Serratia marcescens Bullous Cellulitis in a Splenectomized Patient

Abstract

Serratia marcescens is a Gram-negative bacillus belonging to the Enterobacteriaceae family. Cutaneous infection with Serratia is rare, and usually occurs in immunocompromised individuals. Primary cutaneous infections are uncommon, but they are typically severe and are associated with significant morbidity and mortality. The pathogenetic factors leading to S. marcescens infection are not fully understood, but contributing virulence factors include proteases, secreted exotoxins, and the formation of biofilm. We report a case of cellulitis occurring in a splenectomized patient, which led to multiple wound debridements and a transmetatarsal amputation. This dramatic case led us to review the published literature on soft tissue infections caused by S. marcescens.

Severe and Progressive Cellulitis Caused by Serratia marcescens Following a Dog Scratch

“…Presentations include isolated plaques, 15 bullous cellulitis, 16 papillovesicular eruptions, 17 abscesses, 18,19 nodules, 20,21 granulomatous lesions, 22,23 and necrotizing cellulitis. 24 Cases have been reported in the extremities of patients with uncontrolled diabetes 25 and end-stage renal disease, 26 as well as those who have undergone splenectomy 27 and chemotherapy. 17 Infections associated with immunocompromised state frequently disseminate and lead to life-threatening sepsis.…”

Severe Skin Infections Due to Serratia marcescens

“…[1][2][3][4] Other forms of being immunocompromised in patients with S. marcescens cellulitis or NF included a history of splenectomy, chronic steroid use, and neutropenia from chemotherapy. 1,[5][6][7] In addition to an immunocompromised state, factors that are thought to predispose patients to the skin and soft tissue infections from S. marcescens include external trauma and compromised skin integrity such as chronic venous stasis. 4,5 This patient had chronic kidney disease, diabetes mellitus, and end-stage liver disease, all of which have been associated with high mortality in patients with cellulitis secondary to S. marcescens.…”

“…A mice model has shown that cell-mediated immunity in the spleen helps clear Serratia marcescens and so splenectomized patients are at high risk of developing severe soft tissue infection. 5…”

“…and gram-negative (Enterobacter cloacae, E. coli, and Salmonella enteritidis). 5 It can also be associated with rare and unusual pathogens including Vibrio vulnificus which has high susceptibility in patients with cirrhosis. Testing of bullous fluid can help isolate the pathogen.…”

“…Serratia marcescens has intrinsic resistance to penicillin, macrolide, and first-generation cephalosporin, linezolid, and rifampin same as other groups of Enterobacteriaceae. 5,6 Resistance can be either chromosomal mediated or plasmid-mediated producing either AmpC-β-lactamase, extended-spectrum β-lactamase, or carbapenemase, which provide resistance to penicillins, cephalosporins, and carbapenems.…”