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Case Reports Indian Pediatrics 2001; 38: 186-189 |
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Pleural Empyema Due to Group B Salmonella in a Child with Diarrhea |
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Salmonella species (non-typhoidal) are commonly associated with acute gastro-enteritis in children in the developing world and contribute to one of the common causes of morbidity and mortality(1). Extraintestinal infections due to these organisms are less frequently encountered, but if they are, most of them occur in immunocompromised children(1). With the advent of AIDS, the problem of disseminated infections by Salmonella species is being increasingly reported(2,3). Meningitis is the commonest form of extraintestinal salmonellosis in the immunocompetent child(4). Pleural empyema in the immunocompetent has rarely been reported (CD-ROM search of the last two decades did not reveal any). We report a case of pleural empyema due to Group B Salmonella with no obvious underlying immunodeficiency.
A 1-year-old male baby was admitted to the Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) hospital with two weeks history of high fever and cough, with diarrhea of one week duration. There was no family history of fever, diarrhea or any other recent illness. The patient was the only child of parents hailing from a poor socioeconomic background. The child’s developmental milestones were normal. On examination, the baby weighed 7 kg, appeared acutely ill with chest indrawing, with a respiratory rate of 50/min and temperature of 39° C. Diminished breath sounds were noted in the left upper lobe. There was no lymph-adenopathy or organomegally. The child had been immunized with BCG, DPT and measles vaccination in the normal schedule. Laboratory investigations revealed a hemo-globin level of 11.5 g/dl, total leukocyte count of 21,900/cu mm with 67% neutrophils, 32% lymphocytes and 1% eosinophils. An ultra-sound of the thorax revealed loculated fluid in the left upper zone. Forty mililiter of viscid purulent fluid was aspirated from the localized area. Cell count of the fluid revealed 80% polymorphonuclear leukocytes and 20% lymphocytes. Gram smear of the aspirate showed numerous gram negative rods, amidst plenty of polymorphs. Pleural fluid was subjected to culture and the patient was empirically treated with gentamicin 5 mg/kg/day in 2 divided doses, and cloxacillin 100 mg/kg/day in 4 divided doses, administered intra-venously. Intercostal tube was placed for continuous under water seal drainage for 72 h. After 24 h culture of the pus yielded Salmo-nella serogroup B, identified by its growth on MacConkey agar, production of gas from glucose, abundant H2S in Kligler iron agar, and ability to grow in Simmons citrate medium. It agglutinated with Salmonella polyvalent antiserum and O4 factor serum. The organism was sensitive to chloramphenicol, gentamicin, ciprofloxacin and cefotaxime, but was resistant to ampicillin. Blood and stool cultures did not yield the organism. Serum of the baby tested negative for both HIV-1 and HIV-2 (Innogenetics ELISA) as was the case with mother’s serum. The antibiotic regimen was modified to include cefotaxime 100 mg/kg/day in four divided doses by intravenous route and cloxacillin was discontinued after antibiogram report. Pleural aspirate was again performed on day 8 when there was no improvement in respiratory symptoms and radiological evi-dence of pus in the pleural space persisted. Collection yielded 70 ml of purulent fluid, culture of which again grew Salmonella group B with similar antibiogram as before. The antibiotic therapy however was continued on the same lines for an additional period of 8 days after which the temperature came down to normal and an ultrasound did not reveal any further fluid accumulation in the pleural space. The child was discharged home after full recovery, with no evidence of infection.
Gastroenteritis due to salmonella is common among infants and children in the developing countries(1). However, extra-intestinal infec-tion due to Salmonella have been frequently associated with septicaemia and or menin-gitis(4). In a five year study of 150 cases of non-typhoidal salmonellosis associated with diarrhea (84% of them being infants) from this hospital, septicemia occurred in 7% and meningitis in 2% of them. There was no case of pneumonia or empyema(4). Although, pleural empyema due to Salmonella has been reported from cases with HIV and other immunocompromised conditions, most of them in adults, it has rarely been encountered in immunocompetent children(5). Salmonella enteritides has been isolated from a case of empyema with underlying pulmonary tuber-culosis(6). Malignant pleural effusion infected with S. enteritides has also been docu-mented(7). Pleuropulmonary infection by Gr. E Salmonella as a consequence of leak of gastric content into the mediastinum following esophageal stricture due to corrosive acid intake has been documented(8). The organism was isolated from sputum, blood and pleural fluid. Pleuropulmonary manifestations consti-tute one of the common extra-intestinal salmonella infections(9). Respiratory involve-ment results from blood borne diffusion from mesenteric lymphnodes or by contiguous spread through fistula or leakage as seen in the two cases mentioned above(6,7). Our patient did not have any underlying immunodeficiency condition, as he was apparently healthy, without tuberculosis or seropositive for HIV. The spread of infection in this child may have been either hematogenous or transdia-phragmatic from the abdominal focus. How-ever, neither mechanism could be proved, due to a negative blood and stool culture. Primary infection in the lung parenchyma also could not be established as the ultrasound did not reveal any abnormality elsewhere in the chest. Pneumonia is uncommon, occurring in about 1% of typhoid cases(8). In our patient, as fever preceded diarrhea by a week, the primary focus of infection remains unknown, although Salmonella septicemia cannot be ruled out. It is recommended that acute diarrhea be treated only with fluid and electrolyte supplement(1). However, one of the complications that could arise, would be a spread of the offending organism from the gastrointestinal tract with consequent seeding in other organs. Aspirate from the empyema remained culture positive for upto 8 days post-therapy, thus making it necessary to bacteriologically monitor, for effective therapy. Antibiotic susceptibility is also essential, as the Salmo-nella serogroup B (especially S. typhimurium) are notorious for their plasmid mediated drug resistance, having acquired it from other enteric bacteria(1). Infection by drug resistant Salmonella is a problem typically faced by the developing countries, where, over-the-counter purchase of antibiotics is a common practice, thus leading to indiscriminate usage, resulting in emergence of resistant strains. Our case responded to third generation cephalosporin, to which the organism was susceptible in vitro. Ciprofloxacin although a potent drug to treat S. typhi infection and pleural empyema due to S. enteritides(11), was not administered to this one year old child. We recommend that Salmonella pleural empyema not only be kept in mind in patients with HIV and tuberculosis as it may signal previously unsuspected pulmonary disease, but also rarely in healthy children with history of diarrhea. Treatment needs to be instituted with appropriate antibiotic, to prevent recurrence and complica-tion, keeping in mind the potential resistant strains circulating in the community. Contributors: RK co-ordinated the case and drafted the manuscript. She will act as the guarantor for the paper. AK participated in the data collection. SS provided the clinical support. SB helped in drafting the paper.
Funding:
None.
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