Hackensack University Medical Center Hackensack, NJ
Sophia H. Dar, MD, Rosario Ligresti, MD; Hackensack University Medical Center, Hackensack, NJ
Introduction: Stenotrophomonas Maltophilia (SM), an aerobic, multi-drug resistant, gram-negative (GN) bacillus is an increasingly recognized nosocomial pathogen. Its pathogenicity arises from its ability to form a biofilm, so it is commonly seen in immunocompromised patients who have undergone invasive procedures. This organism is also consistently resistant to carbapenems, the drug of choice (DOC) for treating necrotizing pancreatitis (NP). We report an immunocompetent patient with NP infected with SM whose most likely source of exposure was the environment.
Methods: We present a 21-year old female with a past medical history significant for a spontaneous vaginal delivery 2 weeks prior to admission and hypothyroidism. She had presented with epigastric pain radiating to the back and vomiting. Her labs were significant for a WBC count at 15.6/mcL, amylase of 1847 and a lipase >8000. An MRI abdomen with MRCP revealed severe hemorrhagic NP involving the pancreatic tail and cholelithiasis. She subsequently developed fevers, so a CT scan was done, now showing a pancreatic fluid collection (PFC) (Figure 1). She was treated with a course of meropenem, after which she stated she felt better and decided to have her PFC drained outpatient. On day 27, she presented to the outpatient endoscopy suite for an endoscopic ultrasound (EUS) guided cystogastrostomy with placement of an AXIOS stent. She returned to the emergency room on day 31 with epigastric pain and fevers. She was taken for a necrosectomy and was found to have necrotic debris blocking off her drainage site, which after removal, resulted in significant drainage (Figure 2). Cultures returned positive for SM and methicillin-resistant Staphylococcus Aureus. She further went on to have 3 more endoscopic necrosectomies and was treated with a course of vancomycin and trimethoprim-sulfamethoxazole (TMP-SMX). The patient experienced significant relief from her pain and one month after her last necrosectomy, underwent a laparoscopic cholecystectomy. Discussion: One-third of patients with NP will develop infections, which is associated with markedly increased morbidity and mortality. GN bacteria are usually the responsible pathogen and although, most infections are covered with the DOC, carbapenems, SM is best treated with TMP-SMX. This case is important because it highlights a rare pathogen, that should be considered as a cause of infected NP especially in those patients that are not responding to their plan of care.
Figure 1: CT scan showing the pancreatic fluid collection measuring 13.2 x 5.5 cm in cross section and 12.8 cm in craniocaudal length.
Figure 2: Endoscopic image showing pus drainage after dislodging necrotic debris noted to occlude the cystogastrostomy tract.
Disclosures: Sophia Dar indicated no relevant financial relationships. Rosario Ligresti indicated no relevant financial relationships.