Indian Journal of Pathology and Microbiology

CASE REPORT
Year
: 2009  |  Volume : 52  |  Issue : 1  |  Page : 117--119

Isolation of Salmonella paratyphi A from renal abscess


Sanjay D'Cruz1, Suman Kochhar2, Sandeep Chauhan2, Varsha Gupta3,  
1 Department of Medicine, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030, UT Chandigarh, India
2 Department of Radiodiagnosis, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030, UT Chandigarh, India
3 Department of Microbiology, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030, UT Chandigarh, India

Correspondence Address:
Sanjay DSQCruz
1158 B, Medical College Campus, Sector 32 B, Chandigarh - 160 030
India

Abstract

Intrarenal abscesses remain a significant cause of morbidity and mortality as well as a diagnostic dilemma because a plethora of microorganisms can cause this condition. A definitive diagnosis is made by demonstrating the organisms from the aspirate and the success or failure of therapy depends upon the antimicrobial sensitivity pattern. Enteric fever is a multisystem disorder caused by invasive strains of salmonella. Salmonellosis continues to be a major public health problem, especially in developing countries. Classic enteric fever is caused by S. typhi and usually less severe enteric fevers are caused by S. paratyphi A, B, or C. However, at times S. paratyphi is capable of causing serious and often life-threatening infections like infective endocarditis, pericarditis, empyma, sino-venous thrombosis, osteomyelitis, meningitis, bone marrow infiltration, hepatitis and pancreatitis. There are anecdotal case reports in world literature of abscesses being caused by this organism. Renal involvement like bacteriuria, nephrotic syndrome and acute renal failure have been reported due to S. parayphi A. S. paratyphi A has never been implicated in renal abscess, we report one such case that was managed successfully with medical therapy.



How to cite this article:
D'Cruz S, Kochhar S, Chauhan S, Gupta V. Isolation of Salmonella paratyphi A from renal abscess.Indian J Pathol Microbiol 2009;52:117-119


How to cite this URL:
D'Cruz S, Kochhar S, Chauhan S, Gupta V. Isolation of Salmonella paratyphi A from renal abscess. Indian J Pathol Microbiol [serial online] 2009 [cited 2020 Jul 12 ];52:117-119
Available from: http://www.ijpmonline.org/text.asp?2009/52/1/117/44996


Full Text

 Introduction



Renal abscess is commonly caused by Staphylococci, Escherichia coli, Klebsiella and Proteus . Occasionally, fungi have also been implicated as causative organisms especially in immunocompromised patients. Anecdotal case reports of Shigella, Gardnella, Streptococcus, Meliodiosis, Pseudomonas and Nocardia causing renal abscess have been documented. [1],[2] Infrequently, salmonella species like S. virchow, S. enteritidis and S. typhimurium have been isolated [3],[4],[5] from renal abscess. We report the first case in which a causative organism of renal abscess was Salmonella paratyphi A .

 Case Report



A 17-year-old male presented to our division with fever and left-sided flank pain of 15 days duration. He did not have a history of vomiting, jaundice, dysuria, bladder or bowel disturbance, prior valvular heart disease, or substance abuse.

General physical and systemic examinations were unremarkable except for fever and mild tenderness over the left lumbar region. On investigation, his hemoglobin levels were 11 g/dl, his total leukocyte count was 3600/l (polymorphs 55%, lymphocytes 43%, monocytes 1% and eosinophils 1%), with a normal platelet count, liver and renal functions and fasting blood sugar. A urine examination was normal except for 20 pus cells/per high power field with traces of albumin. No acid fast bacilli were seen on three consecutive early morning urine samples. A hypo echoic lesion measuring 2.5 2.6 cm suggestive of an abscess was seen in the postero-medial cortex of the left kidney in the mid-polar region on an ultrasound of the abdomen and was confirmed on contrast-enhanced computed tomogram (CT) scan [Figure 1]. No abnormality was detected on the chest X-ray or echocardiography. He tested negative for human immunodeficiency virus (HIV I and II). No organism was isolated from urine and blood cultures. A ultrasound guided [Figure 2] needle aspirate was sent for culture and sensitivity. The patient was empirically started on intravenous cloxacillin pending culture and sensitivity reports. Mac Conkey and blood agar grew non lactose fermenting gram negative bacilli, which was identified as Salmonella paratyphi A on standard biochemical reactions. Serotyping was also done to confirm the isolate. The strain was sensitive to ceftriaxone, cefoperazone-salbactam, ofloxacin, amikacin and gentamicin. A repeat aspirate was done; again the culture showed Salmonella paratyphi A with the same antimicrobial sensitivity. His widal was positive for Salmonella paratyphi A (O and H antigens in the titer of 1:320 and 1:640, respectively). Cloxacillin was discontinued and he started receiving amikacin and ofloxacin. He responded to the treatment and his fever normalized on the fifth day after initiation of definitive therapy. Amikacin was discontinued after 14 days and ofloxacin was given for a total of 4 weeks. A review ultrasound done at 4 weeks showed a marked reduction in the size of the abscess [Figure 3].

 Discussion



Salmonella paratyphi A , a gram negative bacillus, is one of the three causative organisms of enteric fever. First detected in 1976, the spectrum of diseases caused by this organism is steadily increasing. Infection begins with the ingestion of contaminated food or water. After surpassing the gastric defences, they reach the gut where they penetrate the epithelial cells, are phagocytosed by macrophages and disseminate throughout the body colonizing in reticuloendothelial tissues causing protean clinical manifestations. The diagnostic gold standard is positive culture for Salmonella paratyphi A from blood, stool, urine, gastric or intestinal secretions, or bone marrow.

Typhoid fever is the classical and most common clinical manifestation of this organism. Rarely, this organism has been reported in patients with infective endocarditis, pericarditis, empyma, thrombosis (deep vein of the legs and cerebral dural sinuses), osteomyelitis, meningitis, bone marrow infiltration, hepatitis and pancreatitis. There are anecdotal case reports in world literature of abscesses (liver, subphrenic space, ovary, inguinal region, thyroid, psoas muscle and spleen) being caused by this organism. [6],[7] In an electronic review of the literature, Salmonella paratyphi A has never been implicated in renal abscess, though renal involvement (bacteriuria, nephrotic syndrome and acute renal failure) has been reported. [8],[9],[10] The resistance of kidneys to the invasion by this fastidious organism is still a matter of speculation.

Renal cortical abscess is three times more common in men than in women. It occurs at all ages but is more common in the second and third decades. The classification of intrarenal abscesses currently includes acute focal bacterial nephritis, acute multifocal bacterial nephritis, renal cortical abscess, renal corticomedullary abscess and xanthogranulomatous pyelonephritis. The route of spreading is hematogenous spreading from the skin furuncles, paronychia, boils, or infective endocarditis. The most common etiological agent of renal cortical abscess is S. aureus unlike what was isolated in the index case . An etiological diagnosis is confirmed by culture of the aspirated pus from the abscess.

Treatment is empirically started with anti-staphylococcal drugs (intravenous vancomycin or flucloxacillin) while awaiting culture and sensitivity reports. Once the culture and sensitivity reports are available, antibiotic treatment is modified accordingly. An attempt should be made to aspirate the pus as much as possible at the time of diagnostic aspiration to reduce the toxemia. If collection is significant, a drainage catheter must be inserted. Parenteral therapy should be continued for at least 7 days followed by oral antibiotics for at least 4 weeks as was given to our patient. Clinical improvement with gradual resolution of fever usually occurs over 3 to 7 days. Failure to do so requires a review of the diagnosis and bacterial sensitivities.

This is the first case report of renal abscess caused by Salmonella paratyphi A. Salmonellosis continues to be a major public health problem, especially in developing countries. Awareness of unusual clinical presentations of s almonella infection is important for physicians.

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