A Rare Case of Fatal Necrotizing Fasciitis and Bacteremia From Myroides Odoratimimus

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Abstract Introduction: Myroides odoratimimus is a non-motile, gram-negative rod bacterium and often identified as an environmental organism. In rare circumstances, it has been identified as a human pathogen and often exhibits significant, unpredictable antibiotic resistance. Case:We present the case of a 73 year old male with past medical history of heart failure, AL amyloidosis, coronary artery disease status post CABG 19 years prior and PCI to circumflex 1 month prior, ESRD on dialysis, type 2 diabetes mellitus, and Waldenstrom macroglobulinemia who presented with right leg cellulitis. 3 days prior to presentation, the patient reported that he slipped while getting out of the shower, hit his head and scraped his arm and leg. He was started on vancomycin and piperacillin-tazobactam, and fluid resuscitated with ∼35cc/kg of crystalloid. He remained hypotensive, requiring norepinephrine infusion, and was admitted to the ICU. On hospital day 2, his blood cultures grew Myroides o doratimimus, and he developed worsening pain and bullous rash with dark red discoloration over his right leg. A bedside fasciotomy was performed, and did not show fascial involvement. The following day, the patient's surgical cultures also grew Myroides o doratimimus . Sensitivities were now available and demonstrated multidrug resistance. Antibiotics were adjusted to meropenem, levofloxacin and trimethoprim-sulfamethoxazole (TMP-SMX). His vasopressor requirements increased and his leg pain and rash worsened, so he underwent repeat fasciotomy, which demonstrated extensive necrotizing fasciitis requiring 4 compartment fasciotomy. Despite fasciotomy and continued antibiotics, he continued to clinically deteriorate, and ultimately passed away on hospital day 5. Discussion:Myroides odoratimimus is a rare aerobic environmental opportunistic pathogen which shows variable resistance, complicating it's empiric management in community-acquired infections. Here we discuss a case of necrotizing fasciitis and bacteremia, in which management was complicated by delays in initiating appropriate empiric antibiotics due to minimal existing cases to reference and variable resistance patterns cited. Current literature identifies a few suspected mechanisms of resistance: resistance transfer factor plasmids, a thick and non-permeable outer membrane, the active discharge system of the bacterial cell membrane, and broad spectrum β-lactamase production. Ultimately the strain isolated in our patient was resistant to piperacillin-tazobactam, as well as cephalosporins, aztreonam, ciprofloxacin and aminoglycosides. We resorted to using a combination of 3 antibiotics – TMP-SMX, meropenem and levofloxacin – however, the amount of antibiotics required for successful treatment is unclear and not noted in literature. Despite finally being on appropriate antibiotics and surgical intervention, the patient succumbed to his illness.-

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