Anna Conen, MD; Stefan Zimmerer, MD; Andrej Trampuz, MD; Reno Frei, MD; Manuel Battegay, MD; Luigia Elzi, MD, MSc
Potential Conflicts of Interest: None disclosed.
Conen A, Zimmerer S, Trampuz A, Frei R, Battegay M, Elzi L. A Pain in the Neck: Probiotics for Ulcerative Colitis. Ann Intern Med. 2009;151:895-897. doi: 10.7326/0003-4819-151-12-200912150-00020
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Published: Ann Intern Med. 2009;151(12):895-897.
Background: The use of probiotics in medical practice deserves closer attention and careful individual evaluation because probiotics may cause life-threatening infections, especially in immunocompromised persons.
Objective: To describe a case of abscesses caused by a probiotic.
Case Report: A 38-year-old woman presented in May 2008 with a 4-week history of progressive neck pain radiating to the head. The patient had had severe ulcerative colitis since 2002, with increasing activity during the preceding 5 months. Past treatments included high-dose steroids (recently prednisone, 40 mg/d), tumor necrosis factor-α blockers, azathioprine, cyclosporine, and granulocyte adsorptive apheresis. Because of persistent bloody diarrhea and abdominal cramps, a dairy product containing probiotics (Aktifit, Emmi, Lucerne, Switzerland) was added in March 2008. On admission, the patient had fever (temperature, 38.9 °C) and impaired cervical spine mobility without neck stiffness or neurologic deficits. She had slight abdominal pain on palpation without signs of peritonitis. Blood pressure was 100/70 mm Hg, and heart rate was 88 beats/min. Leukocyte count was 10 × 109 cells/L, and C-reactive protein level was 150 mg/L (normal, <10 mg/L). Blood cultures were sterile, and stool cultures showed no growth of Salmonella, Campylobacter, or Shigella species or Clostridium difficile. Computed tomography of the abdomen excluded abscess and perforation. Magnetic resonance imaging of the cervical spinal cord (Figure) showed an epidural abscess (1.8 × 0.7 × 4.5 cm) at the level of the first and second vertebral body and a left retropharyngeal abscess (1.5 × 1.7 × 0.8 cm). Echocardiography revealed no signs of endocarditis. Both abscesses were surgically drained, and culture yielded Lactobacillus rhamnosus (resistant to cephalosporin classes I through IV and carbapenems) and Candida kefyr. We cultivated Aktifit and found L. rhamnosus with a genetic sequencing pattern and resistance testing identical to the abscess organism. We gave the patient empirical treatment with imipenem, followed by clindamycin and fluconazole according to susceptibility tests. The patient continued antibiotic therapy for 3 months and antifungal therapy for 6 months. The patient recovered and had no symptoms when last seen in April 2009, at which time the ulcerative colitis was also asymptomatic during treatment with mesalazine and prednisone, 5 mg/d.
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