Ventriculoperitoneal Shunt Infection and Meningitis Due to Bergeyella zoohelcum in a Young Child

To the Editors: Bergeyella zoohelcum, a non-fermenting Gram-negative rod, has been reported in several infections involving adults, but just 3 cases in children. Commonly found in canine and feline oral flora, it is a rare cause of human infections. We report a case of ventriculoperitoneal (VP) shunt infection and meningitis caused by B. zoohelcum in a toddler with an open post-surgical wound and recent exposure to a family dog. Surgical management and intravenous antibiotics successfully treated the infection. A 14-month-old female with a VP shunt presented for fussiness, fatigue and concern for cerebrospinal fluid (CSF) leak from the scalp. Medical history was significant for 24-week gestational age prematurity, intraventricular hemorrhage, meningitis and communicating hydrocephalus requiring VP shunt. In recent months, she underwent neurosurgical interventions including bilateral catheters due to shunt malfunction and septations. Wound revision secondary to poor healing and CSF leak was completed 2 days before presentation. On admission, her scalp showed well-approximated wound edges overlying the VP shunt valve with minimal erythema and clear drainage concerning for CSF. She developed seizures requiring intubation and mechanical ventilation. Laboratories were notable for CRP 184 mg/L and white blood cell 9.1 K/u. Infectious workup revealed CSF protein 422.5 mg/dL, CSF glucose <1 mg/dL, CSF nucleated cells 772 cells/mm3 and CSF red blood cell 190 cells/mm3. CSF Gram stain revealed many white blood cells (>25 per low power field) and moderate Gram-negative bacilli (6–30 per oil immersion field). Meningitic dosing of meropenem and vancomycin was initiated. The VP shunt was removed, and bilateral externalized ventricular drains were placed. CT head obtained postoperatively demonstrated retained VP shunt tubing in the right lateral ventricle. Moderate growth of Gram-negative bacilli from CSF was observed at 25 hours, later identified as B. zoohelcum using matrix-associated laser desorption ionization-time of flight mass spectrometry (Vitek MS, Biomerieux, Marcy-l'Etoile, France) with the research use only database. Antimicrobial treatment was changed to ceftriaxone (100 mg/kg/d). Subsequent CSF cultures yielded no growth. The child’s family revealed that their pet dog often gave the patient “kisses,” which was the suspected mode of transmission, given postoperative CSF leak. Ultimately, retained shunt tubing was removed, and ceftriaxone was continued for 14 days following (total duration of 26 days). A new VP shunt was placed on hospital day 24, with discharge at neurologic baseline 30 days following admission. B. zoohelcum infections in humans have been reported, including skin/soft tissue infection, pneumonia, septicemia, tenosynovitis and endocarditis. The only report of B. zoohelcum central nervous system infection involved a child with B. zoohelcum meningitis after a dog bite to the scalp.1 Of the reported pediatric cases, all 3 developed after dog bites (Table 1).1–3 Despite this patient having no bite history, the surgical incision was possibly exposed to canine saliva. Adult cases describe B. zoohelcum infection after dog or cat exposure, without a known bite.4 TABLE 1. - Pediatric Cases of Bergeyella zoohelcum Infection Reference Year Age Site Treatment Exposure Yi et al2 2016 22 mo SSTI Amoxicillin/clavulanate Dog bite Bracis et al1 1979 5 yr Meningitis Penicillin Dog bite Reina and Borrell3 1992 10 yr SSTI Cefotaxime Dog bite SSTI indicates skin and soft tissue infection. This case demonstrates the importance of educating patients and families about the risk of infection with family pets, particularly children with open wounds or immunosuppression. The growing list of infections caused by B. zoohelcum should increase awareness of this rare but important cause of zoonotic infection.