| Abstract|| |
Salmonella Enteritidis is one of the most important serovars transmitted from animals to humans and a serovar most commonly reported worldwide. Infection with Enteritidis is mainly limited to the intestinal tract, but under certain circumstances may cross the mucosal barrier to disseminate and get established as some localized infectious focus. Although cited as one of the very uncommon causes, Enteritidis may involve the liver and evolve into an overt abscess. Pyogenic liver abscess by a gas forming organism like Enteritidis usually follow a serious fulminant course and associated morbidity and mortality is unacceptably high unless immediate therapeutic interventions are initiated.
Keywords: Salmonella Enteritidis, pyogenic liver abscess, gas forming organisms
|How to cite this article:|
Mahajan RK, Sharma S, Madan P, Duggal N. Pyogenic liver abscess caused by Salmonella Enteritidis: A rare case report
. Indian J Pathol Microbiol 2014;57:632-4
|How to cite this URL:|
Mahajan RK, Sharma S, Madan P, Duggal N. Pyogenic liver abscess caused by Salmonella Enteritidis: A rare case report
. Indian J Pathol Microbiol [serial online] 2014 [cited 2020 Jan 29];57:632-4. Available from: http://www.ijpmonline.org/text.asp?2014/57/4/632/142715
| Introduction|| |
0Salmonella is motile Gram negative bacilli that may infect or colonize a wide range of mammalian hosts. Gastroenteritis, enteric fever and bacteremia are the most common presenting features, but after entering the blood stream, all tissues and organs are susceptible and may manifest in a variety of clinical entities depending upon the site of localization. Localization of systemic infections is usually associated with certain predisposed conditions such as malignancy, diabetes, sickle cell disease, immunosuppression, structural abnormalities, etc. It is estimated that perhaps 1% of enteric infections with nontyphoidal Salmonella result in bacteremia, but the true rate of bacteremia is not known since many primary enteric infections are mild or not microbiologically diagnosed.  Pyogenic liver abscess (PLA) is one of common liver pathologies and data from different sources place the incidence rate from 1.1 to 17.6/1,00,000 individuals.  Salmonella is one of the well-known causes of liver abscess and at least four Salmonella serovars viz; typhi, paratyphi A, Enteritidis and infantis have been identified as causative agents of liver abscess. Here we report a case of liver abscess caused by Salmonella enterica serovar Enteritidis in an immunocompetent male. This organism being prolific fermenter producing a large amount of gas at the site of localization, contributes significantly to amplified morbidity and mortality. Prompt diagnosis coupled with immediate therapeutic intervention will go a long way in minimizing the injury to the patient.
| Case report|| |
A 30-year-old male was admitted to the Medicine Department of our hospital with 1-week history of high-grade fever with chills and rigors, moderate abdominal pain in the epigastric region and vomiting. Patient gave history of diarrhea and pain abdomen about 1 month before reporting to the hospital. There was no history of tuberculosis or diabetes in the past. On examination, he was conscious, febrile (temperature- 39 °C), pulse rate 160/min, and blood pressure were 100/60 mm. He had pallor, but icterus was absent. Per abdomen examination elicited the tenderness in the right hypochondrium and epigastric region, and liver was palpable about 6 cm below the costal margin. Rest of the systemic examination was within normal limits. Routine hematological investigations revealed hemoglobin 9 g%, total leucocyte count-18,200/cu mm (polymorphs 76%, lymphocytes 19%, eosinophils 2%) and platelet count of 2.5 lacs/cu mm. Alkaline phosphatase was borderline elevated to 240 IU. Other liver function test, renal function values and serum electrolytes were within reference ranges. Serology for HIV, hepatitis B surface antigen and anti- hepatitis C virus were nonreactive. Widal test and IgM leptospira were negative. Ultrasonography of the abdomen showed enlargement of the liver with features suggestive of abscess measuring 8 cm 8 cm 8.6 cm and volume 320 cc involving segment VI and VII along with mild ascites. The patient was empirically started on intravenous vancomycin, monocef and metronidazole, but patient's condition deteriorated further with the development of features of respiratory distress. Respiratory examination uncovered decreased air entry and crepitations in the right lower lobe. X-ray chest showed right sided pleural effusion associated with subdiaphragmatic collection. Contrast enhanced computed tomography scan abdomen revealed a large liver abscess in the right lobe of size 8 cm 8 cm 8.6 cm communicating with the pleural cavity.
Ultrasound guided liver aspiration done. About 30 ml of pus was aspirated and sent for microbiological investigations. The pus sample received was processed as per standard microbiological techniques. A wet mount of pus was negative for trophozoites of Entamoeba histolytica. Gram smear showed Gram-negative bacilli along with pus cells. Ziehl-Neelsen stain was negative for acid fast bacilli. On blood agar, 2-3 mm diameter nonhemolytic colonies and on MacConkey agar, nonlactose fermenting colonies were obtained. The isolate was identified as S. enterica subspecies enterica serovar Enteritidis on the basis of biochemical reactions and further confirmed by agglutination test with specific antisera. It was found to be susceptible to ampicillin, cotrimoxazole, cephalosporins of third generation, and ciprofloxacin by Kirby Bauer disc diffusion method. Blood and urine cultures were sterile. No pathogenic organism was grown in stool culture. For pleural effusion pleural tapping was done and intercostal drain was inserted with 20 F tube. Pleural fluid also grew S. Enteritidis with the antibiotic pattern compatible with the isolate from liver abscess. The patient treatment was changed accordingly and metronidazole was stopped and ofloxacin was added in the treatment. However, the condition of the patient continued to deteriorate, developed septicemia shock and succumbed to his illness after 6 days of admission.
| Discussion|| |
The three major forms of hepatic abscess, classified by etiology, are pyogenic, amoebic, and fungal. The most common pathogens of the pyogenic hepatic abscesses are Escherichia coli, Klebsiella pneumoniae, Bacteroides, Enterococci, Streptococci, and Staphylococci.  Among gas forming PLA, K. pneumoniae is the most frequently cultured organism.  PLA due to Salmonella species is not that common and low incidence of hepatic manifestations may be explained by the phagocytic activity of its well-established reticulo- endothelial system. Soni et al. have also commented on the low frequency of abscess formation in Salmonella infections in their work on hepatic abscess by typhi. Of all the serovars associated with hepatic involvement, Enteritidis is of special concern because of its potential to form a gas from carbohydrates. It produces the formic hydrogen lyase, which converts formic acid, a product of carbohydrate fermentation into CO 2 and H 2 . The gas accumulation results in an impaired transportation of gases and nutrients in the local tissues and promotes tissue destruction into an abscess.  In our case, S. Enteritidis was the causative agent of PLA, which produces a large amount of gas which increases the mortality to as high as 27.7% when compared with the 14.4% mortality in nongas forming group.  Hence, prompt recognition of the condition and appropriate treatment is crucial for the management of patient.
Pyogenic liver abscess due to Enteritidis have been reported with some preexisting hepatobiliary diseases, including cholelithiasis, amoebic abscess, echinococcal cysts, intrahepatic hematoma, hepatocellular carcinoma, etc.  However in this case no such preexisting condition was present. Furthermore, Salmonella liver abscess is mostly seen in the immunocompromised state, while our case was an immunocompetent adult male. Common presentations of PLA include abdominal pain, fever, chills, nausea and vomiting, and a general feeling of illness. The blood culture was sterile in this case. The likely source of the liver abscess in our patient could be secondary to the seeding of infection from the transient portal bacteremia or infection localized in the gall bladder could have travelled to the liver parenchyma. Pyogenic abscesses can be single or multiple, but Salmonella abscesses, like amebic abscesses, are predominantly solitary and located in the right lobe.  Ultrasonography and other imaging studies have wonderful sensitivities to pick up abscess pathologies, but microbiological diagnosis is absolutely essential to establish a causal relationship and strategizing further therapeutic plans.  Here despite the fact that treatment was immediately modified to confirm to the antimicrobial sensitivity pattern of Enteritidis, but the patient could not be saved probably because the patient had already landed into septicemia. The organism like Enteritidis, which mainly tend to restrict to the intestinal tract and behave in a predictable manner, but at extra-intestinal sites like liver, these may express themselves with great indignation and vehemence, and may cause fatal damage as seen in this subject case. Such cases also warrant the scientific community to take a relook at the treatment algorithms for situations where the cases need to be picked up at the stage of the initial insult and be kept on surveillance for the development of morbid conditions like liver abscess more so in geographical areas where Salmonella infections are endemic.
Liver abscess caused by gas forming organisms carry a high mortality and warrant immediate therapeutic interventions, which may include decisive surgical management and dedicated Intensive Care. Enteritidis is one of the rare causes of liver abscess but in endemic geographical locations, this should be entertained in the differential diagnosis especially in cases with a proven history of intestinal illness.
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Department of Microbiology, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None