Anaerobe 34 (2015) 161e163

Contents lists available at ScienceDirect

Anaerobe
journal homepage: www.elsevier.com/locate/anaerobe

Clinical microbiology

Bacteremic meningitis caused by Parvimonas micra in an

immunocompetent host
Jae-Hoon Ko a, 1, Jin Yang Baek b, 1, Cheol-In Kang a, *, Woo Joo Lee a, Ji Yong Lee a,
Sun Young Cho a, Young Eun Ha a, So Hyun Kim b, Doo Ryeon Chung a, Kyong Ran Peck a,
Nam Yong Lee c, Jae-Hoon Song a
a

Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710,
Republic of Korea
Asia Pacic Foundation for Infectious Diseases (APFID), Seoul, Republic of Korea
c
Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 4 March 2015
Received in revised form
25 April 2015
Accepted 4 May 2015
Available online 12 May 2015

A 61-year-old man with chronic hepatitis B and dyslipidemia visited the emergency department with a
fever and severe headache. He was diagnosed with bacterial meningitis after a lumbar puncture, and
blood culture revealed Parvimonas micra bacteremia. Although he had a history of extraction of a molar
two weeks before symptom onset, there was no evidence of abscess formation on physical examination
or imaging studies. He was successfully treated with oral metronidazole for 12 days after 9 days of
treatment with IV ceftriaxone and vancomcycin. This is the rst report of primary bacterial meningitis
caused by this organism, which indicates that this organism is capable of being a bacterial meningitis
pathogen.
2015 Elsevier Ltd. All rights reserved.

Keywords:
Parvimonas micra
Meningitis

1. Introduction

2. Case report

Parvimonas micra is part of the normal ora of the oral cavity,

and it has been recognized to cause gingival infection [1,2]. Cases of
meningitis due to P. micra have been reported in the setting of
vertebral osteomyelitis and epidural abscesses and there has been
no report of primary bacterial meningitis caused by this organism
[3e5]. We experienced a case of meningitis with bacteremia caused
by P. micra after tooth extraction. Since anaerobic culture is not
routinely performed with Cerebrospinal uid (CSF) specimen, the
pathogen was isolated only from blood cultures. Our case suggests
that this organism is capable of being a bacterial meningitis pathogen and meningitis caused by oral anaerobes could be
underdiagnosed.

A 61-year-old man visited the emergency department with a

fever and severe headache. He was diagnosed with chronic hepatitis B and dyslipidemia 10 years ago and his viral load and lipid
prole were well-controlled with entecavir and rosuvastatin. Two
weeks before symptom onset, he had undergone extraction of a
molar due to dental caries, but there were no complications identied after extraction on follow-up dental examination. No prophylactic antibiotics were prescribed.
On examination, he had a fever (38
C), neck stiffness and a
positive Brudzinski sign. Initial laboratory tests showed a white
blood cell (WBC) count of 6570/mL with 81.5% neutrophils, a hemoglobin level of 15.6 g/dL, a platelet count of 162,000/mL, an
erythrocyte sediment rate of 57 mm/h, and a C-reactive protein
(CRP) level of 12.15 mg/dL. Under suspicion of meningitis, two pairs
of aerobic and anaerobic blood cultures were collected and a
lumbar puncture was performed. CSF revealed a glucose level of
13 mg/dL with a serum glucose level of 124 mg/dL, a protein level of
205.8 mg/dL, a red blood cell (RBC) count of 160/mL, and a WBC
count of 3430/mL with 50% neutrophils. Gram staining of the CSF
exhibited no organisms. CSF samples for bacterial culture were
inoculated in the blood agar plates, MacConkey agar plates,

* Corresponding author. Division of Infectious Diseases, Department of Medicine,

Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwonro, Gangnam-gu, Seoul 135-710, Republic of Korea.
E-mail addresses: collacin@gmail.com, cikang@skku.edu (C.-I. Kang).
1
These authors contributed equally to this article.
http://dx.doi.org/10.1016/j.anaerobe.2015.05.004
1075-9964/ 2015 Elsevier Ltd. All rights reserved.

162

J.-H. Ko et al. / Anaerobe 34 (2015) 161e163

chocolate agar plates, and thioglycollate broth.

With a diagnosis of bacterial meningitis, he received intravenous (IV) ceftriaxone, vancomycin, and ampicillin empirically with
dexamethasone. After 24 h, the growth of gram positive cocci in
chains was reported in the anaerobic blood culture bottles, and
ampicillin was discontinued. On hospital day 3, his fever subsided
and the initial CSF culture showed no growth of microorganisms.
Two pairs of aerobic and anaerobic blood cultures were performed
on the same day to conrm bacteremia clear-up, and they reported
negative after 5 days of incubation. The patient underwent a repeat
lumbar puncture on hospital day 6 as his headache worsened
despite the decrease in peripheral leukocytes and CRP. The followup CSF results were much improved e a glucose level of 29 mg/dL
with a serum glucose level of 115 mg/dL, a protein level of 79.8 mg/
dL, a RBC count of 5/mL, and a WBC count of 270/mL with 79%
neutrophils. On hospital day 8, the initial blood culture isolate was
identied as P. micra.
To explore possible co-existing infection foci such as a periodontal, epidural, or brain abscess, brain MRI and dental examination were performed, which showed leptomeningeal
enhancement along the cerebellar folia and chronic periodontitis.
There was no evidence of abscess formation on physical examination or imaging studies. On hospital day 10, his antibiotics were
changed to oral metronidazole 500 mg qid. He was discharged from
the hospital and continued antimicrobial therapy for a total of 21
days.
The blood isolate was initially identied as P. micra by VITEK 2
rieux Inc., Durham, NC, USA). Since P. micra is not a typical
(bioMe
bacterial meningitis pathogen, we also performed 16S rDNA
sequencing analysis to conrm the test results. 16S rDNA PCR
amplication and sequencing were performed as previously
described [6]. The universal eubacterial primers fD1 (50 AGAGTTTGATCCTGGCTCAG-30 ) and rP2 (ACGGCTACCTTGTTACGACTT-30 ) were used. The 16S rRNA gene sequence (1420 bp) was
compared using BLAST searches in the GenBank and EzTaxon public
databases. The sequence was 99.72% identical (four nucleotides
difference) to that of P. micra (GenBank accession number
ABEE02000013).
Minimum inhibitory concentrations (MICs) of penicillin, ampicillin, ceftriaxone, cefoxitin, clindamycin, metronidazole, and vancomycin were determined by the agar dilution method according to
Clinical and Laboratory Standards Institute (CLSI) guidelines [7].
In vitro antimicrobial susceptibility testing was performed using
Brucella agar plates supplemented with 5 mg of hemin, 1 mg of
vitamin K per milliliter, and 5% laked sheep blood. The plates were
incubated for 48 h at 37
C in anaerobic jars (GasPak Anaerobic
System; BBL, Cockeysville, MD, USA) [8]. The reference strains were
Bacteroides thetaiotaomicron ATCC 29741 and Clostridium difcile
ATCC70057. Interpretive criteria for susceptibility were those
indicated in a CLSI document [7]. The strain was found to be susceptible to all antibiotics tested (Table 1). Although CLSI guidelines
do not suggest a susceptibility breakpoint for vancomycin, the
present strain was susceptible to vancomycin based on recommendations by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) (http://www.srga.org/eucastwt/
mictab/index.html).
3. Discussion
P. micra, previously known as Peptostreptococcus micros, is part
of the normal ora of the gingival crevices and gastrointestinal tract
[1]. It is being increasingly recognized as important oral pathogen
[1,2], and sporadic cases of extra-oral cavity infections such as an
empyema, endocarditis, pericarditis, septic pulmonary embolism,
septic knee, prosthetic joint infection, and vertebral osteomyelitis

Table 1
In vitro activity of antimicrobial agents against the Parvimonas micra isolate.
Antimicrobial agent

MIC (mg/L)

Susceptibility

Ampicillina
Penicillina
Clindamycina
Ceftriaxonea
Metronidazolea
Vancomycinb
Cefoxitina

0.12
<0.06
0.25
0.12
0.12
0.5
0.25

S
S
S
S
S
S
S

Abbreviation: MIC, minimum inhibitory concentration.

a
Breakpoints recommended by the Clinical and Laboratory Standards Institute.
b
Breakpoints recommended by the European Committee on Antibiotic Susceptibility Testing.

have been reported [3e5,9e14]. Cases of meningitis due to P. micra

have been reported in the setting of vertebral osteomyelitis and
epidural abscesses [3e5]. There has been no report of primary
bacterial meningitis caused by this organism, thus the patient underwent dental examination and brain MRI to determine the
possible source of infection, and these studies revealed only chronic
periodontitis. Considering the history of tooth extraction two
weeks before admission, the pathogenesis of bacterial meningitis in
this patient is thought to be hematogenous seeding of transient
P. micra bacteremia during the dental procedure. To our knowledge,
this is the rst report of primary bacterial meningitis caused by
P. micra.
Since common bacterial meningitis pathogens are considered to
be aerobic bacteria [15,16], anaerobic culture of CSF is not recommended [17]. This could explain why P. micra was discovered in
blood cultures, but not in CSF cultures in this case. Such phenomenon was also observed in a previous report of bacterial meningitis
caused by fusobacterium necrophorum [18]. Although 16S rDNA PCR
might help detection of the pathogen from CSF, no CSF sample was
remained when we noticed that blood culture isolate was P. micra.
Given this point, bacterial meningitis caused by oral anaerobes
could be underdiagnosed. Our case suggests that CSF cultures for
anaerobes should be considered in cases with a high risk of
anaerobic infection due to oral ora such as patients with a history
of dental procedures.
P. micra has been reported to be highly susceptible to antibiotics
including penicillin, amoxicillin, cefoxitin, imipenem, clindamycin,
metronidazole, and vancomycin [1,8,19]. Susceptibility data for
ceftriaxone was not readily available, probably because it is
considered a drug for aerobic infections. Since the patient in the
present case report improved with ceftriaxone and vancomycin, we
also determined the MIC of ceftriaxone in addition to other antibiotics considered to be active against Gram-positive anaerobic
cocci (GPAC). Although we do not know which antibiotic played a
major role in treating the meningitis in the present case, the isolate
was susceptible to all antibiotics used. Given these antimicrobial
susceptibility data, we think ceftriaxone and vancomycin can be
safely used as an empiric antimicrobial regimen for bacterial
meningitis, even in cases of GPAC infection.
We treated the patient with oral metronidazole for 12 days after
9 days of treatment with IV antibiotics. The optimal duration of
antimicrobial therapy for bacterial meningitis depends on the
causative pathogens and clinical course [20]. Since there are no
clinical practice guidelines for the management of anaerobic
meningitis and the patient's headache slowly improved, we treated
him for 21 days. Although IV antibiotics are recommended for
bacterial meningitis to ensure an adequate CSF concentration, we
prescribed oral metronidazole as it has high oral bioavailability
approaching 100% [21]. There was no recurrence of the infection or
complications after one year of outpatient follow-up.

J.-H. Ko et al. / Anaerobe 34 (2015) 161e163

4. Conclusion
This is the rst report of primary bacterial meningitis caused by
P. micra after tooth extraction and suggests that this organism can be
a bacterial meningitis pathogen, even in an immunocompetent host.
Potential conicts of interest
On behalf of all authors, the corresponding author states that
there is no conict of interest.
References
[1] D.A. Murdoch, Gram-positive anaerobic cocci, Clin. Microbiol. Rev. 11 (1998)
81e120.
[2] D. Belstrom, N.E. Fiehn, C.H. Nielsen, N. Kirkby, S. Twetman, V. Klepac-Ceraj,
B.J. Paster, P. Holmstrup, Differences in bacterial saliva prole between periodontitis patients and a control cohort, J. Clin. Periodontol. 41 (2014) 104e112.
[3] H. Uemura, K. Hayakawa, K. Shimada, M. Tojo, M. Nagamatsu, T. MiyoshiAkiyama, S. Tamura, K. Mesaki, K. Yamamoto, Y. Yanagawa, J. Sugihara,
S. Kutsuna, N. Takeshita, N. Shoda, A. Hagiwara, T. Kirikae, N. Ohmagari,
Parvimonas micra as a causative organism of spondylodiscitis: a report of two
cases and a literature review, Int. J. Infect. Dis. 23 (2014) 53e55.
[4] K.S. Leder, T.F. Barlam, A case of paraspinal abscess and diskitis due to Peptostreptococcus micros, Clin. Infect. Dis. 30 (2000) 622e623.
[5] J.P. Frat, C. Godet, G. Grollier, J.L. Blanc, R. Robert, Cervical spinal epidural
abscess and meningitis due to Prevotella oris and Peptostreptococcus micros
after retropharyngeal surgery, Intensive Care Med. 30 (2004) 1695.
[6] M. Al Masalma, F. Armougom, W.M. Scheld, H. Dufour, P.H. Roche,
M. Drancourt, D. Raoult, The expansion of the microbiological spectrum of
brain abscesses with use of multiple 16S ribosomal DNA sequencing, Clin.
Infect. Dis. 48 (2009) 1169e1178.
[7] Clinical and Laboratory Standards Institute (CLSI), Performance Standards for
Antimicrobial Susceptibility Testing; Twenty-fourth Informational Supplement, 2014 (M100eS24)(Wayne, PA).
[8] J. Brazier, D. Chmelar, L. Dubreuil, G. Feierl, M. Hedberg, S. Kalenic, E. Kononen,
B. Lundgren, H. Malamou-Ladas, E. Nagy, A. Sullivan, C.E. Nord, European
surveillance study on antimicrobial susceptibility of Gram-positive anaerobic
cocci, Int. J. Antimicrob. Agents 31 (2008) 316e320.
[9] C. Poetter, C. Pithois, S. Caty, V. Petit, J.P. Combier, P. Mourtialon, F. Mattner,
Hiding behind confusion: pleural empyema caused by Parvimonas micra,
Surg. Infect. (Larchmt) 15 (2014) 356e357.

163

[10] G.K. Taylor, L. Elliott, M.D. Sosin, S.S. Soo, Complication of etanercept treatment for rheumatoid arthritisepurulent pericarditis caused by a commensal
organism, BMJ Case Rep. (2012) 2012.
[11] P. Ubeda, J. Todoli, E. Saro, M.D. Gomez, C. Perez Belles, M. Gobernado, Subacute infectious endocarditis in prosthetic valve by Peptostreptococcus micros, Enferm. Infecc. Microbiol. Clin. 16 (1998) 101e102.
[12] T. Stoll, G. Stucki, P. Bruhlmann, M. Vogt, N. Gschwend, B.A. Michel, Infection
of a total knee joint prosthesis by peptostreptococcus micros and propionibacterium acnes in an elderly RA patient: implant salvage with longterm
antibiotics and needle aspiration/irrigation, Clin. Rheumatol. 15 (1996)
399e402.
[13] C.J. Papasian, D.H. McGregor, G.R. Hodges, J. Kennedy, Peptostreptococcal
vertebral osteomyelitis, J. Clin. Microbiol. 24 (1986) 633e635.
[14] M. Garcia Gonzalez, J.R. Muniz Montes, D. Garcia Rosado, S. Bustabad Reyes,
Multifocal hematogenous vertebral osteomyelitis due to Parvimonas micra
and a subsequent pleural effusion in a diabetic patient, Reumatol. Clin. 10
(2014) 191e192.
[15] D. van de Beek, J. de Gans, A.R. Tunkel, E.F. Wijdicks, Community-acquired
bacterial meningitis in adults, N. Engl. J. Med. 354 (2006) 44e53.
[16] S.Y. Moon, D.R. Chung, S.W. Kim, H.H. Chang, H. Lee, D.S. Jung, Y.S. Kim,
S.I. Jung, S.Y. Ryu, S.T. Heo, C. Moon, H.K. Ki, J.S. Son, K.T. Kwon, S.Y. Shin,
J.S. Lee, S.S. Lee, J.Y. Rhee, J.A. Lee, M.K. Joung, H.S. Cheong, K.R. Peck, J.H. Song,
Changing etiology of community-acquired bacterial meningitis in adults: a
nationwide multicenter study in Korea, Eur. J. Clin. Microbiol. Infect. Dis. 29
(2010) 793e800.
[17] E.J. Baron, J.M. Miller, M.P. Weinstein, S.S. Richter, P.H. Gilligan,
R.B. Thomson Jr., P. Bourbeau, K.C. Carroll, S.C. Kehl, W.M. Dunne, B. RobinsonDunn, J.D. Schwartzman, K.C. Chapin, J.W. Snyder, B.A. Forbes, R. Patel,
J.E. Rosenblatt, B.S. Pritt, A guide to utilization of the microbiology laboratory
for diagnosis of infectious diseases: 2013 recommendations by the Infectious
Diseases Society of America (IDSA) and the American Society for Microbiology
(ASM)(a), Clin. Infect. Dis. 57 (2013) e22ee121.
[18] G. Angelino, N. Cantarutti, S. Chiurchiu, D. Amodio, M. De Luca, L. Lancella,
L. Coltella, C. Russo, A. Finocchi, Fulminant Fusobacterium necrophorum
meningitis in an immunocompetent adolescent, Pediatr. Emerg. Care 28
(2012) 703e704.
[19] A. Marchand-Austin, P. Rawte, B. Toye, F.B. Jamieson, D.J. Farrell, S.N. Patel,
Antimicrobial susceptibility of clinical isolates of anaerobic bacteria in
Ontario, 2010-2011, Anaerobe 28 (2014) 120e125.
[20] A.R. Tunkel, B.J. Hartman, S.L. Kaplan, B.A. Kaufman, K.L. Roos, W.M. Scheld,
R.J. Whitley, Practice guidelines for the management of bacterial meningitis,
Clin. Infect. Dis. 39 (2004) 1267e1284.
[21] A.H. Lau, N.P. Lam, S.C. Piscitelli, L. Wilkes, L.H. Danziger, Clinical pharmacokinetics of metronidazole and other nitroimidazole anti-infectives, Clin.
Pharmacokinet. 23 (1992) 328e364.