Abstract | April 6, 2022

A Rare Case of Polymicrobial Infection with Pseudomonas stutzeri Urinary Tract Infection in a Patient on Sarilumab

Presenting Author: Jordan Torres, MD, BS, Internal Medicine Resident PGY1, Department of Internal Medicine, Graduate Medical Education, HCA Houston Healthcare Kingwood, Kingwood, TX

Coauthors: Jordan Torres, MD, Internal Medicine, PGY1, HCA Healthcare, Kingwood,TX; Aswin Srinivasan, DO, Internal Medicine, PGY2, HCA Healthcare, Kingwood,TX; Matthew Bear DO, Internal Medicine, PGY2, HCA Healthcare, Kingwood,TX; Alex Llop, Internal Medicine, PGY1, HCA Healthcare, Kingwood,TX; Ramesh B Kesavan, MD, Core Faculty, Pulmonary Critical Care, HCA Healthcare, Kingwood, TX; Jayaraman Gnananandh, MD, Faculty, Pulmonary Critical Care, HCA Healthcare, Kingwood, TX; Siva T. Sarva, MD, PhD, Core Faculty, Pulmonary Critical Care, HCA Healthcare, Kingwood, TX.

Learning Objectives

  1. To identify Pseudomonas stutzeri as an atypical organism capable of causing severe disease especially in immunocompromised patients.
  2. To identify Sarilumab as a potential risk factor for atypical organisms like P. stutzeri.

Introduction: Pseudomonas stutzeri is an uncommonly isolated organism; it is typically isolated from blood, respiratory tract, and urine. Patients with P. stutzeri typically have severe underlying diseases and require aggressive treatment with fluoroquinolones, antipseudomonal penicillins, aminoglycosides, or 3rd/4th generation cephalosporins. Sarilumab is an interleukin-6 inhibitor used to treat Rheumatoid Arthritis in patients who fail Methotrexate. We present a rare case of a patient on sarilumab with septic shock, urinary tract infection, and perinephric abscess with urine culture growing Pseudomonas stutzeri.

Case Description: A 65-year-old female with a history of Rheumatoid Arthritis on Sarilumab, Factor V Leiden deficiency, and Pulmonary Embolism on Apixaban presented with altered mental status, dyspnea, and dysuria. Admission vital signs were remarkable for temperature of 103 F, blood pressure 98/58 mmHg and rate of 91 beats/min. She was started on intravenous Ceftriaxone and fluids. CT Abdomen pelvis was significant for a left perinephric renal abscess. A prior CT Scan (2 months prior) showed a perinephric hematoma, secondary to a ground-level fall on anticoagulation. She was instructed to follow up with Urology for repeat imaging, but could not. Interventional radiology was consulted for the placement of a drain. Blood and urine cultures initially grew Escherichia coli. However surprisingly, the patient’s urine culture at a later date grew Pseudomonas stutzeri in addition to the prior identified E.coli.

Final Diagnosis: In view of the complex, polymicrobial culture, the patient was transitioned to six weeks of IV cefepime and discharged in stable condition after discontinuation of the drain. Sarilumab treatment likely predisposed the patient to have this complex infection.

Outcome: Patients on sarilumab have increased susceptibility to atypical organisms including Pseudomonas stutzeri. It is important for clinicians to treat these infections aggressively with appropriate antibiotics and duration of treatment.

References and Resources:

  1. Behzadi P, Behzadi E, Yazdanbod H, Aghapour R, Akbari Cheshmeh M, Salehian Omran D. A survey on urinary tract infections associated with the three most common uropathogenic bacteria. Maedica (Bucur). 2010;5(2):111-115.