Prof. Mridul Panditrao, discusses, a case report; presentation, with unusual symptoms, unusual lab findings, unusual progression, but the same old ususal fatal outcome, in spite of trying everything. The main cause of thisultimately turned out to be Uncommon Genus Pantoea species dispersa. He adds the lextensive literatute Review too

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Volume 12 / Issue 4 / October-December 2018
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Case Report
Introduction
The ventilated patients in intensive care units (ICUs) are prone
to contracting hospital‑acquired infections (HAIs). In fact,
it would not be an exaggeration to say that, “sepsis due to
multiresistant strains” of these microbes may actually be the
main cause of morbidity/mortality in such patients.[1]
Most of the ICUs have their own fair share of these “monsters,”
such as Klebsiella spp., Pseudomonas spp., and the latecomer,
but now well entrenched, Acinetobacter spp. All of these are
from the Gram‑negative (Gm‑ve) spectrum, while on the
Gram‑positive side are of course Staphylococci spp., inclusive
of methicillin‑resistant Staphylococcus aureus and Streptococci
spp. As the evidence stands, most of these have developed
resistance to multiples of the antimicrobials leaving aside a very
few at present, like, tigecycline, colistin and polymyxin‑B.[2]
Such is the dire state of affairs that the available literature
is being flooded with the reports of very high incidence of
multidrug resistant (MDR) Acinetobacter spp.[3]
We are reporting a case of a multiparous patient who in
postoperative period following lower uterine segment cesarean
section (LUSCS) developed sepsis, became critically ill, was
referred to our ICU, had a very protracted, downward trend,
did not respond to even the “reserve” antimicrobials, and
succumbed. The peculiarity of this case was the isolation of
an unusual and not so common microbial organism called
“Pantoea dispersa.”
Case Report
A 23‑year‑old female patient was brought to our casualty on
May 16, 2018 (CR No. 18/17499); she was 2nd
para (P2
L1
), with
a cuffed endotracheal tube in situ, being ventilated with ambu
bag and oxygen supplementation, while being transferred from
a private hospital about 70 km from our hospital.
The elicited relevant history was very sketchy. In the
referring hospital, on April 30 (17 days before referral),
after doing ultrasound examination and finding, a single
Hospital‑acquired infections and their consequences are the main cause of morbidity/mortality in critically ill and immunocompromised patients.
It becomes interesting when an unusual and uncommon microorganism is found to be the causative agent, rather than the known commensals
and opportunists. We present such a case, when a multiparous female, in post lower uterine segment cesarean section period presented with
fulminant septic shock, hepatic failure, coagulopathy, and ventilator‑associated pneumonitis. The organism grown in the tracheal secretions
turned out to be an uncommon, unusual Gram‑negative Coccobacillus by the name of Pantoea dispersa, resistant to almost all the conventional
antimicrobial agents. In spite of all the efforts, the patient could not be saved. However, the case has opened up a virtual “Pandora’s box” of
questions. Are these microorganisms, known plant pathogens, really harmful to humans? Are they commensals or virulent opportunists? Are
we once again on the way to a new “Acinetobacter,” like near‑epidemic? This is an attempt to try and find some insight about this presently
uncommon and not well known genus of Pantoea! We have tried to trace and review the related available literature in the clinical medicine.
Keywords: Hospital‑acquired pneumonitis, multiorgan failure syndrome, Pantoea dispersa, peripartum sepsis
Address for correspondence: Dr. Minnu Panditrao,
Department of Anaesthesiology and Intensive Care, Adesh Institute of
Medical Sciences and Research, Adesh University, Bathinda ‑ 151 001,
Punjab, India.
E‑mail: drmmprao@gmail.com
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Pantoea dispersa: Is it the Next Emerging “Monster” in our
Intensive Care Units? A Case Report and Review of Literature
Mridul Panditrao, Minnu Panditrao
Department of Anaesthesiology and Intensive Care, Adesh Institute of Medical Sciences and Research, Adesh University, Bathinda, Punjab, India
Abstract
How to cite this article: Panditrao M, Panditrao M. Pantoea dispersa: Is it
the next emerging “monster” in our intensive care units? A case report and
review of literature. Anesth Essays Res 2018;12:963-6.

3. Panditrao and Panditrao: An emerging threat in ICUs?
964 Anesthesia: Essays and Researches ¦ Volume 12 ¦ Issue 4 ¦ October-December 2018964
fetus of 38 weeks +1 day ±2 weeks, oligohydramnios, no
fetal cardiac activity, no fetal movement, anterior placenta,
an emergency LUSCS had been performed for intrauterine
death (IUD). Apparently on the 4th
postoperative day, the
patient became oliguric, drowsy, developed jaundice and
high‑grade fever, and had to be intubated and ventilated. For
the next almost 12 days, the patient remained on ventilator
and was transfused four packed blood cells and 21 fresh
frozen plasmas. It was also elicited that she had 2½‑year‑old
female baby by previous LUSCS. Apart from this, there was
no significant relevant present, past, family or personal history.
On examination, she was a young moderately built female,
febrile, with temperature of 38.9°C, pulse rate of 140/min, blood
pressure of 130/80 mmHg, SpO2
of 99% with 5–6 L/min of
oxygen‑enriched bag ventilation. Icterus+, pallor+, generalized
anasarca, and abdominal distention++ were noted.Auscultation
of the chest showed few scattered rhonchi and crepitations,
abdominal wound was apparently clean, urinary catheter was in
place, draining very high colored, scanty urine (about 200 ml),
and nasogastric tube in situ draining dark green‑colored
aspirate of about 50 ml. There was bleeding per vaginum.
The patient was transferred to the ICU, where she was started
on intermittent positive pressure ventilation, with volume
control and pressure support.
Immediate blood investigations revealed the following:
total leukocyte count of 22,000 cu/mm, polymorphonuclear
leukocytosis (84%), hemoglobin of 9.3 g/dl, Prothrombin Time
of (PT) 17.4 seconds. PTI Index of 74.7, and renal function
tests were normal except urea of 50 mg/dl. Liver function
was very severely deranged: serum glutamic‑oxaloacetic
transaminase 220 (6–40) IU/L, serum glutamic pyruvic
transaminase 132 (6–40) IU/L, total bilirubin 3.4 (0.1–1.2) mg/
dl, conjugated 2.1 mg/dl, alkaline phosphatase 120 (25–110)
IU/L, total proteins 4.5 g/L (6–8), and albumin 2.0 g/L. Viral
markers were nonreactive.
Subsequently, 24 h urine for albumin showed 2+ positive.
On the 2nd
ICU day, May 17, all the samples, inclusive of
secretions from endotracheal tube, were sent for culture and
sensitivity. The patient’s general condition remained critical
and support with vasopressor noradrenaline and inotropic,
dopamine had to be initiated.
On May 18, i.e., on the 3rd
ICU day, in view of persistent
abdominal distention, fever, worsening international
normalized ratio (1.69), and finding of free fluid in abdominal
cavity on ultrasonographic examination, the admitting team
in conjunction with surgical team carried out an exploratory
laparotomy. Intraoperatively, blood and blood products were
provided. The intraoperative findings were insignificant except
the collection of serosanguineous fluid.
OnMay20,postoperativesupportwascontinued,butthepatient’s
condition did not improve.The persistent hepatic derangement,
hypoproteinemia, persistent pyrexia (38.9°C–39.4°C),
polymorphonuclear leukocytosis (ranging from 25,000
to 33,000), and derangement of coagulation were the
striking findings. The samples for culture and sensitivity of
endotracheal secretions, which had been collected on the
May 17 (next day of admission), after 72 h of incubation and
reported on May 20, showed the presence of P. dispersa, as
the microorganism isolated with the sensitivity and I D report,
from Vitek®
2 (bioMérieux, USA) as follows:
Resistant to all the standard antimicrobials, like,
amoxicillin-clavulanic acid, piperacillin/tazobactam, all
the cephalosporins; all penems (mero, imi, and erta); all
aminoglycosides;fluoroquinolonessuchasciprofloxacin,nalidixic
acid, nitrofurantoin, and trimethoprim + sulphamethoxazole,
sensitive only to tigecycline minimum inhibitory concentration
(MIC) 1 and colistin with MIC of ≤0.5. Hence, immediately,
injection colistimethate with loading dose of 9 MU followed
by 4.5 MU/day (in view of compromised renal function) was
started. In spite of this treatment, the fever was persistently
present, ranging between 38.9°C and 39.4°C. On May 23, the
fibrin degradation products were positive and D‑Dimer was
negative (>200 ng/mL). The closed tracheal suctioning was
revealing blood‑stained secretions initially, and later on frank
blood.
Inaddition,othersamplessuchasblood(fromcentralvenousline),
urinarycathetertip,pericardialtap,andasciticfluidwerenegative
for any microorganismal growth except urine on May 31,
showing, “growth of Candida spp. after 24 h of incubation.”
In spite of all the possible efforts, her condition showed
downward trend. The need for vasopressors and inotropes
remained unabated. There was obvious and relentless
progression toward frank acute respiratory distress
syndrome (ARDS), with continued ventilator support
varying from volume‑controlled pressure support to at the
end, pressure control with large amount of positive end
expiratory pressure, and even inverse ratio ventilation had
to be provided to maintain bare minimum oxygen saturation
levels. The renal failure required multiple dialyses. Multiple
packs of red blood cells, fresh frozen plasma, total parentral
nutrition, enteral nutrition, and albumin were administered by
appropriate routes.
On June 3, at around 12.30AM (18th
day of ICU admission), the
patient suffered cardiac arrest, but was successfully resuscitated
after three cycles of cardiopulmonary cerebral resuscitation.The
intensive care management was continued with added support
of inotropes and vasopressors. On June 5, 6.15 a.m. (20th
ICU
day), she had another episode of cardiac arrest, from which
could not be revived in spite of sustained efforts. Hence, she
was declared dead on June 5, 2018, at 7.38 a.m.
Discussion
The patient came to us with the following major problems:
1. In postcesarean section period, already in sepsis
2. The sepsis was secondary to the infection by
microorganism called P. dispersa, in her lungs, which
she acquired in the previous hospital (most probably after

4. Panditrao and Panditrao: An emerging threat in ICUs?
965Anesthesia: Essays and Researches ¦ Volume 12 ¦ Issue 4 ¦ October-December 2018 965
the intubation and when she was on ventilator for pretty
long time), from where she was referred to us (because
before her admission and since then, we have no report
of the same/similar organism)
3. As a result and secondary to complicated obstetrics,
she was already in HELLP‑like syndrome, with
elevated hepatic enzymes, deranged coagulation profile,
presence of hemolysis, and hypoproteinemia, which
never improved despite of all the appropriate and timely
measures/interventions
4. The clinical situation complicated by anemia,
coagulopathy, hypoproteinemia, hyperpyrexia, and
hepato‑renal syndrome‑like picture culminating into
acute tubular necrosis and acute renal failure, requiring
multiple dialyses and gradually worsening pulmonary
fields leading to ARDS and its consequences, ultimately
culminating into multiorgan failure syndrome (MOFS)
leading to mortality.
This generally is a common presentation of patients, especially
critically ill, when they land up with HAI. The propensity
for hepatic derangement associated with complicated
obstetrics (IUD of the fetus) was further augmented by the
presence of the microorganism P. dispersa, which colonized the
lungs, precipitatingARDS‑like picture. Then onward, it was a
downward spiral and end result was predictable. Whatever was
the primary pathology, the sepsis was induced by this unusual
and uncommon microorganism, which eventually blew into a
fast‑progressing cascade of systemic inflammatory response
syndrome and MOFS and death.
The genus Pantoea belongs to family Enterobacteriaceae.
They are disparate group of yellow‑pigmented, rod‑shaped
species of Gm‑ve bacteria. It was named first as Bacillus
agglomerans, which was later called as Enterobacter
agglomerans. Some other names such as Bacterium herbicola,
Pseudomonas herbicola, Erwinia herbicola, and Erwinia
millitiae were also given.[4]
However, Gavini et al. in 1989
recognized all these as being synonymous, so a genus by the
name of Pantoea was created for similar kind of species.[5]
Genus Pantoea has around twenty different species. Two
other genera, known as Tatumella and Erwinia, have close
association with Pantoea, all three clubbed together in the
family Enterobacteriaceae along with other groups/genera
such as Citrobacter, Cronobacter, Enterobacter, Escherichia,
Klebsiella, and Salmonella.[4]
Of the species reported, some like Pantoea anthophila were
isolated from the plants and plant products, while some like
Pantoea agglomerans from the human tissues lacerated by
the plants, while some like Pantoea conspicua and Pantoea
septica from human blood and stool, respectively. Surprisingly,
P. dispersa was originally found from soil or processed products.
Some species may have specific predilection to insects.[4]
Till recently, Pantoea was an ambiguous occurrence. In the
words of researchers, “some species are plant pathogens while
some are found in humans, especially Pantoea agglomerans.[6]
It is noteworthy that, on the one hand, P. agglomerans is a
well‑documented human pathogen,[4,7‑9]
even reported to be
a confirmed contaminant, isolated from consumed powdered
infant formula milk in neonatal ICU ward, a first report
from Iran,[10]
while on the other hand, it is being used for the
production of “Andrimid,” a newer, promising acetyl‑CoA
carboxylase inhibitor, a potent, broad‑spectrum antibiotic![11]
Hence, the researchers are flummoxed by the dilemma that
whether Pantoea as a genus is harmless naturally existing,
plant and insect pathogen, which can play a very crucial role
as an antiherbicide, in chelation and absorption of heavy
metals from the soil, killing of insect pests, improving the
quality of soil, a producer of a promising new antimicrobial,
or an innocent commensal or virulent opportunist. This most
probably was true in our patient. Because of the already
mentioned co‑existing factors, the microorganisms acquired
higher virulence, leading to rather deterioration and death.
The point of interest here is, since 2003 onward, there have been
slowly, but steadily emerging evidence about the increasing
involvement of P. dispersa spp. in producing opportunistic
infections, especially in compromised, elderly patients.[12,13]
This was followed by apparently the self‑proclaimed, first
report of neonatal sepsis involving this subspecies in central
India.[14]
In 2014, there was a reported case of P dispersa, being
the cause of bacteremia via a central line, again an opportunistic
invasion.[15]
Surprisingly, in another report from Iraq, the
majority of samples contained P. agglomerans, followed
by Pantoea ananatis and Pantoea calida. Their conclusion
was that these are the opportunistic, MDR microorganisms
commonly causing the nosocomial infections.[16]
Alatest report
from Nepal has again shown P. agglomerans as the cause of
infection in two pediatric cases, especially in the postsurgical
period.[17]
Logically, based on these observations and the emerging
evidence of the increasingly reported cases related to Pantoea
spp. in general, recently occurring P. dispersa can be a cause
for the concern, which led the authors to dwell upon the matter
more in depth.The paucity of available literature, on the matter,
especially related to P. dispersa, also was one of the reasons
for this review.
Conclusion
It appears that the various subspecies of genus Pantoea, in
their natural habitat, are plant or insect pathogens; although
they may also play some beneficial roles, but in some
special circumstances such as puncture/lacerated wounds
because of plant matter; contaminated cotton bolls/dressing
material, or in the hospital settings, in intravenous fluids, as
virulent opportunists; in immunosuppressed or compromised,
elderly or newborn, especially premature patients can produce
life‑threatening HAIs. The cause of concern is the increasing
emergence of spp. P. dispersa with highly virulent form,
shown by already acquired MDR nature, as was the case in our
patient. With such a “monster” lurking around on the horizon,

5. Panditrao and Panditrao: An emerging threat in ICUs?
966 Anesthesia: Essays and Researches ¦ Volume 12 ¦ Issue 4 ¦ October-December 2018966
more awareness, about these, is needed to be spread so that
the specialized systems of diagnosis, such as API®
50CHE
(bioMérieux, USA) system and Vitek®
system (bioMérieux,
USA) and matrix‑assisted laser desorption/ionization‑time of
flight mass spectrometry analysis (Shimadzu, Japan), are used
to reach the correct identification and culture and sensitivity
analysis. Rationalization of antimicrobial therapy, either
empirically or with evidence, is the need of the hour!
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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