Indian Journal of Medical Sciences Medknow Publications on behalf of Indian Journal of Medical Sciences Trust ISSN: 0019-5359 EISSN: 1998-3654 Vol. 58, Num. 4, 2004, pp. 161-162

Indian Journal of Medical Science Vol. 58 No. 4, April 2004 , pp. 161-162

Letter to Editor

Salmonella enterica serotype paratyphi A induced acute diarrhea

Pawan Maheshwari, Sunil Gupta,* Subhash C Arya, Shashi Khare,* Shiv Lal^*

Sant Parmanand Hospital, 18 Alipore Road, Delhi - 110054, India; *National Institute of Communicable Diseases, Delhi. E-mail: subhashji@hotmail.com

Code Number: ms04027

Sir,

Infections with Salmonella enterica serotype paratyphi A are occasionally associated with acute renal failure,¹ and diarrhea.² We encountered a case of Salmonella enterica serotype paratyphi A induced acute diarrhea in a 45-year male in the Indian capital metropolis of New Delhi.

A 45-year-male was suffering from high-grade fever with shivering and temperature reaching 105⁰F for the past three days, nausea and loose watery stools for three days. On admission, his pulse was 96/minute, blood pressure 100/60 mmHg and temperature, of 99⁰F. He had vague tenderness in abdomen and there was no radiological abnormality in the chest.

Examination of the loose stool showed mucus but no blood. Microscopic examination showed 25-35 pus cells per high power field but no erythrocytes, cysts, or parasitic ova. Culture of the stool of MacConkey and Desoxyxcholate citrate medium showed pure growth of one type of non-lactose fermenting colonies. Gram staining showed Gram-negative bacill.

Isolate was characterized by biochemical and serological tests. Slide agglutination with typing antisera (Central Research Institute, Kasauli) produced a profile of O: 2,H: a. The isolate was sensitive to ampicillin, ampicillin-sulbactam, amoxicillin-clavulanic acid , tetracycline, chloramphenicol, gentamicin, ofloxacin, amikacin, erythromycin, ciprofloxacin, pefloxacin, and gatifloxacin. The patient received intravenous fluids, metronizadole, pentaprazole, hydrocortisone and gatifloxacin intravenous. The response was remarkable and he was discharged with gatifloxacin for a further period of four days. He was lost for a subsequent evaluation.

In southeast Asian countries, Salmonella paratyphi A is not regarded as all that common enteric pathogen associated with acute diarrhea.³ Nevertheless, Salmonella paratyphi A has been associated with replication at unusual locations. For example, it had caused multiple liver abscesses in a 28-year-old male patient. The imaging studies revealed multiple liver abscesses and an ultrasound (US) guided aspiration of the abscess yielded heavy growth of Salmonella paratyphi A.⁴ Salmonella enterica serotype paratyphi A was also isolated from the urine of a 37-year-old Saudi patient who was a known case of nephrolithiasis and hydronephrosis with frequent admission for management of renal stones.⁵

Current affliction of a 45-year-old male with acute diarrhea with pure bacterial growth in the stool on the fourth day of illness is intriguing. The patient might have been labeled as an inflammatory bowel disease had it not been for the stool culture. There would be no chance of a Salmonella enterica serotype paratyphi A diagnosis. The patient responded well to one of the quinolones. Identification of the offending microbe and antibiotic therapy were effective in control of the acute enteritis. Serum could not be tested by Widal test for quantification of antibodies to different salmonella antigens associated with Salmonella typhi, S. paratyphi A. or S. paratyphi B.

Right now multidrug resistance among Salmonella paratyphi A isolates would not appear to be all that frequent in developing countries in Asia.⁴ In all probability, considerable period would elapse before one could expect an ideal environmental sanitation in typhoid-paratyphoid endemic area. Prophylactic vaccines could address the scourge of enteric fevers. Prophylactic vaccines were available against Salmonella typhi, paratyphi A and paratyphi B. Constant exclusion of the paratyphoid A, B and C components from the recent typhoid vaccines is most unfortunate. Such a combined immunization agent would address a wide range of Salmonella induced enteric fever and unusual manifestations at other sites.^1,2

ACKNOWLEDGEMENTS

The technical assistance by Ms Seema George, Mr. Paras Ram Joshi, Ms Kamini Singh and Ms Shirley Joseph is acknowledged.

REFERENCES

1. Nakaya Y, Shiato S, Sakamoto K, Iwase A, Aoki S, Matsuoka R, et al. Double infection with Giardia lamblia and Salmonella paratyphi A associated with acute renal failure. Intern Med 1998;37:489-92.
2. Sakamato M, Adachi T, Sagara H, Kawata K, Itoh A, Izeki M. A case of imported paratyphoid fever associated with Giardia lamblia and Isospora belli infection. Kansenshogaku Zasshi 1998;72: 1317-20.
3. Tjaniadi P, Lesmanaubekti D, Subekti D, Machpud N, Komalarini S, Santoso W, et al. Antimicrobial resistance of bacterial pathogens associated with diarrheal patients in Indonesia. Am J Trop Med Hyg 2003;68:666-70.
4. Rajagopal A, Ramasamy R, Mahendran G, Thomas M. Hepatic abscess complicating paratyphoid infection. Trop Gastroenterol 2002;23:181-2.
5. Al-Otaibi FE. Isolation of Salmonella paratyphi A from a patient with nephrolithiases. Saudi Med J 2003;24:406-8.

Copyright by The Indian Journal of Medical Sciences