Renal Salmonella enteritidis abscess in a patient with severe aplastic anemia after allogeneic stem cell transplantation

We describe an unusual case of a renal abscess by Salmonella enteritidis in a 32-year-old man with severe aplastic anemia undergoing allogeneic stem cell transplantation. He was receiving immunosuppressive therapy with CsA and corticosteroids for chronic GVHD. He was not neutropenic and had no history of enterocolitis or cholelithiasis before the onset. Four months after the transplantation, he developed an abscess in the upper pole of his right kidney from which Salmonella enteritidis was isolated in culture. He was successfully treated with a combination of percutaneous drainage and washing the cyst through the catheter using piperacillin sodium-containing solution. The possibility of salmonellosis should be considered in the differential diagnosis of such patients.     

Maternal and neonatal outcome following prolonged labor induction

Early diagnosis of invasive group A beta streptococcal (GABS) infection has been achieved in a patient using magnetic resonance imaging (MRI) complemented by needle aspiration. Life-saving treatments of GABS infection that include immediate surgical debridement along with the administration of i.v. antibiotics, gamma globulin, and hyperbaric oxygen were then implemented successfully to prevent the development of streptococcal toxic shock syndrome. While MRI is valuable in making early diagnosis of GABS, it should not delay surgical intervention.     

An unusual haemarthrosis in an HIV-seronegative haemophilia A patient

We report the case of a severe haemophilia A patient with an anti-factor VIII antibody who presented with a thigh haematoma and 1 year later with an elbow haemarthrosis infected by Salmonella enteritidis. These two infections were treated by antibiotics. The probable origin of these infections seems to be an anal fistula. The occurrence of a septic arthritis due to Salmonella is rare, and to our knowledge has never been reported in HIV-negative haemophilic patients. The differential diagnosis of haemarthrosis and septic arthritis in a haemophilic patient is also discussed.     

Artificial nutrition of patients with toxic epidermal necrolysis (Lyell syndrome)

The authors report the case of a 30-year-old man treated with toxic epidermal necrolysis. Toxic epidermal necrolysis was due to anticonvulsive drug treatment. The patient was admitted with denudated skin surface similar to second-degree burn that covered 90 per cent of the patient's body surface. The patient was isolated and treated, receiving sterile wound care, broad spectrum antibiotic and corticosteroid. Total parenteral nutrition was instituted until the 5th day of care because the patient was unable to take normal food. The energy intake reached 146 kJ/kg bodyweight containing 4 g/kg bodyweight carbohydrates and 2 g/kg bodyweight fat emulsion supplemented with 10-15 g of nitrogen per day. The enteral nutrition was commenced gradually with decreasing parenteral nutrition. The nutritive solutions were supplemented with ions, vitamins and trace elements. The patient left the intensive care unit after 23 days of care. The toxic epidermal necrolysis is a life-threatening dermatological disease and should be treated at intensive care unit. The early recognition of the disease, the intensive care and nutritional therapy may improve the survival of patients with toxic epidermal necrolysis.     

Supraclavicular abscess caused by Salmonella enteritidis in patient without gastrointestinal symptoms

Soft tissue infections are among the rare manifestations of extra intestinal salmonellosis and occur more frequently in immunocompromised patients. Herein we report a case of a 51-year-old white male with type II. diabetes mellitus, diagnosed with supraclavicular abscess caused by Salmonella enteritidis. The patient denied any gastrointestinal symptoms, and stool cultures were negative. After incision, drainage, and administration of intravenous ampicillin (4 x 1.5 g/day for two weeks) the patient recovered completely. To our knowledge, this is the first reported case of cervical soft tissue abscess caused by Salmonella enteritidis without preceding gastrointestinal symptoms. We feel that the presence of diabetes was a risk factor for developing the infection.     

Pulmonary cavitation lesions in patients infected with the human immunodeficiency virus: an analysis of a series of 78 cases

BACKGROUND: To assess the clinical, radiologic and microbiological features of lung cavitation and HIV infection. Evaluation of the differences related to this disease in the last years. PATIENTS AND METHODS: Retrospective review of all patients with lung cavitation and HIV infection admitted at our hospital from January 1989 until December 1994 and prospective study of all patients with the same characteristics during 1995 and 1996. Lung cavitation was defined as any parenchymal lesion, with air content, visible in a simple X-ray and greater than 1 cm of diameter. Criteria for confirmed, probable or possible diagnosis were defined. RESULTS: 78 cases of lung cavitation have been identified in 73 patients. The radiologic patterns included unilobar and multilobular involvement in 31 and 47 cases, respectively. Cavities were multiple and single in 40 and 38 cases respectively. Findings with fine needle aspiration biopsy (FNAB) were diagnostic in 11 out of 14 cases. A clinical diagnosis was performed in all 78 cases, with microbiological results in 69 cases (88.5%): Mycobacterium tuberculosis in 20, Pneumocystis carinii in nine, Pseudomonas aeruginosa in nine, Staphylococcus aureus in eight (5 endocarditis with cavitary septic emboli), Rhodococcus equi in six, P. aeruginosa and S. aureus in three, Salmonella enteritidis in three, Cryptococcus neoformans in two, Aspergillus fumigatus in two and others in 7 cases. Confirmed, probable and possible diagnosis was considered in 54, 15 and 9 cases, respectively. Thirteen episodes of spontaneous pneumothorax were found. CONCLUSIONS: The lung cavitation rate is low, compared with the number of admissions related to HIV infection; nevertheless, many of them are in close relationship with HIV infection, and most of them are caused by treatable infections. It is important to know the clinical and radiological characteristics, in order to establish an early diagnosis and an appropriate therapy. Pseudomonas aeruginosa is becoming an important cause of lung cavitation. In our series, spontaneous pneumo-thorax was not related to Pneumocystis carinii pneumonia in 61.5% of cases.     

Fluoride treatment for facial nerve stimulation caused by cochlear implants in otosclerosis

Clostridium difficile (C. difficile) pseudomembraneous colitis was diagnosed in a 13-year-old boy with Hodgkin's disease 3 months after autologous bone marrow transplantation. Hematopoiesis was fully reconstituted at the time. C. difficile infection occurred after gall bladder empyema had been treated conservatively with i.v. antibiotics and prophylactic 4-week administration of oral amoxicillin. C. difficile colitis was diagnosed early and intensive supportive therapy combined with administration of i.v. and subsequently oral vancomycin therapy failed. It is a phenomenon rarely seen and successful eradication of the clostridium infection was only achieved by a combination of higher dose vancomycin with metronidazole. During the post-colitis recovery the patient experienced a relapse of Hodgkin's disease and died following further surgical intervention 137 days post-transplantation.     

Prolonged weakness after cisatracurium infusion: a case report

OBJECTIVE: To present the first documented case report of myopathy persisting for >48 hrs in a patient treated with cisatracurium and concomitant high-dose corticosteroids. DESIGN: Anecdotal observations in one patient. SETTING: Medical-respiratory intensive care unit (ICU) at a tertiary care, university teaching hospital. PATIENT: A 45-yr-old female admitted status for post-bilateral total knee replacement complicated by aspiration pneumonitis and acute respiratory distress syndrome (ARDS). INTERVENTIONS: The patient required pressure control ventilation and sedation with midazolam and fentanyl infusions. On ICU day 2, the patient was placed on inverse ratio ventilation and paralyzed with cisatracurium. On ICU day 6, methylprednisolone 125 mg i.v. every 6 hrs was initiated for fibroproliferative ARDS. On ICU day 11, methylprednisolone was reduced to 60 mg i.v. every 6 hrs and tapered over several weeks. Cisatracurium infusion rates ranged from 6.3 to 10.5 microg/kg/min, with an average of 8.0 microg/kg/min. MEASUREMENTS AND MAIN RESULTS: Train-of-Four was assessed before initiation of therapy and every 4 hrs, thereafter. Train-of-Four values were maintained from 1 to 4 throughout therapy and a value of 4 was recorded when therapy was discontinued. On day 13, neuromuscular blocking agent therapy was discontinued, but severe proximal and distal muscle weakness was observed bilaterally. Creatinine kinase concentrations on 3 and 13 days after discontinuation of the paralytic agent were 181 and 96 units/L, respectively. On day 24, the patient moved her fingertips. On ICU day 30, the patient was weaned from the mechanical ventilator. The patient was transferred to the ward on day 33. Extensive rehabilitation with physical and occupational therapy was required for several months. CONCLUSION: Clinicians should remember that irrespective of chemical structural, neuromuscular blocking agents might produce prolonged paralysis in predisposed patients.     

Efficacy of a live avirulent Salmonella typhimurium vaccine in preventing colonization and invasion of laying hens by Salmonella typhimurium and Salmonella enteritidis

An avirulent live delta cya delta crp Salmonella typhimurium strain chi 3985 that precludes colonization and invasion of chickens by homologous and heterologous Salmonella serotypes was evaluated for its long-term protection efficacy. Chickens vaccinated orally at 2 and 4 wk of age were assessed for protection against oral challenge with wild-type S. typhimurium and Salmonella enteritidis strains at 3, 6, 9, and 12 mo of age. A comparison of Salmonella isolation from vaccinated and nonvaccinated layers after challenge with S. typhimurium or S. enteritidis showed that delta cya delta crp S. typhimurium chi 3985 induced excellent protection against intestinal, visceral, reproductive tract, and egg colonization, invasion, and/or contamination by Salmonella. The duration of protection lasted for 11 mo after vaccination, at which time the experiment was terminated. S. enteritidis and S. typhimurium were isolated from the yolk, albumen, and shells of eggs laid by nonvaccinated chickens challenged with Salmonella. S. typhimurium caused pathological lesions in nonvaccinated chickens, whereas vaccinated and nonvaccinated chickens challenged with S. enteritidis showed no pathological lesion in the visceral and reproductive organs. Vaccination with chi 3985 prevented transmission of S. typhimurium or S. enteritidis into eggs laid by vaccinated layers with no effect on egg production. To our knowledge, this is the first publication confirming that vaccination with live avirulent Salmonella can induce long-term protection against Salmonella infection in layers.     

Migraine in childhood and adolescence

A 62 years old man was admitted to hospital because of fever; a small superficial hepatic nodule was showed by ultrasonography. Blood cultures grew Salmonella enteritidis. Cefotaxime was administered for ten days. Fever promptly disappeared but one week later recurred with abdominal and back pain. Cultures grew again Salmonella enteritidis. Biopsy of the hepatic nodule showed hepatocarcinoma. Computed abdominal tomography showed a paraaortic mass. Angiography demonstrated hematoma communicating with the aortic lumen. The patient underwent revascularization of the involved aortic tract and resection of the hepatic nodule. Histology showed suppurative aortic endarteritis and a well-differentiated hepatocellular carcinoma with a large area of suppurative necrosis. The recovery of Salmonella species as of any uncommon bacteria from blood should warrant a through research of underlying disease, especially cancer.     

Sudden hearing loss complicating general surgery: report of a case and review of the literature]

The first outbreak of Salmonella enteritidis phage type (PT) 5a infection to be reported occurred after a party in a residential home for elderly people in May 1995. The party was attended attended by 96 residents, staff and guests. S. enteritidis PT5a was isolated from 14 of the 25 clinical cases identified after the party and S. enteritidis PT4 from another clinical case. Two elderly residents with S. enteritidis PT5a infection died. Infection with S. enteritidis PT5a was associated with consumption of prawn in mayonnaise vol-au-vents, sausage rolls, corned beef sandwiches, and sausages. The investigation of this outbreak illustrated the difficulty that elderly people may have in the completion of questionnaires. It also highlighted areas for intervention; such as reminders about basic hygiene precautions to prevent secondary spread and the importance of coordinated reinforcement in the workplace of formal food hygiene training for cooks. The Food Safety Regulations 1995 came into force soon after this outbreak: their implementation would probably have prevented it.     

Demographic data on Salmonella enteritidis infection in Thailand, 1990-1995

The data for the comprehensive analysis of Salmonella enteritidis infection was based on the information recorded in the request form submitted for Salmonella typing and the results of serotyping at the WHO National Salmonella and Shigella Center, Department of Medical Sciences, Ministry of Public Health, Thailand during 1990-1995. Fifty-one cases of S. enteritidis (SE) infection were confirmed in 1990. The morbidity being markedly increased each year from 1991 to 1995, with 105, 307, 471, 659 and 877 cases being identified, respectively. Among the isolates of Salmonella spp, SE was the most common serotype during 1993-1995. The cases were mostly predominant in Bangkok and then in southern, northeastern, central and northern regions, respectively. The morbidity rates per 100,000 population per year of SE infection in 1990-1995 were 0.09, 0.18, 0.53, 0.8, 1.11 and 1.47, respectively. Analysis of the infection rate by sex and age demonstrated that the incidence in males was higher than in females. Adult patients were more frequently found than adolescent patients. The organism was found in feces, blood, pus, urine, cerebrospinal fluid and sputum, accounting for 41.7, 35.8, 5.5, 2.5, 1.7 and 0.4%, respectively. The average extraintestinal isolation index was 0.52.     

Sanitation of biowaste compost by using Salmonella enteritidis as a pathogen indicator and survival of Salmonella in seepage water

The following investigations show the frequency of the occurrence of Salmonella in biowastes. Salmonellae, belonging to the serotypes Salmonella enteritidis, infantis and agona were detected in 50% of the investigated biowaste samples. In order to control the reliability of compositing techniques on eliminating pathogens, Salmonella enteritidis was used as a pathogen indicator, which was brought into a container composting process and investigated on it's decline. Although the input indicator bacteria were eliminated in every case latest until the end of container composting, Salmonella was detected in 36% of the investigated fresh compost samples. Every time when Salmonella was detected in input material, the same serotypes were to be found in seepage water and survived there until the end of intensive rot. In laboratory experiments the maximum survival time of Salmonella enteritidis in seepage water at +5 degrees C was 42 days. Seepage water was found out to be a reservoir for survival of Salmonellae and has to be considered as a permanent source of contamination. In the question of the disposal of seepage water there are disagreements between the instructions of TA Siedlungsabfall and TA Luft.     

Congenital cholesteatoma in a child carrying a gene mutation for adenomatous polyposis coli

A 53-year-old woman with a history of cervical carcinoma 14 years ago, treated with hysterectomy and radiation therapy, was admitted to the intensive care unit with severe SIRS (systemic inflammatory response syndrome) progressing to shock, multiple organ failure and death within 5 d. Bilateral hydronephrosis diagnosed by sonography and an enlarged left kidney with suspected abscesses verified in a CT-scan suggested the diagnosis of urosepsis. However, multiple microbiological examinations remained sterile. Despite surgical treatment and aggressive intensive care, she died in unresponsive shock. Pathohistologically, an angiotropic large B-cell lymphoma, a rare diffuse intravascular neoplasm of lymphoid origin, was diagnosed. The patient's history of abdominal radiation therapy 14 years earlier as well as multiple negative microbiological specimens in a patient with suspected urosepsis should have initiated the search for a non-infectious cause of the disease.     

Evaluation of bacterins containing three predominant phage types of Salmonella enteritidis for prevention of infection in egg-laying chickens

Six Salmonella enteritidis bacterin formulations differing in adjuvant content and whole-cell inactivation procedures were evaluated in egg-laying chickens. Chickens given S enteritidis bacterins containing modified Freund's incomplete adjuvant had greater humoral immune responses to S enteritidis than did birds given other bacterin formulations (P < 0.05). Better protection against infection by S enteritidis phage types 8, 13a, and 23 was obtained in birds vaccinated with bacterin 5. Bacterin 5 contained S enteritidis cells inactivated by 20% acetone and modified Freund's incomplete adjuvant.     

Raw egg ingestion and salmonellosis in body builders

Four patients with Salmonella enteritidis infection are reported. All were body builders who regularly consumed substantial quantities of raw eggs. They presented with a severe febrile illness and diarrhoea--presumably reflecting a large bacterial inoculum. Advice regarding the potential hazards of raw egg ingestion has been repeatedly issued by the Department of Health--but this report highlights the fact that this practice continues in spite of this. The epidemiology of S. enteritidis infection in relation to raw egg ingestion is discussed.     

Mice as carriers of Salmonella enteritidis on persistently infected poultry units

Evidence of the possible role of wild mice in the epidemiology of Salmonella enteritidis infection on broiler breeder and layer breeder units was obtained by a bacteriological examination of local mice. Persistent S enteritidis infection in birds on these units had been a problem and a high proportion of the mice were found to carry salmonella. S enteritidis was isolated from the liver and the intestine of most of the mice, indicating a systemic infection. Three-week-old chicks were infected by contact with droppings from mice which had been infected experimentally with S enteritidis two and five months previously. Wild mice infected artificially or naturally excreted S enteritidis intermittently, with up to 10(4) organisms in some individual droppings. A naturally infected mouse which died after intermittently excreting small numbers of S enteritidis in its droppings for 19 weeks had 10(4) organisms/g of liver and 10(3)/g of macerated intestine and contents. S enteritidis was also found in fetal tissue in a naturally infected mouse suggesting the possibility that the organism might be transmitted vertically.     

Clostridium difficile-associated diarrhea and colitis: clinical manifestations, diagnosis, and treatment

PURPOSE: This review examines the pathogenesis, clinical manifestations, diagnosis, and current medical and operative strategies in the treatment of Clostridium difficile diarrhea and colitis. Prevention and future avenues of research are also investigated. METHODS: A review of the literature was conducted with the use of MEDLINE. RESULTS: C. difficile is a gram-positive, spore-forming bacterium capable of causing toxigenic colitis in susceptible patients, usually those receiving antibiotics. Overgrowth of toxigenic strains may result in a spectrum of disease, including becoming an asymptomatic carrier, diarrhea, self-limited colitis, fulminant colitis, and toxic megacolon. Diagnosis requires a high index of suspicion and depends on clinical data, laboratory stool studies (enzyme-linked immunoabsorbent assay and cytotoxin test), and endoscopy in selected cases. Protocols for treatment of primary and relapsing infections are provided in algorithm format. Discontinuation of antibiotics may be enough to resolve symptoms. Medical management with oral metronidazole or vancomycin is the first-line therapy for those with symptomatic colitis. Teicoplanin, Saccharomyces spp. and Lactobacillus spp., and intravenous IgG antitoxin are reserved for more recalcitrant cases. Refractory or relapsing infections may require vancomycin given orally or other newer modalities. Fulminant colitis and toxic megacolon warrant subtotal colectomy. Cost, in terms of extended hospital stay, medical and surgical management, and, in some cases, ward closure, is thought to be formidable. Review of perioperative antibiotic policies and analysis of hospital formularies may contribute to prevention and decreased costs. CONCLUSION: C. difficile diarrhea and colitis is a nosocomial infection that may result in significant morbidity, mortality, and medical costs. Standard laboratory studies and endoscopic evaluation assist in the diagnosis of clinically suspicious cases. Appropriate perioperative antibiotic dosing, narrowing the antibiotic spectrum when treating infections, and discontinuing antibiotics at appropriate intervals prevent toxic sequelae.     

Treating congenital hypothyroidism: maximum age limit up to which a socially compatible child is expected

Salmonella osteomyelitis is an uncommon disease, usually associated with sickle cell anemia and other hemoglobinopathies, as well as with other disease states. In this case, osteomyelites was apparently caused by hematogenous spread of an enteric infection by Salmonella enteritidis. Bone involvement, in vertebral bodies, was resolved after prolonged clinical treatment with antibiotics. We discuss the pathogeny and compare the findings of four case with others related in literature.     

Analysis of splenic and thymic lymphocyte subpopulations in chickens infected with Salmonella enteritidis

Lymphocytes expressing CD3, CD4, CD8, pan lymphocyte, IgA, IgG and IgM cell surface antigens were assessed by in the spleen and thymus of chickens following infection with Salmonella enteritidis using flow cytometric analysis. At 6 days post primary infection and 2 days post secondary infection with S. enteritidis, the percentages of IgA+ and IgM+ lymphocytes in the spleen were significantly increased (P < 0.05). At 2 days post secondary infection with S. enteritidis, the percentage of CD4+ T lymphocyte in the spleen and CD8+ T lymphocyte percentage in the thymus were significantly increased (P < 0.05). These results indicate that S. enteritidis infection induces changes in the spleen and thymus that reflect the dynamics of the host protective immune response.