Erysipelothrix rhusiopathiae-associated bloodstream infection in a patient with systemic lupus erythematosus: a case report and literature review
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Introduction. Systemic human infections caused by Erysipelothrix rhusiopathiae have been increasingly reported especially within immunocompromised hosts and those with significant occupational exposure to livestock and aquatic animals. We report a case of E. rhusiopathiae bacteraemia in a patient with systemic lupus erythematosus (SLE) and present a literature review on clinical outcomes and microbiologic diagnosis for this organism.
Case presentation. A 43-year-old female patient was reporting a 1-month history of intermittent fevers. She recently increased her immunosuppression medication for her underlying SLE on the advice of her rheumatologist. The patient sustained a finger laceration from butchering cattle meat 2 weeks after the onset of her initial symptoms, with worsening index finger swelling and increased febrile episodes. Two weeks post-injury, multiple blood cultures were drawn, and each isolated Gram-positive bacilli. Given her recurrent intermittent fevers, there was a concern for ongoing infection, and therefore, intravenous vancomycin was started with prompt referral to an outpatient parenteral antibiotic therapy clinic. The Gram-positive bacillus was confirmed as E. rhusiopathiae via matrix-assisted laser desorption/ionization-time of flight analysis. Given intrinsic resistance to vancomycin, vancomycin was switched to intravenous ceftriaxone as targeted antimicrobial therapy for 2 weeks. Reassuringly, there was no echocardiographic evidence of infective endocarditis, warranting the prolonged treatment course. Post-treatment, she remained symptom-free with the resolution of joint symptoms and fevers.
Conclusion. Our report illustrates a case of E. rhusiopathiae bacteraemia from an immunodeficient host, with prompt microbiologic diagnosis and intervention with appropriate antimicrobial coverage. Literature reflects the rarity of this infection, predilections to specific susceptible hosts and the importance of raising awareness of zoonotic infections.
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The work presented is clear and the arguments well formed. This study would be a valuable contribution to the existing literature.
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Comments to Author
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
Please ONLY put comments for the Author(s) in hereReviewer Comments: n: Overall, the text is well-structured and informative. The proposed literature review will provide valuable insights into the epidemiology and clinical manifestations of Erysipelothrix rhusiopathiae infections in immunosuppressed individuals. Minor Suggestions for improvement: Specific occupations: While the text mentions occupational exposure, providing examples of specific at-risk occupations (e.g., farmers, veterinarians, slaughterhouse workers) could enhance clarity. Immunosuppressed hosts: The text could briefly mention the specific immunosuppressive medications used by the patient with SLE. Risk factors: The literature review could explore additional risk factors beyond occupational exposure, such as skin trauma or …
Comments to Author
Please ONLY put comments for the Author(s) in hereReviewer Comments: n: Overall, the text is well-structured and informative. The proposed literature review will provide valuable insights into the epidemiology and clinical manifestations of Erysipelothrix rhusiopathiae infections in immunosuppressed individuals. Minor Suggestions for improvement: Specific occupations: While the text mentions occupational exposure, providing examples of specific at-risk occupations (e.g., farmers, veterinarians, slaughterhouse workers) could enhance clarity. Immunosuppressed hosts: The text could briefly mention the specific immunosuppressive medications used by the patient with SLE. Risk factors: The literature review could explore additional risk factors beyond occupational exposure, such as skin trauma or preexisting skin conditions. Case presentation Minor Suggestions for improvement: * Symptom timeline: The timeline of the patient's symptoms could be further clarified, especially regarding the onset and progression of the fevers and chest pain. * Medication adherence: Information on the patient's medication adherence could be helpful, as non-adherence can contribute to disease flares. * Other potential diagnoses: While the initial diagnosis was a lupus flare, other potential diagnoses (e.g., infection, autoimmune flare) could be briefly mentioned. * Additional tests: While the mentioned tests are relevant, considering other potential tests, such as a complete blood count with differential and inflammatory markers, could provide additional insights. * Differential diagnosis: A brief discussion of other potential diagnoses that were considered or ruled out could be included. * Follow-up: Information about the patient's response to treatment and long-term outcome would be valuable. * Immunosuppressive medications: Specifying the type(s) of immunosuppressive medications used could be helpful. * Inoculation injury: Describing the nature of the inoculation injury (e.g., puncture wound, abrasion) could provide additional context. * Duration of treatment: The duration of ceftriaxone therapy could be mentioned. Discussion: Overall, the discussion section is well-written and informative. It contributes significantly to the understanding of Erysipelothrix rhusiopathiae infections, particularly in immunosuppressed patients.
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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The reviewers have highlighted minor concerns with the work presented. Please ensure that you address their comments.
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Comments to Author
1. Line 69, 74, 81, 83, 89, 102, 124, 106 All of the above lines, you mentioned the word (fever), how much it was? And why it was normal in the line 106 (36.9)! Please mention the degree of fever precisely 2. Line 56-60 You mentioned that were confusion among the gram positive bacilli, and such confusion can be assured by MALDI-TOF, but it was not clear how such technique removes the doubt 3. Please verify the aim of your case presentation by only line 60 -63 (we…….identification ) 4. Line 87-89 The patient discharged with increase the prednisone dosage, who decide such issue? Especially you mentioned that there was no follow-up a Canada rheumatologist in with Nigeria rheumatologist 5. Line 93-94 You said there was no chest pain! While in the line 83 said she had a …
Comments to Author
1. Line 69, 74, 81, 83, 89, 102, 124, 106 All of the above lines, you mentioned the word (fever), how much it was? And why it was normal in the line 106 (36.9)! Please mention the degree of fever precisely 2. Line 56-60 You mentioned that were confusion among the gram positive bacilli, and such confusion can be assured by MALDI-TOF, but it was not clear how such technique removes the doubt 3. Please verify the aim of your case presentation by only line 60 -63 (we…….identification ) 4. Line 87-89 The patient discharged with increase the prednisone dosage, who decide such issue? Especially you mentioned that there was no follow-up a Canada rheumatologist in with Nigeria rheumatologist 5. Line 93-94 You said there was no chest pain! While in the line 83 said she had a pleuritic chest pain. Is the pain relieved after ED assessment? Please verify that 6. Lines 96,78, 103, 104 You said three events which are (fever onset, knife -contamination blood inoculation and resolving of the index figure swelling, you troubled between late September, early October and mid October !! Please be specify about the dates (day/month/year) because it is very important to knew the onset of all events consequences 7. Line 105-116 When such physical examination happened? At the ED assessment? If the physical examination was occurred during the ED assessment, please unify that with the paragraph of ED assessment (line 80-89). 8. Line 126 (the organism ------------------negative) is the best if it transfer to the line 119 after the word (was) so the statement will be (initially, the gram -positive bacilli isolated from blood culture was beige---------negative. 9. In the line 136 you said (vancomycin was changed to intravenous ceftriaxone 2 g daily) so it is the best to remove the statement of line 34, (therefore intravenous vancomycin was started with prompt referral to outpatient parenteral antibiotic therapy clinic), because it is an abstract! 10. The discussion must be focused on your case and other immunocompromised cases 11. Lines 150 -158(Minnesota) , it is actually an introduction rather than discussion! 12. Table 1,2 and figure 2, are not your work so please separate them under a title of (PubMed database) 13. Table 3, line 223-235, is your previous work? If yes, please put a title of (our previous studies). 14. Line 236-253 is best to put a title of (Erysipelothrix identification)
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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