiliary disease. Among M. morganii bacteremia in solid tumors, renal or bladder tumor accounts for the most cases, followed by hepatobiliary and gastrointestinal tract tumors [4]. Here, we report a unique case of bacteremia caused by M. morganii in a patient with GIST. Over 90% of GISTs occur in adults over 40 years of age (median age, 63 years) [5]. The most common locations of GISTs are the stomach (50—60%) and small intestine (30—40%), followed by the colon and rectum (5—10%), and esophagus (5%). The most commonly reported clinical symptoms are bleeding and obstruction [6]. Other manifestations include abdominal pain, nausea, and anorexia [7]. In the present case, the GIST was located in the small intestine and presented all the typical symptoms. Our patient’s age was lesser than those of patients described in previous reports of such cases. Our patient initially presented with fever, abdominal pain, and leukocytosis. An abdominal CT image showed a lobulated lesion with an irregular wall and low-attenuated areas, revealing an intra-abdominal abscess. CT-guided tube drainage was performed, and a culture of the drained
GIST abscess with Morganella morganii bacteremia fluid yielded the same species obtained on blood culture. A GIST abscess formation caused by M. morganii complicated with bacteremia can be summarized as follows: M. morganii is a part of the normal flora of the colon. GISTs tend to disrupt gastrointestinal mucosal integrity, thereby forming a conduit through which colonizing bacteria can gain access to the circulation. Thus, the GIST formed a necrotic tumor mass, which was a result of M. morganii clustering, followed by secondary seeding into the systemic circulation because of altered physiological structure and abundant blood supply to the tumors. Cases of GIST abscess complicated with bacteremia are rare. This case report reinforces that an infected GIST should be considered during differential diagnosis for patients with suspected abdominal neoplasm and bacteremia. Radiological, microbiological, and histopathological examinations are important to verify the pathogen and neoplasm. Adequate antibiotic treatment and surgical intervention are required for successfully treating patients with a GIST abscess and bacteremia.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Funding: none. Ethical approval: not required.
e31
References [1] O’Hara CM, Brenner FW, Miller JM. Classification, identification, and clinical significance of Proteus, Providencia, and Morganella. Clin Microbiol Rev 2000;13(4): 534—46. [2] Miettinen M, Lasota J. Gastrointestinal stromal tumorsdefinition, clinical, histological, immunohistochemical and molecular genetic features and differential diagnosis. Virchows Arch 2001;438(1):1—12. [3] Kim BN, Kim NJ, Kim MN, Kim YS, Woo JH, Ryu J. Bacteremia due to tribe Proteeae: a review of 132 cases during a decade (1991—2000). Scand J Infect Dis 2003;35(2):98— 103. [4] Lee IK, Liu JW. Clinical characteristics and risk factors for mortality in Morganella morganii bacteremia. J Microbiol Immunol Infect 2006;39(4):328—34. [5] Goettsch WG, Bos SD, Breekveldt-Postma N, Casparie M, Herings RM, Hogendoorn PC. Incidence of gastrointestinal stromal tumours is underestimated: Results of a nation-wide study. Eur J Cancer 2005;41(18):2868—72. [6] Fletcher CD, Berman JJ, Corless C, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 2002;33(5):459—65. [7] DeMatteo R, Lewis J, Leung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg 2000;231(1):51—8.