Williamsia muralis bacteraemia in a patient with Fanconi anaemia after haematopoietic cell transplantation
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Introduction. Williamsia muralis is an environmental bacterium first detected in 1999. Infections with W. muralis isolated have been reported in two elderly patients, and were associated with the surgical intervention of artificial objects. We present a case of bacteraemia caused by W. muralis following haematopoietic cell transplantation (HCT).
Case presentation. A 10-year-old Japanese boy presented with fever and the swelling of the left cheek 8 days after HCT for the treatment of Fanconi anaemia. Gram-positive, rod-shaped bacteria were isolated from the blood cultures after 5 days incubation. 16S rRNA sequencing, but not mass spectrometry, identified a strain of W. muralis (1 414 bp, %ID 100 %). The phlegmon did not respond to antimicrobial therapy, but remitted with defervescence after a successful engraftment with teicoplanin and meropenem therapy on day 16 after HCT. The patient experienced recurrence of the bacteraemia, leading to central venous catheter (CVC) line removal. The same strain of W. muralis was isolated from the cultured tip of the CVC. To our knowledge, this is the first reported case of W. muralis bacteraemia and was complicated by CVC infection after HCT.
Conclusion. W. muralis bacteraemia developed in an immunocompromised child. Introduction of artificial objects into the body raises a risk of rare infection with slowly growing environmental bacteria.
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This study would be a valuable contribution to the existing literature. This is a study that would be of interest to the field and community.
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This is a study that would be of interest to the field and community. The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
Interesting case. I really like the Figure 1 - it makes the timeline very clear. The only minor adjustments I would suggest are with the language - in general this is good but there is the odd sentence where the choice of words does not make clear sense and could do with proofreading e.g. line 131-133 "These suggest a precaution that W. muralis infection occurs when environmental bacteria attach to these artificial objects." - I am not sure that the word precaution is the correct one in this context.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical …
Comments to Author
Interesting case. I really like the Figure 1 - it makes the timeline very clear. The only minor adjustments I would suggest are with the language - in general this is good but there is the odd sentence where the choice of words does not make clear sense and could do with proofreading e.g. line 131-133 "These suggest a precaution that W. muralis infection occurs when environmental bacteria attach to these artificial objects." - I am not sure that the word precaution is the correct one in this context.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
Thank you - interesting case. 1. Description of the case(s) a. Investigations and diagnosis (Section 5) - please clarify if the blood cultures were processed in an automated continuously monitored commercial blood culture machine and manufacturer or is this a terminal subculture? b. Investigations and diagnosis (Section 5)- please clarify if the positive blood cultures are peripheral / CVC and if aerobic / anaerobic bottles or separate sets. c. Investigations and diagnosis (Section 5) - please clarify if 16S PCR was done by Sanger sequencing / platform used / if external laboratory. d. Investigations and diagnosis (Section 5) - please expand on VITEK MS to make clear it's a mass spectroscopy, MALDI-TOF system. e. Investigations and diagnosis (Section 5)- please clarify if agar plate dilution …
Comments to Author
Thank you - interesting case. 1. Description of the case(s) a. Investigations and diagnosis (Section 5) - please clarify if the blood cultures were processed in an automated continuously monitored commercial blood culture machine and manufacturer or is this a terminal subculture? b. Investigations and diagnosis (Section 5)- please clarify if the positive blood cultures are peripheral / CVC and if aerobic / anaerobic bottles or separate sets. c. Investigations and diagnosis (Section 5) - please clarify if 16S PCR was done by Sanger sequencing / platform used / if external laboratory. d. Investigations and diagnosis (Section 5) - please expand on VITEK MS to make clear it's a mass spectroscopy, MALDI-TOF system. e. Investigations and diagnosis (Section 5)- please clarify if agar plate dilution microplates are prepared in house or if commercial and what media is used. f. Treatment and outcome (Section 5)- how was it determined the same strain of W. muralis isolated again? This statement should be supported or simply state that W. muralis was isolated again. 2. Presentation of results a. Abstract (Section 2) Case presentation - previous reports of W. muralis infection should be moved to the introductory section above this and should state these were associated with prosthetic material / intervention to support comment about introduction of artificial objects in the abstract conclusion section. I'd suggest also mentioning in the main introduction (Section 4) that previous cases of W. muralis infection have been associated with intervention / prosthetic material. b. Abstract (Section 2) Case presentation - please make it clear that there was recurrence of bacteraemia, leading to line removal and positive line tip culture. c. Figure 1 and 2 are excellent and table 1 with AST is very clear. 3. How the style and organization of the paper communicates and represents key findings a. Abstract (Section 2) Case presentation - stating "bacteraemia was determined to arise from the catheter-related bloodstream infection" - I don't think it's possible to determine if this is a primary CRBSI or secondary to facial cellulitis. I'd suggest rewording this sentence to reflect it's the first reported case of W. muralis bacteramia and was complicated by CVC infection. b. Introduction (Section 4) - last statement "findings provide evidence that W. muralis forms biofilm on the inserted artificial objects" - this is speculation without any previous reference to the presence of CVC in the introduction. Please consider moving this to the discussion section (Section 7) and add supporting comments, such as recalcitrant bacteramia prior to line removal and positive culture from line tip. 4. Literature analysis or discussion a. Table 2 is good - clearly presents previous cases of W. muralis infection. b. Discussion (Section 7) - "facial cellulitis with bacteraemia originating from the CVC" - this implies CVC is the primary source of bacteraemia which I don't think is possible to confirm / refute. As before, I'd suggest rewording this. c. In Introduction (Section 4) and Figure 1 - reference made to bloody diarrhoea but no further comment in the manuscript. Please comment in the Discussion (Section 7) if bloody diarrhoea was thought to be related or unrelated to bacteraemia. d. Discussion (Section 7)- I'd suggest a comment about difficulties in laboratory identification of this organism and risk of misidentification with commercial biochemical systems. I think this is a key message from this paper. 5. Any other relevant comments a. Abstract (Section 2) - "blood cultures after five day's incubation" - remove apostrophe. b. Discussion (Section 7) - "The first oldest patient without immunodeficiency" should be reworded for clarity - suggest removing "oldest". c. Discussion (Section 7) - "...there was no description of the positive blood culture" - this implies there was a positive blood culture, consider rewording to clarify if any mention of blood cultures in the paper. d. Discussion (Section 7) - consider rewording to clarify what is meant by a "blood-born lesion" - source of bacteraemia or metastatic site of infection?
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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