Yokenella regensbergei : Unveiling a hidden pathogen causing skin and soft tissue infection in an immunocompetent patient: a case report

  1. Mahima Khatri
  2. Shikhir Malhotra
  3. Sarika Kombade

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Abstract

Background : Yokenella regensburgei is Gram-negative, oxidase-negative, non-sporing, motile rod with peritrichous flagella . It is rarely isolated from human samples. Case presentation: This a case report of a 52 year old male patient who presented to our centre with a non healing ulcer. A culture from the biopsy sample (from the ulcer) isolated Yokenella regensburgei . The patient was started on antibiotics for the same which lead to healing of the ulcer. Conclusion : Increased discussion about such rare isolates will aid in proper identification and proper treatment of such patients especially in low income centres. To the best of our knowledge this is a first case report from India regarding Yokenella regensburgei as a cause of skin and soft tissue infection.

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  1. Version published to 10.1099/acmi.0.001007.v2 on Access Microbiology
  2. Access Microbiology

    Comments to Author

    There are multiple spelling & grammatical errors, please run a spell & grammar check. I cannot see any mention of selective plates for Gram positives, eg colistin-naladixic acid or similar. Without such plates (or even with, if the Yokenella was not inhibited) the growth of an Enterobacterales species, even in pure growth, cannot be unequivocally considered to be a true pathogen. Please clarify what was done to exclude a slower growing Gram positive pathogenic organism. The amount of growth on the original plates is not stated. Please confirm and explicitly state that the primary plates did in fact isolate the Yokenella. I am sure readers would be concerned that Yokenella represented colonising flora only. Could the authors please include a short paragraph summarising the evidence that Yokenella was the true pathogen in this case? The case would have benefited by histology if it were available. Please specify the type of Vitek card used, presumably a form of GNI card, and the specific result obtained. While I appreciate the local identification and susceptibility methods quoted, for an international audience a MALDI-TOF identification is in my opinion essential information. This should include the machine manufacturer, preparation of the sample, database utilised and best score achieved. If the authors performed any disc apporoximation studies to detect ampC & ESBL beta-lactamases (eg Rosco method or similar) could they please describe the results. While the patient appeared to respond to antibiotics, levofloxacin is very broad spectrum, as is the topical neomycin ointment, and together they would have treated many other possible pathogens. The patient is described as immunocompromised in the abstract (line 78) but immunocompetent in the discussion (line 200). Please amend one of these. I presume the patient did not require surgery. This is not explicitly stated. Also, could the authors clarify if there was a recurrence of infection over time? It is difficult to believe that osteomyelitis in a man with severe peripheral vascular disease was cured with 7 days of levofloxacin, as implied (line 178), although I acknowledge that the total duration of antibiotics is not mentioned. The exact duration of antibiotic therapy is not stated. Perhaps the authors could remedy this.

    Please rate the quality of the presentation and structure of the manuscript

    Poor

    To what extent are the conclusions supported by the data?

    Not at all

    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

  3. Access Microbiology

    Both reviewers have expressed concerns about the strength of evidence provided to support the claims of Yokenella regensbergei being the causative agent of the non healing ulcer wound. Please can you address the comments below to provide. I also recommend a title change to more accurately convey the type of infection the case report is dealing with.

  4. Access Microbiology

    Comments to Author

    Please ONLY put comments for the Author(s) in here Thank you for submitting your work to Access Microbiology. Please find below the points on which a clarification is requested: The underlying diagnosis in this case presentation: 1. The presentation of initial right sided weakness and the diagnosis of paraplegia in view of the Left cerebellar CVA. The bacterial isolation methodology: 1. There has been local treatment and thus manipulation of the wound site. [a] what was the initial presentation - why did he seek local treatment - [b] what did the local treatment include? antiseptics? why did he not seek further help? what was his pain level? [c] since this organism is found in the environment, how can the environmental wound contamination be ruled out? 2. Is it a practice at this hospital to perform punch biopsies on all incidental non-healing dry ulcers? 3. Why was the second punch biopsy performed? what was the time difference between the two biopsies? 4. The biopsy material was directly inoculated into Brain heart infusion broth and then subcultured- it is then obvious that all subcultures will have the same finding. Why was this practice adopted? 5. This organism has been found to be resistant to the third generation cephalosporins- this isolate is reported as susceptible- comment. Discussion: 1. The discussion includes the history of the organisms taxonomy, articles from India and the difficulties in identification. However, does not allude to any discussion of other articles on wound presentation and management issues bringing clarity to one aspect of this emerging bacterial infection - in which subset of patients can it cause wound infections, their presentations and management issues. Since molecular work has not been undertaken, comments or discussion about the same may be avoided. Consents: Information on patient consent is not included. Co-authors does not include a neurologist to confirm the findings of the underlying diagnosis.

    Please rate the quality of the presentation and structure of the manuscript

    Satisfactory

    To what extent are the conclusions supported by the data?

    Partially 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

  5. Version published to 10.1099/acmi.0.001007.v1 on Access Microbiology