ORAL LESIONS DUE TO ACINETOBACTER BAUMANNII INFECTION IN A PATIENT AFFECTED BY AUTOIMMUNE HEMOLYTIC ANEMIA (AIHA): FIRST CLINICAL REPORT

Abstract

Aim. Acinetobacter Baumannii (coming from the Greek “akinetos,” i.e. non-motile) is an opportunistic bacterial pathogen primarily associated with hospital-acquired infections. Commonly associated with aquatic environments, A. Baumannii easily contaminates the surrounding environment and it colonizes acute ill patients in which can survive for several days. Generally, A. Baumannii is able to damage mucous membranes or exposed skin after accident or injury; it may be responsible of many diseases such as pneumonia, bacteremia, meningitis, urinary tract infections, peritonitis and infections of skin and soft tissues. Tissues infected by A. Baumannii initially present “orange peel” appearance followed by sandpaper-like presentation, when there is a disruption, hemorrhagic bullae can be seen with a visible necrotizing process followed by bacteremia. Current therapy is based on intravenous administration of tigecycline 100-200 mg (first dose) and 50-100 mg every 12 h for up to 14 days, unless complications. If untreated, this infection can lead to septicemia and death. The mortality rate of this infection is high, especially in case of bacteremia (52%) and pneumonia (23–73%). A. Baumannii is resistant to many drugs and represents an important nosocomial pathogen that particularly infects critically ill patients. At the best of our knowledge, no case of oral infection has been reported. to present the first one case characterized by oral soft tissue infection due to A. Baumannii responsive to imipenem. Materials and methods. a 78 years male was hospitalized in August of 2013 at the Hematology unit of the A.O.U.P. “P. Giaccone” of Palermo with a diagnosis of autoimmune hemolytic anemia (AIHA). He was treated per os with corticosteroids (Prednisone) and immunosuppressants (Rituximab and Cyclophosphamide), also IVIG (Intra Venous Immuno-Globulin) was administreted. In November 2013, the patient was treated with piperacillin IV (Tazocin) for treating an urinary tract infection; four days after, multiple oral ulcerative bullous lesions on the lingual and buccal mucosa and crusted lesions on the lip vermilion appeared, associated with intense pain. An oral swab for bacteria research was carried out; topical therapy (chlorhexidine rinses and hyaluronic acid gel) has been prescribed and piperacillin therapy was stopped. Oral swab outcome resulted positive for A. Baumannii and Enterococcus Faecalis, both sensitive only to imipenem, that was administrated (500 mg IV every 8h) for 10 days. The patient was immediately isolated in a single room for preventing and controlling the spread of A. Baumannii. Results. From diagnosis, every 3 days clinical examination of the oral cavity was performed, revealing the progressive regression within thirty days until complete healing without leaving scars. After, a second oral swab confirmed the absence of any bacteria. Conclusions. The World Health Organization has recently identified antimicrobial resistance as one of the three most important problems facing human health and among the most common and serious pathogens, including A. Baumannii. It is an emerging potentially drug-resistant micro-organism and its isolation must alert physicians to carry on all preventive measures for avoiding contamination of other patients, especially those immunosuppressed, at risk for severe persistent infections or death. This precaution should be continued for all the duration of hospitalization and until the negativization of culture samples was obtained. It is important that physicians and dentists recognize suspicious lesions in unusual locations, such as oral mucosa, in absence of other known etiological factors in a timely manner before the diffusion among other patients in order to avoid the spread of a nosocomial outbreaks