<b><i>Ewingella americana</i></b> Peritonitis in a Patient on Peritoneal Dialysis: A Case Report and Review of the Literature

Abstract

Most episodes of peritoneal dialysis (PD)-associated peritonitis are caused by skin-dwelling gram-positive bacteria and gram-negative bacteria colonizing gut and urinary tract. Occasionally, however, uncommon bacteria can cause peritonitis in PD patients. We describe a case of &lt;i&gt;Ewingella americana&lt;/i&gt; peritonitis, the first such case reported from the United States. A 68-year-old woman with end-stage kidney disease due to hypertension was initiated on PD 2 years prior to the present event. She presented with abdominal pain associated with nausea and vomiting. She was afebrile and hemodynamically stable. Abdomen was diffusely tender with guarding and rebound. No obvious root cause was apparent. Initial PD fluid white count was 502/mm&lt;sup&gt;3&lt;/sup&gt; with 87% neutrophils. Gram stain was negative. Culture grew gram-negative rods, which were later identified as &lt;i&gt;Ewingella americana&lt;/i&gt;, resistant to ampicillin and cefazolin but sensitive to gentamicin, ceftazidime, and cefepime. After empiric intraperitoneal vancomycin and gentamicin, she was continued on intraperitoneal gentamicin for a total period of 21 days. She responded to the treatment rapidly with complete recovery. PD fluid on day four showed 40 nucleated cells with 12% neutrophils. Patient remained on PD without consequences. &lt;i&gt;Ewingella americana&lt;/i&gt; is a gram-negative facultative anaerobic bacillus that can survive in water, including domestic water. Inadequate hand hygiene is a potential root cause of infection. Although rare, &lt;i&gt;Ewingella&lt;/i&gt; peritonitis can be observed in PD patients and is treatable. Clinicians should be aware of &lt;i&gt;Ewingella&lt;/i&gt; as a potential cause of PD peritonitis.

A Case of Peritoneal Dialysis-Related Peritonitis Caused by Ewingella americana

“…Available data from case reports suggest that E. americana survives without relevant nutritional needs and preferably grows at 4 °C. It was also proposed in two case reports that water could be a reservoir for this pathogen [14,16]. Similarly, in our case, despite the fact that the source of this Gram-negative microorganism remains undetermined, we may presume that use of contaminated water and break in sterile technique could help explaining this infection.…”

“…e rarity of reported infections in humans raised initial doubts as to its true pathogenicity. However, though sparse and scattered in time, increasing reports have confirmed clinical infections due to E. americana in multiple contexts, including bacteremia [6][7][8][9], pneumonia [10], conjunctivitis [11,12], Waterhouse-Friderichsen syndrome [13], and peritonitis [14][15][16]. Susceptible populations include immunocompromised patients, but previously healthy patients were described too.…”

“…A recent review by Khurana et al [16] showed only three reported cases of peritonitis secondary to E. americana. To the best of our knowledge, this is the fourth worldwide peritonitis caused by this organism and the first ever reported in Portugal.…”

Intestinal Microbes of Hooded Cranes (Grus monacha) Wintering in Three Lakes of the Middle and Lower Yangtze River Floodplain

“…Indeed, our study showed that the Hooded Cranes at Shengjin Lake harbored more abundant genus, such as Bacillus, Clostridium and Paenibacillus which can metabolize cellulose and improve the degradation of non-starch polysaccharides ( Figure 5 ) [ 54 , 55 ]. In addition, we found that the genera Anaerorhabdus and Ewingella were more abundant in the gut of the Hooded Cranes at Caizi Lake, which might be detrimental for the host and increase the risk of host infection, respectively ( Figure 5 ) [ 56 , 57 ]. Moreover, many indicators ( Ewingella americana , Epicoccum nigrum, Enterococcus cecorum ) with a high indicator value of Hooded Cranes at Caizi Lake were also potential pathogenic microbes ( Table 4 ) [ 57 , 58 , 59 ].…”

“…In addition, we found that the genera Anaerorhabdus and Ewingella were more abundant in the gut of the Hooded Cranes at Caizi Lake, which might be detrimental for the host and increase the risk of host infection, respectively ( Figure 5 ) [ 56 , 57 ]. Moreover, many indicators ( Ewingella americana , Epicoccum nigrum, Enterococcus cecorum ) with a high indicator value of Hooded Cranes at Caizi Lake were also potential pathogenic microbes ( Table 4 ) [ 57 , 58 , 59 ]. For example, E. nigrum could cause respiratory fungal infections in wild birds, such as owls [ 58 ].…”