a 47-year - old female presented to her general practitioner on january 14 , 2013 , with increasing confusion and weakness since being discharged from hospital that day and a urine culture was sent . co - morbidities included organic brain disease secondary to a stroke ten years prior , possible past seizures , bipolar and borderline personality disorder , gastroesophageal reflux disease , dyslipidemia , hypertension , hypothyroidism and a past history of substance abuse . she was admitted to hospital on december 1 , 2012 due to confusion caused by high levels of valproate . during her admission subsequently , she developed multiple urinary tract infections ( uti ) ( table 1 ) . after her confusion improved , she developed fever and leukocytosis 10 days into admission that was attributed to a bowel micro - perforation indicated by a small amount of extraluminal air on ct abdomen . her fever and wbc count resolved 2 days after treatment with vancomycin , ciprofloxacin and metronidazole , which were continued for ten days . she required intensive rehabilitation and continued to require intermittent catheterization up until discharge on january 14th , 2013 . before discharge , a urine culture was submitted to our laboratory on january 9th . as per routine protocols , the urine was submitted in a sterile container and dipped at the point of collection using the uricult trio dip slide culture method with macconkey medium , a -glucuronidase - producing escherichia coli detection medium , and cled medium . pure 10  cfu / ml gram - negative cocci , grew only on the cled media after 24  h of incubation and the organism failed to grow for identification by routine aerobic culture methods . at the direction of the medical microbiologist , the isolate was further plated onto other types of media to rule out other possible uropathogens , including haemophilus and neisseria species , but no growth was observed ( table 2 ) . considering the possibility of an anaerobic uti , the january 12 and 14 isolates were cultured anaerobically . anaerobic gram - negative cocci grew in 48  h under these conditions ( table 2 ) . suspecting an anaerobic uti , the medical microbiologist notified the general practitioner about the possibility and advised appropriate antimicrobial coverage with metronidazole . the patient was treated with metronidazole 500  mg twice daily starting january 14 , but was readmitted in the hospital on january 20 due to her persistent delirium . while waiting for antimicrobial susceptibility results on the anaerobic gram - negative cocci , the infectious diseases service started empiric coverage for a uti with intravenous ceftriaxone 2  g daily . head ct and mri , both revealed a subacute right - sided pontine infarct not present on her last ct head ( december 3rd ) , which was associated with no new focal neurological exam findings and no significant findings on stroke work up . using the vitek ms ( biomrieux , marcy letoile , france ) , the isolate was identified as veillonella parvula with 99.9% certainty . molecular confirmation using 16s rrna sequencing was later done with primers 16s - f ( 5-agagtttgatcatggctcag-3 ) and 16s - r ( 5-ggactaccagggtatctaat-3 ) . a 624  bp product confirmed the identity with 99% sequence homology based on the genbank database using the basic local alignment search tool algorithm ( http://blast.ncbi.nlm.nih.gov/blast.cgi ) . the isolate was sensitive to ceftriaxone , tetracycline , imipenem , meropenem , ertapenem , penicillin , and metronidazole ( clinical laboratory standards institute breakpoints ) and was tested by e - test ( biomrieux ) on brucella agar with laked blood ( dalynn biologicals ) . uti , which is a report of pyelonephritis with bacteremia in a pregnant woman caused by an unspecified species of veillonella 
 . in this case , v. parvula was isolated as a pure culture in three separate in and out catheter urine collections at 10  cfu / ml and subsequent urine cultures after treatment no longer grew v. parvula nor any other uropathogen . with treatment of the uti , this was despite the presence of a subacute ( based on imaging characteristics ) pontine infarct that could have occurred at any point between head cts on december 3rd and january 20th . often , an episode of delirium may persist for weeks , months , or even years especially if the underlying inciting etiology causes permanent physio - neurological damage , as in the case of an infarct . the reversibility of delirium , at the same time , is often directly dependent on whether its underlying cause can be promptly diagnosed and is treatable . due to the rapid improvement of this patient 's delirium following appropriate antimicrobial therapy , her initial cognitive decline was postulated to be most likely due to an uti caused by v. parvula and not to the infarct . this case exemplifies the difficulty in diagnosing an uti in patients presenting with atypical symptoms ( i.e. confusion / delirium ) , which is typically seen in the elderly population . it is more common to find anaerobes associated with abscesses of the urinary tract than with utis . when urine is cultured anaerobically , the isolation of anaerobic bacteria is rare ( < 1% ) and the patients are often asymptomatic . there are however , case reports demonstrating the ability of anaerobic bacteria to cause cystitis and pyelonephritis , especially in patients such as ours with a recent history of catheterization and/or instrumentation ( i.e. cystoscopy ) , , . due to the rare occurrence of utis caused by anaerobes , microbiology laboratories have discontinued routine urine culture for them ; consequently , clinicians must be aware that laboratories may not culture anaerobes unless specifically requested . in this case , the urine dip slide method with cled media allowed for isolation of the v. parvula . clinically significant anaerobes including veillonella can be aerotolerant , therefore we hypothesize that because the dip slide is incubated in a sealed container , the oxygen content is low enough to permit growth of v. parvula . additional nutrients such as cysteine found in cled media may have also provided additional growth support . we report on v. parvula 's role in utis and illustrate how v. parvula can be reliably identified in the clinical laboratory . our case highlights several clinical and laboratory pitfalls for consideration including the need for consultation with the medical microbiologist to investigate for anaerobic and fastidious organisms when a patient presents with a clinical picture consistent with recurrent or persistent utis .
we report a case of veillonella parvula causing a urinary tract infection . 
 the organism was isolated from urine using cystine - lactose - electrolyte deficient media and identified using matrix - assisted laser desorption ionization - time of flight mass spectrometry confirmed by 16s rna . 
 this case highlights important clinical and microbiological considerations for urinary tract infections .