Unusual presentation of enteric fever: three cases of splenic and liver abscesses due to Salmonella typhi and Salmonella paratyphi A.

Enteric fever is a multisystem disorder caused mainly by Salmonella typhi and Salmonella paratyphi A. It continues to be a major public health problem, especially in developing countries. Unusual presentations of Salmonellosis are rare. We report 3 such cases of young adult males, one of splenic abscess due to Salmonella typhi and one each of liver abscess due to Salmonella typhi and Salmonella paratyphi A. A brief review of the literature pertaining to the cases is also given.     

Splenobronchial fistula: interventional radiologic management

A 71-year-old man had a splenic abscess complicated by rupture into the left subphrenic space with formation of a splenobronchial fistula. One percutaneous catheter was placed into the splenic abscess and a second was placed in the subphrenic collection. The abscesses resolved and the bronchial fistula closed in 12 days.     

Recurrent thoracic abscess due to Salmonella typhi

Abscess formation by Salmonella typhi is an unusual manifestation. A woman aged 62 suffered from recurrent abscess in the anterior thorax for 35 years, which was released by spontaneous pus drainage each time. Pus cultures grew S. typhi, and the CT scan revealed a large abscess enclosing the sternum and left ribs.     

Quinolone antibiotics in the treatment of Salmonella infections

The 4-fluoroquinolones are a new class of antimicrobial agents that possess broad in vitro antibacterial activity, including efficacy against enteric pathogens such as Salmonella, Shigella, Campylobacter, Yersinia, and Vibrio species. These drugs are clinically effective against both drug-sensitive and multiresistant strains of Salmonella typhi and Salmonella paratyphi that cause enteric fever. In salmonella enterocolitis, the quinolones--unlike older antimicrobial agents that may have little impact on the duration of symptomatic illness and can in fact prolong fecal carriage of salmonellae--actually shorten the course of clinical disease and terminate excretion of these organisms in the stool. Similarly, for chronic carriers of both typhoidal and nontyphoidal Salmonella strains, the quinolones are effective in eradicating biliary and fecal reservoirs of infection. Immunosuppressed persons with salmonellosis, such as those with AIDS, may benefit from both short-term treatment and prolonged prophylaxis with a quinolone antibiotic. The optimal agent, dose, and duration of quinolone therapy for all salmonella syndromes remain to be determined by larger controlled trials.     

Unusual presentation of typhoid fever: cutaneous vasculitis, pancreatitis, and splenic abscess

We report a case of typhoid fever with an unusual presentation: prolonged fever with cutaneous vasculitis, pancreatitis, and splenic abscess. This is the first case of cutaneous leukocytoclastic vasculitis associated with Salmonella typhi. The diagnosis was made upon isolation of S. typhi in blood cultures, and after ruling out other causes of leukocytoclastic vasculitis. The outcome was favourable with antibiotics alone without surgery.     

Salmonella enterica serotype Typhi from a case of breast abscess

Enteric fever is an acute systemic febrile infection caused by Salmonella enterica serotype Typhi. Breast abscess due to S. typhi infection is a rare sequelae. We report here a classical case of Salmonella typhi infection in a rare clinical form of a breast abscess in a non-lactating immuno-compromised female.     

Use of norfloxacin to treat chronic typhoid carriers

High relapse rates and low tolerability to ampicillin characterize present therapy for carriers of Salmonella typhi. Norfloxacin, a carboxyquinolone with a 90% minimum inhibitory concentration for S. typhi of less than or equal to 0.5 micrograms/mL, is a promising alternative. Carriers of S. typhi were treated in a double-blind trial with either norfloxacin (400 mg) or matching placebo given every 12 h for 28 d. Twelve assessable individuals were treated in each group. After therapy, 11 of 12 individuals treated with norfloxacin had negative stool and bile cultures for S. typhi. All placebo-treated carriers still had positive cultures immediately after therapy. Subsequently, 11 individuals were treated openly with norfloxacin. S. typhi was eradicated in seven of 11. Overall, the eradication rate for 23 individuals treated with norfloxacin was 78%. Eighteen individuals were followed up for one year, and their stool and/or bile cultures remained negative. From our results, norfloxacin is an effective and well-tolerated antimicrobial agent for eradicating the chronic typhoid carrier state.     

A case of pancreatic intraductal papillary-mucinous carcinoma with penetration to the stomach and splenic abscess]

We report the case of an 80-year-old man given a diagnosis of pancreatic intraductal papillary-mucinous carcinoma (IPMC) and early gastric cancer. He refused surgery, therefore endoscopic mucosal resection (EMR) for gastric cancer and careful observation were performed. Penetration of the IPMC to the stomach was observed 3 months later. Ten months after the initial diagnosis, he was found to have a splenic abscess and was subsequently treated by antibiotics and percutaneous drainage, and a fistula between the IPMC and the splenic abscess was observed. We suppose IPMC penetration to the spleen and bacterial transmission from the stomach through the fistula caused the splenic abscess. While IPMC is recognized as a low-grade malignancy, some cases of invasive carcinoma with fistulation to adjacent organs have been reported. To the best of our knowledge, this is the first case of IPMC associated with splenic abscess due to pancreatosplenic fistula.     

Bacteroides (Parabacteroides) distasonis splenic abscess in a sickle cell patient

Splenic abscess is not an uncommon complication of patients with sickle-cell disease. Here we describe an 18 year-old boy with sickle cell disease and left upper quadrant abdominal pain. Computerized axial tomography revealed left sided free flowing pleural effusion and splenomegaly with liquefaction and possible gas formation. The splenic fluid grew an unusual organism known as Bacteroides distasonis. The patient received antimicrobial therapy and underwent a splenectomy with full recovery. The spleen was cystically infarcted and measured 22 x 16 x 5 cm. The capsule was thickened and covered by fibrinous exudate. Histopathologic examination of the spleen showed complete necrosis with reparative fibrosis. This case presents an unusual cause of splenic abscess due to Bacteroides distasonis with a subacute to chronic course. The presence of fever and left sided pleuritic chest pain in patients with sickle cell disease should raise the suspicion of splenic abscess.     

Acute renal failure likely due to acute nephritic syndrome associated with typhoid fever

A 45-year-old woman was admitted to our hospital because of high fever and malaise. She also presented abnormal urine findings including macrohematuria and proteinuria with transient renal insufficiency. Salmonella Typhi was isolated from her blood and stool culture, and then she was diagnosed as having typhoid fever. Salmonella enterica serotype typhi infection can be complicated by renal involvement, although rare. In Japan, few cases have been reported about acute nephritic syndrome in typhoid fever. Here, we report a case of endemic acquired typhoid fever associated with acute renal failure probably due to acute nephritic syndrome successfully treated with levofloxacin.     

Gastrointestinal manifestations of melioidosis: A single center experience

Melioidosis, being increasing, is reported from India. Gastrointestinal manifestations are typically reported as unusual cause of liver and/or splenic abscess. We aimed to describe various gastrointestinal manifestation of melioidosis in the present study. We retrospectively collected data of culture positive melioidosis cases from hospital database during August 2014–October 2016 at Asian Institute of Gastroenterology, Hyderabad. A total of nine culture positive cases (8 male) of melioidosis with median age of 40 years (range 23–66) were analyzed. Median duration of symptoms was 45 days. Two patients were being treated as tuberculosis. Three patients presented with liver abscess with two of them having simultaneous splenic abscess, and one had prostatic abscess. Three patients (43%) with history of acute pancreatitis had infected pancreatic collection, and one patient had left empyema with splenic abscess. One patient had wound infection with left lower limb cellulitis, presented as acute in chronic liver failure and another as spontaneous bacterial peritonitis (SBP). Diabetes and/or alcoholism was present in all patients. Seven patients had disseminated organ involvement. Seven patients underwent percutaneous intervention for drainage of abscess. Induction therapy as ceftazidime (n=4) or meropenem (n=5) followed by continuation therapy as oral cotrimoxazole (n=6) and doxycycline (n=1) was given. Six patients completed therapy and asymptomatic at end of follow up. Two patients died in the study period. One patient died due to acute-on-chronic liver failure (ACLF) with acute kidney injury and the other due to cardiac failure. One patient with SBP had lost to follow up. Apart from being unusual cause of liver/splenic abscess, melioidosis can present with infection of pancreatic collection, SBP, and infection in a compensated cirrhosis which can precipitate ACLF. Early recognition and specific therapy can improve prognosis.     

Congenital H-type anovestibuler fistula

The congenital H-type fistula between the anorectum and genital tract besides a normal anus is a rare entity in the spectrum of anorectal anomalies. We described a girl with an anovestibuler H-type fistula and left vulvar abscess. A 40-day-old girl presented symptoms after her parents noted the presence of stool at the vestibulum. On the physical examination, anus was in normal location and size, and had normal sphincter tone. A vestibuler opening was seen in the midline just below of the hymen. A fistulous communication was found between the vestibuler opening and the anus, just above the dentate line. There was a vulvar abscess which had a left lateral vulvar drainage opening 15 mm left lateral to the perineum. After the management of local inflammation and abscess, the patient was operated for primary repair of the fistula. A protective colostomy wasn‘t performed prior the operation. A profuse diarrhea started after 5 hours of postoperation. After the diarrhea, a recurrent fistula was occurred on the second postoperative day. A divided sigmoid colostomy was performed. 2 months later, and anterior sagital anorectoplasty was reconstructed and colostomy was closed 1 month later. Various surgical techniques with or without protective colostomy have been described for double termination repair. But there is no consensus regarding surgical management of double termination.     

Extra-pulmonary Pneumocystis jiroveci infection: a case report

In physical examination abdominal tenderness, gate disturbance and penile herpetic lesions were detected. Decreased disc height at T11-T12 level was detected in chest X-ray. Abdominal sonography and CT scan revealed hypo dense lesions in Lt left Lobe of liver and multiple hypo dense splenic and pancreatic lesions, ascitis, Lt left sided pleural effusion, thickening of jejuneal mucosa and edema of bowel wall. Vertebral body lesion and paravertebral abscess, bony calvarial involvement and adjacent extra axial brain lesion were observed in imaging were other findings. RNA analysis for HIV was positive. Vertebral lesion biopsy and aspiration of splenic lesion were performed and pathology revealed Pneumocystis jirovecii suggestive of extra pulmonary Pneumocystis carinii infection.     

Splenic Abscess: A Diagnostic Challenge

Splenic abscess is uncommon and remains a diagnostic challenge. We present two cases. Both patients had predisposing factors that may have led to the splenic abscess. At admission, both patients presented clinical and roentgenographic signs, suggestive but nonspecific for splenic suppuration. Of particular interest was the isolation of Salmonella typhimurium in our first patient. The literature on splenic abscess is reviewed.     

Pleural empyema due to Salmonella typhi

65 years old female was admitted to hospital with fever, purulent sputum and dyspnea. The patient has hepatic cirrhosis secondary to autoimmune hepatitis and hepatocellular carcinoma. Immunosuppressive treatment is used for autoimmune hepatitis. In physical examination matute and diminished respiratory sounds were determined at right hemithorax. Ascitis was determined in abdominal examination. Chest X-ray showed pleural effusion in right hemithorax. Serohemorrhagic fluid was aspirated by thoraco-synthesis. Pleural fluid pH was 6.9 and had an exudative nature. The patient was the diagnosed as empyema. Right tube thoracostomy was performed and sulbactam-ampicillin 6 g/day therapy was started. In patient's ascite fluid no bacteria and leucocytes was seen. Salmonella typhi was isolated from pleural fluid. No microorganisms were isolated from ascite fluid, urine and stool culture. Klebsiella pneumoniae is isolated in patient's hemoculture. Clinical improving was detected. Chest X-ray showed total regression of pleural fluid and the tube thoracostomy removed. We presented this case because of rarely seen microorganism (S. typhi) in immunocompromised patients a cause of pleural empyema which is frequently seen gastrointestinal infections.     

Intestinal occlusion due to pancreatitis mimicking stenosing neoplasm of the splenic angle of the colon

Colonic involvement in patients with severe acute pancreatitis or chronic pancreatitis is common and complications such as paralytic ileus, segmental necrosis and pancreatic-colonic fistulae have been described. However, mechanical occlusion of the colon due to pancreatitis is infrequent. We present the case of a 45-year-old man with occlusion of the colon secondary to asymptomatic pancreatitis mimicking a locally advanced stenosing neoplasm of the splenic angle. Ten years prior to the present episode the patient had presented acute alcoholic pancreatitis complicated by a pseudocyst requiring surgery. The current reason for admission was abdominal colic pain and constipation with onset 5 days previously. Contrast enema was administered showing colonic occlusion caused by stenosis at the splenic flexure, suggesting the presence of a neoplasm. Urgent laparotomy showed the presence of a tumor originating in the colon that infiltrated the splenic hilum. Subtotal colectomy and en-bloc splenectomy were performed. Histopathological analysis showed pericolonic inflammation and fibrosis secondary to pancreatitis; the colonic mucosa showed no tumoral infiltration. To date, fewer than 30 cases of this infrequent complication have been published.     

A case of cervical abscess caused by Salmonella enteritidis after intestinal infection

Salmonella Enteritidis often causes food poisoning. In this study, an extremely rare case of cervical abscess caused by S. Enteritidis is reported. In January 2003, a 44-year-old man visited our hospital with swelling of the left submandibular region. He had been suffering from a severe diabetic condition but had neglected to seek medical attention. An incision was made at the abscess to drain the pus from which only S. Enteritidis was isolated. This finding led to the discovery that he had suffered from an episode of food poisoning 6 months earlier. However, the organism was not isolated from the stool. The patient recovered with the administration of panipenem/betamipron and gatifloxacin. The S. Enteritidis strain isolated from the pus obtained from this case and that detected from the samples originating from the other patients during the episode of food poisoning 6 months earlier were examined by using pulse-field gel electrophoresis (PFGE). The PFGE patterns of the strains were almost identical. The molecular epidemiological analysis by PFGE was useful in estimating the infection route. In an immuno-compromised host such as those suffering from diabetes mellitus, one must be reminded that unusual bacteria (including S. Enteritidis) may cause a cervical abscess.     

Unusual complications of Salmonella enteriditis group D infection

A 25-year-old Syrian presented complaining mainly of fever, night sweats and nausea. He had 3 days earlier mild abdominal cramps and short-lived diarrhoea. On admission, he developed signs of deep vein thrombosis and blood and stool cultures showed Salmonella enteriditis infection. The patient was started on chloramphenicol and later showed acute abdominal signs. Laparotomy revealed intestinal perforation on the lower ileum. The case together with the experience in this hospital and elsewhere of Salmonella enteriditis infections are discussed, showing that two complications shown in this case are common for Salmonella typhi and paratyphi infections but are unusual for other Salmonella infections.     

Rare case of left colic flexure is supplied by a branch from splenic artery--a case report

A variation of a branch of the splenic artery was reported in a Taiwanese male cadaver during dissection in 1999. This artery arose from the splenic artery and ran inferiolaterally to the area of the left colic flexure. Since left colic flexure is a segment of embryonic hindgut and the splenic artery typically supplies the foregut, the condition in which an artery of foregut crosses midgut to supply an area of the hindgut becomes interesting.     

Salmonella paratyphi osteomyelitis and psoas abscess

Bone and joint infections associated with Salmonella spp account for less than 1% of all Salmonella infections. Most of the isolates are Salmonella typhi. Joint infections with S. paratyphi are uncommon, and there have been only a few reported cases in literature. Psoas abscess caused by S. paratyphi has not been reported previously in the literature. We report a case of S. paratyphi A osteomyelitis and psoas abscess.