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Indian Journal of Medical Microbiology, Vol. 23, No. 1, January-March, 2005, pp. 66-67 Correspondence Neonatal septic arthritis due to Salmonella typhimurium Sarguna P, Lakshmi V Department of Microbiology, Nizams Institute of Medical
Sciences, Panjagutta, Hyderabad - 500 082, AP Code Number: mb05017 Dear Editor, Salmonella infection is endemic in developing countries. Isolation of Salmonella species from aberrant sites with variety of clinical syndromes, where they are hardly expected, has been reported.[1] Septic arthritis and osteomyelitis are uncommon due to this organism, compared to other gram negative bacteria. They are usually associated with underlying disease including haemoglobinopathies, previous joint trauma, surgery, connective tissue diseases, lymphoma or immunosuppressive state.[2],[3],[4],[5] Arthritis usually involves large joints such as hip, knee, ankle and shoulder.[2] S.choleraesuis, S.typhimurium[3] and S. enteritidis[4] have a high arthritogenic potential. We report this case of septic arthritis of left knee joint caused by S.typhimurium in a neonate. A 15-day-old male neonate, with a history of full term normal institutional delivery, diagnosed to have a patent ductus arteriosus, was admitted in our institute with complaints of fever and swelling of left knee since one week. There was no history of trauma of any kind. On examination, the swelling was soft, fluctuating, painful, tender with increased local temperature and restricted movements. A provisional diagnosis of septic arthritis of left knee with septicaemia with patent ductus arteriosus with congestive heart failure was made. All the vital parameters and peripheral blood picture were within normal limits, except for a low haemoglobin percentage of 6.2 gm%. With the clinical suspicion of septic arthritis of the knee joint, the synovial fluid was aspirated from the joint and sent for microbiological evaluation. A Gram stained smear of the purulent synovial fluid showed plenty of polymorphonuclear cells and gram negative bacilli. The synovial fluid was inoculated onto blood agar, MacConkey agar, Lowenstein Jensen medium and Sabouraud dextrose agar (SDA). Lactose fermenting and non-lactose fermenting colonies were observed on MacConkey agar after 24 hours incubation at 37°C. Biochemical tests confirmed the isolation of Klebsiella pneumoniae and Salmonella spp. The Salmonella isolate was sent for confirmation and serotyping to National Salmonella and Escherichia reference centre, Kasuali, Himachal Pradesh, India. It was identified as S.typhimurim 4, 5 12:i:1,2. The isolate was sensitive to ciprofloxacin and norfloxacin with resistance to third generation cephalosporins, aminoglycosides, ampicillin, chloramphenicol and co-trimonazole. No Mycobacterium or fungus was isolated. Blood culture was sterile and Widal test did not show any diagnostic titre. The patient was started on intravenous cefotaxime and metronidazole before the culture result was available. Arthrocentesis was done. On postoperative follow up, active movements were elicited, on stimulation showing a clinical improvement. The patient was treated for a week and was discharged. S.choleraesuis and S.typhimurium are the most commonly reported strains causing arthritis.[3],[4] The joint aspirate culture yielded S.typhimurium along with K.pneumoniae, the most important causative organisms of septic arthritis in infants.[1] Synovial fluid gram stained smears have been reported to be positive in two-thirds of the cases.[5] Salmonella has been isolated from blood in 65% of cases.[2] The combination of blood culture and joint aspirate culture results in very high rate (72%) of bacterial isolation. In this case, the blood culture was sterile probably because the patient was on prior antibiotic therapy. Two to four weeks of appropriate intravenous antibiotics and repeated arthrocentesis result in good clinical outcome in most cases of Salmonella septic arthritis. Surgical drainage is indicated only in cases with inadequate aspirations. To conclude, where enteric infections with Salmonella are endemic, bacteraemia could occur in immunosupressed individuals or in children with congenital disease in whom the infection has a tendency to spread haematogenously to the larger joint metaphysis which is one of the most commonly affected sites.[3] S.typhimurium being invasive, should be added to the spectrum of potential list of pathogen that cause septic arthritis in immunosuppressed state.[3] REFERENCES
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