Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection

Salmonella Bacteremia in Spanish Pediatric Emergency Departments: Uncommon But Not Mild

BACKGROUND

Salmonella spp. is an uncommon microorganism in bloodstream infections among pediatric patients in our setting, although in developing countries it is the most common causative organism in blood cultures.

METHODS

We describe the children presenting to pediatric emergency departments and diagnosed with Salmonella bacteremia (SB) and identify clinical and laboratory predictors of poor outcome (ie, complications, sequelae and death) by bivariate analysis. We performed an observational study and subanalysis of a multicenter prospective registry, including patients <18 years of age with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered young age, chronic diseases, immunosuppressive treatment and intestinal flora disruption as risk factors for SB.

RESULTS

Of the 55 patients with SB (3.2% of registered bacteremia), 32 (58.2%) had no risk factors for SB, 42 (76.3%) had a normal pediatric assessment triangle and 45 (81.8%) an associated gastrointestinal infection (acute gastroenteritis or enteric fever). Nine (16.4%) had a poor outcome, including 1 death (1.8%). A poor outcome was more common in patients with an abnormal pediatric assessment triangle [odds ratio (OR): 51.6; 95% confidence interval (CI): 9.2-289.5], an altered physical examination (OR: 15.2; 95% CI: 4.4-58.8) and elevated C-reactive protein (OR: 1.01; 95% CI: 1.005-1.03).

CONCLUSIONS

Most SBs were related to a gastrointestinal infection. One in 6 children had a poor outcome; abnormal pediatric assessment triangle on arrival (25% of patients) was the main risk factor identified.

Salmonella Subcutaneous Abscess: A Rare Complication Post Salmonella Gastroenteritis

Salmonella is a gram-negative bacilli bacterium that can infect and colonize humans, causing a wide range of clinical manifestations. The most common manifestation is gastroenteritis, usually after ingestion of undercooked and ill-prepared food, particularly in developing countries. Indonesia is among those reported to have a high incidence of Salmonella infection. Uncommonly, extraintestinal manifestations can affect distant body sites, either during or after the episode of bacteremia. This case report presents a rare case of a healthy 19-year-old female who developed an atypical chest wall abscess colonized by Salmonella in the context of experiencing gastroenteritis three weeks prior on her return from Bali, Indonesia. This case highlights the indolent course associated with a Salmonella chest wall abscess with a discussion of the current literature and management.

From Eberthella typhi to Salmonella Typhi: The Fascinating Journey of the Virulence and Pathogenicity of Salmonella Typhi

Salmonella Typhi (S. Typhi), the invasive typhoidal serovar of Salmonella enterica that causes typhoid fever in humans, is a severe threat to global health. It is one of the major causes of high morbidity and mortality in developing countries. According to recent WHO estimates, approximately 11-21 million typhoid fever illnesses occur annually worldwide, accounting for 0.12-0.16 million deaths. Salmonella infection can spread to healthy individuals by the consumption of contaminated food and water. Typhoid fever in humans sometimes is accompanied by several other critical extraintestinal complications related to the central nervous system, cardiovascular system, pulmonary system, and hepatobiliary system. Salmonella Pathogenicity Island-1 and Salmonella Pathogenicity Island-2 are the two genomic segments containing genes encoding virulent factors that regulate its invasion and systemic pathogenesis. This Review aims to shed light on a comparative analysis of the virulence and pathogenesis of the typhoidal and nontyphoidal serovars of S. enterica.

phoP maintains the environmental persistence and virulence of pathogenic bacteria in mechanically stressed desiccated droplets

Despite extensive studies on kinematic features of impacting drops, the effect of mechanical stress on desiccated bacteria-laden droplets remains unexplored. In the present study, we unveiled the consequences of the impaction of bacteria-laden droplets on solid surfaces and their subsequent desiccation on the virulence of an enteropathogen Salmonella typhimurium (STM). The methodology elucidated the deformation, cell-cell interactions, adhesion energy, and roughness in bacteria induced by impact velocity and low moisture because of evaporation. Salmonella retrieved from the dried droplets were used to understand fomite-mediated pathogenesis. The impact velocity-induced mechanical stress deteriorated the in vitro viability of Salmonella. Of interest, an uninterrupted bacterial proliferation was observed in macrophages at higher mechanical stress. Wild-type Salmonella under mechanical stress induced the expression of phoP whereas infecting macrophages. The inability of STM ΔphoP to grow in nutrient-rich dried droplets signifies the role of phoP in sensing the mechanical stress and maintaining the virulence of Salmonella.

Non-typhoid Salmonella endocarditis complicated by cardiac failure and acute limb ischaemia in a person living with HIV and hepatitis C: A Case Report and literature review

Salmonella infections are responsible for a large burden of disease worldwide. Non-typhoidal Salmonella (NTS) species cause a myriad of disease manifestations, particularly amongst severely immunocompromised individuals. We present a rare case of endocarditis caused by the NTS species Salmonella Enteritidis in an individual living with HIV and hepatitis C. In this case, endocarditis was complicated by embolization and acute arterial occlusion of the left arm, as well as mitral valve perforation resulting in cardiac failure. A review of the available literature shows few cases of NTS causing endocarditis in people living with HIV, with the earliest reported case in 1983. Our case demonstrates the potential complications of NTS endocarditis and highlights the importance of evaluating patients with NTS-associated blood stream infection for cardiovascular involvement. Prompt surgical intervention in addition to appropriate antimicrobial therapy is essential to reduce the high morbidity and mortality associated with NTS endocarditis.

Bacteriuria due to Typhoidal and Nontyphoidal Salmonella: A Report of Three Cases from South India

Urinary tract infection (UTI) with Salmonella is uncommon, accounting for merely 0.01% to 0.1% of cases of UTIs. It is reported more frequently in the presence of predisposing factors such as structural abnormalities of the urinary tract or weakened immune system. We present a case series of three patients with Salmonella bacteriuria and their susceptibility patterns. All three patients had underlying urologic features such as neurogenic bladder, chronic kidney disease, and urethral stricture, and two presented with urinary tract involvement symptoms.

Contribution of typhoid toxin in the pathogenesis of Salmonella Typhi

To persist and establish infection, Salmonella utilizes a battery of different virulence determinants at every stage of infection. Typhoid toxin, a newly identified toxin in Salmonella enterica serovar Typhi is recognized as one of the virulence factors that has been linked with Salmonella pathogenesis. In this study, we have further investigated the role of typhoid toxin in the symptomatology of typhoid fever through in-vivo and ex-vivo studies. In mice, administration of cloned and purified typhoid toxin induces similar symptoms observed during typhoid fever such as fever, weight loss with a decrease in peripheral leucocyte count along with an increase in levels of pro-inflammatory cytokines (Il-6, TNF-α). Results of DNA analysis, fluorescence microscopy and flow cytometry of typhoid toxin-treated macrophages (ex-vivo) altogether revealed the CdtB (subunit of typhoid toxin) mediated DNA damage that led to the apoptosis of cells. Furthermore, to validate CdtB's catalytic role, macrophages were treated with typhoid toxin preincubated with anti-CdtB antibodies (generated in mice). Re-assessment of macrophage DNA by gel electrophoresis and flow cytometry analysis indicated a significant decrease in DNA damage and cells undergoing apoptosis, respectively. Moreover, a significant reduction in in-vitro DNase activity of CdtB protein was also observed on preincubating holotoxin with anti-CdtB antibodies. In total, this study highlights the role of typhoid toxin in inducing typhoid fever-like symptomatology, which may be executed through the toxin's catalytic subunit CdtB.

British Infection Association Guidelines for the Diagnosis and Management of Enteric Fever in England

Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.

Typhoid perforation in children below 5 years: a 10-year review of cases managed and outcome

INTRODUCTION

Typhoid perforation is still prevalent in children in developing countries. Hence, the need for a review of the morbidity and mortality from typhoid perforation in children from poor countries.

AIM

We review the clinical features, morbidity, and mortality of typhoid perforation in children aged ≤ 5 years in a developing country.

METHODS

A retrospective 10-year study of children aged ≤ 5 years with typhoid perforation in two tertiary hospitals in northeastern Nigeria. Data regarding clinical presentation, investigations, intra-operative findings, treatment, and outcome were reviewed.

RESULTS

Out of 221 children aged ≤ 15 years with typhoid perforation, 45 (20.4%) were aged ≤ 5 years. Fever and abdominal distension were present in all 45 (100.0%), followed by abdominal pain 33 (73.3%), constipation 19 (42.2%), diarrhoea and vomiting 18 (40.0%) and vomiting 13 (28.8%). All patients presented in second week of infection. Plain abdominal radiograph showed pneumoperitoneum suggestive of bowel perforation in 39 (86.7%) patients. Forty-one (91.1%) patients had ileal perforations with various severities of peritonitis. Out of which, 30 (73.2%) were single and 11 (26.8%) were multiple perforations. Two (4.4%) patients had peritonitis without bowel perforation, while 2 (4.4%) others had caecal, gall bladder perforations, respectively. Serious post-operative wound complications occurred in patients with severe peritonitis, multiple perforations, prolonged pre-operative resuscitation, and operation beyond 2 h. Overall, mortality rate was about 26.7% mainly in patients who had multiple perforations, severe peritonitis, prolonged pre-operative resuscitation, and operation time more than 2 h.

CONCLUSION

Multiple perforations, severe peritonitis, and operation time more than 2 h are poor post-operative factors that were associated with poor post-operative outcome in our patients.

An Extremely Rare Case of Upper Thoracic Salmonella Infection

Background

Vertebral osteomyelitis is rare. Finding the right etiological agent is important to administer antibiotic regimen accordingly. The occurrence of this disease in endemic countries raises the susceptibility of a more common infection such as tuberculosis and pyogenic bacteria. Salmonella spp. infection is also common in endemic countries; however, extra-intestinal manifestation is very rare.

Methods

We present an extremely rare case of salmonella vertebral osteomyelitis (SVO) in the upper thoracic vertebrae of a 64-year-old patient with history of cardiac surgery and other pre-existing comorbidities. SVO was treated by antibiotics, surgical debridement and spinal stabilization.

Results

Three weeks after surgery and intravenous antibiotics, the patient recovered and was discharged without fever and back pain, with excellent motoric improvement.

Conclusion

Salmonella infection must be considered to be one of possible etiological agents in patients with suggestive spondylitis in emerging countries, especially in those with comorbidities.

Extraintestinal Seeding of Salmonella enterica Serotype Typhi, Pakistan

We evaluated Salmonella enterica serotype Typhi strains isolated from all body sites in Pakistan during 2013–2018. Despite an increase in overall number of localized, extensively drug-resistant Salmonella Typhi in organ infections during 2018, there was no increase in the proportion of such isolates in comparison with non–extensively drug-resistant isolates.

Drug resistance in Salmonella Typhi: implications for South Asia and travel

PURPOSE OF REVIEW

Recent attempts at mapping Typhoid epidemiology have revealed an enormous burden of disease in developing countries. Countries hitherto believed to have a low incidence, such as the African subcontinent, on accurate mapping were found to have a significant burden of disease. Drug resistance, because of rampant overuse of antibiotics, has driven selection pressure to extensively drug-resistant typhoid becoming a reality in the Indian subcontinent. With widespread travel, importation of this variety of typhoid to nonendemic countries is likely to lead to outbreaks in a nonimmune population.

RECENT FINDINGS

A strain of extensively drug-resistant Salmonella Typhi isolated in Pakistan in 2016 has been responsible for multiple outbreaks in Pakistan and multiple travel-related cases all over the world in United States, UK, and Australia. This novel strain belongs to H58 lineage harbouring a plasmid encoding additional resistance elements like blaCTX-M-15 and a qnrS fluoroquinolone resistance gene. This resistance pattern has rendered many therapeutic options like Ceftriaxone and Fluoroquinolones clinically inactive impacting care in endemic and traveller populations alike.

SUMMARY

Changing epidemiology and drug resistance in typhoid indicates that it may be prudent to vaccinate nonimmune travellers travelling to typhoid endemic areas, especially the Indian subcontinent.

Salmonella infection after anterior cruciate ligament reconstruction: A case report

BACKGROUND

Infections after anterior cruciate ligament reconstruction (ACLR) are rare. No cases of Salmonella infection have been described to our knowledge.

CASE SUMMARY

We describe a rare case of Salmonella infection in a 23-year-old patient following an ACLR. The patient presented with subacute septic arthritis, 26 d after a hamstring autograft ACLR. The pathogen, Salmonella enterica typhimurium was isolated by bacteriological sampling of the first arthroscopic lavage. Two arthroscopic lavages were required, with intravenous antibiotic therapy for two weeks with cefotaxime and ciprofloxacin, followed by oral antibiotics with amoxicillin and ciprofloxacin for a total duration of three months. This approach treated the infection but two years after the septic arthritis, faced with ongoing knee instability due to graft damage, a revision ACLR with a bone-tendon-bone graft was performed. At the last follow-up, full range of knee motion had been achieved and sports activities resumed.

CONCLUSION

Infection after ACLR is rare and requires an early diagnosis and management in order to treat the infection and prevent arthritis-related joint cartilage destruction and damage to the graft.

Drug-resistant Salmonella Typhi induced kidney injury with rhabdomyolysis: A case report, and literature review

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AKI secondary to Salmonella Typhi can present with rhabdomyolysis.

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Patients may require temporary dialysis with a prolonged hospital stay.

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The prognosis of ST induced rhabdomyolysis is excellent.

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We present an extensive literature review of all reported ST bacteremia cases with AKI secondary to rhabdomyolysis.

Salmonella Typhi (ST) is a rod-shaped gram-negative bacterium that infects humans via contaminated food or water. Humans are the only reservoirs for the bacteria. Infection usually manifests as fever, abdominal pain, and diarrhea. However, complications such as intestinal perforation, hepatosplenomegaly, and renal injury can occasionally occur. Acute kidney injury (AKI) is associated more commonly with ST than other bacteria causing gastrointestinal (GI) infections. The exact pathophysiology of AKI in ST infection is unknown. One of the rarely reported mechanisms is rhabdomyolysis. We present a similar case of resistant ST infection leading to AKI with rhabdomyolysis. This article also contains an extensive literature reviews of all reported ST bacteremia cases with AKI secondary to rhabdomyolysis.

In Vitro and In Vivo Evaluation of the Probiotic Potential of Antarctic Yeasts

Antarctica is one of the most pristine and inhospitable regions of the planet, mostly inhabited by microorganisms that survive due to unusual metabolic pathways to adapt to its extreme conditions, which could be interesting for the selection of new probiotics. The aim of the present study was to screen in vitro and in vivo putative probiotics among 254 yeasts isolated from different habitats of Antarctica. In vitro selection evaluated functional (growth at 37 °C, resistance to simulated gastric environment, and to bile salts), safety (degradation of mucin, production of β-haemolysis and resistance to antifungal drugs), and beneficial (production of antagonistic substances and adhesion to pathogens) properties. Twelve yeasts were able to grow at 37 °C, one of which was eliminated to present β-haemolytic ability. The remained yeasts resisted to gastric simulation and bile salts, but none presented antagonism against the pathogens tested. Because of the high co-aggregation with Salmonella enterica Typhimurium and growth yield, Rhodotorula mucilaginosa UFMGCB 18377 and Saccharomyces cerevisiae UFMGCB 11120 were selected for in vivo steps using mice challenged with S. Typhimurium. Both yeasts reached high faecal population levels when daily administered, but only R. mucilaginosa UFMGCB 18377 protected mice against Salmonella infection presenting a higher survival and reduced weight loss, bacterial translocation to the liver, sIgA intestinal levels, and intestinal and hepatic MPO and EPO activities. Our in vitro and in vivo results suggest that R. mucilaginosa UFMGCB 18377 presents probiotic potential and deserve further studies as candidate of probiotic by-products. In addition, this is the first screening study of yeasts isolated from Antarctic environments and of Rhodotorula genus for probiotic use.

A Case-Control Study on the Association between Salmonella Bacteriuria and Cystoscopy

To date, there is only one published report of an outbreak of urinary tract infections by Salmonella species after cystoscopy. Disinfection procedures for cystoscope have come into question. The current study aimed to determine the odds of developing Salmonella bacteriuria after cystoscopy. A retrospective case-control study was conducted on all patients with Salmonella species in urine (case) and blood (control) from 2017 to 2019 in 16 hospitals in Eastern Ontario, Canada. Eight of the 11 patients had cystoscopy prior to Salmonella bacteriuria; three of the 74 patients had urological procedures prior to Salmonella bacteremia, but none of their procedures were cystoscopy. The odds ratio of urological procedures with Salmonella bacteriuria was 63.1 (95% CI 10.9 to 366.6; p < 0.0001). In the bacteriuria group, the most frequently identified isolates were Salmonella enteritidis (n = 8), followed by Salmonella oranienburg, and Salmonella heidelberg. Seven of the S. enteritidis isolates had identical susceptibilities (ampicillin-sensitive; sulfamethoxazole/trimethoprim-sensitive; ciprofloxacin intermediate). In the bacteremia group, the most frequently identified isolates were S. enteritidis (n = 22), followed by Salmonella typhi, S. heidelberg, S. oranienburg, and Salmonella typhimurium. The result suggested cystoscopy is a risk factor for Salmonella bacteriuria. Identification of Salmonella bacteriuria should prompt public health investigations of linkage between cystoscopy and Salmonella bacteriuria.

An unusual case of sepsis due to Salmonella enterica serovar Weltevreden, an emerging pathogen of non-typhoidal salmonellosis

Salmonella enterica serovar Weltevreden is identified as an emerging pathogen, especially in the South and Southeast Asian regions. A 45-year-old male presented with an acute febrile illness, disoriented and confused. Blood culture became positive for Salmonellae enterica serovar Weltevreden. The patient was started on intravenous Ceftriaxone. Despite aggressive management, he developed acute respiratory distress syndrome with septic shock, which required intubation and mechanical ventilation. On the 11th day of admission, he succumbed due to sepsis from peritonitis with bowel infarction. Severe sepsis due to S. Weltevreden is rare. Diabetes, malignancy, therapeutic immune suppression may predispose to invasive disease. Biochemical similarities to other Salmonella species may lead to S. Weltevreden being overlooked by clinicians. Isolates from around the world remain sensitive to most freely available antibiotics. Emergence of resistance to common antimicrobial agents could pose an obvious public health threat.

Primary Spontaneous Pneumothorax in Typhoid

We report a rare case of a 12-year-old girl who presented with a short history of diarrhea, vomiting and fever after traveling to Pakistan. During the course of initial investigations, her chest radiograph showed a primary spontaneous pneumothorax. There was no previous history of pulmonary disease. She was diagnosed as having Salmonella Typhi based on positive blood cultures. In the literature, spontaneous pneumothorax has been associated with typhoid fever as a complication of the disease in the pre-antibiotic era. However, a spontaneous pneumothorax associated with typhoid fever has never been reported to our knowledge in the post-antibiotic era.

Splenic Abscess Caused by Salmonella Typhi: an Uncommon Presentation

Splenic abscess is an uncommon extra-intestinal complication of Salmonella Typhi infection in the post-antibiotic era. The condition is associated with high morbidity and mortality if not diagnosed in a timely manner. We report the case of a 20-year-old man who presented with left upper abdominal pain, high-grade fever, and a lump in the abdomen. Ultrasound and computed tomography scan of the abdomen revealed a large solitary splenic abscess. The abscess was drained percutaneously and Salmonella Typhi was isolated on a culture board, which was an unexpected finding. The patient was prescribed the appropriate antibiotics based on an antimicrobial susceptibility report and periodic follow-up was planned. The clinical condition of the patient improved along with complete resolution of the abscess. This report reiterates the importance of clinical diagnosis and radiological imaging even for common diseases presenting in an unusual fashion. Percutaneous drainage and microbial culture, with antibiotics prescribed based on susceptibility are key to the treatment of such abscesses.

Salmonella Strain Specificity Determines Post-typhoid Central Nervous System Complications: Intervention by Lactiplantibacillus plantarum at Gut-Brain Axis

Neurological complications occurring due to Salmonella infection in some typhoid patients remain a relatively unexplored serious complication. This study firstly aimed to explore whether disseminative ability of Salmonella from gut to brain is strain specific or not and on the basis of bacterial load, histopathology, and behavioral changes, it was observed that Salmonella enterica serovar Typhimurium NCTC 74 did not cause brain infection in murine model in contrast to Salmonella Typhimurium SL1344. Simultaneously, alarming escalation in antimicrobial resistance, making the existing antibiotics treatment inefficacious, prompted us to evaluate other bio-compatible strategies as a potential treatment option. In this context, the role of gut microbiota in influencing behavior, brain neurochemistry, and physiology by modulating key molecules associated with gut-brain axis has captured the interest of the scientific community. Followed by in vitro screening of potential probiotic strains for beneficial attributes, efficacy of the selected strain was systematically evaluated at various levels of gut-brain axis against Salmonella induced brain infection. Analysis of behavioral (depression, anxiety, and locomotor), neurochemical [gamma amino butyric acid and acetylcholinesterase (AChE)], neuropathological (brain and intestinal histology; bacterial burden), and immunohistochemical studies (tight junction proteins expression) revealed its role in preventing serious manifestations and proving its potential as "psychobiotic." To the best of our knowledge, this is the first report elaborating strain specificity of Salmonella in causing post-typhoidal neurological manifestations and simultaneous use of probiotic in managing the same by influencing the pathophysiology at gut-brain axis.

Salmonella Prostatic Abscess in an Immunocompetent Patient

Patients returning from travel to a foreign country often present with atypical infections that can present as diagnostic challenges. Although rarely seen in the United States, Salmonella infections are commonly seen in Sub-Saharan Africa. The common clinical manifestations of Salmonella infection include fever and diarrhea; however, about 5% of cases of non-typhi Salmonella progress to bacteremia. Here, we present a case of a unique presentation of Salmonella infection manifesting as a prostatic abscess in an immunocompetent patient. 

Case Report: Typhoid Fever Complicated by Acute Respiratory Distress Syndrome in a Pediatric Traveler

Acute respiratory distress syndrome (ARDS) is seldom described as a complication of typhoid fever (TF). Only 13 cases have hitherto been reported in the English and non-English literature since 1990. We report an 8-year-old boy with TF after return from India who developed pediatric ARDS (pARDS) despite adequate antibiotic treatment. Among patients with available information including this case, we noted that most not born or raised in a TF-endemic country (4/6) compared with none (0/6) of the domestic cases in a TF-endemic country developed ARDS within 48 hours of starting the antibiotic treatment. Our case raises important questions regarding the frequency, pathophysiology, and appropriate management of ARDS and pARDS in patients with TF.

Salmonella typhimurium myopericarditis: A case report and review of literature

BACKGROUND

Non-typhoidal salmonella (NTS) is a rare, but well-established cause of myopericarditis. Presenting symptoms may be varied, however often revolve around the dual presentation of both myopericarditis and infectious diarrhoea. Given the rarity of NTS related myopericarditis, we conducted a systematic review of the literature, identifying 41 previously reported cases.

CASE SUMMARY

We present the case of an otherwise healthy 39-year old male, presenting with chest pain in the setting of documented Salmonella typhimurium infection. After further investigation with echocardiogram and laboratory blood tests, a diagnosis of NTS associated myopericarditis was made, and the patient received antibiotic treatment with an excellent clinical outcome. Overall, myopericarditis is rare in NTS. Although treatment for myopericarditis has not been well established, there are guidelines for the treatment of NTS infection. In our review, we found that the majority of NTS cases has been pericarditis (27/42, 64.3%), with an average age of 48.3 years, and 71.4% being male. The average mortality across all cases was 31%.

CONCLUSION

Myopericarditis is a rare, but potentially serious complication of NTS infection, associated with an increased morbidity and mortality.

Cardiac Involvement in Travelers with Enteric Fever

Data regarding cardiac involvement in enteric fever among travelers are scarce. In this retrospective study, 59 patients were hospitalized with enteric fever during 2004-2017 and 28 had cardiac workups. Among those, four had evidence of cardiac involvement, including clinical myocarditis, electrocardiogram changes, or troponin elevation. Cardiac involvement was higher among patients infected with Salmonella Typhi than with Salmonella Paratyphi A (P = 0.08), with a significant relative risk of 6 (95% CI: 1.15-31.22, P = 0.03). Time from symptoms onset to effective treatment was longer for patients with cardiac involvement (13 versus 7.15 days, P < 0.05). It seems that cardiac involvement in enteric fever is not uncommon in travelers. Such involvement seems to be more common in patients with delay of effective treatment to the second week of illness. Although fatal or complicated cases are rare in travelers, the cardiac complication may be an important contributor to morbidity and mortality in this group.

Chain effects of clean water: The Mills-Reincke phenomenon in early 20th-century Japan

This study explores the validity of chain effects of clean water, which are known as the "Mills-Reincke phenomenon," in early 20-century Japan. Recent studies have reported that water purifications systems are responsible for huge contributions to human capital. Although some studies have investigated the instantaneous effects of water-supply systems in pre-war Japan, little is known about the chain effects of these systems. By analyzing city-level cause-specific mortality data from 1922 to 1940, we find that a decline in typhoid deaths by one per 1000 people decreased the risk of death due to non-waterborne diseases such as tuberculosis and pneumonia by 0.742-2.942 per 1000 people. Our finding suggests that the observed Mills-Reincke phenomenon could have resulted in the relatively rapid decline in the mortality rate in early 20-century Japan.

Antioxidant activity of dichloromethane fraction of Dichrocephala integrifolia in Salmonella typhi-infected rats

OBJECTIVE

Infectious diseases such as typhoid fever lead to the formation of free radicals which can damage the body. Many medicinal plants have antioxidant molecules that neutralize free radicals. The present work evaluated the antioxidant activity and histopathological effects of the dichloromethane fraction of Dichrocephala integrifolia in Salmonella typhi-infected rats.

METHODS

The S. typhi-infected rats concurrently received daily doses of D. integrifolia extract at doses of 25, 50 and 100 mg/kg body weight or ciprofloxacin (5 mg/kg body weight) for 15 days. Body temperature was measured daily during infection and treatment periods. At the end of treatment period, the animals were sacrificed and biological responses including hematological parameters, superoxide dismutase and catalase activities, and glutathione, malondialdehyde and nitric oxide concentrations were evaluated.

RESULTS

The elevated body temperature induced by infection was significantly decreased in animals treated with 25, 50 or 100 mg/kg of the extract. Platelet levels decreased slightly in infected rats, while treatment with the dichloromethane fraction of D. integrifolia significantly increased platelet levels; this response was greater than that elicited by ciprofloxacin. The doses of 50 and 100 mg/kg of the dichloromethane fraction of D. integrifolia notably decreased monocyte and neutrophil values. Activity of superoxide dismutase and catalase and levels of glutathione in the tissues of treated animals were increased significantly (P < 0.01), while malondialdehyde and nitric oxide levels were significantly decreased (P < 0.01), following treatment with the dichloromethane fraction of D. integrifolia.

CONCLUSION

The results of this study show that the dichloromethane fraction of D. integrifolia has protective effects against a series of pathological conditions initiated by oxidation and tissue damage in the course of a S. typhi infection.

Ovarian abscess caused by Salmonella enterica serovar Typhi: a case report

Background

Typhoid fever is a human-specific disease caused by a bacterium, Salmonella enterica subspecies enterica serovar Typhi. It is transmitted through ingestion of contaminated food or water. It is mostly diagnosed by blood culture. Salmonella Typhi usually manifests as a febrile illness with bacteremia after initial entry through the gastrointestinal route, but it can occasionally cause significant disease in extraintestinal sites. We report a case of a girl in Fiji with a right ovarian abscess infected by Salmonella Typhi.

Case presentation

A 14-year-old iTaukei (indigenous Fijian) girl presented to our hospital with abdominal pain of 1 month’s duration. Two days prior to her admission, she developed high-grade fever and nausea and had one episode of vomiting. On presentation, she appeared unwell; she was tachycardic (116 beats per minute) and febrile (38.8 °C). Her abdominal examination revealed generalized tenderness. Other examination findings were normal. The provisional diagnosis of abdominal sepsis led to an emergency laparotomy during which an enlarged right ovary was found to be spontaneously discharging pus. The ovary was incised and drained, and the patient was commenced on intravenous ceftriaxone 1 g twice daily, cloxacillin 1 g four times daily, and metronidazole 500 mg three times daily. She recovered promptly and was discharged to home on the sixth postoperative day. The purulent material from the ovary grew Salmonella Typhi.

Conclusion

Extraintestinal infections caused by Salmonella Typhi are rare but can cause severe and life-threatening disease. Our patient had a prolonged history of abdominal pain and was found to have a ruptured right ovarian abscess due to Salmonella Typhi. Ovarian abscesses in girls who are not sexually active are not associated with pelvic inflammatory disease and suggest local or hematogenous spread. This case report may increase health workers awareness to include common and endemic infections in the differential diagnosis of unusual clinical presentations to help the initiation of appropriate investigation and management as quickly as possible.

From Gut to Heart: Havoc in a Young Patient with Typhoid-associated Cardiomyopathy

Typhoid is an endemic hassle, especially in third-world countries like Pakistan. It is an enteric fever characterized by systemic manifestations that include high temperature and abdominal pain. If not properly treated, at times, it can transgress into complications predominantly involving the gut, where the site of pathology lies. Sometimes, however, it can involve other organ systems and pose diagnostic challenges owing to unfamiliar modes of presentation. Here in, we present a case of a 14-year-old male, previously afflicted and treated for typhoid who presented to the medical consult service with abdominal pain, high-grade fever, and mild chest discomfort. His hemodynamic parameters deteriorated within weeks as he developed pulmonary edema and hypoxemia. He was later diagnosed with echocardiography which earlier on, showed signs of acute myocarditis and eventually dilated cardiomyopathy. The patient was treated with antibiotics coupled with supportive and intensive care which yielded relief in his symptoms. He was later followed up with serial echocardiograms and showed improvement in the cardiac parameters.

Serodiagnostic evaluation of recombinant CdtB of S. Typhi as a potential candidate for acute typhoid

Typhoid fever caused by human restricted Salmonella typhi presents a considerable health burden on developing South-Asian nations like India. The suboptimal sensitivity and specificity associated with culture-based isolation of etiological agent and the extensively used surface antigen-based serological assays often lead to misdiagnosis and inappropriate antimicrobial treatment. The increasing reports of the emergence of resistant strains and undefined disease burden signify the critical need for an inexpensive, reliable, easy-to-use, and highly sensitive diagnostic test for typhoid fever. Utilizing S. typhi-specific and immunogenic antigens in sero-diagnostic assays could lead to precise diagnosis of acute typhoid and prompt treatment. In this study, we report cloning, expression, and purification of recombinant Cytolethal distending toxin subunit B (CdtB) of S. typhi, which is reported to be highly specific, immunogenic, and expressed only upon S. typhi infection. We further evaluated the purified recombinant CdtB for its diagnostic potential in an IgM-based indirect ELISA format using 33 human samples. Twenty-one serum samples from blood culture confirmed cases (n = 21) of typhoid and 12 samples from healthy controls (n = 12) were tested. The assay showed sensitivity of 100% and specificity of 83.3% respectively with positive and negative predictive values of 91.3 and 100% respectively. Efficient detection of specific IgM antibodies indicates that CdtB could be highly valuable in sero-diagnosis of acute typhoid and rapid screening of clinical samples.

Disseminated Salmonella infection

A 47-year-old Malay man who presented with fever, poor oral intake and loss of weight for 1 month duration. Further work-up revealed evidence of disseminated Salmonella infection that was further complicated with pericardial and pleural empyema. Cultures from pericardial and pleural fluids grew Salmonella species with negative serial blood cultures. Contrast enhanced CT thorax showed pleural effusion with large pericardial effusion. The patient was treated with antibiotics and drainage of pericardial and pleural empyema was done and he was discharged well.

Salmonella osteomyelitis: A rare extraintestinal manifestation of an endemic pathogen

Salmonella enterica serovar Typhi and Paratyphi usually cause enteric fever in humans characterized by fever and gastrointestinal symptoms such as diarrhea. Bacteremia is a constant feature of enteric fever, and occasionally, dissemination of bacilli throughout the body results in the establishment of one or more localized foci of persisting infection. This happens especially in patients with preexisting conditions such as hemoglobinopathies, previous joint trauma, surgery, connective tissue diseases, lymphoma, diabetes, alcoholism, immunosuppressive state, and extremes of ages. Rarely, these extraintestinal Salmonella infection cases have also been reported in immunocompetent individuals without any obvious predisposing factors. Salmonella osteomyelitis, a rare sequelae of typhoid, may occur as a result of hematogenous seeding of the bone or joints due to a bacteremic episode. It may also spread from nearby areas of infection or penetrating trauma. Timely diagnosis and treatment of this condition are necessary because if left untreated, it can lead to permanent functional deficits later on. We hereby present a case series with brief review of literature on Salmonella osteomyelitis in immunocompetent patients without any known predisposing conditions over a period of 1 year (2017-2018) from a Tertiary Care Teaching Hospital in Uttarakhand, India.

Acute epididymo-orchitis due to Salmonella Typhi in a young man from Bangladesh

S. typhi infection rarely involves the genitourinary system. We report the first described case of acute epididymo-orchitis due to S. typhi in a 14-year-old boy from Bangladesh. A high index of suspicion should be maintained when evaluating patients coming from endemic countries also in case of unusual sites of infection.

Multiple splenic abscesses in a case of enteric fever: Salvaging spleen through pigtail drainage and antibiotics is a good alternative approach

Splenic abscess is a rare complication of enteric fever in developing countries. This is seen mostly solitary rather than being multiple and can be fatal if untreated. In general clinical practice, multiple splenic abscesses or thick pus with septations may require splenectomy. Here, we report a rare case of enteric fever with multiple splenic abscesses in a young immunocompetent male who was successfully managed with antibiotics and percutaneous pigtail drainage of pus from the larger cavity.

Microbiological features of indigenous typhoid cases in Taiwan and relatedness to imported cases, 2001-2014: A cross-sectional analysis

BACKGROUND

Typhoid fever was rare in Taiwan but approximately two-thirds of the cases were indigenous. The transmission source of the indigenous cases and the relatedness to the imported cases remained unknown.

METHODS

Patients with any site culture positive for Salmonella enterica serovar Typhi were identified in a teaching hospital during 2001-2014. The isolates were determined for antibiotic susceptibilities, pulsed-field gel electrophoresis (PFGE) types and single nucleotide polymorphisms (SNP) types.

RESULTS

A total of 64 typhoid episodes were identified in 63 patients. Seventeen episodes (26.6%) were imported and a majority (10, 58.8%) of them were from Indonesia. The clinical manifestations, outcomes of patients and antibiograms of isolates were similar between indigenous and imported cases. 63.3% of the isolates were ciprofloxacin-resistant. The distributions of PFGE and SNP types did not differ significantly between indigenous and imported isolates, either (P = 0.191 and 0.124, respectively). Identical PFGE pattern could be identified in indigenous isolates appearing at certain time frames, indicating outbreaks due to local transmission of certain Typhi strains.

CONCLUSIONS

The imported cases of typhoid fever from Southeast Asia were the major sources of indigenous S. Typhi infections in Taiwan. Small-scale outbreaks occurred due to local transmission of the strains after their importation.

Typhoid fever causing haemophagocytic lymphohistiocytosis in a non-endemic country - first case report and review of the current literature

INTRODUCTION

Development of secondary haemophagocytic lymphohistiocytosis (sHLH) in the context of typhoid fever (TF) is a very rare but serious complication.

METHODS

Description of the first pediatric case of typhoid fever acquired in a non-endemic area complicated by sHLH. A systematic literature review of sHLH in the context of TF was performed with extraction of epidemiological, clinical and laboratory data.

RESULTS

The literature search revealed 17 articles (22 patients). Fifteen patients were eligible for data analysis (53.4% children). All patients had fever and pancytopenia. Transaminases and LDH were frequently elevated (46.6%). Salmonella typhi was detected mainly by blood culture (64.3%). All the patients received antibiotics whereas immunomodulation (dexamethasone) was used in two cases.

CONCLUSIONS

A high suspicion index for this condition is needed even in non-endemic areas. The addition of immunmodulation to standard antimicrobial therapy should be considered in selected cases.

Breast abscess due to Salmonella paratyphi A : Case reports with review of literature

Salmonella paratyphi A causes paratyphoid fever which is characterized by acute onset of fever, abdominal pain, diarrhoea, nausea and vomiting. Localized disease can occur following both overt and silent bacteremia followed by seeding of bacteria at distant sites. Salmonella species though associated with abscess formation in various organs,are rarely associated with breast abscess. We report 2 cases of breast abscess due to Salmonella enterica serotype paratyphi A. Appropriate sampling, surgery supplemented by a comprehensive microbiological work up aided in pathogen identification and appropriate antibiotic administration for a successful outcome of these patients.

Other Potentially Life-Threatening Conditions with Mucocutaneous Findings (Leptospirosis, Typhoid Fever, Dengue, Diphtheria, Murine Typhus)

There are several conditions with mucocutaneous findings that are potentially life-threatening, particularly in certain vulnerable populations. In this chapter, leptospirosis, typhoid fever, dengue, diphtheria, and murine typhus are reviewed. The disease time course of classic and atypical presentations is detailed to assist making the diagnosis in subtle cases. Associated symptoms are discussed as well as a comparison with disease mimics and differential diagnoses. Key diagnostic features are emphasized, and evidence-based management of each condition is detailed in this chapter.

Immune-Stimulatory and Therapeutic Activity of Tinospora cordifolia: Double-Edged Sword against Salmonellosis

The present study was aimed at determining the activity of aqueous and methanolic extracts of Tinospora cordifolia (AETC and METC) against Salmonella typhimurium. In vitro anti-Salmonella activity of T. cordifolia was determined through the broth dilution and agar well diffusion assays. The immune-stimulating potential of AETC or METC was determined by measuring the cytokine levels in the culture supernatants of treated murine J774 macrophages. Antibacterial activity of AETC or METC was determined by treating S. typhimurium-infected macrophages and BALB/C mice. The toxicity of AETC or METC was determined by measuring the levels of liver inflammation markers aspartate transaminase (AST) and alanine transaminase (ALT) and antioxidant enzymes. Macrophages treated with AETC or METC secreted greater levels of IFN-γ, TNF-α, and IL-1β. METC showed greater activity against S. typhimurium infection in macrophages and mice as well. Treatment with METC resulted in increased survival and reduced bacterial load in S. typhimurium-infected mice. Moreover, METC or AETC treatment reduced the liver inflammation and rescued the levels of antioxidant enzymes in S. typhimurium-infected mice. The results of the present study suggest that the use of T. cordifolia may act as a double-edged sword in combating salmonellosis.