To the Editors:
Staphylococcus schleiferi subsp. schleiferi was described in 1988 by Freney et al.1 It is a member of the human preaxillary skin flora,2 but it is not known whether carriage is persistent or transient. It has been implicated as the causative agent of several human infections. We here report the first case of meningitis in a child with this infection.
A 6-year-old female child had a history of fever, headache and vomiting. She had 1 episode of generalized tonic clonic seizure on the day of presentation, and developed left focal seizures followed by left hemiparesis within 20 minutes of admission. She had no prior history of seizures. The child was developmentally normal and academically brilliant. The heart rate was 100/min; capillary refill time, 2 seconds; respiratory rate, 24/min and blood pressure, 120/84 mm Hg. The Glasgow coma scale score at admission was 10/15, both pupils were of equal size and well reacting to light and fundus examination was normal. Facial nerve palsy, increased motor tone, brisk deep tendon reflexes, was evident on the left side. Bilateral plantar reflexes were extensor. The child had nuchal rigidity, and Kernig and Brudzinski signs were present. She had intermittent decorticate posturing. The liver was enlarged with a span of 12 cm. She was clinically diagnosed as meningitis/meningoencephalitis with raised intracranial pressure.
The white blood cell count was 13900/dL with 79% neutrophils. Cerebrospinal fluid (CSF) had 2200 cells/dL with 90% neutrophils and 10% lymphocytes, protein 107 mg/dL and glucose 45 mg/dL (blood glucose 122 mg/dL). Gram staining of CSF did not reveal any organism but CSF and blood cultures grew abundant coagulase-negative staphylococcal species. The isolate was identified by Microscan Autoscan 4 (Siemens, West Sacramento, CA) as S. schleiferi. The identification was confirmed by phenotypic tests for sugar fermentation and showed the following: mannitol negative, maltose negative, lactose negative, mannose positive and trehalose negative. By Microscan Autoscan 4 system, the organism was susceptible to ciprofloxacin, clindamycin, erythromycin, gentamicin, moxifloxacin, oxacillin, rifampin, tetracycline, trimethoprim–sulfamethoxazole and vancomycin. The patient was treated with intravenous cloxacillin. Hypertonic saline (3%) was used in infusion at 0.2–1 ml/kg/h as osmotherapy. She responded well to this therapy and was discharged with residual left hemiparesis. At 3 months follow-up examination, she was walking without assistance with mild residual weakness of the left upper and lower limbs. She has started attending school.
Most S. schleiferi infections have been reported in dogs.1 Infections in human have been wound infection, prosthetic infections and bacteremia.2–6S. schleiferi is often mistaken for S. aureus because both express clumping factor and heat stable DNase. The subspecies schleiferi does not produce a staphylocoagulase, but can produce a pseudocoagulase and therefore is sometimes described as coagulase positive. Protease inhibitors and anticoagulants can frequently inhibit clotting activity and therefore it is usually reported as coagulase negative.7 A review of 28 reported cases4 in 2001 reported that all isolates were coagulase negative: 50% of cultures were from wound infections, 19.4% were found in blood cultures, 13.8% from catheter tips, 8.3% from ear exudates and 5.5% from CSF. Other sites included pleural fluid, corneal exudate, biliary drainage and urine. Most patients were older men (mean age of 64 years) and the most common underlying comorbidity was immunosuppression and malignancy. The series included 2 patients with meningism secondary to neoplasms (meningioma, multiple cholesteatoma), and both of them had ventriculo-peritoneal shunts. S. schleiferi was recovered from CSF and the parietal reservoir in one of them.
This is the first reported case of meningitis by this organism in humans in the absence of an indwelling intracranial device. We suspect that this patient became infected with S. schleiferi through contact with her dog. This dog had numerous skin pustules and ear infection and culture from his ears and hairs grew S. schleiferi.
Atul Jindal, MBBS, MD, DM
Department of Pediatrics
All India Institute of Medical Sciences
Raipur, Chhattisgarh, India
Deepak Shivpuri, MBBS, MD
Department of Pediatrics
Centre for Advanced Pediatrics
Fortis Escorts Hospital
Smita Sood, MBBS, MD
Department of Microbiology
Fortis Escorts Hospital
Jaipur, Rajasthan, India
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