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LETTER TO EDITOR  
Year : 2011  |  Volume : 54  |  Issue : 2  |  Page : 427-428
Isolation of Salmonella paratyphi A from a female with diabetic foot ulcer


1 Department of Microbiology, Government Medical College Hospital, Chandigarh, India
2 Department of General Surgery, Government Medical College Hospital, Chandigarh, India

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Date of Web Publication27-May-2011
 

How to cite this article:
Chander J, Gupta V, Sidhu S, Sharma R. Isolation of Salmonella paratyphi A from a female with diabetic foot ulcer. Indian J Pathol Microbiol 2011;54:427-8

How to cite this URL:
Chander J, Gupta V, Sidhu S, Sharma R. Isolation of Salmonella paratyphi A from a female with diabetic foot ulcer. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Dec 10];54:427-8. Available from: http://www.ijpmonline.org/text.asp?2011/54/2/427/81619


Sir,

Diabetes is a progressive disease with chronic complications. Foot infections in diabetic patients are potentially serious leading to high morbidity and sometimes amputation of the lower limb. They range in severity from superficial paronychia to deep infection involving bone. About 50-60% of severe foot infections are complicated by osteomyelitis. [1] The spectrum of the bacteria isolated from diabetic foot infections is usually polymicrobial depending on various clinical factors and microbiological issues. [2],[3] Osteomyelitis is most often caused by staphylococci, but they are often accompanied by other organisms, especially aerobic gram-positive cocci and gram-negative bacilli. [4]  Salmonella More Details osteomyelitis is a rare entity constituting 0.8% of all Salmonella infections and 0.45% of all types of osteomyelitis. [5] Here in, we report a case of complicated foot ulcer leading to osteomyelitis with Salmonella enterica serovar Paratyphi A and Ps. aeruginosa in a diabetic female.

A 47-year-old female patient was seen in the surgical out-patient department with the chief complaints of swelling foot for the past 3 months, for which patient had got done incision and drainage from a private practitioner. This episode was followed by development of ulcer with discharge for the past 1 to 1.5 month. The lesion appeared first on the dorsum of the foot. Pain was constantly present at the site and also around the area. On examination there was purulent discharge from the wound near ankle and dorsum of the left foot. The discharge was thick, foul smelling, necrotic tissue was there, erythema and induration were also there. Patient also gave history of tingling sensation on the plantar surfaces of both the feet. She also complained of febrile episodes for the past 10 days with general malaise but she gave no history of trauma. Her history of diabetes mellitus was 20 years old being treated with oral hypoglycemics and insulin. She also gave history of hypertension. Family history for diabetes was also positive.

Laboratory investigations revealed a hemoglobin level of 11.8 g/dl. The peripheral blood leukocyte count was within normal limits but with a significant left shift. The C-reactive protein (CRP) test was positive (19.8 μg/ml). Investigation revealed random blood sugar levels to be 352, 350, 470, 308 mg% on four different days. Liver function tests and renal function tests were within normal limits. Urine examination revealed 1+ protein in urine. Blood culture was found to be sterile. Widal test revealed titres of 1:320 for both S. paratyphi A-O (Somatic) and H (Flagellar) antigens. Radiologically, there was soft tissue swelling. A serosanguineous fluid was aspirated with syringe alone without using needle after removing the overlying debris from the infected site which was sent for microbiological examination. The culture revealed the presence of Ps. aeruginosa and S. enterica serovar Paratyphi A after overnight incubation of the pus sample. Standard microbiological methods were used to identify the isolate as S. paratyphi A. [6] S. paratyphi A was sensitive to chloramphenicol, ciprofloxacin, ceftriaxone and resistant to ampicillin, cotrimoxazole and nalidixic acid. The minimum inhibitory concentration of ciprofloxacin was 0.5 μg/ml and that of chloramphenicol was 4.0 μg/ml. Ps. aeruginosa was sensitive to imipenem, ceftazidime, amikacin, ciprofloxacin, gentamicin and piperacillin--tazobactam. An orthopedic diagnosis of distal osteomyelitis was made. The left foot debridement was done under general anesthesia. Tendo-Achilles sloughed out with edematous fluid in the dorsal surface of the foot. This was again sent for culture and sensitivity. The results were a repeat finding of the earlier results. The patient was given a full course of third-generation cephalosporin along with ciprofloxacin for 15 days and foot cast was given to avoid foot drop. On follow up, there was no fever and discharge from the affected site decreased significantly with patient showing improvement in signs and symptoms.

In the index case, a non-healing ulcer developed on the foot after incision and drainage for swelling was done. Then patient developed enteric fever (as suggested by her Widal status) leading to bacteremia and due to immune compromised status the bacteria got access into the bone. Ps. aeruginosa an environmental pathogen must have been exogenously acquired resulting in polymicrobial infection.

Bacteremia is a constant feature of enteric fever. Occasionally dissemination of bacilli throughout the body results in establishment of one or more localized foci of persisting infection. Isolation of Salmonella species, with variety of clinical syndromes from aberrant sites, where they are hardly expected has been reported. [6] Salmonella osteomyelitis is a relatively rare clinical entity which usually develops in immunocompromised patients. In the present case also, Salmonella isolation from the wound was an indicator of osteomyelitis developing in a diabetic female.

Further to conclude, besides the rarity of the etiological agent the report also emphasizes the need for doing culture and sensitivity testing in complicated diabetic foot ulcer cases to know the spectrum of causative agents and since multidrug resistance has increased to know the antibiotic susceptibility pattern also which is a simple, rapid and dependable method of diagnosis. Early and appropriate treatment helps to prevent the associated complication of lower limb amputation.

 
   References Top

1.Lipsky BA. Medical treatment of diabetic foot infections. Clin Infect Dis 2004;39:S104-14.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Lipsky BA. A current approach to diabetic foot infections. Curr Infect Dis Rep 1999;1:253-60.  Back to cited text no. 2
[PUBMED]    
3.Bansal E, Garg A, Bhatia S, Attri AK, Chander J. Spectrum of microbial flora in diabetic foot ulcers. Indian J Pathol Microbiol 2008;51:204-8.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: An entity with different characteristics, treatments, and prognosis. J Diabetes Complications 1999;13:254-63.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Arora A, Singh S, Aggarwal A, Aggarwal PK. Salmonella osteomyelitis in an otherwise healthy adult male-successful management with conservative treatment: A case report. J Orthop Surg (Hong Kong) 2003;11:217-20.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Cohen JI, Bartlett JA, Corey GR. Extra-intestinal manifestations of Salmonella infections. Medicine (Baltimore) 1987;66:349-88.  Back to cited text no. 6
[PUBMED]    

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Correspondence Address:
Varsha Gupta
Department of Microbiology, Government Medical College Hospital, Sector 32, Chandigarh - 160 030
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.81619

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