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Case Reports Indian Pediatrics 2002; 39:777-779 |
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Shigella Septicemia |
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K. Saraswathi Anuradha DE Alka Jog* Alka Gogate
Shigellae are potentially known to cause diarrhea and dysentery in all age groups(1-3). Shigellemia due to S. dysenteriae, S. flexneri, S. boydii and S. sonnei has been reported from all parts of the world in children as well as in the adults(1,3-6). However, limited reports are available from India regarding septicemia due to Shigella species(2,7-9). Four cases of septicemia caused by Shigella species are reported in children admitted to L.T.M. General Hospital, Mumbai. Case Reports Case 1 : A three year old male child presented with bloody diarrhea for 5 days, associated with fever for 2 days and altered sensorium for one day. The clinical findings revealed severe dehydration with protein energy malnutrition (PEM) grade II, hypotonia and pallor. His height was 90 cm, weight was 11.5 kg and head circumference was 49 cm. Hemoglobin was 9.5 g/dL. Total leucocyte count was 6.8 × 103/µL with 60% polymorphs and 40% lymphocytes; platelet count was 32 ×103/µL. Peripheral smear showed occasional burr cells. The serum creatinine was 1.4 mg/dL and urine albumin was trace. C-reactive protein was 6 mg/L. Buffy coat smear showed gram negative bacilli. Blood and stool culture grew S. dysenteriae type 1. The isolate was sensitive to gentamicin, amikacin, norfloxacin and nalidixic acid and was resistant to amoxycillin, chlora-mphenicol, tetracycline and cotrimoxazole. The patient was treated with intravenous (IV) fluids and parenteral amplicillin and gentamicin were administered. However the patient succumbed to the infection. Case 2: A two year old female patient presented with bloody diarrhea for 4 days, and fever and abdominal pain for 2 days. On examination, she had pallor, moderate dehydration, altered sensorium and abdominal distention. Her height was 84 cm, weight was 11.1 kg and head circumference was 47.5 cm. Hemoglobin was 7.6 g/dL. Total leucocyte count was 12.6 × 103/µL with 74% polymorphs, 24% lymphocytes and 2% eosinophils. Platelet count was 48 × 103/µL. The serum creatinine was 1.8 mg/dL with trace urine albumin. C-reactive protein was > 6 mg/L. Buffy coat smear showed gram negative bacilli. Blood and stool culture grew S. flexneri type 2. The isolate was sensitive to gentamicin, amikacin, norfloxacin and nalidixic acid and was resistant to amoxycillin, chloramphenicol, tetracycline and cotrimoxazole. The patient was treated with IV fluids and parenteral gentamicin were administered, however, the patient expired. Case 3: A two month male infant was admitted with fever of 2 days duration and unconsciousness for 1 day. The child was moderately dehydrated and did not react to any stimuli. The length was 53 cm, weight was 3.4 kg and head circumference was 35.5 cm. Hemoglobin was 8.4 g/dL. Total leucocyte count was 22.4 × 103/µL with 84% polymorphs and 16% lymphocytes, platelet count was 26 × 103/µL. Peripheral smear showed 10% normoblasts with occasional burr cells. The serum creatinine was 1.2 mg/dL and urine albumin was +1. C-reactive protein was > 6 mg/L. Buffy coat smear showed gram negative bacilli. Blood and stool culture grew S. dysenteriae type 1. The isolate was sensitive to gentamicin, amikacin, norfloxacin and nalidixic acid and was resistant to amoxycillin, chloramphenicol, tetracycline and cotrimoxazole. The patient was treated with intravenous fluids and parenteral ampicillin and gentamicin. The patient did not survive. Case 4: A five month old unimmunized male infant presented with bloody diarrhea with nucus for 3 days and fever and oliguria since 1 day. The child had severe dehydration, pallor, oral candidiasis and features of early rickets. His length was 64 cm, weight was 5 kg and head circumference was 42 cm. Hemoglobin was 10.2 g/dL. Total leucocyte count was 11.4 × 103/µL with 55% polymorphs and 45% lymphocytes; platelet count was 75 × 103/µL. The serum creatinine was 0.6 mg/dL and urine albumin being +1. C-reactive protein was > 6 mg/L. Buffy coat smear showed gram negative bacilli. Blood and stool culture grew S. dysenteriae type 1. The isolate was sensitive to gentamicin, amikacin, norfloxacin and nalidixic acid and was resistant to amoxy-cillin, chloramphenical, tetracycline and cotrimoxazole. The patient was treated with intravenous fluids and parenteral amipicillin and cloxacillin were administered along with candid mouth paint. He was discharged against medical advice and was lost to follow up. Discussion Shigella septicemia as a complication of shigellosis has been reported in infants and children (1,2,4,5). Most common Shigella species implicated in cases of septicemia is S. dysenteriae type 1(1,4,8). Hematological complications with other species of Shigella can also occur, though very rare(5,7-9). S.flexneri is involved in approximately one third of total shigellaemias reported(3). We isolated S. flexneri type 2 in a two year old female child from both blood and stool samples. Thapa et al(2) had also isolated S. flexneri in a 11 month old child from blood and stool cultures. The incidence of Shigella septicemia is definitely increasing. Koshi et al(1) reported 7 cases in 10 years while Srinivasa et al(9) reported 6 cases in 3 years. We report four cases in just one year. Hemolytic uremic syndrome (HUS), a systemic complication of shigellosis, is due to hematogenous dissemination of actively multiplying bacteria releasing endotoxin(8). Cases 1,2&3 had associated HUS, creatinine levels were raised and Burr cells were seen in all (except Case 4). Shigellemia without diarrhea as observed in Case 3, has been reported earlier(9,10). Altered sensorium observed in Case 1 may be due to toxic encephalopathy. Oliguria in Case 4 may be due to the endotoxin which particularly affects the kidneys. Anuria and acute renal shut down following Shigella bacteremia has been reported(1). In our study, three of the four patients expired. Probable reason for high mortality with Shigella septicemia could be due to multi drug resistant shigella species and majority of them had an infection with S. dysenteriae type 1, most toxic of all the serotypes of Shigella. Early recognition of dysenteric illness and timely, initiation of appropriate antimicrobial cover is mandatory to avoid such life threatening situations. Contributors: KS reviewed and edited the article and will act as the guarantor for the manuscript. AD drafted and designed the article. AV co-drafted the article. AJ was involved with management of the patients. AG assisted in editing the article. Funding: None. Competing interests: None stated.
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