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Journal of Medical Microbiology (2013), 62, 1360–1362
Case Report
DOI 10.1099/jmm.0.059352-0
Salmonella enterica serovar Minnesota urosepsis in
a patient with Crohn’s disease in the absence of
recent or current gastrointestinal symptoms
Niels Steinebrunner,1 Catharina Sandig,1 Stefan Zimmermann,2
Wolfgang Stremmel,1 Christoph Eisenbach1 and Alexander Mischnik2
Correspondence
Niels Steinebrunner
[email protected]
Received 18 February 2013
Accepted 14 June 2013
1
Department of Gastroenterology, Intoxications and Infectious Diseases, Heidelberg University
Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
2
Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University
Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
Salmonella enterica serovar Minnesota is a rarely isolated organism in clinical samples mainly
grown from stool cultures. Sepsis due to Salmonella is known in severely immunocompromised
patients, but so far urosepsis due to S. enterica serovar Minnesota has not been described. We
report a case of a 31-year-old patient suffering from Crohn’s disease treated with infliximab and
azathioprine, in whom was implanted a double-J ureteric catheter for urolithiasis. The patient
presented with urinary tract infection and severe sepsis. S. enterica serovar Minnesota was grown
from urine and blood cultures. After empiric antimicrobial treatment with meropenem and
vancomycin, treatment was changed to ceftriaxone. Antimicrobial treatment was continued for a
total of 3 weeks without evidence of Salmonella recurrence on follow-up visits. Salmonella spp.
rarely cause urinary tract infection and sepsis. However, in immunocompromised patients, nontyphoidal salmonellosis merits a thorough clinical and microbiological evaluation.
Introduction
Salmonella enterica serovar Minnesota first emerged in
literature in the 1950s (Borbolla et al., 1956; McCracken,
1954). Since the initial description, the organism has only
rarely been isolated from clinical patient specimens.
Salmonella infection is mostly associated with gastroenteritis, or can rarely cause typhoid-like illnesses, even in
immunocompetent patients (Eckerle et al., 2010).
To the best of our knowledge, urosepsis due to Salmonella
spp. without presenting gastrointestinal symptoms has not
been described previously.
Case report
A 31-year-old male patient was admitted to the emergency
department with somnolence, high fever (39.8 uC), tachycardia and acute renal failure. On admission, his medication
consisted of infliximab (5 mg kg21 every 4 weeks) and
azathioprine (150 mg daily) for treatment of Crohn’s
disease. The patient denied the use of any other medication.
Nine years previously, a loop ileostomy was created due to
perianal fistulas. Current stool consistency and frequency
was unchanged with eight to ten ileostomy bag changes per
Abbreviation: NTS, non-typhoidal Salmonella.
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day. Physical examination showed abdominal guarding and
a right flank pain.
Laboratory findings revealed a leukocyte count of 4.25 nl21
(normal 4–10 nl21), a C-reactive protein level of 184.1 mg l21
(normal ,5 mg l21), a procalcitonin level of 440.05
ng ml21 (normal ,0.05 ng ml21), a serum creatinine level
of 15.66 mg dl21 (normal 0.1–1.3 mg dl21) and a urea
nitrogen level of 308 mg dl21 (normal ,45 mg dl21). His
international normalized ratio was elevated to 1.29. Arterial
blood gases showed a pH of 7.32, a pCO2 of 11 mmHg, a
pO2 of 98 mmHg and a base excess of 218.2 mmol l21. His
lactate level was not elevated at 0.80 mmol l21 (normal 0.9–
1.6 mmol l21).
Because of compensatory hyperventilation due to acidosis
and imminent respiratory failure, the patient was intubated
and mechanically ventilated. After collection of urine and
blood cultures, empiric antibiotic treatment with meropenem and vancomycin was started. Immunosuppressive
therapy was discontinued.
Urinalysis revealed 10 702 leukocytes ml21 and was strongly
positive for bacteria. Five months earlier, a double-J
catheter had been placed in the right ureter because of an
obstruction of urinary flow due to urolithiasis causing
hydronephrosis and post-renal kidney failure. The double-J
catheter was promptly exchanged and replaced by two
bilateral externally draining single-J catheters. Fluid
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Salmonella enterica serovar Minnesota urosepsis
resuscitation was started and the initially high demand for
catecholamines following intubation could incrementally
be tapered.
Clinical work-up revealed no infectious focus other than
the urinary tract system. Abdominal ultrasound revealed a
minimally dilated renal pelvis on the right side and no
signs of abscesses. Transthoracic echocardiography and
chest and abdominal X-rays were normal.
On the second day following admission, urine culture
(105 c.f.u. ml21) as well as blood cultures yielded
Salmonella enterica. The National Reference Center for
Salmonellae and Other Enteric Pathogens (Robert KochInstitut, Wernigerode, Germany) identified S. enterica
serovar Minnesota by agglutination testing and lysotyping.
Antimicrobial susceptibility testing revealed resistance to
ampicillin, cefuroxime and aminoglycosides according to
the European Committee on Antimicrobial Susceptibility
Testing guidelines (EUCAST, 2013).
Haemodialysis was performed on days 1, 2 and 6 following
admission until spontaneous urine production returned
and retention parameters declined. After 3 days on
mechanical ventilation, the patient was extubated. At this
time, laboratory findings showed a leukocyte count of
3.30 nl21, a C-reactive protein level of 169.9 mg l21, a
procalcitonin level of 126.15 ng ml21, a serum creatinine
level of 3.11 mg dl21, a urea nitrogen level of 85 mg dl21
and an international normalized ratio of 1.08. Urinary
white blood counts were still high but had dropped to
4723 ml21. Antibiotic treatment with meropenem and
vancomycin was downscaled to ceftriaxone and subsequently applied for a total of 3 weeks until cultures of urine
were negative for Salmonella. Several stool cultures taken
on days 4, 5 and 17 during hospitalization did not yield the
organism.
Discussion
Strains of Salmonella are categorized as typhoidal and nontyphoidal, corresponding to the symptoms caused by
infection. Strains of non-typhoidal Salmonella (NTS) usually
cause an intestinal infection (accompanied by diarrhoea,
fever and abdominal cramps) that might last 1 week or longer
(Hohmann, 2001). Salmonella is not a common microorganism to cause sepsis. When causative, Salmonella sepsis
can be a very dangerous disease (Lee et al., 1994b).
Nevertheless, the incidence of NTS infections has risen in
recent years (Weinberger et al., 2004). Most NTS infections
cause gastroenteritis. Invasive diseases are only seen in 3–8 %
of patients infected by NTS (Mandal & Brennand, 1988). The
patient reported here never presented abdominal symptoms
although suffering from Crohn’s disease, which is remarkable. Current stool consistency and frequency was unchanged
with eight to ten ileostomy bag changes per day and no
abdominal pain. To the best of our knowledge, the patient
was not vaccinated against typhoid fever, which could
potentially have explained the attenuated clinical course.
http://jmm.sgmjournals.org
Patients experiencing severe Salmonella infections are
typically immunocompromised due to co-morbidities such
as malignancy, human immunodeficiency virus infection,
diabetes and treatment with corticosteroids or other
immunotherapy agents (Yen et al., 2007). In our patient,
Crohn’s disease and treatment with infliximab and
azathioprine were important risk factors to explain the
susceptibility for Salmonella sepsis. In immunocompromised patients, NTS bacteraemia mostly occurs without
gastroenteritis (Ramos et al., 1994).
Extra-intestinal Salmonella infections may occur at different sites of infection. Urosepsis due to Salmonella is a rare
disease, and there are only a few cases published in the
literature (Cohen et al., 1987; Ramos et al., 1996). In a
series of 7779 Salmonella infections reported by Saphra &
Winter (1957), 49 (0.6 %) involved the urinary tract. The
four most common serotypes among urinary infections
were Salmonella typhimurium (n516), Salmonella oranienburg (n57), Salmonella paratyphi C and Salmonella
choleraesuis (n56), and Salmonella montevideo (n53).
Treatment options usually comprise fluoroquinolones.
Third-generation cephalosporins are a reasonable treatment
alternative. There are no clinical data that suggest that
combination therapy (e.g. a fluoroquinolone plus a thirdgeneration cephalosporin) is more effective than treatment
with a single agent (Hohmann, 2001). Antimicrobial
resistance, particularly multiple drug resistance, has been
noted in several NTS and is a rising problem (Lee et al.,
1994a; Stevenson et al., 2007). Treatment with the
appropriate antimicrobial agent is crucial for patients with
invasive Salmonella infections, and the susceptibilities of
these isolates should be reported as soon as possible (Lee et
al., 1994a). Because of the severity on admission, an initial
treatment with meropenem plus vancomycin was given
according to the guidelines for treatment of sepsis (Dellinger
et al., 2004). When the results of the susceptibility testing
became available, treatment was de-escalated to ceftriaxone.
The most interesting point of the case report is the source
of infection, which remains unknown. Animal contact is an
important source of human non-typhoidal infection
(Hoelzer et al., 2011). The range of animals that harbour
Salmonella spp. is wide and even includes reptiles
(Hinshaw & McNeil, 1945). In the present case, the
organism could not be isolated from various faecal
samples. The patient did not have any pets or contact
with other animals. Before admission, he had not been
travelling abroad or visited zoos. From his work in a
museum, he had much contact with visitors, which did not
seem to be a relevant reservoir for Salmonella spp.
In conclusion, Salmonella spp. rarely cause urosepsis or
severe sepsis. However, in immunocompromised hosts,
salmonellosis may present as a severe disease. To the best of
our knowledge, this is the first case of urosepsis due to S.
enterica serovar Minnesota in a patient with Crohn’s
disease without abdominal symptoms. Therefore, extraintestinal Salmonella infections have to be taken into
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N. Steinebrunner and others
consideration in immunocompromised patients presenting
with sepsis. Immunocompromised patients should be
aware of the risk of transmission when having contact
with human carriers of Salmonella spp. or with reptiles.
Hohmann, E. L. (2001). Nontyphoidal salmonellosis. Clin Infect Dis
32, 263–269.
Lee, L. A., Puhr, N. D., Maloney, E. K., Bean, N. H. & Tauxe, R. V.
(1994a). Increase in antimicrobial-resistant Salmonella infections in
the United States, 1989–1990. J Infect Dis 170, 128–134.
Lee, S. C., Yang, P. H., Shieh, W. B. & Lasserre, R. (1994b).
Acknowledgements
We thank the National Reference Center for Salmonellae and Other
Enteric Pathogens, Robert Koch-Institut, Wernigerode, Germany, for
specification of the isolate.
Bacteremia due to non-typhi Salmonella: analysis of 64 cases and
review. Clin Infect Dis 19, 693–696.
Mandal, B. K. & Brennand, J. (1988). Bacteraemia in salmonellosis: a
15 year retrospective study from a regional infectious diseases unit.
BMJ 297, 1242–1243.
McCracken, D. A. (1954). Salmonella minnesota infection in
References
Northamptonshire. J R Sanit Inst 74, 1091–1094, discussion 1098–
1100.
Borbolla, L., Guerra Chabau, A., Prieto, E. & Valledor, T. (1956).
Ramos, J. M., Garcı́a-Corbeira, P., Aguado, J. M., Arjona, R., Alés, J. M.
& Soriano, F. (1994). Clinical significance of primary vs. secondary
[Meningitis caused by Salmonella minnesota; case report]. Rev Cubana
Pediatr 28, 611–618 (in Spanish).
Cohen, J. I., Bartlett, J. A. & Corey, G. R. (1987). Extra-intestinal
manifestations of salmonella infections. Medicine (Baltimore) 66, 349–388.
Dellinger, R. P., Carlet, J. M., Masur, H., Gerlach, H., Calandra, T.,
Cohen, J., Gea-Banacloche, J., Keh, D., Marshall, J. C. & other
authors (2004). Surviving Sepsis Campaign guidelines for manage-
ment of severe sepsis and septic shock. Crit Care Med 32, 858–873.
[Erratum: Crit Care Med (2004) 32, 1448 (dosage error in article text);
Crit Care Med (2004) 32, 2169–2170.]
Eckerle, I., Zimmermann, S., Kapaun, A. & Junghanss, T. (2010).
Salmonella enterica serovar Virchow bacteremia presenting as typhoidlike illness in an immunocompetent patient. J Clin Microbiol 48, 2643–
2644.
bacteremia due to nontyphoid Salmonella in patients without AIDS.
Clin Infect Dis 19, 777–780.
Ramos, J. M., Aguado, J. M., Garcı́a-Corbeira, P., Alés, J. M. &
Soriano, F. (1996). Clinical spectrum of urinary tract infections due
on nontyphoidal Salmonella species. Clin Infect Dis 23, 388–
390.
Saphra, I. & Winter, J. W. (1957). Clinical manifestations of
salmonellosis in man; an evaluation of 7779 human infections
identified at the New York Salmonella Center. N Engl J Med 256,
1128–1134.
Stevenson, J. E., Gay, K., Barrett, T. J., Medalla, F., Chiller, T. M. &
Angulo, F. J. (2007). Increase in nalidixic acid resistance among non-
EUCAST (2013). Clinical breakpoints. The European Committee on
Typhi Salmonella enterica isolates in the United States from 1996 to
2003. Antimicrob Agents Chemother 51, 195–197.
Antimicrobial Susceptibility Testing. http://www.eucast.org/clinical_
breakpoints%5D.
Weinberger, M., Andorn, N., Agmon, V., Cohen, D., Shohat, T. &
Pitlik, S. D. (2004). Blood invasiveness of Salmonella enterica as a
Hinshaw, W. R. & McNeil, E. (1945). Salmonella types isolated from
function of age and serotype. Epidemiol Infect 132, 1023–1028.
snakes. Am J Vet Res 6, 264–266.
Hoelzer, K., Moreno Switt, A. I. & Wiedmann, M. (2011). Animal contact
Yen, Y. F., Lin, Y. C., Chen, T. L., Chen, Y. Y., Lin, M. L., Wang, F. D. &
Liu, C. Y. (2007). Non-typhoidal Salmonella bacteremia in adults.
as a source of human non-typhoidal salmonellosis. Vet Res 42, 34.
J Microbiol Immunol Infect 40, 227–233.
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Journal of Medical Microbiology 62