Fatal Elizabethkingia anophelis Bacteremia Complicated by Meningitis in a Hemodialysis Patient: A Case Report and Review of the Literature

Elizabethkingia anophelis (E. anophelis​​​​​​) is an emerging multidrug-resistant pathogen in hospital aquatic environments associated with severe infections. Reports of E. anophelis infection in hemodialysis patients are rare, and meningitis caused by this organism has been poorly characterized. We report a fatal case of meningitis in a hemodialysis patient caused by E. anophelis bacteremia and review previous cases of E. anophelis infection in hemodialysis patients. A 68-year-old man with end-stage renal disease due to diabetic kidney disease on maintenance hemodialysis was admitted with fever after recent glucocorticoid therapy. Blood cultures grew E. anophelis. Despite initial antimicrobial treatment, the patient developed bacterial meningitis with impaired consciousness and abnormal cerebrospinal fluid (CSF) findings. Although CSF cultures were negative, repeated blood cultures remained positive for E. anophelis, and alternative pathogens were excluded using a multiplex meningitis/encephalitis panel. Therefore, meningitis due to E. anophelis was considered. Antimicrobial therapy was changed to levofloxacin (LVFX) plus sulfamethoxazole-trimethoprim according to susceptibility testing and CSF penetration, resulting in improvement of inflammatory markers, CSF findings, and consciousness. However, the patient subsequently developed nonocclusive mesenteric ischemia (NOMI) and massive iliopsoas hematomas and died of hemorrhagic shock. Autopsy confirmed NOMI without bowel necrosis, and the cause of death was attributed to hemorrhagic shock with NOMI, not directly related to E. anophelis infection. A literature review identified only three cases of E. anophelis infection in hemodialysis patients. Unlike our case, those patients had catheter-related bloodstream infection or pneumonia and survived following antimicrobial therapy, most commonly including LVFX. This case highlights that E. anophelis can cause meningitis in hemodialysis patients. Given its multidrug resistance and persistence in healthcare aquatic environments, clinicians and dialysis healthcare workers should be aware of this uncommon but potentially life-threatening pathogen.