Cochlear Implant Infection in a Teenager with CHARGE Syndrome: A Case Report

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Johnson, Natalie N Neu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8870865/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 15 You are reading this latest preprint version Abstract Background Pastuerella multicoda is a gram-negative coccobacillus commonly found in the oral flora of many animals, most commonly in cats and implicated in zoonotic infections, commonly cellulitis secondary to cat bites and scratches. Here we describe a teenager with CHARGE syndrome who developed an infection of her cochlear implant secondary to P multicoda. Case Presentation An 18-year-old female with CHARGE syndrome developed headache, ear pain and cellulitis at the site of her cochlear implant and was found to have osteomyelitis and transient bacteremia secondary to P. multicoda . She required both surgical and medical management, including removal of her cochlear implant and four weeks of antibiotic therapy. Exposure history included numerous excoriations from her new kitten at home. Conclusion This case highlights the importance of obtaining thorough exposure history as part of the evaluation of any pediatric patient with headache, ear pain and cellulitis with complicating factors such as presence of cochlear implant to include zoonotic infections on the differential diagnosis. Additionally, this case highlights the importance of a multidisciplinary team for care of patients with complex medical and surgical history. zoonotic infection CHARGE syndrome cochlear implant infection multidisciplinary care Figures Figure 1 Figure 2 Figure 3 Background Zoonotic infections in pediatric patients are relatively common given presence of household pets ( 1 , 2 ). Pediatric patients with complex medical history including presence of foreign material are also at risk ( 3 , 4 ). Cats are a common reservoir for Pasteurella multocida and can lead to infections in humans through direct inoculation or through indirect contact with secretions ( 5 ). We describe a patient with genetic mutation CHD7 variant, which is associated with sensorineural hearing loss and CHARGE (coloboma, heart defects, choanal atresia, retardation of growth and development, genitourinary abnormalities, and ear abnormalities) syndrome ( 4 ) who presented with headache, ear pain and cellulitis in the setting of a previously placed cochlear implant. This case underscores the importance of obtaining exposure history and the importance of multidisciplinary care. Case Presentation An 18-year-old female presented with one day history of severe right ear pain and fever. She was noted to have CHD7 variant, a genetic mutation associated sensorineural hearing loss and associated with CHARGE syndrome. Four years prior to presentation she had a right-sided cochlear implantation. Five years prior to presentation, given her history of chronic otitis media, she had a right-sided mastoidectomy with eustachian tube and external auditory canal closure to eliminate potential pathways for entrance of bacteria into the inner ear to reduce risk for CI infection. She described severe, sharp pain inside the right ear, a pounding bitemporal headache, new onset photophobia, and the sensation of a “snake crawling” and “bubbles of water” inside the right ear. She also had fevers up to 102 degrees Fahrenheit at home and multiple episodes of non-bloody, non-bilious emesis. She denied any changes in hearing, drainage from the ear, vertigo, or tinnitus. In addition, she denied any recent trauma to the ear, changes to vision, lethargy or increased sleepiness, or any recent sore throat, congestion, cough, or rashes. Family history was notable for bilateral hearing loss in the patient’s mother, likely secondary to CHARGE syndrome, as well as a sister with CHARGE syndrome. On initial exam, the patient had significant post-auricular tenderness along with mild peri-incisional erythema and no fluctuance or edema over the mastoid area (Fig. 1 ). The patient also had a right sided facial asymmetry at rest though was able to achieve complete eye closure (House-Brackmann III/VI). Pediatric Otolaryngology was consulted in the emergency room. The patient’s labs were notable for a mild leukocytosis (WBC 9.7 cells/uL, normal range 3.5–9.4) with left shift along with elevated inflammatory markers (CRP 33.0 mg/L, normal range 0.0–10.0). Blood cultures were collected on presentation. Lumbar puncture was completed, and cerebrospinal fluid studies showed an elevated WBC (221 cells/uL) count and neutrophil predominance (89%) with normal glucose and normal protein. Cerebrospinal fluid culture was without any growth. Computed Tomography (CT) of temporal bone with contrast showed an increased soft tissue prominence along the extracochlear portion of the CI electrode lead along with new foci of air within the middle ear concerning for infection, but no fluid collection or abscess (Fig. 2 ). The patient was admitted to the general pediatrics service for further workup and empirically started on meningitis dosing of vancomycin and cefepime. Pediatric infectious diseases was consulted on hospital day 2. On hospital day two, the patient’s blood cultures turned positive, with Gram stain showing Gram-positive cocci in clusters and Gram-negative rods (GNR). Multiplex PCR performed on the positive blood culture bottle detected Staphylococcus epidermidis and mecA/C gene (FilmArray Blood Culture Identification Panel, Biomerieux, Durham NC). Subculture from the bottle showed growth the next day on both chocolate and blood agar plates, with no growth on MacConkey agar. Gram-stain performed from the chocolate agar plate on the presumptive GNR showed tiny Gram-negative coccobacilli (Fig. 3 ) that were identified as Pasteurella multocida by MALDI-TOF mass spectrometry (Bruker Daltonics, Billerica, MA). Antimicrobial susceptibility testing was performed by gradient agar diffusion (Etest, Biomerieux, Durham, NC) and showed susceptibility to penicillin, ceftriaxone, erythromycin, levofloxacin, and trimethoprim-sulfamethoxazole. The patient’s post-auricular pain remained persistent and her right sided facial weakness became progressively worse for which she was started on high dose prednisone. Given the bacteremia, pain, and worsening facial weakness, on hospital day three she was taken to the operating room with the otolaryngology team for a revision mastoidectomy. Intra-operatively, there was an abscess within the right mastoid that was extensively debrided (and sent for culture). The cochlear implant device was intact but was removed given its potential to remain as a nidus of infection (of note, the intracochlear portion was retained to allow for the possibility of future cochlear implant use if the patient desired). Post-operatively, the patient’s facial nerve function, ear pain, and headaches improved. Her intraoperative mastoid abscess cultures subsequently were also positive for Pasteurella multocida . She was transitioned to vancomycin and ceftriaxone and ultimately to amoxicillin-clavulanate once she had two subsequent blood cultures that had no growth for at least forty-eight hours, and she demonstrated sufficient clinical improvement (The Staphylococcus epidermidis was considered a contaminant given it is a common skin flora and since the bacteria only grew on one culture). She was treated for a total of four weeks due to concern for bony involvement (presumed osteomyelitis) and due to likelihood of re-implantation of cochlear implant. Upon identification of implicated pathogen, exposure history was acquired and revealed that patient had a new kitten at home who scratched the patient frequently, including near her ear. Discussion We surmise that Pasteurella multocida bacteremia and right-sided mastoid abscess without meningitis was result of direct inoculation from a scratch or bite from the patient’s kitten at home. The infection in the ear likely led to significant inflammation, abscess and transient bacteremia. Pasteurella multocida is a gram-negative coccobacillus that is the most common cause of soft tissue infection after animal bites or scratches ( 5 , 6 , 7 ). In the United States, dogs and cats are the most common carriers of Pasteurella spp, which includes Pasteurella canis, P. dagmatis, P. stomatis ( 7 , 8 ), but the bacteria can also be found in the oral cavity and respiratory tract of a wide range of animals including raccoons, rabbits, domestic fowl, cattle, and more ( 9 ). Clinically, patients develop cellulitis with pain, erythema, and edema 12–24 hours after a bite or scratch from an infected animal given that the incubation period for P. multocida is about 24 hours ( 11 ). Systemic manifestations of Pasteurella spp are possible and include bacteremia, meningitis, endocarditis, and peritonitis ( 10 ); most at-risk patients include neonates, elderly and immunocompromised patients. Estimates for Pasteurella spp bacteremia, which was seen in our patient’s case, vary in the literature but range from 3%-33% ( 12 , 13 ). Pasteurella spp is almost universally susceptible to penicillin, thus amoxicillin-clavulanate is a common treatment choice. This antibiotic provides coverage for other potential pathogens including respiratory flora and oral anaerobes ( 11 ). Our patient was presumed immunocompetent. However, immunologic deficiencies can be seen in CHARGE syndrome, with documented cases ranging from isolated humoral immune problems to severe T-cell deficiencies ( 14 , 15 ). Cochlear implant infections, like all hardware-associated infections, are a worrisome potential complication and can span from simple soft tissue infections limited to the surgical site to more serious, life-threatening complications such as meningitis ( 16 , 17 , 18 ). In children, the incidence typically ranges from 1.5–6.5% and predominantly occurs within the first five months post-operatively ( 19 , 20 , 21 ). Imaging and cultures are cornerstones of diagnostic workup in these scenarios and management ranges broadly from antibiotic treatment and close observation to cochlear explantation ( 16 , 17 , 18 ). This patient had prior history of chronic otitis media and had undergone a procedure to obliterate the mastoid cavity and eustachian tube, along with closure of the external auditory canal prior to cochlear implant placement. This procedure is used to seal off potential physical entry points of infection into the middle and inner ear prior to cochlear implantation in patients who also have chronic otitis media ( 22 , 23 ). Duration of therapy for this unique patient presentation is not well established. Typically, duration of therapy skin soft tissue infection related to Pastuerella spp is 7–10 days ( 7 , 11 ). Meningitis is typically 3–4 weeks ( 11 , 24 , 25 ). Duration of therapy for osteomyelitis and bacteremia is not well described, including when to transition from intravenous to enteral. Source control is imperative for therapy; in this case, evacuation of the abscess and explantation of hardware was needed. We elected to treat for a total of four weeks given likely bone involvement and to not to seed any new hardware in the future. This case emphasizes the importance of obtaining exposure history for improved clinical care and represents the unique intersection of general pediatrics, infectious diseases and otolaryngology. Conclusion We describe a cochlear zoonotic infection with Pasteurella multocida in a patient with a complex medical history who presented with a broad constellation of symptoms. We highlight the importance of obtaining an exposure history to strengthen the differential diagnosis and improve clinical care. Abbreviations CHARGE = coloboma, heart defects, choanal atresia, retardation of growth and development, genitourinary abnormalities, and ear abnormalities CI = cochlear implant CT = Computed Tomography spp = species pluralis Declarations Ethics approval and consent to participate: Not applicable Consent for Publication: Written Informed consent was obtained from the patient for the publication of this case report and corresponding photos and imaging studies. Patient was an adult at the time of her clinical care and at the time consent was obtained. Availability of data and material: Not applicable. This is not a clinical trial, but rather it is a case report. Competing Interests: The authors have no conflicts of interest to disclose. The authors have no financial disclosures. Funding: No funding was secured for this study. Authors Contributions Dr. Nicola M Pereira delivered clinical care, conceptualized and designed the case report, drafted the initial manuscript and critically reviewed and revised the manuscript. Dr. Samiksha Tarun delivered clinical care, conceptualized and designed the case report and critically reviewed and revised the manuscript. Dr. Pereira and Dr. Tarun serve as co-first authors. Dr. Daniel A. Green provided microbiological images and critically reviewed and revised the manuscript. Dr. Ronald Wang critically reviewed and revised the manuscript. Dr. Candace Johnson, Dr. Natalie N Neu and Dr. Justin S Golub delivered clinical care, conceptualized and designed the case report and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Acknowledgements: We are deeply appreciative to our patient for allowing us to share her case with others. We also acknowledge the rest of her care team. References Pets H. October, Healthy People. Centers for Disease Control and Prevention, United States. https://www.cdc.gov/healthy-pets/ (Accessed 31 2025). Chomel BB. Emerging and Re-Emerging Zoonoses of Dogs and Cats. Anim (Basel). 2014;4(3):434–45. 10.3390/ani4030434 . Published 2014 Jul 15. Honnorat E, Seng P, Savini H, Pinelli PO, Simon F, Stein A. Prosthetic joint infection caused by Pasteurella multocida: a case series and review of literature. BMC Infect Dis . 2016;16(1):435. Published 2016 Aug 20. 10.1186/s12879-016-1763-0 Abel WF, Eckman CS, Summers RP, Sessions WS, Schnee AE. An Abrasion, a Prosthetic Shoulder, and a Cat with a Licking Tendency: Case Report and Literature Review of P. multocida Joint Seeding. Case Rep Infect Dis. 2020;2020:2842315. 10.1155/2020/2842315 . Published 2020 Nov 18. Wilkie IW, Harper M, Boyce JD, Adler B. Pasteurella multocida: diseases and pathogenesis. Curr Top Microbiol Immunol. 2012;361:1–22. 10.1007/82_2012_216 . Hsu P, Ma A, Wilson M, Williams G, Curotta J, Munns CF, et al. CHARGE syndrome: A review. J Paediatr Child Health. 2014;50(7):504–11. Piorunek M, Brajer-Luftmann B, Walkowiak J. Pasteurella Multocida Infection in Humans. Pathogens . 2023;12(10):1210. Published 2023 Oct 1. 10.3390/pathogens12101210 Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJC. Bacteriologic Analysis of Infected Dog and Cat Bites. N Engl J Med. 1999;340(2):85–92. Owen CR, Buker EO, Bell JF, Jellison WL. Pasteurella multocida in animals’ mouths. Rocky Mt Med J. 1968;65(11):45–6. Wilson BA, Ho M. Pasteurella multocida: from Zoonosis to Cellular Microbiology. Clin Microbiol Rev. 2013;26(3):631–55. American Academy of Pediatrics. Committee on Infectious Diseases. Red book: 2024–2027 report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2024. Jeong S, Chang E, Lee N, Kim HS, Kim HS, Kim JS et al. Pasteurella Infections in South Korea and Systematic Review and Meta-analysis of Pasteurella Bacteremia. Emerg Infect Dis [Internet]. 2024 Oct [cited 2024 Nov 19];30(10). Available from: https://wwwnc.cdc.gov/eid/article/30/10/24-0245_intro Laupland KB, Stewart AG, Edwards F, Harris P, Heney C, George N, et al. Pasteurella species bloodstream infections in Queensland, Australia, 2000–2019. Eur J Clin Microbiol Infect Dis Off Publ Eur Soc Clin Microbiol. 2022;41(4):609–14. Mehr S, Hsu P, Campbell D. Immunodeficiency in CHARGE syndrome. Am J Med Genet C Semin Med Genet. 2017;175(4):516–23. Writzl K, Cale CM, Pierce CM, Wilson LC, Hennekam RCM. Immunological abnormalities in CHARGE syndrome. Eur J Med Genet. 2007;50(5):338–45. Rubin LG, Papsin B, Committee on Infectious Diseases and Section on Otolaryngology–Head and Neck Surgery. Cochlear Implants in Children: Surgical Site Infections and Prevention and Treatment of Acute Otitis Media and Meningitis. Pediatrics. 2010;126(2):381–91. Biernath KR, Reefhuis J, Whitney CG, Mann EA, Costa P, Eichwald J, et al. Bacterial Meningitis Among Children With Cochlear Implants Beyond 24 Months After Implantation. Pediatrics. 2006;117(2):284–9. Reefhuis J, Honein MA, Whitney CG, Chamany S, Mann EA, Biernath KR, et al. Risk of Bacterial Meningitis in Children with Cochlear Implants. N Engl J Med. 2003;349(5):435–45. Nisenbaum E, Thomas Roland J, Waltzman SB, Friedmann DR. Risk Factors and Management of Postoperative Infection Following Cochlear Implantation. Otology Neurotology. 2020;41(7):e823–8. https://doi.org/10.1097/mao.0000000000002685 . Quimby AE, Grose E, Reddy D, Webster R, Malic C, Vaccani JP. Predictors of Surgical Site Infection in Pediatric Cochlear Implantation. Otolaryngology–Head and Neck Surgery. Published online June. 2022;7:019459982211049. https://doi.org/10.1177/01945998221104933 . Moon PK, Qian ZJ, Ahmad IN, Stankovic KM, Chang KW, Cheng AG. Infectious Complications Following Cochlear Implant: Risk Factors, Natural History, and Management Patterns. Otolaryngology–head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2022;167(4):745–752. https://doi.org/10.1177/01945998221082530 Macielak RJ, Kull AJ, Carlson ML, Patel NS. Disease recidivism after subtotal petrosectomy and ear canal closure. Am J Otolaryngol. 2023;44(2):103743. Yan F, Reddy PD, Isaac MJ, Nguyen SA, McRackan TR, Meyer TA. Subtotal Petrosectomy and Cochlear Implantation: A Systematic Review and Meta-analysis. JAMA Otolaryngol Neck Surg. 2021;147(1):23. Slehria T, Hendricks S, Honeycutt T. Pasteurella multocida Bacterial Meningitis in a 33-Day-Old Infant. Pediatr Infect Dis J. 2022;41(6):e267–8. 10.1097/INF.0000000000003523 . Yamaguchi H, Tamura T, Abe M, et al. Prolonged incubation period in neonatal Pasteurella multocida meningitis and bacteremia. Pediatr Int. 2014;56(6):e79–81. 10.1111/ped.12432 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 13 May, 2026 Reviews received at journal 08 May, 2026 Reviewers agreed at journal 03 May, 2026 Reviews received at journal 30 Apr, 2026 Reviews received at journal 30 Apr, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviews received at journal 28 Feb, 2026 Reviewers agreed at journal 22 Feb, 2026 Reviewers invited by journal 20 Feb, 2026 Editor invited by journal 18 Feb, 2026 Editor assigned by journal 17 Feb, 2026 Submission checks completed at journal 17 Feb, 2026 First submitted to journal 13 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8870865","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":595394796,"identity":"0e7e58a0-b17f-4f83-a82b-3d662c5b08b5","order_by":0,"name":"Nicola M Pereira","email":"","orcid":"","institution":"Columbia University Irving Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nicola","middleName":"M","lastName":"Pereira","suffix":""},{"id":595394797,"identity":"7f596e6d-4d40-43a7-80f6-3e303e6cd53f","order_by":1,"name":"Samiksha Tarun","email":"data:image/png;base64,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","orcid":"","institution":"Ohio State University-Nationwide Children’s","correspondingAuthor":true,"prefix":"","firstName":"Samiksha","middleName":"","lastName":"Tarun","suffix":""},{"id":595394798,"identity":"7e4f891f-ec56-47fe-9265-8c43f93d1670","order_by":2,"name":"Candace L. 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White arrow points to intracochlear electrode lead. \u0026nbsp;R = Right side of patient\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8870865/v1/be96d95adf3bcc58cc39201a.jpeg"},{"id":103438915,"identity":"5e5327e3-8527-464d-b5d1-c4d909f9bb8e","added_by":"auto","created_at":"2026-02-25 16:56:19","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1928226,"visible":true,"origin":"","legend":"\u003cp\u003eGram stain on showing Gram-negative coccobacilli (black arrows show select few organisms).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8870865/v1/622a2b5188079fb19d625994.jpeg"},{"id":103438962,"identity":"b1eed03e-e4bf-4d20-9094-2355e2b58d58","added_by":"auto","created_at":"2026-02-25 16:56:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3123997,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8870865/v1/9df66763-8e04-44f5-9711-be7741e3eb83.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cochlear Implant Infection in a Teenager with CHARGE Syndrome: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eZoonotic infections in pediatric patients are relatively common given presence of household pets (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Pediatric patients with complex medical history including presence of foreign material are also at risk (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Cats are a common reservoir for \u003cem\u003ePasteurella multocida\u003c/em\u003e and can lead to infections in humans through direct inoculation or through indirect contact with secretions (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe describe a patient with genetic mutation CHD7 variant, which is associated with sensorineural hearing loss and CHARGE (coloboma, heart defects, choanal atresia, retardation of growth and development, genitourinary abnormalities, and ear abnormalities) syndrome (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) who presented with headache, ear pain and cellulitis in the setting of a previously placed cochlear implant. This case underscores the importance of obtaining exposure history and the importance of multidisciplinary care.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eAn 18-year-old female presented with one day history of severe right ear pain and fever. She was noted to have CHD7 variant, a genetic mutation associated sensorineural hearing loss and associated with CHARGE syndrome. Four years prior to presentation she had a right-sided cochlear implantation. Five years prior to presentation, given her history of chronic otitis media, she had a right-sided mastoidectomy with eustachian tube and external auditory canal closure to eliminate potential pathways for entrance of bacteria into the inner ear to reduce risk for CI infection. She described severe, sharp pain inside the right ear, a pounding bitemporal headache, new onset photophobia, and the sensation of a \u0026ldquo;snake crawling\u0026rdquo; and \u0026ldquo;bubbles of water\u0026rdquo; inside the right ear. She also had fevers up to 102 degrees Fahrenheit at home and multiple episodes of non-bloody, non-bilious emesis. She denied any changes in hearing, drainage from the ear, vertigo, or tinnitus. In addition, she denied any recent trauma to the ear, changes to vision, lethargy or increased sleepiness, or any recent sore throat, congestion, cough, or rashes. Family history was notable for bilateral hearing loss in the patient\u0026rsquo;s mother, likely secondary to CHARGE syndrome, as well as a sister with CHARGE syndrome.\u003c/p\u003e \u003cp\u003eOn initial exam, the patient had significant post-auricular tenderness along with mild peri-incisional erythema and no fluctuance or edema over the mastoid area (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The patient also had a right sided facial asymmetry at rest though was able to achieve complete eye closure (House-Brackmann III/VI). Pediatric Otolaryngology was consulted in the emergency room. The patient\u0026rsquo;s labs were notable for a mild leukocytosis (WBC 9.7 cells/uL, normal range 3.5\u0026ndash;9.4) with left shift along with elevated inflammatory markers (CRP 33.0 mg/L, normal range 0.0\u0026ndash;10.0). Blood cultures were collected on presentation. Lumbar puncture was completed, and cerebrospinal fluid studies showed an elevated WBC (221 cells/uL) count and neutrophil predominance (89%) with normal glucose and normal protein. Cerebrospinal fluid culture was without any growth. Computed Tomography (CT) of temporal bone with contrast showed an increased soft tissue prominence along the extracochlear portion of the CI electrode lead along with new foci of air within the middle ear concerning for infection, but no fluid collection or abscess (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient was admitted to the general pediatrics service for further workup and empirically started on meningitis dosing of vancomycin and cefepime. Pediatric infectious diseases was consulted on hospital day 2. On hospital day two, the patient\u0026rsquo;s blood cultures turned positive, with Gram stain showing Gram-positive cocci in clusters and Gram-negative rods (GNR). Multiplex PCR performed on the positive blood culture bottle detected \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e and mecA/C gene (FilmArray Blood Culture Identification Panel, Biomerieux, Durham NC). Subculture from the bottle showed growth the next day on both chocolate and blood agar plates, with no growth on MacConkey agar. Gram-stain performed from the chocolate agar plate on the presumptive GNR showed tiny Gram-negative coccobacilli (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) that were identified as \u003cem\u003ePasteurella multocida\u003c/em\u003e by MALDI-TOF mass spectrometry (Bruker Daltonics, Billerica, MA). Antimicrobial susceptibility testing was performed by gradient agar diffusion (Etest, Biomerieux, Durham, NC) and showed susceptibility to penicillin, ceftriaxone, erythromycin, levofloxacin, and trimethoprim-sulfamethoxazole.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s post-auricular pain remained persistent and her right sided facial weakness became progressively worse for which she was started on high dose prednisone. Given the bacteremia, pain, and worsening facial weakness, on hospital day three she was taken to the operating room with the otolaryngology team for a revision mastoidectomy. Intra-operatively, there was an abscess within the right mastoid that was extensively debrided (and sent for culture). The cochlear implant device was intact but was removed given its potential to remain as a nidus of infection (of note, the intracochlear portion was retained to allow for the possibility of future cochlear implant use if the patient desired).\u003c/p\u003e \u003cp\u003ePost-operatively, the patient\u0026rsquo;s facial nerve function, ear pain, and headaches improved. Her intraoperative mastoid abscess cultures subsequently were also positive for \u003cem\u003ePasteurella multocida\u003c/em\u003e. She was transitioned to vancomycin and ceftriaxone and ultimately to amoxicillin-clavulanate once she had two subsequent blood cultures that had no growth for at least forty-eight hours, and she demonstrated sufficient clinical improvement (The \u003cem\u003eStaphylococcus epidermidis\u003c/em\u003e was considered a contaminant given it is a common skin flora and since the bacteria only grew on one culture). She was treated for a total of four weeks due to concern for bony involvement (presumed osteomyelitis) and due to likelihood of re-implantation of cochlear implant.\u003c/p\u003e \u003cp\u003eUpon identification of implicated pathogen, exposure history was acquired and revealed that patient had a new kitten at home who scratched the patient frequently, including near her ear.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe surmise that \u003cem\u003ePasteurella multocida\u003c/em\u003e bacteremia and right-sided mastoid abscess without meningitis was result of direct inoculation from a scratch or bite from the patient\u0026rsquo;s kitten at home. The infection in the ear likely led to significant inflammation, abscess and transient bacteremia.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePasteurella multocida\u003c/em\u003e is a gram-negative coccobacillus that is the most common cause of soft tissue infection after animal bites or scratches (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In the United States, dogs and cats are the most common carriers of \u003cem\u003ePasteurella\u003c/em\u003e spp, which includes \u003cem\u003ePasteurella canis, P. dagmatis, P. stomatis\u003c/em\u003e (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), but the bacteria can also be found in the oral cavity and respiratory tract of a wide range of animals including raccoons, rabbits, domestic fowl, cattle, and more (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Clinically, patients develop cellulitis with pain, erythema, and edema 12\u0026ndash;24 hours after a bite or scratch from an infected animal given that the incubation period for \u003cem\u003eP. multocida\u003c/em\u003e is about 24 hours (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Systemic manifestations of \u003cem\u003ePasteurella\u003c/em\u003e spp are possible and include bacteremia, meningitis, endocarditis, and peritonitis (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e); most at-risk patients include neonates, elderly and immunocompromised patients. Estimates for \u003cem\u003ePasteurella\u003c/em\u003e spp bacteremia, which was seen in our patient\u0026rsquo;s case, vary in the literature but range from 3%-33% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003ePasteurella\u003c/em\u003e spp is almost universally susceptible to penicillin, thus amoxicillin-clavulanate is a common treatment choice. This antibiotic provides coverage for other potential pathogens including respiratory flora and oral anaerobes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur patient was presumed immunocompetent. However, immunologic deficiencies can be seen in CHARGE syndrome, with documented cases ranging from isolated humoral immune problems to severe T-cell deficiencies (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCochlear implant infections, like all hardware-associated infections, are a worrisome potential complication and can span from simple soft tissue infections limited to the surgical site to more serious, life-threatening complications such as meningitis (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In children, the incidence typically ranges from 1.5\u0026ndash;6.5% and predominantly occurs within the first five months post-operatively (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Imaging and cultures are cornerstones of diagnostic workup in these scenarios and management ranges broadly from antibiotic treatment and close observation to cochlear explantation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This patient had prior history of chronic otitis media and had undergone a procedure to obliterate the mastoid cavity and eustachian tube, along with closure of the external auditory canal prior to cochlear implant placement. This procedure is used to seal off potential physical entry points of infection into the middle and inner ear prior to cochlear implantation in patients who also have chronic otitis media (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuration of therapy for this unique patient presentation is not well established. Typically, duration of therapy skin soft tissue infection related to \u003cem\u003ePastuerella\u003c/em\u003e spp is 7\u0026ndash;10 days (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Meningitis is typically 3\u0026ndash;4 weeks (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Duration of therapy for osteomyelitis and bacteremia is not well described, including when to transition from intravenous to enteral. Source control is imperative for therapy; in this case, evacuation of the abscess and explantation of hardware was needed. We elected to treat for a total of four weeks given likely bone involvement and to not to seed any new hardware in the future.\u003c/p\u003e \u003cp\u003eThis case emphasizes the importance of obtaining exposure history for improved clinical care and represents the unique intersection of general pediatrics, infectious diseases and otolaryngology.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe describe a cochlear zoonotic infection with \u003cem\u003ePasteurella multocida\u003c/em\u003e in a patient with a complex medical history who presented with a broad constellation of symptoms. We highlight the importance of obtaining an exposure history to strengthen the differential diagnosis and improve clinical care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHARGE = coloboma, heart defects, choanal atresia, retardation of growth and development, genitourinary abnormalities, and ear abnormalities\u003c/p\u003e\n\u003cp\u003eCI = cochlear implant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT = Computed Tomography\u003c/p\u003e\n\u003cp\u003espp = species pluralis\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eWritten Informed consent was obtained from the patient for the publication of this case report and corresponding photos and imaging studies. Patient was an adult at the time of her clinical care and at the time consent was obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e Not applicable. This is not a clinical trial, but rather it is a case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e The authors have no conflicts of interest to disclose. The authors have no financial disclosures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was secured for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Nicola M Pereira\u0026nbsp;delivered clinical care,\u0026nbsp;conceptualized and designed the case report, drafted the initial manuscript and critically reviewed and revised the manuscript. Dr. Samiksha Tarun delivered clinical care, conceptualized and designed the case report and critically reviewed and revised the manuscript. Dr. Pereira and Dr. Tarun serve as co-first authors.\u003c/p\u003e\n\u003cp\u003eDr. Daniel A. Green provided microbiological images and critically reviewed and revised the manuscript. Dr. Ronald Wang critically reviewed and revised the manuscript. Dr. Candace Johnson, Dr. Natalie N Neu and Dr. Justin S Golub delivered clinical care, conceptualized and designed the case report and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe are deeply appreciative to our patient for allowing us to share her case with others. 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Otolaryngology\u0026ndash;head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2022;167(4):745\u0026ndash;752. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/01945998221082530\u003c/span\u003e\u003cspan address=\"10.1177/01945998221082530\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacielak RJ, Kull AJ, Carlson ML, Patel NS. Disease recidivism after subtotal petrosectomy and ear canal closure. Am J Otolaryngol. 2023;44(2):103743.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan F, Reddy PD, Isaac MJ, Nguyen SA, McRackan TR, Meyer TA. Subtotal Petrosectomy and Cochlear Implantation: A Systematic Review and Meta-analysis. JAMA Otolaryngol Neck Surg. 2021;147(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlehria T, Hendricks S, Honeycutt T. Pasteurella multocida Bacterial Meningitis in a 33-Day-Old Infant. Pediatr Infect Dis J. 2022;41(6):e267\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/INF.0000000000003523\u003c/span\u003e\u003cspan address=\"10.1097/INF.0000000000003523\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamaguchi H, Tamura T, Abe M, et al. Prolonged incubation period in neonatal Pasteurella multocida meningitis and bacteremia. Pediatr Int. 2014;56(6):e79\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ped.12432\u003c/span\u003e\u003cspan address=\"10.1111/ped.12432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"zoonotic infection, CHARGE syndrome, cochlear implant infection, multidisciplinary care","lastPublishedDoi":"10.21203/rs.3.rs-8870865/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8870865/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e \u003cem\u003ePastuerella multicoda\u003c/em\u003e is a gram-negative coccobacillus commonly found in the oral flora of many animals, most commonly in cats and implicated in zoonotic infections, commonly cellulitis secondary to cat bites and scratches. Here we describe a teenager with CHARGE syndrome who developed an infection of her cochlear implant secondary to \u003cem\u003eP multicoda.\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eCase Presentation\u003c/h2\u003e \u003cp\u003eAn 18-year-old female with CHARGE syndrome developed headache, ear pain and cellulitis at the site of her cochlear implant and was found to have osteomyelitis and transient bacteremia secondary to \u003cem\u003eP. multicoda\u003c/em\u003e. She required both surgical and medical management, including removal of her cochlear implant and four weeks of antibiotic therapy. Exposure history included numerous excoriations from her new kitten at home.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case highlights the importance of obtaining thorough exposure history as part of the evaluation of any pediatric patient with headache, ear pain and cellulitis with complicating factors such as presence of cochlear implant to include zoonotic infections on the differential diagnosis. Additionally, this case highlights the importance of a multidisciplinary team for care of patients with complex medical and surgical history.\u003c/p\u003e","manuscriptTitle":"Cochlear Implant Infection in a Teenager with CHARGE Syndrome: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 16:55:36","doi":"10.21203/rs.3.rs-8870865/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-13T18:20:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T03:06:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106508655931561620626695177089314134759","date":"2026-05-03T08:37:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T02:19:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T13:02:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325097069820296881064238338900467068700","date":"2026-04-30T11:30:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36440045894365752887887793378274007834","date":"2026-04-30T11:17:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97348810661805025425958499581914258232","date":"2026-04-14T10:00:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-28T21:50:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180824869399544162159451167710546441685","date":"2026-02-23T00:41:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-20T13:21:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-18T06:11:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-18T02:36:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-18T02:36:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-02-13T10:38:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"790d5961-3b79-4022-9c2b-e7af55f0491f","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-13T18:20:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-09T03:06:43+00:00","index":56,"fulltext":""},{"type":"reviewerAgreed","content":"106508655931561620626695177089314134759","date":"2026-05-03T08:37:43+00:00","index":55,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T02:19:05+00:00","index":54,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T13:02:18+00:00","index":53,"fulltext":""},{"type":"reviewerAgreed","content":"325097069820296881064238338900467068700","date":"2026-04-30T11:30:12+00:00","index":52,"fulltext":""},{"type":"reviewerAgreed","content":"36440045894365752887887793378274007834","date":"2026-04-30T11:17:41+00:00","index":51,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T18:23:41+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 16:55:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8870865","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8870865","identity":"rs-8870865","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}