PowerPoint Presentation Empedobacter brevis, as a part of the Flavobacteriaceae family, is a non-motile, strictly aerobic, gram negative, yellow colony-forming bacterium that typically resides in soil, plants, water sources, and hospital environments.1,2 The first reported case of a human infection was in 2002 when 11 out of 12 patients were diagnosed with endophthalmitis from an E. brevis infection post cataract surgery.3 More cases of E. brevis infections have since been reported ranging from meningitis to cellulitis.3,4,6 Treatment can be complicated by the bacteria’s beta lactamase gene, which results in resistance to extended cephalosporins and carbapenems.5 There have been a few dermatologic manifestations of E. Brevis infections reported in the literature that warrant further evaluation.6,7 We present a case of an E. brevis infection in a 61-year-old male who presented with a persistent right mid-thigh lesion. INTRODUCTION A Rare Case of Empedobacter Brevis Cutaneous Infection Treated Successfully with Oral Sarecycline Susuana Adjei, MD1; Austinn C. Miller, MD 1; Laurie A. Temiz, BA2 ; Stephen K. Tyring, MD, PhD, MBA 1,3 1Center for Clinical Studies Webster, TX; 2Meharry Medical College, Nashville, TN; 3UT Houston Department of Dermatology, Houston TX DISCUSSION Thought to be an environmental pathogen, increasing cases of human E. brevis infections are now being reported as portrayed in Table 1. There have been cases ranging from neonates to the elderly, namely those who are immunocompromised. Exposure of E. Brevis can be from hospital facilities to soils, water sources, and plants-- as also depicted in some of the reported cases. While human E. brevis infections increase, its dermatologic manifestations are also emerging. E. brevis is not found on normal skin flora, so skin infections tend to stem from environmental exposure from breaks in the skin such as the knee laceration with cellulitis and foot lesion with anaphylactoid purpura and blisters. Treatment of infections due to E. brevis is by antibiotics that have activity against gram-negatives. However, this is only complicated by resistance to certain beta-lactams due to E. Brevis’ beta-lactamase gene, conferring resistance to extended cephalosporins and carbapenems, as demonstrated by the sensitivities from our patient. Patient Information Case Details Sensitivity Results/Treatment 65 YO female with PMH of COPD, Brown Sequard syndrome Right knee cellulitis & bacteremia due to E. brevis 6 weeks post right knee replacement & subsequent fall with knee laceration - Sensitive to most antibiotics - Treated with Levaquin for 10 days 83 YO female Presented with anaphylactoid purpura, erythema, blisters, and erosion of the right foot. E. Brevis was cultured from the lesion. Biopsy showed leukocytoclastic vasculitis. - Sensitive: minocycline HCl - Treated with minocycline HCl Table 1. Reported cases of skin infections due to E. Brevis CASE PRESENTATION A 61-year-old male with a past medical history of hypertension, actinic keratoses, history of valve replacement (chronically on Warfarin) and prior knee replacement surgery presented with a lesion that persisted for 6 weeks after doing yard work. He reported using hydrogen peroxide and antibiotic bandages with no improvement. Physical Exam A non-painful right mid-thigh red, crusted linear erosion with honey-yellow crusting. Culture - Empedobacter brevis was identified by DNA sequencing. - Resistant to meropenem and tobramycin Treatment Patient was initially treated with mupirocin with no improvement. 15-day course of 150mg once-daily. Sarecycline was added after the results returned and the lesion healed well over the upcoming weeks. Figure 1. Lesion at initial visit Figure 3. One-month post- treatment Figure 2. Lesion after a week of Seracycline 1. Vandamme P, Bernardet JF, Segers P, Kersters K, Holmes B. New Perspectives in the Classification of the Flavobacteria: Description of Chryseobacterium gen. nov., Bergeyella gen. nov., and Empedobacter nom. rev. International Journal of Systematic and Evolutionary Microbiology. 1994 Oct 1;44(4):827-31 2. Jooste PJ, Hugo CJ. The taxonomy, ecology and cultivation of bacterial genera belonging to the family Flavobacteriaceae. International journal of food microbiology. 1999 Dec 15;53(2-3):81-94. 3. Janknecht P, Schneider CM, Ness T. Outbreak of Empedobacter brevis endophthalmitis after cataract extraction. Graefes Arch Clin Exp Ophthalmol. 2002 Apr;240(4):291-5. doi: 10.1007/s00417-002-0435-5. Epub 2002 Mar 12. PMID: 11981643 4. Sharma D, Patel A, Soni P, Sharma P, Gupta B. Empedobacter brevis Meningitis in a Neonate: A Very Rare Case of Neonatal Meningitis and Literature Review. Case Rep Pediatr. 2016;2016:7609602. doi:10.1155/2016/7609602 5. Bellais S, Girlich D, Karim A, Nordmann P. EBR-1, a novel Ambler subclass B1 beta-lactamase from Empedobacter brevis. Antimicrob Agents Chemother. 2002 Oct;46(10):3223-7. doi: 10.1128/AAC.46.10.3223-3227.2002. PMID: 12234848; PMCID: PMC128804 6. Raman S, Shaaban H, Sensakovic JW, Perez G. An interesting case of empedobacter brevis bacteremia after right knee cellulitis. J Glob Infect Dis. 2012;4(2):136-137. doi:10.4103/0974-777X.96783 7. Nishio E. [A case of Anaphylactoid purpura suggested to Empedobacter (flavobacterium) brevis infection concerned]. Arerugi. 2010 May;59(5):558-61. Japanese. PMID: 20502105.] ACKNOWLEDGEMENTS We would like to thank the patient for providing permission to report his case. REFERENCES Conflict of Interest Dr. Stephen K. Tyring is a Principal Investigator for a Clinical Trial for one of Almirall’s trials.