| Abstract|| |
Salmonella typhi infection presents most commonly as typhoid fever and infrequently as extraintestinal localized infections of bone, joints, soft tissues, spleen, endocardium, pulmonary, hepatobiliary, genital and urinary systems. Urinary tract infection ( UTI) is rare and clinical presentation is indistinguishable from UTIs due to other etiological agents or may even be asymptomatic. We report two cases of patients with chronic kidney disease with UTI due to S. typhi. Renal cyst, nephrolithiasis, and urethral strictures were the concomitant findings in one case and renal tubular acidosis with nephrocalcinosis in the other. In patients with relapses and a chronic course with coexisting functional or structural abnormalities of the urinary tract system, the suspicion of Salmonella as one of the probable causative agents should be kept in mind so as to ensure appropriate and adequate therapy. Furthermore, in the presence of long-standing hypokalemia, one should investigate for renal abnormalities and vice versa.
Keywords: Chronic kidney disease, nephrocalcinosis, nephrolithiasis, Salmonella, urinary tract infection
|How to cite this article:|
Dawar R, Jasuja S, Imdadi F, Ghonge NP. Salmonella typhi bacteriuria, predispositions and complications: Two case reports and review of literature. Ann Trop Med Public Health 2017;10:1058-60
|How to cite this URL:|
Dawar R, Jasuja S, Imdadi F, Ghonge NP. Salmonella typhi bacteriuria, predispositions and complications: Two case reports and review of literature. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Feb 29];10:1058-60. Available from: http://www.atmph.org/text.asp?2017/10/4/1058/215894
| Introduction|| |
Salmonellosis More Details may manifest as gastroenteritis, enteric fever, localized infection or as carrier state. One million foodborne illnesses in the USA are due to Salmonella More Details infection. Enteric fever is endemic in many tropical countries.
Predisposing conditions such as hemoglobinopathies, joint trauma, surgery, cholelithiasis, or other immunosuppressive states have been documented in patients with extraintestinal manifestations.
We present here two cases of urinary tract infection (UTI) due to Salmonella typhi and their associated predisposing conditions from our hospital in North India.
| Case Reports|| |
A 56-year-old male presented to Indraprastha Apollo Hospitals, New Delhi with complaint of off and on right flank pain for the past 1 month. He was admitted for further evaluation and management. Ultrasound (USG) abdomen and contrast-enhanced computed tomography findings were suggestive of large pelviureteric junction calculus with marked back pressure and the left upper pole calculus. 99m Tc-DTPA Renal Dynamic Study showed subnormal glomerular filtration rate, left side nonobstructed kidney, and right enlarged partially obstructed kidney with moderately impaired cortical function.
Right double J (DJ) stenting was done [Figure 1]. His urine routine microscopy (R/M) showed raised proteins and pus cells full high-power field. Patient was started empirically on ofloxacin 200 mg orally 12 hourly. Urine culture showed pure growth of >100,000 CFU/ml of nonlactose fermenting colonies on MacConkey agar. These were identified as S. typhi on Vitek 2 Compact and Vitek MS (bioMerieux, France). Agglutination with Salmonella Polyvalent O antisera (Denka Seiken, Japan) and Salmonella O Antiserum Factor 9 (Becton Dickinson and Company, Ltd., USA) were positive.
|Figure 1: Coronal noncontrast computed tomography image showing gross hydronephrosis involving the right kidney with calculus in the lower major calyx and gross parenchymal thinning. Ureteric stent is also noted on the right side|
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Antibiotic susceptibility tests were perfomed and interpreted according to Clinical and Laboratory Standards Institute guidelines  showed that strain was sensitive to ceftriaxone and cefixime and resistant to ampicillin, nalidixic acid, co-trimoxazole, and quinolones. Following the sensitivity report, antibiotic treatment was changed to cefixime 200 mg twice a day for 2 weeks, and patient was advised to come for follow-up and evaluation of renal functions. Percutaneous nephrolithotomy (PCNL) was planned if the renal functions improved. On follow-up after 2 weeks, his serum urea level was 75 mg/dl (reference range 10–50 mg/dl), serum creatinine 2.4 mg/dl (reference range 0.5–1.3 mg/dl), and urine R/M still showed pus cells full field. USG abdomen showed right-sided hydronephrosis with renal calculus and left renal cyst. The same antibiotics were continued and his renal parameters were monitored. After 6 weeks, PCNL was performed, and urine, stones, and DJ cultures were sent to the microbiology laboratory. All the three revealed growth of S. typhi with the same antibiotic susceptibility pattern as earlier. Thus, the treatment was continued for another 2 weeks.
DJ stent was removed after 2 months. At this time, the urine culture showed no growth of S. typhi. After 2 years, the patient presented with pain and swelling of the left side of scrotum. Uroflowmetry was suggestive of obstructive pattern. Retrograde urethrogram and micturating cystourethrogram were suggestive of proximal penile urethral stricture. Cystoscopy and optical internal urethrotomy were performed. Serum creatinine started improving, and the patient was discharged in a stable condition.
A 27-year-old male patient presented for evaluation of weakness for the past one month and complaints of difficulty in walking. Over the past 4 years, he had been hospitalized 4 times with episode of extreme muscle weakness in his hometown and received intravenous therapy for low potassium levels. His history revealed inability to hear and speak since 4 months of age and persistent hypokalemia since childhood. Patient was thoroughly evaluated and found to have distal renal tubular acidosis with nephrocalcinosis on USG abdomen. Investigations ruled out sickle cell anemia, hypercalciuria, hyperglobulinemia, and cirrhosis.
Potassium levels were optimized with oral potassium citrate solution. Urine culture revealed S. typhi colony count >105/ml and the isolate was sensitive to amoxicillin and clavulanate, cefotaxime, ceftriaxone, co-trimoxazole, nalidixic acid, and quinolones. The patient was started on cefixime 200 mg daily till next follow-up after 2 weeks. He was discharged in stable condition.
| Discussion|| |
Salmonella enters the urinary tract either hematogenously following a recent episode of typhoid fever once a threshold of the organism is reached in the bloodstream or in chronic carrier states involving the urinary system or by direct invasion of the bladder through the urethra through fecal contamination.
The two cases reported by us represent true UTIs, as opposed to colonization or fecal contamination, by virtue of being isolated in pure culture and in high concentrations (>100,000 CFU/ml) and urine R/M showed pus cells full field.
Salmonella was reported as the cause of 0.056%–0.07% of UTI in Spain  and 0.002%–0.0037% of UTI in the United States. Although S. typhi bacteriuria is rare even where it is endemic, this specific infection should be kept in mind in patients who have an unidentified chronic UTI.
Interstitial nephritis and renal microabscesses can develop as important complications in the course of Salmonella UTI. Salmonella emphysematous pyelonephritis has been reported in a nondiabetic and nonobstructive end-stage renal disease patient from Taiwan.
Recent surveys of Salmonella bacteriuria have focused on risk factors associated with acquisition of UTIs. Such risk factors include immunocompromised conditions, underlying urologic abnormalities, neoplasms of the kidney, nephrolithiasis, hydronephrosis, anatomic abnormalities, schistosomiasis, tuberculosis, prostatic hypertrophy, renal transplant recipients, and lupus nephritis., Renal cyst, nephrolithiasis, and urethral strictures were the concomitant findings in one case and renal tubular acidosis with nephrocal in the other in our study. Many of these cases do not have a history of typhoid fever. In our patients too, no past history of typhoid fever was documented.
Many cases of bacteriuria do occur in individuals without known risk factors. An Australian investigation by Paterson et al. of 23 persons with Salmonella UTIs (>1000 leukocytes/ml, >105 CFU/ml) identified no immunocompromised patients in their study and only 3 (13%) with urologic abnormalities.
In our second case, there was a history of treatment with kanamycin in childhood which is known causes of deafness and renal damage. Hypokalemia results in addition to an alkaline urine and bladder dysfunction lead to urinary stasis and luxuriant bacterial growth.
Thus in the presence of long-standing hypokalemia, one should investigate for renal abnormalities and vice versa. Antibiotic treatment is challenging, and prolonged treatment is indicated due to chronic bacteriuria and relapses. Thus, it is crucial to request for repeat urine cultures in follow-ups. In case of UTI associated with anatomic obstructive abnormalities, surgical correction may be required in addition to prolonged antimicrobial therapy (≥6 weeks) to eradicate infection.
Prolonged course of antibiotic treatment with cephalosporins, surgical removal of the calculi, and drainage procedure in conjunction helped in cure in our cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Department of Microbiology, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 076
Source of Support: None, Conflict of Interest: None