Indian Journal of Critical Care Medicine
Volume 26 | Issue 6 | Year 2022

Scrub Typhus Complicated by Rare Human Pathogen Sphingobacterium spiritivorum

Sonali Bansal1, Siddarth Varshney2

1Department of Critical Care, SPS Hospital, Ludhiana, Punjab, India
2Department of Cardiology, CMC Hospital, Ludhiana, Punjab, India

Corresponding Author: Siddarth Varshney, Department of Cardiology, CMC Hospital, Ludhiana, Punjab, India, Phone: +91 9045502542, e-mail:

How to cite this article: Bansal S, Varshney S. Scrub Typhus Complicated by Rare Human Pathogen Sphingobacterium spiritivorum. Indian J Crit Care Med 2022;26(6):742–744.

Source of support: Nil

Conflict of interest: None


Sphingobacterium spiritivorum is a rare cause of human infections worldwide. After reviewing the literature, we could find only eight case reports to date. The majority of cases were of cellulitis and septicemia. Most of these patients were immunocompromised and the recovery rate was lesser. We present a case of a young female diagnosed with scrub typhus complicated by acute respiratory distress syndrome who developed septicemia and septic shock due to S. spiritivorum. She was managed with sensitive antibiotic levofloxacin, clinically improved, and discharged in satisfactory condition.

Keywords: Acute respiratory distress syndrome, Scrub typhus, Sphingobacterium spiritivorum.


Sphingobacterium spiritivorum is a rare cause of infection in humans. This bacterium has been associated with causing cellulitis,14 bacteremia,5,6 hypersensitivity pneumonitis,7 sepsis, and infective endocarditis8 in humans. Most reported cases were in immunocompromised patients or patients with multiple comorbidities. Here we present the first reported case of a young female with no comorbidities diagnosed as a case of scrub typhus with bacteremia attributing to S. spiritivorum, who clinically recovered well after appropriate antibiotic treatment.


A 37-year-old female with a single live baby and no comorbidities presented with complaints of persistent fever of 100°F for the last 5 days, increased frequency of stools for the last 3 days, and decreased urine output for the last 2 days. On examination, she was of average build, conscious, and oriented to time, place, and person. Her blood pressure was 80/50 mm Hg with a heart rate of 140/minutes (sinus tachycardia), and respiratory rate was 36/minutes with abdominal thoracic breathing. Laboratory investigations revealed—Hemoglobin—10 mg%, blood urea—84 mg%, serum creatinine—2.80 mg%, total leukocyte count (TLC)—14,300/mm3 with 80% neutrophils, platelets—54,000/mm3, sodium—125 mEq/L, potassium—3.1 mEq/L, PT-INR—1.18, SGOT—51 µ/L, SGPT—89 µ/L, total serum bilirubin—2.0 mg/dL, albumin 2.1 mg%. Fever workup was sent for tropical fevers and scrub typhus ELISA IgM reported positive. Her chest X-ray, 2D echocardiography, and ultrasonography of the abdomen were all normal. Fluid resuscitation and inotropic support were started with 0.9% normal saline and noradrenaline at 1.2 µg/kg/minute, respectively. The patient was put on noninvasive ventilatory support, and antibiotics meropenem, metronidazole, and doxycycline were added empirically. Right internal jugular venous cannulation was done. On day 2, IV fluids and noradrenaline were continued, as her shock was not responding vasopressin 0.04 µ/minute intravenously was added. Meanwhile, in 24 hour her blood, urine, and stool cultures reported no bacterial growth. She developed an oral mucosal bleed owing to worsening thrombocytopenia and it was managed with platelets transfusion. In view of oliguric acute kidney injury, she underwent one cycle of slow low efficient dialysis. On day 3, TLC got raised to 36,000/mm3 with a neutrophilic predominance and she was started on teicoplanin. On day 4, the vasopressors’ requirement decreased, and daily fluid adjustments were done. However later on day 4, her oxygen requirement increased because of worsening tachypnea and fatigue leading to mixed respiratory failure. Chest auscultation revealed coarse crepitations in bilateral lower zones. Chest X-ray now suggested pulmonary edema. Bedside echocardiography revealed decreased left ventricular ejection fraction (LVEF) of 40%. In view of severe acute respiratory distress syndrome (PaO2/FiO2 <100), she was kept on mechanical ventilation as per the lung-protective ventilation strategy. She was kept sedated and paralyzed. She received methylprednisolone 40 mg twice daily for 48 hours and then tapered off. In due course of time, on day 7 fractional oxygen requirement decreased to 40%. Vasopressors started tapering. Left ventricular ejection fraction (LVEF) improved to 60%, and chest X-ray, TLC, and serum creatinine showed an improving trend. A sedation vacation was given, and she regained consciousness but developed neuromuscular weakness in all four limbs. On day 8, fever again spiked to 103°F, TLC increased to 19,000/mm3 with neutrophilic predominance, and vasopressors’ requirement increased. Repeat blood culture and urine culture were sent. Antibiotics escalated to colistin and fluconazole. Blood cultures after 2 days of incubation period reported the growth of gram-negative, non-motile, non-fermenting, oxidase-positive bacilli S. spiritivorum. Using the automated microdilution broth technique (vitek-2), antibiotic susceptibility testing was done. The results were reported as minimum inhibitory concentration (MIC): Cefoperazone/sulbactam ≤8 µg/mL, ciprofloxacin ≤1 µ/mL, levofloxacin ≤0.5 µ/mL, minocycline ≤1 µ/mL, trimethoprim/sulfamethoxazole ≤20 µ/mL. This bacterium was highly resistant to colistin, meropenem, imipenem, piperacillin/tazobactam, amikacin, gentamicin, cefepime, and ceftazidime. She was started on levofloxacin 500 mg intravenously once a day. On day 14 her fever subsided, vasopressors tapered off, and minimal oxygen requirement, and liberated from mechanical ventilation with no adverse event. Diagnostic workup was done for residual limb weakness and was diagnosed as critical illness-induced myopathy. Her clinical condition improved and was discharged in satisfactory condition on oral levofloxacin. Repeated blood cultures were done after 2 weeks of therapy and showed no growth of any organism. Her clinical events are summarized in Table 1.

Table 1: Patient timeline summarizing clinical events from presentation till discharge
Day 0 IV fluids, Inotropes, NIV, Antibiotics-meropenem, Doxycycline, Metronidazole
Day 1 Vasopressin started
Day 2 Platelets transfused for thrombocytopenia and dialysis given for acute kidney injury
Day 3 Antibiotic escalated to teicoplanin
Day 4 Inotropes reduced
Day 4 Features of myocarditis and ARDS, Steroids given
Day 7 Improvement in blood parameters, ARDS and myocarditis
Day 8 Fever spiked, Neutrophilic leukocytosis, Inotropes increased, Antibiotics escalated to colistin
Day 10 S. spiritivorum identified and levofloxacin started subsequently
Day 14 Clinical recovery, Inotropes tapered off, Weaning from ventilatory support
Day 18 Patient discharged in satisfactory condition on oral levofloxacin

ARDS, acute respiratory distress syndrome


We report the first human case of S. spiritivorum infection in a patient of scrub typhus. Sphingobacterium species mainly S. multivorum and S. spiritivorum are known to cause the majority of infections in humans. S. spiritivorum is a gram-negative rod, aerobic, non-fermenting, non-motile, non-sporing, oxidase-positive bacilli and was first described in humans by Holmes et al.9 in 1982. After that only a few cases have been reported worldwide as described in Table 2. It is named Sphingobacterium because of the high content of sphingolipids in their cell walls. They are usually isolated from soil, water bodies, and plants and the isolation from human secretions is a rare event. In view of severe acute respiratory distress syndrome caused by scrub typhus, she received steroids which could have led to a pronounced immunocompromised state and supported the growth of bacteria in our patient. Interestingly she did not respond to empirical colistin and carbapenem initially as bacterial strains are inherently resistant to these antibiotics and the patient showed drastic recovery after receiving levofloxacin. We emphasize the use of repeated cultures and species identification among high-risk ICU patients as an utmost priority due to the intrinsic multidrug resistance behavior of this microorganism and increased risk of human infections.

Table 2: Summary of reported cases of S. spiritivorum in humans
Case Age (years) Sex Year Comorbidity Diagnosis Source Treatment Outcome
Marinella1 72 Male 2002 Parkinson Cellulitis Blood NA Recovery
Tronel2 84 Male 2003 Anemia Cellulitis Blood Amoxicillin-clavulanate Recovery
Anthony3 89 Male 2016 Parkinson Cellulitis Blood Piperacillin tazobactam Recovery
Arata4 80 Male 2017 COPD Cellulitis Blood Levofloxacin Recovery
Koh5 68 Female 2013 Leukemia Septicemia Blood Ciprofloxacin Death
Gupta6 80 Female 2016 End-stage renal disease Septicemia Blood NA Recovery
Kämpfer7 34 Female 2005 NS Extrinsic allergic alveolitis Water reservoir NA Recovery
Hugo8 61 Male 2016 Nephrotic syndrome Infective endocarditis Mitral valve Piperacillin-tazobactam Death
PC 37 Female 2021 NS Septicemia Blood Levofloxacin Recovery

PC, present case; NA, not available; NS, nothing significant


We present the first case of a young female with scrub typhus complicated by acute respiratory distress syndrome later on developing septicemia and septic shock due to the extremely rare human pathogen S. spiritivorum.


Sonali Bansal

Siddarth Varshney


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2. Tronel H, Plesiat P, Ageron E, Grimont PAD. Bacteremia caused by a novel species of Sphingobacterium. Clin Microbiol Infect 2003;9:1242–1244. DOI: 10.1111/j.1469-0691.2003.00801.x.

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4. Hibi A, Kumano Y. Sphingobacterium spiritivorum bacteremia due to cellulitis in an elderly man with chronic obstructive pulmonary disease and congestive heart failure: a case report. J Med Case Rep 2017;11:277. DOI: 10.1186/s13256-017-1445-6.

5. Koh YR, Kim SY, Chang CL, Shin HJ, Kim KH, Yi J. The first Korean case of Sphingobacterium spiritivorum bacteremia in a patient with acute myeloid leukemia. Ann Laboratory Med 2013;33(4):283–287. DOI: 10.3343/alm.2013.33.4.283.

6. Gupta A, Logan J, Elhag N, Almond M. Sphingobacterium spiritivorum infection in a patient with end stage renal disease on haemodialysis. Ann Clin Microbiol Antimicrob 2016;15:25. DOI: 10.1186/s12941-016-0141-5.

7. Kämpfer P, Engelhart S, Rolke M, Sennekamp J. Extrinsic allergic alveolitis (hypersensitivity pneumonitis) caused by Sphingobacterium spiritivorum from the water reservoir of a steam iron. J Clin Microbiol 2005;43(9):4908–4910. DOI: 10.1128/JCM.43.9.4908-4910.2005.

8. Abensur H, Dantas FMB, Araujo MRE, Campos RN, Araujo MRT. Infective endocarditis related to the uncommon gram-negative pathogen Sphingobacterium spiritivorum. Clin Microbiol Infect Dis 2019;4. DOI: 10.15761/CMID.1000160.

9. Holmes B, Owen RJ, Hollis DG. Flavobacterium spiritivorum, a new species isolated from human clinical specimens. Int J Syst Bacteriol 1982;32:157–165. DOI: 10.1099/00207713-32-2-157.

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