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 Table of Contents  
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 51-55

First reported case of Alcaligenes faecalis isolated from bronchoalveolar lavage in a patient with dengue hemorrhagic fever

1 Department of Internal Medicine, Narayana Multispeciality Hospital, Jaipur, Rajasthan, India
2 Department of Laboratory Medicine, Narayana Multispeciality Hospital, Jaipur, Rajasthan, India
3 Department of Critical Care Medicine, Narayana Multispeciality Hospital, Jaipur, Rajasthan, India
4 Department of Microbiology, Santokba Durlabhji Memorial Hospital, Jaipur, Rajasthan, India
5 Department of Radiodiagnosis, Malviya Nagar Clinic and Sonography Centre, Jaipur, Rajasthan, India

Date of Web Publication29-Dec-2016

Correspondence Address:
Dr. Arun Agarwal
Department of Internal Medicine, Narayana Multispeciality Hospital, Jaipur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2320-8775.177512

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Bacterial co-infections have been reported in association with dengue fever (DF) and can exacerbate dengue infections. However, DF with acute respiratory distress syndrome and co-infection with Alcaligenes faecalis (A. faecalis) has not been reported earlier. Most infections caused by A. faecalis are opportunistic. Urinary tract infection, bacterial keratitis, postoperative endophthalmitis, skin and soft tissue infections, bacteremia, meningitis, wound infections, and peritonitis in patients undergoing peritoneal dialysis have been described in association with A. faecalis. A. faecalis, a Gram-negative environmental organism rarely cause significant infections. Treatment can be difficult in some cases due to the high level of resistance to commonly used antibiotics. We report a case of fatal bronchopneumonia caused by extensively drug resistance A. faecalis in a patient of dengue hemorrhagic fever.

Keywords: Acute respiratory distress syndrome, Alcaligenes faecalis, bronchoalveolar lavage, dengue fever, dengue hemorrhagic fever

How to cite this article:
Agarwal A, Sharma S, Bhargava V, Bhargava V, Agarwal M, Airun M. First reported case of Alcaligenes faecalis isolated from bronchoalveolar lavage in a patient with dengue hemorrhagic fever. J Assoc Chest Physicians 2017;5:51-5

How to cite this URL:
Agarwal A, Sharma S, Bhargava V, Bhargava V, Agarwal M, Airun M. First reported case of Alcaligenes faecalis isolated from bronchoalveolar lavage in a patient with dengue hemorrhagic fever. J Assoc Chest Physicians [serial online] 2017 [cited 2021 Dec 5];5:51-5. Available from: https://www.jacpjournal.org/text.asp?2017/5/1/51/177512

  Introduction Top

Dengue fever (DF) is the most common of the arboviral infections in humans. Most of the cases of DF are self-limiting but dengue hemorrhagic fever (DHF) and dengue shock syndrome can be life-threatening and if untreated mortality can be as high as 20%. The endothelium is the target of the immunopathological mechanisms in dengue and DHF. The hallmark is vascular permeability and coagulation disorders. DHF can result in acute respiratory distress syndrome (ARDS).[1] Pulmonary hemorrhage with or without hemoptysis has also been reported in DHF.[2] The lung involvement may get complicated with opportunistic infections and make management difficult in these cases. Various micro-organisms causing co-infection in DF have been reported in literature. We report a case of DHF with ARDS who got infected with fatal extensively drug resistance (XDR) (nonsusceptible to >1 agent in all but <2 categories) Alcaligenes faecalis (A. faecalis). This case highlights the importance of micro-organisms in exacerbating dengue infections and the importance of looking for co-infection in patients with certain clinical manifestations.

  Case Report Top

A 32-year-old man, smoker, with a medical history of fever with chills, body-aches, vomiting, loose-motions, altered behavior, cough, and breathlessness of 8–10 days was transferred from a nearby nursing home to our facility on September 07, 2015 with a diagnosis of DF with acute renal failure and thrombocytopenia. He was transfused five unit of random donor plasma outside for severe thrombocytopenia (platelet count 25,000/cumm). On examination he was restless, febrile (99.2°F), hemodynamically stable, tachypneic (respiratory rate 32/min), SO2 99% on air, had bilateral extensive coarse crepitations, occasional wheeze, and mild nontender hepatomegaly. His outside reports for dengue IgM antibody (card test) was positive. He was admitted in medical Intensive Care Unit (ICU) and further evaluated. His hematology and biochemistry are mentioned in [Table 1] and other investigations in [Table 2]. He was initially managed with noninvasive ventilation in view of persistent tachypnea, dyspnea and increased work of breathing along with azithromycin, moxifloxacin and supportive treatment. On day 2, he developed increased blood stained purulent secretions, respiratory distress, hypoxemia, and ARDS [Figure 1] and [Figure 2]. He was put on mechanical ventilation on September 09, 2015 due to acute ventilatory failure. He also received two sessions of Hemodialysis for acute kidney injury and severe metabolic acidosis. In the meantime, direct fungal and Grams stain showed presence of Candida and Gram-negative Bacilli and antibiotics were escalated to azithromycin, meropenem, moxifloxacin, fluconazole along with torsemide infusion, and supportive treatment. On September 11, 2015 endotracheal tube secretion culture showed heavy growth of Candida albicans and he was started on micafungin and fluconazole was stopped. Computerized tomography (CT) chest was also done [Figure 2]. However, he continued to deteriorate with abundant blood stained mucopurulent respiratory secretions. Bronchoscopy and bronchoalveolar lavage (BAL) were done on September 15, 2015 in ICU and bronchial biopsy was taken from nodule of right intermediate bronchus. Colistin was added empirically on September 15, 2015 and azithromycin stopped. This was done as he did not show any improvement in his clinical status, presence of gram negative Bacilli on Grams stain of BAL fluid and our past experience with carbapenem resistant enterobacteriaceae organisms. After 24 h of incubation at 37°C, a colony type grew on blood agar that was white, smooth, convex and glistening with spreading outer borders and was identified as A. faecalis (105 CFU/ml) on automation vitek 2C system [Figure 3]. A Gram-stain of the colony showed Gram-negative Coccobacilli. Colistin was added and high dose meropenem regime in renal adjusted doses was given. However he continued to deteriorate and developed bilateral extensive heterogenous pulmonary infiltration and dense bronchopneumonia in left mid zone [Figure 4]. He was discharged against medical advice on September 17, 2015. The antibiotic sensitivity report received on September 17, 2015 showed it to be a XDR isolate. He later succumbed to his illness on September 19, 2015. The bronchial biopsy was unremarkable.
Table 1: Hematology and biochemistry

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Table 2: Other investigations

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Figure 1: X-ray chest dated September 09, 2015

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Figure 2: Computerized tomography chest, lung window, dated September 11, 2015, axial view showing discrete and confluent nodular densities in bilateral lung fields with patchy ground glass attenuation changes

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Figure 3: Alcaligenes faecalis appear as white colonies with spreading edges on blood agar (arrow)

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Figure 4: X-ray chest dated September 17, 2015

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  Discussion Top

There are several case reports of micro-organisms other than A. faecalis having been identified as causing co-infection with dengue virus infection. Some of them are  Escherichia More Details coli,  Salmonella More Details sp., Streptococcus pneumoniae, Mycobacterium tuberculosis, Mycoplasma pneumoniae, Shigella sonnei, Klebsiella pneumonia, Klebisella ozaenae, Enterococcus faecalis,  Moraxella More Details lacunata, Staphylococcus aureus, Rosemonas sp., Haemophilus influenza, Candida tropicalis, and herpes viruses.[3],[4],[5],[6],[7],[8],[9] The important observation is that most of these micro-organism are part of the normal gastro-intestinal flora. Capillary endothelial damage or intestinal hemorrhage seen in DF could lead to breach in digestive tract mucosal barrier and thus explain these co-infections. The micro-organisms then get access to systemic blood circulation and can cause bacteremia. Even pathophsiological changes of the vascular and hemostatic system observed in some organs or systems may predispose to complicating infections.[10] Further, the occurrence of bacterial infection superimposed on the dengue virus infection might also be a mere temporal coincidence or secondary to immunosuppression caused by the virus itself.

This is the first case report describing A. faecalis isolated from the lower respiratory tract in a case of DHF with ARDS. A. faecalis is a motile, flagellated, slender, slightly curved, rod shape, nonspore-forming, slowly growing, nonfermenting, nonencapsulated Gram-negative aerobe of the family Alcaligenaceae. On blood agar colonies are white, smooth, convex and glistening and tends to spread at outer border of the colonies [Figure 3]. It is oxidase positive, citrate positive, and catalase positive. It is found in the alimentary tract as a harmless saprophyte in 5–19% of the normal population and numerous strains have been isolated from clinical material such as blood, urine, and feces. It is usually transmitted on exposure to contaminated medical devices and solutions. Systemic infection with this organism is very uncommon and usually involves compromised patients. It has been reported to cause urinary tract infections, bacteremia, sepsis, meningitis, peritonitis, wound infections, keratitis, and postoperative endophthalmitis.[11],[12],[13],[14],[15] It has been associated with fatal outcomes due to the fact that these organisms are resistant to commonly used antibiotics.

Our patient was admitted at two other facilities before being shifted to our institution. The source of A. faecalis in him could not be identified. As discussed, it could be due to compromised gut integrity, immunosuppression or a mere temporal coincidence. Our hospital follows infection control policy and routine surveillance cultures are being done as per standards and A. faecalis has never been reported. C. albicans was isolated on culture of respiratory tract secretions sent after tracheal intubation and in view of CT scan findings, culture reports, acute kidney injury, hemodialysis, history of broad spectrum antibiotics, prolonged hospitalization, indwelling catheter, and worsening ARDS we treated him with antifungals as observational studies have shown worse clinical outcomes in these patients.[16] Subsequent culture and smears of BAL fluid done 4 days later reported no C. albicans but a XDR A. faecalis isolate. It is difficult to know how much of the disease process can specifically be attributed to C. albicans and A. faecalis respectively, but we suspect that the patient’s worsening respiratory status can be attributed to infection with A. faecalis as he was adequately managed for Candida infection with anti-fungal treatment. With relation to antibiotic susceptibility A. faecalis isolate was only sensitive to colistin and tigecycline and colistin was added empirically on September 15, 2015. We did not add tigecycline as the report was received on September 17, 2015 and patient took discharge on the same day against medical advice.

We conclude that Gram-negative rod A. faecalis, though an environmental organism, can cause fatal infections and should be a pathogen of consideration in such patients. The fact that they are resistant to commonly used antibiotics should also be considered in the overall management of patients infected with A. faecalis. On literature search, we could not find any other case of A. faecalis isolated from BAL in a case of DHF with ARDS.

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Conflicts of Interest

There are no conflicts of interest.

  References Top

Gulati S, Maheshwari A. Atypical manifestations of dengue. Trop Med Int Health 2007;12:1087-95.  Back to cited text no. 1
Setlik RF, Ouellette D, Morgan J, McAllister CK, Dorsey D, Agan BK, et al. Pulmonary hemorrhage syndrome associated with an autochthonous case of dengue hemorrhagic fever. South Med J 2004;97:688-91.  Back to cited text no. 2
Suzuki S, Kitazawa T, Ota Y, Okugawa S, Tsukada K, Nukui Y, et al. Dengue hemorrhagic shock and disseminated candidiasis. Intern Med 2007;46:1043-6.  Back to cited text no. 3
Kohli U, Sahu J, Lodha R, Agarwal N, Ray R. Invasive nosocomial aspergillosis associated with heart failure and complete heart block following recovery from dengue shock syndrome. Pediatr Crit Care Med 2007;8:389-91.  Back to cited text no. 4
Tang Y, Kou Z, Tang X, Zhang F, Yao X, Liu S, et al. Unique impacts of HBV co-infection on clinical and laboratory findings in a recent dengue outbreak in China. Am J Trop Med Hyg 2008;79:154-8.  Back to cited text no. 5
Pancharoen C, Thisyakorn U. Coinfections in dengue patients. Pediatr Infect Dis J 1998;17:81-2.  Back to cited text no. 6
Lee IK, Liu JW, Yang KD. Clinical characteristics and risk factors for concurrent bacteremia in adults with dengue hemorrhagic fever. Am J Trop Med Hyg 2005;72:221-6.  Back to cited text no. 7
Charrel RN, Abboud M, Durand JP, Brouqui P, De Lamballerie X. Dual infection by dengue virus and Shigella sonnei in patient returning from India. Emerg Infect Dis 2003;9:271.  Back to cited text no. 8
Chai LY, Lim PL, Lee CC, Hsu LY, Teoh YL, Lye DC, et al. Cluster of Staphylococcus aureus and dengue co-infection in Singapore. Ann Acad Med Singapore 2007;36:847-50.  Back to cited text no. 9
Araújo SA, Moreira DR, Veloso JM, Silva JO, Barros VL, Nobre V. Fatal staphylococcal infection following classic dengue fever. Am J Trop Med Hyg 2010;83:679-82.  Back to cited text no. 10
Kahveci A, Asicioglu E, Tigen E, Ari E, Arikan H, Odabasi Z, et al. Unusual causes of peritonitis in a peritoneal dialysis patient: Alcaligenes faecalis and Pantoea agglomerans. Ann Clin Microbiol Antimicrob 2011;10:12.  Back to cited text no. 11
Sachdeva LD, Bardhan PN. Bacteriological study of an Alkaligenes faecalis strain. A food poisoning epidemic. Indian J Pathol Bacteriol 1963;37:128-33.  Back to cited text no. 12
Kavuncuoglu F, Unal A, Oguzhan N, Tokgoz B, Oymak O, Utas C. First reported case of Alcaligenes faecalis peritonitis. J Int Soc Perit Dial 2010;1:118-9.  Back to cited text no. 13
Tena D, Fernández C, Lago MR. Alcaligenes faecalis: An unusual cause of skin and soft tissue infection. Jpn J Infect Dis 2015;68:128-30.  Back to cited text no. 14
Mordi RM, Yusuf EO, Onemu SO, Igeleke CL, Odjadjare EE. The prevalence of Alcaligenes faecalis in bacteremia, meningitis and wound sepsis in a tertiary health care institution in western part of Nigeria. Int J Biotechnol 2013;2:123-9.  Back to cited text no. 15
Albert M, Williamson D, Muscedere J, Lauzier F, Rotstein C, Kanji S, et al. Candida in the respiratory tract secretions of critically ill patients and the impact of antifungal treatment: A randomized placebo controlled pilot trial (CANTREAT study). Intensive Care Med 2014;40:1313-22.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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