Case Report | Thoracic Imaging

https://doi.org/10.3348/kjr.2016.17.6.961
pISSN 1229-6929 · eISSN 2005-8330
Korean J Radiol 2016;17(6):961-964

Computed Tomography Findings of Community-Acquired

Stenotrophomonas Maltophilia Pneumonia in an
Immunocompetent Patient: A Case Report
Yoon Ki Cha, MD1, Jeung Sook Kim, MD, PhD1, Seong Yeon Park, MD2,
Jin Young Oh, MD, PhD2, Jae Hyun Kwon, MD, PhD1
Departments of 1Radiology and 2Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326,
Korea

Stenotrophomonas maltophilia (S. maltophilia) is a rare, but globally emerging gram-negative multiple-drug-resistant
organism usually found in a nosocomial setting in immunocompromised patients. To our best knowledge, computed
tomography (CT) features of community-acquired S. maltophilia pneumonia have not been previously reported in an
immunocompetent patient. Herein, we presented the CT findings of a previous healthy 56-year-old male with S. maltophilia
pneumonia.
Index terms: Stenotrophomonas maltophilia; Community-acquired pneumonia; Immunocompetent host; CT

INTRODUCTION central venous catheter use, malignancy, trauma, prior

hospitalization, HIV infection, or other forms of immune
Stenotrophomonas maltophilia (S. maltophilia) is an suppression (1).
environmental, globally emerging gram-negative pathogen To our best knowledge, only two case reports have
most commonly associated with respiratory tract infection described computed tomography (CT) features of S.
in humans (1). S. maltophilia mainly causes nosocomial maltophilia pneumonia in immunocompromised patients.
infections in immunocompromised patients. However, However, the CT features of community-acquired S.
community-acquired S. maltophilia infection has been maltophilia pneumonia in immunocompetent patients
occasionally reported in patients with bacteremia, ocular remain unclear. Herein, we reported a case of community-
infection, respiratory tract infection, cellulitis, urinary acquired S. maltophilia pneumonia in an immunocompetent
tract infection, and wound infection (2). Commonly, patient, with particular emphasis on the CT findings. The
patients with S. maltophilia infection have some form of review of this report was exempted by the Institutional
comorbidity such as chronic obstructive pulmonary disease, Review Board of our institution.

Received February 23, 2016; accepted after revision July 2, 2016.

Corresponding author: Jeung Sook Kim, MD, PhD, Department of CASE REPORT
Radiology, Dongguk University Ilsan Hospital, Dongguk University
College of Medicine, 27 Dongguk-ro, Ilsandong-gu, Goyang 10326, A 56-year-old man presented with a 4-day history
Korea.
of febrile sensation. The physical examination was
• Tel: (8231) 961-7820 • Fax: (8231) 961-8281
• E-mail: [email protected] unremarkable apart from a fever (39.0°C). He had been
This is an Open Access article distributed under the terms of prescribed medication for hypertension; otherwise, there
the Creative Commons Attribution Non-Commercial License was no known history of malignancy or chronic disease. On
(http://creativecommons.org/licenses/by-nc/3.0) which permits
unrestricted non-commercial use, distribution, and reproduction in admission, he had a high erythrocyte sedimentation rate
any medium, provided the original work is properly cited. (77 mm/h) and a high C-reactive protein level (26 mg/

Copyright © 2016 The Korean Society of Radiology 961

 Cha et al.

L). The white blood cell count and absolute neutrophil 1A). Chest CT demonstrated a smooth thickening of the
count were both normal (5.14 x 103/μL, 2560/μL). The interlobular septae and peribronchovascular bundle with
initial septic work-up, which included sputum bacterial multifocal ground-glass opacities and ill-defined nodules
culture, acid fast bacilli smear and culture, bacterial and in both lungs. A small amount of bilateral pleural effusion
fungal blood cultures, and a nasal swab for respiratory viral and pericardial effusion was present (Fig. 1B-E). The initial
markers, was negative. The patient was negative for HIV radiologic impression was atypical pneumonia, including
infection. An initial chest radiograph showed increased viral pneumonia. Ceftriaxone was initiated as an empirical
interstitial markings in both lungs, with a suspicion of treatment, with Gemifloxacin for atypical pneumonia. The
interstitial pneumonia or interstitial pulmonary edema (Fig. follow-up chest radiograph showed progression of bilateral

A B C

D E F
Fig. 1. 56-year-old man presented with 4-day history of febrile sensation.
A. Initial chest radiograph shows increased interstitial markings in both lungs. B. Chest CT with lung window setting shows diffuse thickening
of interlobular septae and ill-defined small nodules (arrowheads) in both upper lobes. C. In lower lung zones, CT scan shows diffuse smooth
thickening of interlobular septae and patchy ground-glass opacities (arrows). D. On coronal scan, ill-defined small nodules (arrowheads) are
predominantly seen in upper lung zones. E. Mediastinal window CT image shows small bilateral pleural effusion (arrowheads), pericardial effusion
(white arrows), and thickening of peribronchovascular bundles. F. Follow-up chest radiograph shows ill-defined ground glass opacities in both
parahilar areas and increased interstitial markings with developing bilateral pleural effusion.

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Stenotrophomonas Maltophilia Pneumonia

ground-glass opacities and increased interstitial markings fibrosis patients.

in both lungs, with increased bilateral pleural effusion (Fig. To our best knowledge, only two case reports of three
1F). The patient underwent bronchoscopy, and subsequent patients have described the CT features of S. maltophilia
culture of the bronchoalveolar lavage fluid demonstrated pneumonia. Case 1 showed CT findings of diffuse bilateral
the presence of S. maltophilia, which was sensitive to multifocal consolidation and ground-glass opacities with
Levofloxacin; hence, the antibiotic was switched to small centrilobular nodules in a child who had undergone
Levofloxacin. The patient became afebrile and further bone marrow transplantation (11); Case 2 presented the CT
follow-up chest radiograph showed decreased bilateral findings of bilateral patchy ground-glass opacities without
ground-glass opacities and pleural effusion. Finally, the zonal predominance in a neutropenic patient with diffuse
patient was discharged from the hospital. large B-cell lymphoma; and Case 3 was a neutropenic patient
with advanced esophageal cancer. CT showed bilateral
DISCUSSION ground-glass opacities, consolidation, and numerous
centrilobular nodules with cylindrical bronchiectasis and
Stenotrophomonas maltophilia is a waterborne aerobic, bronchial wall thickening without zonal predominance (12).
gram-negative multiple-drug-resistant organism, most Among these three cases, the most consistent finding of S.
commonly associated with respiratory tract infection in maltophilia pneumonia in immunocompromised patients was
humans (1). It has emerged globally in recent years as a diffuse ground-glass opacities without zonal predominance.
nosocomial infection (3). Although S. maltophilia is not However, in our case, the CT findings differed from the
a highly virulent pathogen, it is an important nosocomial previous reports and included interstitial thickening and ill-
pathogen associated with a high rate of mortality (14–69%) defined nodules with zonal predominance. These findings
in patients with bacteremia (4, 5). The incidence of S. may resemble interstitial pneumonia, caused by Mycoplasma
maltophilia as a hospital-acquired infection is increasing, pneumoniae and viruses. From our experience, the CT
particularly in immunocompromised patients. In addition, findings of S. maltophilia pneumonia are nonspecific and
S. maltophilia is an important emerging pathogen in cystic the final diagnosis is still based on microbiology.
fibrosis patients (6, 7). However, the clinical relevance of In summary, we presented the CT findings of S.
the increased prevalence of S. maltophilia in cystic fibrosis maltophilia pneumonia in an immunocompetent patient.
is unclear (8). Infections associated with S. maltophilia In immunocompromised patients, the CT findings of S.
include respiratory tract infection, bacteremia, eye maltophilia pneumonia are diffuse ground-glass opacities
infection, endocarditis, biliary sepsis, infection of bones without zonal predominance. However, in immunocompetent
and joints and urinary tract infection, and also meningitis patients, the CT findings differ, showing interstitial
(1). In nosocomial settings, S. maltophilia has been isolated thickening and ill-defined nodules with zonal predominance.
from the suction system of dental chair units, tap water, Additional studies of the CT findings of S. maltophilia
contaminated endoscopes and central venous catheters in pneumonia are required for a better understanding of this
patients with neutropenia (1, 9). globally emerging pathogen.
A few reports describe S. maltophilia associated with
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