|Year : 2015 | Volume
| Issue : 3 | Page : 646
Cedecea lapagei in a patient with malignancy: Report of a rare case
Indu Biswal1, Nishat Ahmed Hussain1, RK Grover2
1 Department of Laboratory Medicine, Delhi State Cancer Institute, Dilshad Garden, New Delhi, India
2 Department of Clinical Oncology, Delhi State Cancer Institute, Dilshad Garden, New Delhi, India
|Date of Web Publication||9-Oct-2015|
Nishat Ahmed Hussain
Department of Laboratory Medicine, Delhi State Cancer Institute, Dilshad Garden, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Cedecea lapagei is a member of the family Enterobacteriaceae and is an uncommon pathogen. There are very few reports of isolation of this organism from biological samples; mostly it is found to be a pathogen in elderly or otherwise medically compromised. We present a rare case of a patient with underlying malignancy of buccal mucosa, who developed an oral ulcer superinfected with C. lapagei. According to the available literature, this is the first case of C. lapagei from India detected in a cancer patient.
Keywords: Cedacea lapagei, India, malignancy, VITEK
|How to cite this article:|
Biswal I, Hussain NA, Grover R K. Cedecea lapagei in a patient with malignancy: Report of a rare case. J Can Res Ther 2015;11:646
| > Introduction|| |
The genus Cedecea consists of gram negative, oxidase negative, motile, nonsporing, non-encapsulated bacilli. The genus belongs to the family Enterobacteriaceae and consists of five species-C. davisae, C. lapagei, C. neteri, C. species 3 and 5. The genus Cedecea is closely related to the genus Serratia, but the members of Cedecea do not hydrolyze DNA or gelatin. Cedecea lapagei was named after Stephen Lapage, a British bacteriologist, who contributed to bacterial systematics as the editor of Bacteriological Code.  We searched for relevant studies indexed in the PubMed, Medline and Google database for articles with words 'Cedacea' and 'Cedacea- India'. Based on available literature and to the best of our knowledge, we present the first case report of C. lapagei causing infection in a patient with carcinoma of buccal mucosa in India.
| > Case report|| |
A 50-year-old male patient, businessman by occupation residing in an urban area, having squamous cell carcinoma (SCC) of the right buccal mucosa (T 4 N 2c M 0 ), undergoing chemotherapy with cycloserine, cisplatin, vincristine; and radiotherapy in our institute for 3 months, presented with ulcer and pus formation at the cancer site. The ulcer was a well-defined mass (10 × 4 cm) involving right buccal mucosa. Contrast enhanced computer tomography (CT) of mass showed the mass lesion invading mandible, right myelohyoid muscle and right border of tongue. The ulcer was painful at the local site radiating to ear and forehead. His hematocrit parameters showed leucopoenia (2,190/μl) with monocytosis (N = 25%, L = 34%, M = 40%, E = 0%, B = 0%). Pus samples from the ulcer site were taken and processed by standard microbiological techniques.  Gram stain of the pus sample revealed leukocytes and gram negative bacilli. The sample was cultured into Blood agar and MacConkey agar; after overnight incubation at 37 °C, growth of 1-1.5 mm diameter, convex, non-pigmented, non-lactose forming colonies was seen. Gram stain of the growth showed gram negative, nonsporing, noncapsulated bacilli. The bacteria were motile in nature. The colonies were subjected to automated VITEK R 2 Compact (C) (Biomeriux, North Carolina/USA), for identification using gram negative GN REF 21341 identification (GNID) card. The isolate was identified as Cedecea lapagei. As this is not a usual isolate, a repeat sample was collected on the next visit of the patient and similarly cultured. The pathogen isolated was again identified as Cedecea lapagei. Antibiotic susceptibility of the isolate was done in VITEK with AST-N090 GN card. The bacterium was found to be sensitive to amikacin, gentamicin, ceftazidime, ceftriaxone, cefepime, ciprofloxacin, meropenem and trimethoprim/sulfamethoxazole, and resistant to ampicillin/sulbactam, tetracycline and tigecycline. Urine and blood cultures of the patient were sterile. The patient was started on injection Granulocyte colony stimulating factor (G-CSF) to reverse the myelosuppression induced by cytotoxic drugs, tablet ciprofloxacin 500 mg twice daily, oral betadine washes and mucaine gel to heal the ulcer. After a week, the ulcer regressed in size. The leucocytes count also raised and came back to normal (6, 900/μl) within a fortnight.
| > Discussion|| |
We report a rare and interesting case of malignant oral ulcer superinfected with C. lapagei. The patient had 25% neutrophils and a leukocyte count of 2,190/μl. Unusual microorganisms are often reported to be pathogenic in patients with underlying malignancy accompanied with neutropenia. Although bacterial superinfections are most common, Herpes Simplex virus (HSV), Cytomegalovirus or fungal infections are also known to cause opportunistic superinfections.
In the medical literature, there are very few reports that describe infections such as pneumonia, soft tissue infections, urinary tract infections and sepsis, which were caused by different species of the genus Cedecea. ,, In this case, the patient presented with ulcer at cancer site infected with C. lapagei. Similar finding has been reported by Mawardi et al., where a patient with post renal transplantation developed an oral ulcer super infected with C. davisae. According to literature, Cedecea strains are frequently isolated from sputum but their role in clinical infections is not clear. C. davisae and C. neteri have been reported to cause bacteraemia, ulcer, abscess, wound and ophthalmic infections and C. lapagei has been reported to cause pneumonia as shown in [Table 1]. ,,,
|Table 1: Reports of pathogenic isolates of Cedecea causing infections globally|
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Treatment of this infection is sometimes a challenge because strains can be resistant to a variety of antimicrobial agents, particularly cephalothin, first-generation cephalosporin. Other common antimicrobial agents to which Cedacea is resistant are ampicillin, colistin, and cefoxitin (second-generation cephalosporin). ,,,,, In this case, the patient showed quick recovery with antibiogram guided therapy of oral ciprofloxacin 500 mg twice daily and the haematological parameters returned to normal with 15 days.
The source of C. lapagei in this patient is unclear. It is unlikely to be a nosocomial infection because he presented with this ulcer after a few months of undergoing chemo and radiotherapy. Cedecea is neither a known as a commensal of human skin, nor it is a common resident of hospital environment.  However, Cedecea may have environmental reservoirs, which was proved by a study where Pande et al., reported that over 50% of the isolates from agricultural dust belonged to family Enterobacteriaceae, out of which 0.7% were Cedecea.  In addition, this organism has also been reported in aqueous environments.  Hence, there is a probability that the Cedecea lapagei strain isolated from our patient has been acquired from the community or the environment and has caused infection in our patient due to his immune-compromised status.
In conclusion, we report the first case of Cedecea lapagei infection in a cancer patient from India. This, along with other reports of infection caused by this rare pathogen, points to the opportunistic behavior of this organism, hence highlighting the requirement of prompt identification of the bacterium and commencement of adequate antibiotic therapy.
| > References|| |
Grimont PA, Farmer JJ 3 rd
, Grimont F, Asbury MA. Cedecea davisae
gen. nov., sp. nov. Cedecea lapagei
sp. nov, New Enterobacteriaceae
from clinical specimens. Int J Syst Evol Bacteriol 1981;31:317-26.
Collee JG, Miles RS, Watt B. Laboratory control of antimicrobial therapy. In: Mackie and McCartney Practical Medical Microbiology. Fourteenth Ed. Collee JG, Fraser AG, Marmion BP, Simmons A, editors. USA: Churchill Livingstone; 1996. p.151-78.
Dalamaga M, Pantelaki M, Karmaniolas K, Matekovits A, Daskalopoulou K. Leg ulcer and bacteraemia due to Cedecea davisae
. Eur J Dermatol 2008;18:204-5.
Mawardi H, Pavlakis M, Mandelbrot D, Woo SB. Sirolimus oral ulcer with Cedecea davisae
superinfection. Transpl Infect Dis 2010;12:446-50.
Farmer JJ 3 rd
, Sheth NK, Hudzinsky JA, Rose HD, Asbury MF. Bacteremia due to Cedecea neteri sp. nov. J Clin Microbiol 1982;16:775-8.
Aguilera A, Pascual J, Loza E, Lopez J, Garcia G, Lianio F, et al
. Bacteremia with Cedecea neteri
in a patient with systemic lupus erythematosus. Postgrad Med J 1995;71:179-80.
Yetkin G, Ay S, Kayabas U, Gedik E, Gucluer N, Caliskan A. A pneumonia case caused by Cedecea lapagei. Mikrobiyol Bul 2008;42:681-4.
Aðca H, Bozkurt M. A pneumonia case caused by Cedecea Lapagei
. J Clin Anal Med 2014:5:147-8.
Bae BH, Sureka SB. Cedecea davisae
isolated from scrotal abscess. J Urol 1983;130:148-9.
Pande BN, Krysinska-Traczyk E, Prazmo Z, Skorska C, Sitkowska J, Dutkiewicz J. Occupational biohazards in agricultural dusts from India. Ann Agric Environ Med 2000;7:133-9.