To the Editors,
We report a case of Paenibacillus alvei meningoencephalitis in a premature neonate with a poor neurologic outcome despite early, adequate antibiotic coverage.
Our patient was a 4-week-old ex-33 week premature female who presented with a 1-day history of refusing nighttime feedings and lethargy. She was afebrile with other vital signs normal for age. She was floppy and pale, with an irregular breathing pattern. Cerebrospinal fluid (CSF) analysis showed pale yellow, hazy fluid with 2300/L white blood cells (53% segmented neutrophils and 47% mononuclear cells), protein of 231 mg/dL and glucose of 46 mg/dL. CSF Gram stain demonstrated no organisms. She was treated with ampicillin, cefotaxime and vancomycin.
She subsequently developed apnea and seizures requiring intubation and anti epileptic drugs. The blood and CSF cultures grew a Gram-positive bacillus, later identified as P. alvei. She developed cerebritis and cerebral edema on imaging, and a follow-up magnetic resonance imaging done 2 weeks after initial presentation showed bilateral frontal, bilateral parietal and right temporal lobe cystic encephalomalacia and ex vacuo dilation of the ventricular system.
Given the overall poor neurologic prognosis, the patient’s parents declined further aggressive measures, and she was discharged home with transpyloric feedings on hospice care after completing 21 days of vancomycin and ampicillin therapy. She temporarily regained the ability to eat by mouth but had profound developmental delay, seizures and an increasing head circumference; she died 5 months after discharge.
Five cases of Bacillus alvei infections are reported in English literature1–5; the neonatal patient reported by Wiedermann5 is most similar to ours. That patient also developed seizures during the illness, but the outcome reported was that of a developmentally normal child. In fact, all of these patients were appropriately treated, and patient outcomes were favorable, which is in marked contrast to our patient.
Despite early recognition of illness, adequate antibiotic coverage and aggressive supportive care, our patient’s poor outcome illustrates that P. alvei infections must be considered serious and potentially fatal. Although previous case reports demonstrate resolution of infections without serious sequelae, providers should be aware that extensive brain damage and neurologic deficits may be a consequence of P. alvei meningoencephalitis infections.
Stephanie D. DeLeon, MD
Department of Pediatrics Section of General and Community Pediatrics
Robert C. Welliver Sr, MD
Section of Infectious Diseases University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma
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. J Clin Microbiol. 1989;27:1395–1396
2. Coudron PE, Payne JM, Markowitz SM. Pneumonia and empyema infection associated with a Bacillus
species that resembles B. alvei
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5. Wiedermann BL. Non-anthrax Bacillus infections in children. Pediatr Infect Dis J. 1987;6:218–220