Pleural Empyema Due to Salmonella typhi

Abstract

Salmonella serotypes most often produce gastroenteritis, enteric fever, bacteremia, vascular infection and chronic carrier state. Localized infection may occur at any site after Salmonella bacteremia. Pulmonary involvement due to Salmonella infection is rare. Empyema occurs usually in elderly patients or in patients with underlying diseases such as diabetes mellitus, malignancy, or pulmonary disease. We report the case of an 83-year-old male diabetic patient who presented with fever, productive cough, and difficulty in swallowing. The chest radiographs revealed soft shadowing mild atelactasis and pulmonary abscess on left side. CT-guided aspiration of pus was done. Salmonella enterica serotype typhi was isolated from pus sample. Pleural empyema or abscess usually requires surgical drainage in addition to antimicrobial therapy. After complete course of antimicrobial therapy, the patient improved.

Full text

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (12): 803-805 803
INTRODUCTION
Salmonellae are gram-negative, facultatively anaerobic,
non-spore-forming bacilli. The wide spread distribution
of Salmonella in the environment, their increasing
prevalence in the global food chain, and their virulence
and adaptability result in enormous medical, public
health, and economic impact worldwide.1Specific
Salmonella serotypes most often produce characteristic
clinical manifestations that have been given the
syndrome designations gastroenteritis, enteric fever,
bacteremia and vascular infection, localized infections,
and chronic carrier state.1Localized infections develop
in approximately 5 – 10% cases with Salmonella
bacteremia, and the presentation may be delayed.1
Extra-intestinal infectious complication especially pleural
effusion or empyema due to Salmonella species, is
extremely rare. Although many cases of respiratory
involvement with Salmonella species have been
described worldwide, only few cases with respiratory
manifestations with Salmonella typhi (S. typhi) have
been reported from Turkey, India, and Pakistan.2-4
Serious respiratory complications like pleural empyema
usually occurs in elderly patients or in patients with
severe underlying diseases.
We report a case of S. typhi empyema in an 83-year-old
male diabetic patient.
CASE REPORT
An 83-year-old male patient was admitted in the
gastrointestinal ward of Ziauddin University Hospital,
Karachi, Pakistan with the complaints of fever with
rigors, productive cough and difficulty in swallowing for 1
week duration. He had experienced similar symptoms
about 3 months back, but did not seek medical advice
because the symptoms were self-resolved. The patient
was a known case of non-insulin dependent diabetes
mellitus and essential hypertension for 10 – 12 years. He
smoked 40 – 50 cigarettes per day upto 40 years
previously. He also had several episodes of pneumonia
in the past. These pneumonic episodes were diagnosed
by a general practitioner on clinical ground. He received
various antimicrobials. Names, dosages, and duration of
these antimicrobials are not known.
The examination revealed an ill-looking man who was
clinically anaemic and had signs of a left pleural effusion.
The pulse rate was 80 beats per minute, blood pressure
was 130/80 mmHg, temperature was 100°F, and there
were no signs of heart failure. Respiratory examination
revealed harsh vesicular breathing with scattered left
basal crepitations. Chest radiographs posteroanterior
and left lateral view (Figure 1) showed soft shadowing
mild atelactasis and pleural abscess on left side. Blood
samples were obtained for culture, fasting blood sugar
(FBS), complete picture, malarial parasite, urea,
creatinine, electrolytes, troponin-I. Troponin-I was done
to rule out any cardiac pathology. His sputum sample
was also taken for acid fast bacilli (AFB) smear. He was
started injection piperacillin/tazobactam 4.5 gm I/V 8
hourly and amikacin 500 mg I/V OD empirically. His
fever did not subside after 48 hours of antimicrobial
treatment. Computed tomography (CT) guided
aspiration of left parasternal lung abscess was done.
Approximately, 150 ml collection of pus was aspirated
and sent to laboratory for Gram stain, culture and
antimicrobial sensitivities, AFB smear, and cytology. His
FBS was 150 mg/dl, haemoglobin was 11.3 gm/dl, TLC
12.1 x 109/L, platelet count was 571 x 109/L; differential
leukocyte count was neutrophils 86%, lymphocytes 9%,
CASE REPORT
Pleural Empyema Due to Salmonella typhi
Faisal Iqbal Afridi1, Badar Jahan Farooqi1and Arif Hussain2
ABSTRACT
Salmonella serotypes most often produce gastroenteritis, enteric fever, bacteremia, vascular infection and chronic carrier
state. Localized infection may occur at any site after Salmonella bacteremia. Pulmonary involvement due to Salmonella
infection is rare. Empyema occurs usually in elderly patients or in patients with underlying diseases such as diabetes
mellitus, malignancy, or pulmonary disease. We report the case of an 83-year-old male diabetic patient who presented with
fever, productive cough, and difficulty in swallowing. The chest radiographs revealed soft shadowing mild atelactasis and
pulmonary abscess on left side. CT-guided aspiration of pus was done. Salmonella enterica serotype typhi was isolated
from pus sample. Pleural empyema or abscess usually requires surgical drainage in addition to antimicrobial therapy. After
complete course of antimicrobial therapy, the patient improved.
Key words: Empyema. Salmonella typhi. Pulmonary abscess. Antimicrobial therapy.
Department of Microbiology1/ Pathology2, Dr. Ziauddin
University Hospital, North Nazimabad Campus, Karachi.
Correspondence: Dr. Faisal Iqbal Afridi, A- 79/6,
Block No. 14, Gulistan-e-Jauhar, Karachi-75290.
E-mail: afridi03@hotmail.com
Received January 19, 2012; accepted April 26, 2012.

and monocytes 5%. Malarial parasite was not seen.
Blood urea was 31 mg/dl, creatinine was 0.59 mg/dl,
sodium was 136 mmol/L, potassium was 4.3 mmol/L,
and troponin-I (quantitative) was 0.23 ng/ml. His AFB
smear of sputum was negative.
Cytology report of pus sample showed evidence of acute
inflammation. AFB smear of pus sample was negative.
The pus sample was inoculated on MacConkey (Oxoid
Ltd. UK), chocolate (Oxoid Ltd. UK), sheep blood agar
(Oxoid Ltd. UK), and cooked meat broth (Oxoid Ltd. UK).
All these plates and cooked meat broth were incubated
at 37ºC aerobically for 24 hours. After overnight
incubation, the sample from the bottom of the cooked
meat broth was inoculated on anaerobic sheep blood
agar (Oxoid Ltd. UK) plate. This inoculated anaerobic
sheep blood agar plate was further incubated
anaerobically for 48 hours. Gram stain of pus showed
numerous pus cells and occasional Gram negative rods.
After overnight incubation, the blood culture broth
sample was subcultured on chocolate and MacConkey
agar and incubated at 37°C aerobically for 24 hours.
Blood culture yielded no growth after 7 days of
incubation at 37°C. Culture of pus sample yielded
pure growth of non-lactose fermenting colonies on
MacConkey agar (Figure 2). The chocolate and sheep
blood agar plates also showed pure growth of greyish
mucoid colonies. They were Gram negative rods,
catalase positive, oxidase negative, and were motile.
The organism was tested biochemically using API 20E
(bioMerieux). Antimicrobial susceptibility testing was
carried out on the Mueller-Hinton agar (Oxoid Ltd. UK)
using Clinical Laboratory Standard Institute criteria.5The
antimicrobials tested were ampicillin 10 µg (Oxoid Ltd.
UK), chloramphenicol 30 µg (Oxoid Ltd. UK), co-
trimoxazole 25 µg (Oxoid Ltd. UK), ceftriaxone 30 µg
(Oxoid Ltd. UK), cefixime 5 µg (Oxoid Ltd. UK), and
ciprofloxacin 5 µg (Oxoid Ltd. UK). Escherichia coli
American type culture collection (ATCC®) 25922 used as
control. Next day, the organism was identified as S. typhi
(Figure 3). This was confirmed by type specific antisera
(Bact-Med Diagnostics, Depto Lab Pakistan). Anaerobe
was not isolated from this pus sample after 48 hours of
incubation. The organism was sensitive to ampicillin,
chloramphenicol, co-trimoxazole, ceftriaxone and
cefixime while being resistant to ciprofloxacin. After the
sensitivity report was available, injection piperacillin/
tazobactam and amikacin were stopped and injection
ceftriaxone 1 gm I/V 12 hourly was started for 7 days
along with supportive therapy. After 48 hours of
treatment the patient was afebrile. The patient was
discharged after 7 days on oral cefixime 400 mg 12
hourly for another 2 weeks. At the end of complete 3
weeks of antimicrobial treatment, the patient remained
asymptomatic and afebrile.
DISCUSSION
The most common clinical presentation of Salmonella
infection is acute enterocolitis, but Salmonella can cause
fever, sustained bacteremia, and even extraintestinal
infectious complications like pneumonia without
gastrointestinal manifestations.6The pathogenesis of
extra-intestinal infectious complications of typhoid fever
depends on the ingested inoculum size, virulence of the
strain, host's immune response, previous exposure, and
local protective factors.7
Localized infection may occur at any site after
Salmonella bacteremia. Localized infection has been
reported in the thyroid, meninges, bone, heart, lungs,
Faisal Iqbal Afridi, Badar Jahan Farooqi and Arif Hussain
804 Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (12): 803-805
Figure 1: Posteroanterior and left lateral chest radiographs showing soft
shadowing mild atelactasis and pleural abscess on left side.
Figure 2: Non-lactose fermenting colonies on MacConkey agar.
Figure 3: Biochemical reactions of Salmonella typhi with API 20E strip.

adrenals, pancreas, spleen, liver, testes, pericardium,
soft tissues, areas of necrosis or infarction, benign or
malignant tumours and cysts.8Pneumonia, empyema,
and bronchopleural fistulas caused by S. typhi occur in
1 – 6% of cases.7Saphra et al. reported 85 cases of
pleural empyema with Salmonella species accounting
for 1% of all cases of Salmonellosis.9Thereafter, pleural
empyema due to Salmonella species especially due to
S. typhi has rarely been reported. To our knowledge,
only one case of lung hydatid cyst infected with S. typhi
was reported from Pakistan.4Although few cases due to
S. typhi infection with respiratory involvement has been
reported from India.3,10
Pneumonia or empyema, the predominant types of
serious respiratory disease occurs usually in elderly
patients or in patients with underlying diseases such as
diabetes mellitus, malignancy, or pulmonary disease.
These underlying diseases like diabetes mellitus
decreases the immune status of the host and may result
in the localization of Salmonella empyema as a
consequence of an inapparent Salmonella bacteremia.
We could not explain whether pleural empyema was
initial focus. Bacteremia might have occurred and then
Salmonella settled in lung tissues. However, his blood
culture was sterile, probably due to prior treatment with
antimicrobials for the episodes of pneumonia before
admission. As our patient also had several episodes of
pneumonia before admission, it is possible that these
may have predisposed to the development of empyema.
In addition to this, the patient's glycemic control is not
very good as indicated by his FBS report. Due to poor
immune status, the organism which may have already
settled in pleural cavity got the chance to multiply and
produce symptoms.
The diagnosis of the localized Salmonella infection can
be confirmed by the culture of specimens that are
normally sterile, such as blood, and pleural fluid on
ordinary microbiological media. The presence of
Salmonella in sputum does not necessarily imply lower
respiratory tract infection because S. typhi may colonize
the upper respiratory tract.8
Pleural empyema or abscess usually requires surgical
drainage in addition to antimicrobial therapy. The
recommended therapy for pulmonary manifestations
caused by S. typhi is ceftriaxone or fluoroquinolones for
14 – 21 days.7Alternate therapy for susceptible strains
is co-trimoxazole, ampicillin, or chloramphenicol for
14 – 21 days.7This S. typhi isolate is sensitive to all first
line agents but was resistant to ciprofloxacin. This
indicates the non-judicious use of fluoroquinolones in
the setup.
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Pleural empyema due to Salmonella typhi
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