A case of Wohlfahrtiimonas chitiniclastica bacteremia in continental United States

Wohlfahrtiimonas chitiniclastica: current insights and complementary review from Chinese cases

Wohlfahrtiimonas chitiniclastica is an emerging zoonotic pathogen associated with bacteremia, myiasis, and soft tissue infections. It is insufficiently identified and underestimated due to reasons, such as shortcomings of the traditional identification techniques and language barriers in local case reports from different regions. In this review, we summarize the currently available literature. In particular, we added previously overlooked cases from Chinese and other medical communities. The clinical characteristics, identification, and treatment of W. chitiniclastica are discussed. This work provides a complete review of the previous work including cases from human, animal, and other sources.

The zoonotic pathogen Wohlfahrtiimonas chitiniclastica - current findings from a clinical and genomic perspective

The zoonotic pathogen Wohlfahrtiimonas chitiniclastica can cause several diseases in humans, including sepsis and bacteremia. Although the pathogenesis is not fully understood, the bacterium is thought to enter traumatic skin lesions via fly larvae, resulting in severe myiasis and/or wound contamination. Infections are typically associated with, but not limited to, infestation of an open wound by fly larvae, poor sanitary conditions, cardiovascular disease, substance abuse, and osteomyelitis. W. chitiniclastica is generally sensitive to a broad spectrum of antibiotics with the exception of fosfomycin. However, increasing drug resistance has been observed and its development should be monitored with caution. In this review, we summarize the currently available knowledge and evaluate it from both a clinical and a genomic perspective.

Phylogenomics and comparative genomic analyses support the creation of the novel family Ignatzschineriaceae fam. nov. comprising the genera Ignatzschineria and Wohlfahrtiimonas within the order Cardiobacteriales

The genera Ignatzschineria and Wohlfahrtiimonas were originally classified as members of the family Xanthomonadaceae, order Xanthomonadales of the class Gammaproteobacteria. With the recent taxonomic revisions in the order Xanthomonadales, the two genera were left unclassified in both family and order level. As members of these genera were considered emerging pathogens, their proper classification is therefore relevant. Here, a phylogenomics and comparative genomic approach was used to ascertain the taxonomic position of the two genera. Result showed that the members of the two genera formed a highly supported monophyletic clade with the members of the order Cardiobacteriales. This close affiliation was further supported by the results of the comparative analysis of the 16S rRNA sequence similarity values. The comparative analyses of the 16S rRNA sequence similarity and average amino acid identity values also implied that the two genera represent a single novel family. Conserved signature indels (CSIs) in seven protein sequences were exclusively shared by the members of the novel family. In addition, four CSIs were also found to be useful in delimiting members of the two genera at the genus level. To accommodate the two genera in a single family within the order Cardiobacteriales, the name Ignatzschineriaceae fam. nov. is proposed.

Comparative Genomic Analysis of the Human Pathogen Wohlfahrtiimonas Chitiniclastica Provides Insight Into the Identification of Antimicrobial Resistance Genotypes and Potential Virulence Traits

Recent studies suggest that Wohlfahrtiimonas chitiniclastica may be the cause of several diseases in humans including sepsis and bacteremia making the bacterium as a previously underappreciated human pathogen. However, very little is known about the pathogenicity and genetic potential of W. chitiniclastica; therefore, it is necessary to conduct systematic studies to gain a deeper understanding of its virulence characteristics and treatment options. In this study, the entire genetic repertoire of all publicly available W. chitiniclastica genomes was examined including in silico characterization of bacteriophage content, antibiotic resistome, and putative virulence profile. The pan-genome of W. chitiniclastica comprises 3819 genes with 1622 core genes (43%) indicating a putative metabolic conserved species. Furthermore, in silico analysis indicated presumed resistome expansion as defined by the presence of genome-encoded transposons and bacteriophages. While macrolide resistance genes macA and macB are located within the core genome, additional antimicrobial resistance genotypes for tetracycline (tetH, tetB, and tetD), aminoglycosides (ant(2'')-Ia, aac(6')-Ia,aph(3'')-Ib, aph(3')-Ia, and aph(6)-Id)), sulfonamide (sul2), streptomycin (strA), chloramphenicol (cat3), and beta-lactamase (blaVEB) are distributed among the accessory genome. Notably, our data indicate that the type strain DSM 18708T does not encode any additional clinically relevant antibiotic resistance genes, whereas drug resistance is increasing within the W. chitiniclastica clade. This trend should be monitored with caution. To the best of our knowledge, this is the first comprehensive genome analysis of this species, providing new insights into the genome of this opportunistic human pathogen.

Wohlfahrtiimonas chitiniclastica-related soft-tissue infection and osteomyelitis: A rare case report

Wohlfahrtiimonas chitiniclastica is a rare pathogen that was first isolated from Wohlfahrtia magnifica, a parasitic fly. It is an uncommon, but an emerging human pathogen reported only in Europe and South America. Until today, it has been reported to be a zoonotic pathogen originating from different geographic locations. The present case, a patient suffering from osteomyelitis in Turkey, represents the first report of this pathogen in this country and so far no reports of related osteomyelitis associated with W. chitiniclastica is available. Clin-ical awareness of these emerging human pathogens is crucial for controlling infectious diseases.

Wohlfahrtiimonas chitiniclastica Monomicrobial Bacteremia in a Homeless Man

We report a case of septic shock attributable to monomicrobial bloodstream infection secondary to Wohlfahrtiimonas chitiniclastica infection. This case suggests that W. chitiniclastica likely possesses the virulence to cause severe disease. Culture-independent techniques were essential in the identification of this organism, which enabled selection of appropriate therapy.

Emerging Pathogenic Gammaproteobacteria Wohlfahrtiimonas chitiniclastica and Ignatzschineria Species in a Turkey Vulture (Cathartes aura)

New World vultures, such as turkey vultures (Cathartes aura), are obligate scavengers with large geographic ranges. In a preliminary characterization of the turkey vulture (TV) gastrointestinal microbiome in Southern California, we identified 2 recently described emerging bacterial pathogens not previously known to be associated with this avian species. High-throughput sequencing of broad-range 16S rRNA gene amplicons revealed sequences from TV cloacal swabs that were related closest to Wohlfahrtiimonas chitiniclastica and Ignatzschineria species, both Gammaproteobacteria considered by the United States Centers for Disease Control and Prevention as emerging zoonotic pathogens. None of these bacterial sequence types have been previously identified from samples obtained from the turkey vulture gastrointestinal microbiome. With the use of bioinformatics workflows previously established by our research group, we designed specific and sensitive polymerase chain reaction primer sets that represent novel diagnostic assays for the genera Wohlfahrtiimonas and Ignatzschineria. These primer sets were validated by Sanger sequence confirmation from complex TV samples. Because the genera Wohlfahrtiimonas and Ignatzschineria are both known to have dipteran hosts, the molecular diagnostic tools we present here should be useful for better understanding the role of flies, vultures, and other scavengers in the ecology and epidemiology of the genera Wohlfahrtiimonas and Ignatzschineria from a One Health perspective.

Identification and Antibiotic Profiling of Wohlfahrtiimonas chitiniclastica, an Underestimated Human Pathogen

In the past 12 years, several case reports have clearly demonstrated that Wohlfahrtiimonas chitiniclastica is capable of causing sepsis and bacteremia in humans. However, since most clinicians are not familiar with this species, little is known about its pathogenicity and treatment options while it is as rare but underestimated human pathogen. Therefore, a larger strain collection is required so that methods can be identified that are most suitable to obtain rapid and reliable identification. Moreover, the antimicrobial resistance profile needs to be elucidated in order to explore possible treatment options. Over a period of 6 years, we therefore have collected a total of 14 W. chitiniclastica isolates in routine diagnostics, which now served as the basis for a comprehensive characterization with respect to identification and antibiotic profiling. We compared the accuracy and convenience of several identification techniques in which MALDI-TOF MS and sequencing of the 16S rRNA gene have proven to be suitable for identification of W. chitiniclastica. In addition, whole genome sequencing (WGS)-based digital DNA-DNA hybridization (dDDH) was used as a reference method for strain identification, and surprised with the detection of a novel W. chitiniclastica subspecies. A combination of in silico and in vitro analyses revealed a first insight into the antimicrobial resistance profile and the molecular basis of antimicrobial resistance. Based on our findings, trimethoprim/sulfamethoxazole, levofloxacin, and cephalosporins (e.g., ceftazidime) may be the best antibiotics to use in order to treat infections caused by W. chitiniclastica, while resistance to fosfomycin, amikacin and tobramycin is observed.

Human Infections by Wohlfahrtiimonas chitiniclastica: A Mini-Review and the First Report of a Burn Wound Infection after Accidental Myiasis in Central Europe

Wohlfahrtiimonas chitiniclastica are bacteria that cause rare infections, typically associated with the infestation of an open wound with fly larvae. Here, we present a unique case report of the first W. chitiniclastica isolation from a burn wound with accidental myiasis in a 63-year-old homeless man and a literature review focused on human infections caused by these bacteria. So far, 23 cases of infection with W. chitiniclastica have been reported; in 52% of these, larvae were found in the wound area. Most of these cases suffered from chronic non-healing wound infections but none of these were burn injuries. The overall fatality rate associated directly with W. chitiniclastica in these cases was 17%. Infections with parasitic larvae occur in moderate climates (especially in people living in poor conditions); therefore, an infection with rare bacteria associated with accidental myiasis, such as W. chitiniclastica, can be expected to become more common there. Thus, in view of the absence of recommendations regarding the treatment of patients with accidental myiasis and, therefore, the risk of infection with W. chitiniclastica or other rare pathogens, we provide a list of recommendations for the treatment of such patients. The importance of meticulous microbial surveillance using molecular biological methods to facilitate the detection of rare pathogens is emphasized.

Myiasis absent Wohlfahrtiimonas chitiniclastica bacteremia in a lung cancer patient: a case report

Background

A gruesome infection was found in a woman with advanced lung tumor and associated malnutrition. Worldwide, bacteremia with Wohlfahrtiimonas chitiniclastica was only found in 13 cases yet.

Case presentation

This is the first case in Austria and the first case without infestation of maggots.

Conclusions

This germ is an emerging human pathogen not only in patients with poor personal hygiene, difficult social circumstances, alcohol dependence or chronic wounds. It must be included in the differential diagnosis of immunocompromised patients with pneumonia.

Emerging pathogens: A case of Wohlfahrtiimonas chitiniclastica and Ignatzschineria indica bacteremia

Wohlfahrtiimonas chitiniclastica and Ignatzschineria indica are rare causes of infection in humans and have been linked to infestation with fly larvae in open wounds. Both organisms are emerging causes of disease globally and co-infection resulting in bacteremia is rare. An 82-year-old male with bilateral lower extremity infections was hospitalized due to fall with associated right lower extremity pain. On exam, a maggot infested ulcer was identified on his right lower extremity. On day three of hospitalization, blood cultures grew gram-negative and gram-variable rods, and methicillin-resistant Staphylococcus aureus. Further analysis of the gram negative and gram variable rods revealed W. chitiniclastica and I. indica respectively. Both I. indica and W. chitiniclastica were pan sensitive to all antimicrobials tested with the exception of tetracyclines to which W. chitiniclastica was fully resistant and I. indica was intermediately sensitive. The patient was treated with two weeks of IV ceftriaxone and was discharged with plans to complete a six-week course of IV daptomycin due to MRSA bacteremia. All repeat blood cultures were negative. Until recently W. chitiniclastica and I. indica infections have been documented only in farm and feral animals. Major risk factors for infection include: poor hygiene, open wounds, peripheral vascular disease, and myiasis. Due to the rarity of infection, identification of both organisms can be difficult, therefore a high index of suspicion is required.

Myiasis-induced sepsis: a rare case report of Wohlfahrtiimonas chitiniclastica and Ignatzschineria indica bacteremia in the continental United States

RATIONALE

The presentation of sepsis and bacteremia in cutaneous and cavitary myiasis is uncommon. We present a patient, residing in a temperate region of the United States, with myiasis and sepsis from the emerging human pathogens Wohlfahrtiimonas chitiniclastica and Ignatzschineria indica.

PATIENT CONCERNS

A 37-year-old male patient with an 8-month history of chronic lymphedema and ulcers of the lower left extremity presented with myiasis of the left foot and leg. The patient was initially seen by his family practitioner many times and was prescribed antibiotics which he could not afford. Debridement of the myiasis was not conducted by the family practitioner due to the belief that the patient's current state of myiasis would effectively debride and eventually heal the chronic ulcers along with multiple antibiotic regimens. Over the 8-month period, the patient developed a progressive, painful, necrotizing infection of his lower left extremity.

DIAGNOSES

Physical examination clearly showed myiasis of the patient's lower left extremity, believed to be caused by Lucilia sericata (green bottle fly). Blood cultures revealed the presence of Providencia stuartii, W chitiniclastica, and I indica to be the underlying cause of sepsis and bacteremia.

INTERVENTIONS

All visible maggots were extracted, debridement of devitalized tissue was performed, and the leg ulcers were wrapped in pH neutral bleach. The patient was initially treated with a broad-spectrum antibiotic regimen of vancomycin, clindamycin, piperacillin, and tazobactam which, following clinical improvement, was de-escalated to cefepime.

OUTCOMES

The fly larvae and maggots were removed from the extremity by scrubbing, pulse lavage, and filing away the callused tissue. Additionally, the patient's sepsis and bacteremia, caused by W chitiniclastica and I indica, were successfully treated through antibiotic intervention. Amputation was avoided.

LESSONS

The use of pulse lavage and chlorhexidine-soaked brushes for the removal of cavitary myiasis is an effective and minimally invasive procedure which does not cause additional damage to surrounding tissue. W chitiniclastica and I indica are emerging bacteria that have known association to parasitic fly myiasis in humans and are capable of causing sepsis and/or bacteremia if not accurately identified and treated promptly.