Coltart, G

Fox-Lewis, A

Gourtsoyannis, Y

Gupta, Ravindra

Hyare, H

Rice, S

Sen, R

English

We report a case of a 31 year old male with extensive subclinical sinusitis leading to erosion in the cribriform plate and subsequent meningitis caused by the organism Moraxella osloensis. The patient presented to the emergency department with rapid onset confusion, neck stiffness and headache. Inflammatory markers, renal and liver function, and a chest radiograph were all normal. CT Head showed extensive polyp disease in the paranasal sinuses with expansion of the left frontal sinus and CT Sinuses revealed an area of low attenuation in the cribriform plate consistent with bony erosion. MRI Head showed thick loculated sinus inflammation. Lumbar puncture yielded CSF with a high white cell count of predominantly mononuclear cells, no visible organisms and an elevated protein. CSF microscopy, culture and viral PCR were not diagnostic, and so the CSF was sent for 16S rDNA PCR screening, which identified the rDNA of Moraxella osloensis. Moraxella osloensis is a rare cause of bacterial meningitis, with only a few reported cases. This case illustrates that sinusitis, while a common condition, when severe can predispose to intracranial infection with atypical and low virulence organisms such as Moraxella species, which do not commonly cause invasive CNS disease. This case represents the first case of Moraxella osloensis meningitis reported from the United Kingdom

Gupta, RK

Apollo (Cambridge)

IDCases 6 (2016) 39–42Case reportExtensive subclinical sinusitis leading to Moraxella osloensis meningitisA. Fox-Lewisa,*, G. Coltarta, S. Riceb, R. Sena, Y. Gourtsoyannisa, H. Hyareb, R.K. Guptaa,caDivision of Infection, University College London Hospital NHS Foundation Trust, London, UKbRadiology Department, University College London Hospital NHS Foundation Trust, London, UKcDepartment of Infection, University College London, London, UKA R T I C L E I N F OArticle history:Received 20 July 2016Received in revised form 19 August 2016Accepted 19 August 2016A B S T R A C TWe report a case of a 31 year old male with extensive subclinical sinusitis leading to erosion in thecribriform plate and subsequent meningitis caused by the organism Moraxella osloensis. The patientpresented to the emergency department with rapid onset confusion, neck stiffness and headache.Inflammatory markers, renal and liver function, and a chest radiograph were all normal. CT Head showedextensive polyp disease in the paranasal sinuses with expansion of the left frontal sinus and CT Sinusesrevealed an area of low attenuation in the cribriform plate consistent with bony erosion. MRI Headshowed thick loculated sinus inflammation. Lumbar puncture yielded CSF with a high white cell count ofpredominantly mononuclear cells, no visible organisms and an elevated protein. CSF microscopy, cultureand viral PCR were not diagnostic, and so the CSF was sent for 16S rDNA PCR screening, which identifiedthe rDNA of Moraxella osloensis. Moraxella osloensis is a rare cause of bacterial meningitis, with only a fewreported cases. This case illustrates that sinusitis, while a common condition, when severe canpredispose to intracranial infection with atypical and low virulence organisms such as Moraxella species,which do not commonly cause invasive CNS disease. This case represents the first case of Moraxellaosloensis meningitis reported from the United Kingdom.ã 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license(http://creativecommons.org/licenses/by/4.0/).Contents lists available at ScienceDirectIDCasesjournal homepage: www.elsevier .com/ locate / idcrIntroductionMoraxella osloensis is part of the normal flora of the humanrespiratory tract, and is one of the seven species of the Moraxellagenus, along with M. atlantae,M. canis, M. catarrhalis, M. lacunata,M. lincolnii and M. nonliquefaciens [1]. Members of the genusMoraxella are oxidase-positive, non-motile, and asaccharolyticcoccobacilli. Infections attributed to Moraxella osloensis includeendocarditis, osteomyelitis, septic arthritis, vaginitis, bacteremia,and rarely, meningitis [2].Meningitis makes up 10% of the intracranial complications ofsinusitis in paediatric populations [3], however the presence ofsinusitis is a predictor of a more favorable outcome [4]. We report acase of extensive subclinical sinusitis leading to erosion in thecribriform plate with subsequent meningitis caused by theorganism Moraxella osloensis. To our knowledge there are onlyseven previously reported cases of meningitis caused by Moraxellaosloensis: one case from the Netherlands [5]; one from Scandinavia* Correspondence to: Hospital for Tropical Diseases, 2nd Floor Mortimer MarketCentre, Capper Street, London, WC1E 6JB, UK.E-mail address: a.fox-lewis@nhs.net (A. Fox-Lewis).http://dx.doi.org/10.1016/j.idcr.2016.08.0072214-2509/ã 2016 The Authors. Published by Elsevier Ltd. This is an open access artic[6]; two from Germany [7,8] and three cases from Korea [9]. Two ofthese cases had predisposing factors, one patient with a CSF shuntin situ, and one with C8 compliment deficiency, while theremaining cases were in immunocompetent individuals. This caserepresents the first case of Moraxella osloensis meningitis reportedfrom the United Kingdom.Case reportA 31 year old male with no significant past medical historypresented to the emergency department with rapid onsetconfusion, neck stiffness and headache. There was no history ofrecent travel outside the UK, and no drug use or alcohol intake.Initial assessment revealed normal vital signs and an unremark-able physical examination with no focal neurology. There was noneck stiffness or photophobia. Abbreviated mental test score was6/10 and Glasgow Coma Score was 13/15. The patient was agitated,confused and disoriented in time and place. Inflammatorymarkers, renal and liver function, and a chest radiograph wereall normal.CT Head showed extensive polyp disease in the paranasalsinuses with expansion of the left frontal sinus. ENT review foundmild erythema only in the oropharynx, with erythematous andle under the CC BY license (http://creativecommons.org/licenses/by/4.0/).Fig. 1. (a) CT Sinuses showing area of bony erosion in the left aspect of thecribriform plate (unmarked). (b) CT Sinuses showing area of bony erosion in the leftaspect of the cribriform plate (marked).Fig. 2. (a) MRI Head (T2 weighted) showing severe ethmoid sinusitis (unmarked).(b) MRI Head (T2 weighted) showing severe ethmoid sinusitis (marked).40 A. Fox-Lewis et al. / IDCases 6 (2016) 39–42rhinitic polypoid mucosa in the nasal cavity. A subsequent CTSinuses revealed an area of low attenuation in the left aspect of thecribriform plate consistent with bony erosion (Fig. 1a and b). MRIHead showed thick loculated sinus inflammation (Figs. 2a–4b).Lumbar puncture yielded colorless CSF with an opening pressure of18 cm H2O, a white cell count of 92 cells/cu.mm ( >95%mononuclear cells) and no visible organisms. CSF protein waselevated at 90 mg/dL (0.9 g/L), and CSF glucose was normal at59.5 mg/dL (3.3 mmol/L), compared with a contemporaneouscapillary blood glucose of 104.5 mg/dL (5.8 mmol/L). Bloodcultures, HIV serology, treponemal serology and enterovirusserology (IgM) were negative. CSF PCR was negative formeningococcus, pneumococcus, enteroviruses and herpesviruses(including HSV1, HSV2, EBV, CMV and VZV). Given the lack ofmicrobiological diagnosis at this point, the CSF was sent for 16SrDNA PCR screening, which identified the rDNA of Moraxellaosloensis.Due to ceftriaxone allergy the patient was treated with twoweeks of chloramphenicol followed by two weeks of doxycyclineto clear residual sinus infection. He made an excellent recovery,being well at three month follow up.DiscussionMoraxella osloensis is a rare cause of bacterial meningitis, withonly a few reported cases. This case illustrates that sinusitis, whilea common condition, when severe can predispose to intracranialinfection with atypical and low virulence organisms such asMoraxella species, which do not commonly cause invasive CNSdisease. The cribriform plates of the ethmoid bone form the roof ofthe nasal cavity, with the ethmoid sinuses lying immediatelyinferolaterally, and the frontal sinuses and sphenoid sinuses inclose proximity anteriorly and posteriorly, respectively. In thiscase, bony erosion due to extensive sinusitis created a portal ofFig. 3. (a) MRI Head (T1 weighted with contrast) showing extensive loculatedsinusitis (unmarked). (b) MRI Head (T1 weighted with contrast) showing extensiveloculated sinusitis (marked).Fig. 4. (a) MRI Head (T2 weighted) showing extensive loculated sinusitis(unmarked). (b) MRI Head (T2 weighted) showing extensive loculated sinusitis(unmarked).A. Fox-Lewis et al. / IDCases 6 (2016) 39–42 41entry for infection in the form of a defect in the cribriform plate,leading to Moraxella osloensis meningitis. The degree of loculatedsinus inflammation seen in this case is a rarely seen phenomenonin a patient with no preceding symptoms. Of note, the significanceof the lymphocytic pleocytosis observed in the CSF of this case isunclear: in other reported cases of Moraxella osloensis meningitis aneutrophilic pleocytosis was seen [9], as would be expected in abacterial meningitis.This case also demonstrates the diagnostic utility of 16S rDNAPCR screening when microscopy and culture fails to yield adiagnosis. This is an important point as 16S technology isfrequently used and rarely detects a causative organism. In ourcase, as with previous cases [9], we were only able to identify theorganism using 16S rDNA PCR screening.42 A. Fox-Lewis et al. / IDCases 6 (2016) 39–42Conflict of interest statementThe authors declare no conflict of interest.AcknowledgementThe authors would like to thank the patient for his consent andco-operation in publishing his clinical case.References[1] Schreckenberger PC, Daneshvar MI, Weyant RS, Hollis DG. Acinetobacter,Achromobacter, Chryseobacterium, Moraxella, and other nonfermentativegram-negative rods. In: Murray PR, Baron EJ, Jorgensen JH, Pfaller MA, editors.Manual of Clinical Microbiology. Washington: American Society forMicrobiology; 2003. p. 754–7.[2] Shah SS, Ruth A, Coffin SE. Infection due to Moraxella osloensis: case report andreview of the literature. Clin Infect Dis 2000;30(January (1))179–81 Review.[3] Patel NA, Garber D, Hu S, Kamat A. Systematic review and case report:intracranial complications of pediatric sinusitis. Int J Pediatr Otorhinolaryngol2016;86(July):200–12, doi:http://dx.doi.org/10.1016/j.ijporl.2016.05.009.[4] Bijlsma MW, Brouwer MC, Kasanmoentalib ES, Kloek AT, Lucas MJ, Tanck MW,van der Ende A, van de Beek D. Community-acquired bacterial meningitis inadults in the Netherlands, 2006-14: a prospective cohort study. Lancet Infect Dis2016;16(March (3))339–47, doi:http://dx.doi.org/10.1016/S1473-3099(15)00430-2 Epub 2015 Dec 1.[5] Fijen CA, Kuijper EJ, Tjia HG, Daha MR, Dankert J. Complement deficiencypredisposes for meningitis due to nongroupable meningococci and Neisseria-related bacteria. Clin Infect Dis 1994;18(May (5)):780–4.[6] Hansen W, Butzler JP, Fuglesang JE, Henriksen SD. Isolation of penicillin andstreptomycin resistant strains of Moraxella osloensis. Acta Pathol MicrobiolScand B Microbiol Immunol 1974;82(June (3)):318–22.[7] Berger U, Kreissel M. Menigitis due to Moraxella osloensis. Infection 1974;2(3):166–8.[8] Fritsche D, Karte H, del Solar E. Moraxella osloensis as pathogen in septicemia.Infection 1976;4(2):53–4.[9] Roh KH, Kim CK, Koh E, Kim MS, Yong D, Park SC, Lee K, Chong Y. Three cases ofMoraxella osloensis meningitis: a difficult experience in species identificationand determination of clinical significance. J Korean Med Sci 2010;25(March (3))501–4, doi:http://dx.doi.org/10.3346/jkms.2010.25.3.501 Epub 2010 Feb 17.

Extensive subclinical sinusitis leading to Moraxella osloensis meningitis.

https://www.repository.cam.ac.uk/bitstream/1810/308224/1/Extensive%20subclinical%20sinusitis%20leading%20to%20Moraxella%20osloensis%20meningitis.pdf

Extensive subclinical sinusitis leading to <i>Moraxella osloensis</i> meningitis.

Extensive subclinical sinusitis leading to <i>Moraxella osloensis</i> meningitis.

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