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LETTER TO EDITOR  
Year : 2012  |  Volume : 55  |  Issue : 4  |  Page : 607-608
Multidrug-resistant Shigella flexneri bacteremia in an immunocompetent adult


1 Department of Microbiology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
2 Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India

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Date of Web Publication4-Mar-2013
 

How to cite this article:
Munim FC, Vandana KE, Acharya V, Mukhopadhyay C. Multidrug-resistant Shigella flexneri bacteremia in an immunocompetent adult. Indian J Pathol Microbiol 2012;55:607-8

How to cite this URL:
Munim FC, Vandana KE, Acharya V, Mukhopadhyay C. Multidrug-resistant Shigella flexneri bacteremia in an immunocompetent adult. Indian J Pathol Microbiol [serial online] 2012 [cited 2020 Sep 19];55:607-8. Available from: http://www.ijpmonline.org/text.asp?2012/55/4/607/107855


Sir,

Bacteremia is a rare event following dysentery caused by Shigella despite the intense superficial destructive process in the colonic epithelium. Majority of the reported cases of bacteremia occur in immunocompromised individuals and young children. [1] We report a case of multidrug-resistant Shigella flexneri bacteremia in an immunocompetent adult.

A 62-year-old male was referred to our tertiary care center from a peripheral hospital where he was treated for loose stools, but failed to respond to therapy of 4 days. His symptoms had started 5 days prior to admission to the peripheral hospital in the form of fever, loose stools with mucus, and tenesmus. He was on medications for type 2 diabetes mellitus and hypertension for 15 years. On examination, he was afebrile, blood pressure was 110/68 mm of Hg, and pulse rate was 98 beats/min. His cardiovascular and respiratory system examination was unremarkable. Abdomen was distended and firm. Laboratory investigations revealed hemoglobin concentration of 6.8 g/dl, leukocyte count of 10,800 cells/μl with 45% segmented neutrophils, 10% lymphocytes, 28% band neutrophils, and 13% monocytes, and platelet count of 96,000 cells/μl. His blood urea was 57 mg/dl, serum creatinine 1.2 mg/dl, and random blood glucose was 125 mg/dl. Liver function test was normal. Stool examination showed guaiac positivity, numerous fecal leukocytes, and red blood cells. Urine examination showed hematuria without proteinuria. His prior therapy details could not be retrieved. Diagnosis of acute febrile enterocolitis was made and intravenous rehydration therapy was started after ordering a set of blood culture. As he showed no improvement, intravenous ciprofloxacin 400 mg Q12H and metronidazole 500 mg Q8H were added after 2 days of admission. One of the blood culture bottles (BacT Alert 3D system) signaled positive after 2 days, which was later confirmed as S. flexneri susceptible to ceftriaxone, but resistant to ampicillin, trimethoprim- sulfamethoxazole, nalidixic acid, ciprofloxacin, amoxicillin-clavulanic acid, and gentamicin by Kirbey Bauer disk diffusion test. [2] However, stool culture was negative for Shigella. Considering the multidrug-resistant status of Shigella and lack of clinical improvement, therapy was now changed to intravenous ceftriaxone 2 g Q24H for 7 days along with supportive measures. Clinical improvement was evident on the second day of therapy with ceftriaxone and he showed complete recovery at the time of discharge from the hospital on the 10 th day.

S. flexneri continues to be the common serogroup causing dysentery in developing nations with increasing reports of fluoroquinolone resistance. [3],[4] Shigella bacteremia is rarely reported, while the burden of dysentery by Shigella bacteria remains high. Younger age and immunocompromised status are the common predisposing factors for systemic shigellosis. [1],[5] However, the case reported here did not have any remarkable risk factors for bacteremia. Non-clearance of the multidrug- resistant intestinal pathogen due to initial inadequate therapy might have contributed to prolonged, more severe illness leading to bacteremia. Detection of Shigella in one of the blood culture bottles indicates the intermittent nature of bacteremia. Though blood culture is not a common investigation in acute febrile enterocolitis, it is worthy in cases that do not resolve with supportive therapy and might detect more cases of gastrointestinal infections due to Shigella when stool cultures fail to detect pathogens. Changing susceptibility patterns of Shigella demand a relook into the therapy of bacillary dysentery as early appropriate therapy would prevent complications.

 
   References Top

1.Keddy KH, Sooka A, Crowther-Gibson P, Quan V, Meiring S, Cohen C, et al. Systemic shigellosis in South Africa. Clin Infect Dis 2012;54:1448-54.  Back to cited text no. 1
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2.Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testings. Twentieth informational supplement M100-S20. Wayne, PA: Clinical and Laboratory Standards Institute; 2010;40-4.  Back to cited text no. 2
    
3.Srinivasa H, Baijayanti M, Raksha Y. Magnitude of drug resistant shigellosis: A report from Bangalore. Indian J Med Microbiol 2009;27:358-60.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Taneja N. Changing epidemiology of shigellosis and emergence of ciprofloxacin-resistant Shigellae in India. J Clin Microbiol 2007;45:678-9.  Back to cited text no. 4
[PUBMED]    
5.Greenberg D, Marcu S, Melamed R, Lifshitz M. Shigella bacteremia: A retrospective study. Clin Pediatr (Phila) 2003;42:411-5.  Back to cited text no. 5
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Correspondence Address:
Kalwaje E Vandana
Department of Microbiology, Kasturba Medical College, Manipal University, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.107855

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