e Francisella philomiragia is a very uncommon pathogen of humans. Diseases caused by it are protean and have been reported largely in near-drowning victims and those with chronic granulomatous disease. We present a case of F. philomiragia pneumonia with peripheral edema and bacteremia in a renal transplant patient and review the diverse reports of F. philomiragia infections.
CASE REPORTA 63-year-old female from Indiana presented to an Indianapolis hospital with worsening shortness of breath, nonproductive cough, and increasing bilateral peripheral edema. The patient was afebrile, normotensive, and normocardic but was tachypnic (40 bpm) and denied having fevers, chills, or other symptoms of an infectious process while at home. Significant medical history obtained at the time of presentation included a renal transplant secondary to polycystic kidney disease 14 years prior for which she receives chronic immunosuppressive therapy (tacrolimus and prednisone). The patient did not report recent travel outside Indiana, exposure to wild animals or recreational water sources, or exposure to sick individuals. Because of the possibility of acute transplant rejection, the patient was admitted to the intensive care unit for extensive evaluation. A chest X-ray performed at the time of admission revealed bilateral perihilar and upper-lobe infiltrates consistent with bilateral bronchopneumonia, prompting the collection of a set of blood cultures from the left arm and of another set from the right arm and initiation of empirical broad-spectrum antimicrobial therapy with vancomycin and piperacillin-tazobactam. Aside from blood cultures, no other microbiology testing was performed. Laboratory studies conducted at the time of admission revealed leukocytosis (11,600 cells/l) with 93% neutrophils, anemia (3.32 million cells/l), kidney failure (elevated levels of urea nitrogen [48 mg/dl] and creatinine [3.70 mg/dl]), and hyperglycemia (127 mg of glucose/dl). Elevated levels of procalcitonin (1.86 ng/ml), hematuria (25 cells/l), and proteinuria (500 mg/ dl) were also noted. Because of the possibility of acute-on-chronic kidney disease, a renal biopsy was subsequently performed, and it revealed acute allograft rejection.Following approximately 24 h of incubation in a continuousmonitoring blood culture instrument (BD Bactec 9240; BD Diagnostic Systems, Sparks, MD), the aerobic bottles from both sets of blood cultures signaled positively. Gram stains of broth from both bottles revealed pleomorphic, Gram-negative coccobacilli (Fig. 1A). Subcultures of the blood culture broth grew medium-sized (ϳ5-mm diameter), glossy, convex colonies resembling a member of the Enterobacteriaceae on sheep blood and chocolate agars after 48 h of incubation at 35°C in 5% CO 2 . A Gram stain of the colonies revealed organisms with morphologies identical to those seen in the blood culture broth smear. The isolate tested positive for cytochrome oxidase and catalase. Together, these observations ruled out possible select agents, including Francisella tularensis a...
