Rare serotype Non-typhoidal Salmonella sepsis
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《美国医学杂志》
1 Department of Microbiology, Lady Hardinge Medical College and associated Kalawati Saran Children, Hospital, New Delhi, India
2 Director Professor & Head, Senior Resident (Currently Senior Resident in AIIMS), Lady Hardinge Medical College and associated Kalawati Saran Children, Hospital, New Delhi, India
3 Department of Pediatrics, Lady Hardinge Medical College and associated Kalawati Saran Children, Hospital, New Delhi, India
Abstract
An 11-month female with a poor socio-economic status presented to a tertiary care paediatric hospital with complaints of fever of 4-5 days and diarrhoea of 20 days duration. The patient didn't respond to the prescribed antimicrobials namely - Norfloxacin and metronidazole. On admission she was diagnosed as persistent diarrhea with PEM grade III with sepsis. Stool examination and culture were negative for any pathogens, however blood culture yielded growth of Salmonella Virchow which was susceptible to most common antimicrobial agents excepting Trimethoprim Sulfamethoxazole. Salmonella Virchow is a common non-typhoidal Salmonellae causing bacteremia in the west, however this is the first report of bacteremia by S. virchow from India.
Keywords: Salmonella group C; Salmonella Virchow; Sepsis; Non-typhoidal; Infant
An 11-month-old female infant was admitted to the Kalawati Saran Children Hospital, New Delhi with the complaint of fever for 4-5 days & diarrhoea for a duration of 20 days. The patient had loose stools which were accompanied by mucous & blood initially but later became watery. The patient belonged to a poor socio-economic status and lived in a congested locality of New Delhi. There was no history of contact with poultry or poultry products. There was no recent history of diarrhoea or fever in family members or close contacts. The patient was taking treatment from a private clinic but had not responded to the prescribed antimicrobials namely - Norfloxacin and Metronidazole.
On examination the patient was found to be of poor nutritional status (weighing 52% of expected). She had high fever and was lethargic. She was dehydrated on admission which was corrected with oral rehydration solution. The patient was diagnosed as Persistent diarrhoea with PEM grade III with sepsis and investigated accordingly. She was empirically started on parenteral Cefotaxime and Gentamicin and given low lactose diet, Zinc, and Vitamin A.
Routine investigations done for the patient revealed Hemoglobin 10gm/dl, TLC-11,800/cmm. (A stool sample sent for routine microscopy & culture was negative for any pathogens. Culture of feces did not reveal the presence of any bacterial pathogen). The blood sent for bacterial culture yielded an isolate of Salmonella More Details spp . Serotyping was performed on the isolate and it was finally identified and confirmed as Salmonella enterica serotype Virchow in the National Salmonella Phage Typing Laboratory of Lady Hardinge Medical College. Antimicrobial susceptibility testing of the isolate was performed by disc diffusion method (Stokes method) and the strain was found to be sensitive to ampicillin, chloramphenicol, gentamicin, amikacin, cefotaxime, ceftriaxone, ciprofloxacin and resistant to Trimethoprim-Sulfamethoxazole. The patient was continued with parenteral cefotaxime and gentamicin. The diarrhoea and fever subsided on third day after hospitalization. The patient recovered and was discharged on 10th day of admission with the final diagnosis of persistent diarrhoea and septicemia due to Salmonella Virchow .
Discussion
This article describes a first Indian report to the best of our knowledge of a Salmonella enterica serotype Virchow systemic infection presenting primarily as sepsis and persistent diarrhoea of an infant. Malnutrition was a predisposing factor in the pathogenesis of this case. Microbiological surveillance of the babies in the ward (rectal swabs) and the cultures from the environment (fomites) did not reveal Salmonella Virchow . Blood/rectal swab cultures from family members could not be investigated as the family refused to submit these specimens. It is likely that the infant acquired this organism from an asymptomatic excretor within the family or contacts.
The clinical presentation of human disease by Salmonella spp . is classified into two main types enteric fever and non-typhoidal Salmonellosis More Details.[1] This case belongs to the latter category. The incidence of non-typhoidal salmonellosis account for a majority of Salmonella infections in the industrialized countries as compared to developing countries and an increasing trend is observed over last few decades.[2]
There are studies indicating that non-typhoidal Salmonella bacteremia affects patients at the extremes of life.[2] In children, it commonly occurs in the setting of gastroenteritis and spreads to other organ systems as in the case we described here. Increased incidence of Salmonella Virchow in children has been attributed to host factors, such as decreased gastric acidity or immaturity of gut associated lymphoid tissue, as Salmonella Virchow has been shown to be not harbouring any virulence plasmid.[3]
In western literature there are reports of studies indicating emergence of group C Salmonella (Kaufmann-White scheme) in particular Salmonella Virchow as the most frequent isolate in cases of bacteremia due to non- typhoidal Salmonellae.[2] Salmonella Virchow has a high potential for invasion in humans and has become the third commonest serotype of Salmonella accounting for 9% of human isolates in U.K.[4] There are no such reports of Salmonella Virchow isolation from blood in the Indian population. This disparity in the western literature & Indian literature may be attributed to the fact that the gastroenteritis problems here are considered benign and might actually be underestimated, overlooking their propensity to cause invasive human infections. These cases are usually not properly investigated and also serotyping of Salmonella species and other bacteria is not done in all the centres in India.
An analysis of stool samples of diarrhoeal children carried out in Kolkatta, revealed isolation of Salmonella Virchow in 3.2% of stool samples.[5] Till date two cases of extra intestinal infection due to S. Virchow infection namely hemothorax and meningitis have been reported from India.[6],[7] Another case of Salmonella Virchow dysentery has also been reported in India.[8]
Young children in India are in particular risk of acquiring such salmonella infections due to host related factors, so it should be considered in the differential diagnosis of gastroenteritis and should be aggressively treated to avoid serious consequences as they are at special risk of developing sepsis.
References
1. Miller IS, Pegues DA. Salmonella species, including Salmonella Typhi . In: Mandell GL, Bennett JE, Dolin R (eds). Principles and Practice of Infectious diseases . 5th ed, vol-2. Churchill Livingstone, Philadelphia, US 2000; 2344-2363.
2. Shimoni Z, Pitlik S, Leibovici L et al. Nontyphoid Salmonella Bacteraemia: Age-Related Differences in Clinical presentation, Bacteriology, and Outcome. Clin Inf Dis 1999; 28: 822-827.
3. Guiney DG, Fang FC, Krause M, Libby S, Buchmeir NA, Fierer J. Biology and clinical significance of virulence plasmids in Salmonella serovars. Clin Infect Dis 1995; 21(Suppl 2): S146-S151.
4. Old DC, Threlfall EJ. Salmonella. In: Collier L, Balows A, Sussman M (eds). Topley and Wilson's Microbiology and Microbial Infections. 9th ed.-vol. 2. Arnold, London 1998; 969-997.
5. Saha MR et al. Isolation of Salmonella enterica serotypes from children with diarrhoea in Calcutta, India . J Health Popul Nutr 2001; 19(4): 301-305.
6. Sachdeva LD & Malhotra UP. Meningitis due to Salmonella Virchow in an infant. Indian J Med Res 1963; 37: 134-141.
7. Hayes W & Freeman JF. The incidence, type and bacteriology of Salmonella infection in the army in India. Indian J Med Res 1945; 33: 177-193.
8. Ganguli S. Salmonella serotypes in India . Indian J Med Res 1958; 46: 637-642.(Randhawa VS, Mehta Geeta,)
2 Director Professor & Head, Senior Resident (Currently Senior Resident in AIIMS), Lady Hardinge Medical College and associated Kalawati Saran Children, Hospital, New Delhi, India
3 Department of Pediatrics, Lady Hardinge Medical College and associated Kalawati Saran Children, Hospital, New Delhi, India
Abstract
An 11-month female with a poor socio-economic status presented to a tertiary care paediatric hospital with complaints of fever of 4-5 days and diarrhoea of 20 days duration. The patient didn't respond to the prescribed antimicrobials namely - Norfloxacin and metronidazole. On admission she was diagnosed as persistent diarrhea with PEM grade III with sepsis. Stool examination and culture were negative for any pathogens, however blood culture yielded growth of Salmonella Virchow which was susceptible to most common antimicrobial agents excepting Trimethoprim Sulfamethoxazole. Salmonella Virchow is a common non-typhoidal Salmonellae causing bacteremia in the west, however this is the first report of bacteremia by S. virchow from India.
Keywords: Salmonella group C; Salmonella Virchow; Sepsis; Non-typhoidal; Infant
An 11-month-old female infant was admitted to the Kalawati Saran Children Hospital, New Delhi with the complaint of fever for 4-5 days & diarrhoea for a duration of 20 days. The patient had loose stools which were accompanied by mucous & blood initially but later became watery. The patient belonged to a poor socio-economic status and lived in a congested locality of New Delhi. There was no history of contact with poultry or poultry products. There was no recent history of diarrhoea or fever in family members or close contacts. The patient was taking treatment from a private clinic but had not responded to the prescribed antimicrobials namely - Norfloxacin and Metronidazole.
On examination the patient was found to be of poor nutritional status (weighing 52% of expected). She had high fever and was lethargic. She was dehydrated on admission which was corrected with oral rehydration solution. The patient was diagnosed as Persistent diarrhoea with PEM grade III with sepsis and investigated accordingly. She was empirically started on parenteral Cefotaxime and Gentamicin and given low lactose diet, Zinc, and Vitamin A.
Routine investigations done for the patient revealed Hemoglobin 10gm/dl, TLC-11,800/cmm. (A stool sample sent for routine microscopy & culture was negative for any pathogens. Culture of feces did not reveal the presence of any bacterial pathogen). The blood sent for bacterial culture yielded an isolate of Salmonella More Details spp . Serotyping was performed on the isolate and it was finally identified and confirmed as Salmonella enterica serotype Virchow in the National Salmonella Phage Typing Laboratory of Lady Hardinge Medical College. Antimicrobial susceptibility testing of the isolate was performed by disc diffusion method (Stokes method) and the strain was found to be sensitive to ampicillin, chloramphenicol, gentamicin, amikacin, cefotaxime, ceftriaxone, ciprofloxacin and resistant to Trimethoprim-Sulfamethoxazole. The patient was continued with parenteral cefotaxime and gentamicin. The diarrhoea and fever subsided on third day after hospitalization. The patient recovered and was discharged on 10th day of admission with the final diagnosis of persistent diarrhoea and septicemia due to Salmonella Virchow .
Discussion
This article describes a first Indian report to the best of our knowledge of a Salmonella enterica serotype Virchow systemic infection presenting primarily as sepsis and persistent diarrhoea of an infant. Malnutrition was a predisposing factor in the pathogenesis of this case. Microbiological surveillance of the babies in the ward (rectal swabs) and the cultures from the environment (fomites) did not reveal Salmonella Virchow . Blood/rectal swab cultures from family members could not be investigated as the family refused to submit these specimens. It is likely that the infant acquired this organism from an asymptomatic excretor within the family or contacts.
The clinical presentation of human disease by Salmonella spp . is classified into two main types enteric fever and non-typhoidal Salmonellosis More Details.[1] This case belongs to the latter category. The incidence of non-typhoidal salmonellosis account for a majority of Salmonella infections in the industrialized countries as compared to developing countries and an increasing trend is observed over last few decades.[2]
There are studies indicating that non-typhoidal Salmonella bacteremia affects patients at the extremes of life.[2] In children, it commonly occurs in the setting of gastroenteritis and spreads to other organ systems as in the case we described here. Increased incidence of Salmonella Virchow in children has been attributed to host factors, such as decreased gastric acidity or immaturity of gut associated lymphoid tissue, as Salmonella Virchow has been shown to be not harbouring any virulence plasmid.[3]
In western literature there are reports of studies indicating emergence of group C Salmonella (Kaufmann-White scheme) in particular Salmonella Virchow as the most frequent isolate in cases of bacteremia due to non- typhoidal Salmonellae.[2] Salmonella Virchow has a high potential for invasion in humans and has become the third commonest serotype of Salmonella accounting for 9% of human isolates in U.K.[4] There are no such reports of Salmonella Virchow isolation from blood in the Indian population. This disparity in the western literature & Indian literature may be attributed to the fact that the gastroenteritis problems here are considered benign and might actually be underestimated, overlooking their propensity to cause invasive human infections. These cases are usually not properly investigated and also serotyping of Salmonella species and other bacteria is not done in all the centres in India.
An analysis of stool samples of diarrhoeal children carried out in Kolkatta, revealed isolation of Salmonella Virchow in 3.2% of stool samples.[5] Till date two cases of extra intestinal infection due to S. Virchow infection namely hemothorax and meningitis have been reported from India.[6],[7] Another case of Salmonella Virchow dysentery has also been reported in India.[8]
Young children in India are in particular risk of acquiring such salmonella infections due to host related factors, so it should be considered in the differential diagnosis of gastroenteritis and should be aggressively treated to avoid serious consequences as they are at special risk of developing sepsis.
References
1. Miller IS, Pegues DA. Salmonella species, including Salmonella Typhi . In: Mandell GL, Bennett JE, Dolin R (eds). Principles and Practice of Infectious diseases . 5th ed, vol-2. Churchill Livingstone, Philadelphia, US 2000; 2344-2363.
2. Shimoni Z, Pitlik S, Leibovici L et al. Nontyphoid Salmonella Bacteraemia: Age-Related Differences in Clinical presentation, Bacteriology, and Outcome. Clin Inf Dis 1999; 28: 822-827.
3. Guiney DG, Fang FC, Krause M, Libby S, Buchmeir NA, Fierer J. Biology and clinical significance of virulence plasmids in Salmonella serovars. Clin Infect Dis 1995; 21(Suppl 2): S146-S151.
4. Old DC, Threlfall EJ. Salmonella. In: Collier L, Balows A, Sussman M (eds). Topley and Wilson's Microbiology and Microbial Infections. 9th ed.-vol. 2. Arnold, London 1998; 969-997.
5. Saha MR et al. Isolation of Salmonella enterica serotypes from children with diarrhoea in Calcutta, India . J Health Popul Nutr 2001; 19(4): 301-305.
6. Sachdeva LD & Malhotra UP. Meningitis due to Salmonella Virchow in an infant. Indian J Med Res 1963; 37: 134-141.
7. Hayes W & Freeman JF. The incidence, type and bacteriology of Salmonella infection in the army in India. Indian J Med Res 1945; 33: 177-193.
8. Ganguli S. Salmonella serotypes in India . Indian J Med Res 1958; 46: 637-642.(Randhawa VS, Mehta Geeta,)