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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 41-43

Salmonella enterica var. Typhi as an uncommon cause of perinephric abscess: A case report and review of literature


1 Department of Microbiology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
2 Department of Urology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India

Date of Submission26-May-2015
Date of Acceptance28-Jul-2015
Date of Web Publication9-Nov-2015

Correspondence Address:
K Sandhya Bhat
Department of Microbiology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

An adult male patient presented with a gradually worsening pain in the left-side of the loin region and on and off fever for 1-month duration. Per abdomen examination revealed fullness in the left renal angle with tenderness over the left lumbar region. His complete blood count showed a slight increase in white blood cell count. His computed tomogram (CT) scan abdomen showed left upper ureteric calculi with a hypoechoic lesion suggestive of a perinephric abscess. A percutaneous nephrostomy was done, and aspirated pus was sent for microbiological analysis, which yielded Salmonella Typhi, intermediate sensitive to ciprofloxacin and sensitive to ceftriaxone. The patient was treated with injection ceftriaxone for 10 days followed by tablet cefixime for another 2 weeks. Primary perinephric abscess due to Salmonella Typhi without any evidence of systemic involvement is rare. We report one such case, diagnosed by CT scan abdomen and culture treated successfully with a combination of surgical drainage and medical management.

Keywords: Ceftriaxone, ciprofloxacin, computed tomogram scan, perinephric abscess, Salmonella Typhi


How to cite this article:
Devi S, Bhat K S, Kanungo R, Rajan R P. Salmonella enterica var. Typhi as an uncommon cause of perinephric abscess: A case report and review of literature. J Curr Res Sci Med 2015;1:41-3

How to cite this URL:
Devi S, Bhat K S, Kanungo R, Rajan R P. Salmonella enterica var. Typhi as an uncommon cause of perinephric abscess: A case report and review of literature. J Curr Res Sci Med [serial online] 2015 [cited 2020 Jul 6];1:41-3. Available from: http://www.jcrsmed.org/text.asp?2015/1/1/41/168928


  Introduction Top


A perinephric abscess is a collection of purulent material around kidneys.[1] This may occur secondary to urinary tract obstruction or hematogenous spread from the other sites of infection such as intra-abdominal, pulmonary or wound infections, and rarely furuncles.[2] A perinephric abscess can pose a great diagnostic challenge with increased risk of morbidity and mortality. Common predisposing factors include diabetes mellitus, renal calculi, ureteral obstruction, and vesico-ureteric reflux.[3]

Escherichia coli, Proteus, Staphylococcus, and Pseudomonas are the most common etiological agents affecting both men and women equally.[1] Occasionally, the infection can occur due to Klebsiella, Enterobacter, Serratia, Citrobacter, Salmonella species, Mycobacterium tuberculosis, and Streptococcus pneumonia.[4],[5]

There are only few case reports of perinephric abscess due to Salmonella species in the literature. Kiliç et al. reported a case of left perinephric abscess caused by Salmonella Enteritidis due to colon perforation in 2003 from Turkey,[6] and Kumar et al., reported a case of primary perinephric abscess due to hydrogen sulfide producing variant of Salmonella Paratyphi A in 2011 from Kerala, India.[1]

Salmonella Typhi infection of the genitourinary system is a relatively rare event, even in endemic areas. The risk factors for genitourinary involvement include underlying structural or functional abnormalities of the urinary tract, bladder, pelvic organs, and/or systemic symptoms. Predisposing etiologies include congenital abnormalities, obstruction due to renal calculi, or pyelonephritis.[7]

Perinephric abscess should be considered in the differential diagnosis of any patient presenting with a urinary tract infection that fails to respond promptly to antibiotic therapy, particularly in those known to have anatomical abnormalities of the urinary tract or patients with diabetes mellitus.[3] The most common symptoms include fever (66–90%), flank or abdominal pain (40–50%), chills (40%), dysuria (40%), weight loss, lethargy, and gastrointestinal symptoms (25%).[8]

Increased use of computed tomogram (CT) scanning and magnetic resonance imaging has facilitated early and accurate diagnosis of this condition. Newer antibiotics such as ciprofloxacin, ceftriaxone, azithromycin have helped in appropriate treatment in the last 3 decades.[1],[9] Early recognition of perinephric abscess and prompt drainage either percutaneously or surgically in combination with appropriate antibiotic coverage, will dramatically reduce morbidity and mortality from this condition.[3]


  Case Report Top


A 40-year-old male patient presented with gradually worsening pain in the left-side of the loin region over a period of 3 months. He had on and off fever over the last 1-month. He was a known case of diabetes mellitus and hypertension, on regular medication. He had a cerebro-vascular accident 1-year back for which he was on tablet ecosprin. There was no history suggestive of any other systemic illness.

On examination, his temperature was 38°C, pulse rate was 86 beats per min, blood pressure was 126/80 mmHg, and respiratory rate was 22 breaths per min. Per abdomen examination revealed fullness in the left renal angle and left hypochondrium with tenderness over the left lumbar region. A firm to hard mass was palpable in the left hypochondrium and left the lumbar region.

Investigations revealed hemoglobin of 11.1 g/dl, total leukocyte count of 12,800/µl (polymorphs 69%, lymphocytes 20%, eosinophils 5%, and monocytes 1%), a normal platelet, and red blood cell counts. Liver and renal function tests were within normal limits and fasting blood sugar level was 139 mg/dl. Contrast-enhanced CT scan showed left upper ureteric calculi with a hypoechoic lesion suggestive of a perinephric abscess.

A percutaneous nephrostomy was done, and around 500 ml of the pus was drained. The patient was empirically started on injection piperacillintazobactam 4.5 g, twice daily and continued for 4 days. Diethylene triamine pentacaetic acid scan was done to assess the functioning of the left kidney.

Gram staining of the drained pus revealed Gram-negative bacilli with abundant polymorphonuclear leukocytes. The specimen was inoculated on standard media following overnight incubation the isolate was identified as Salmonella enterica var. Typhi by standard biochemical and serological methods.[10] Antimicrobial susceptibility by epsilometer test strip showed ciprofloxacin to be intermediate sensitive with a minimal inhibitory concentration (MIC) of 1.5 µg/ml and ceftriaxone to be sensitive with an MIC of 0.38 µg/ml. Following the culture and sensitivity report antibiotic treatment was changed to ceftriaxone 80 mg/kg/day for 10 days followed by oral cefixime 400 mg/day for another 2 weeks. Blood and urine cultures were negative. Review ultrasound of the abdomen done 7 days later showed a marked reduction in the size of the abscess. The patient improved clinically and was discharged, with advice to complete the treatment course.


  Discussion Top


Perinephric abscess accounts for 0.02% of all abdominal abscesses and is generally associated with some predisposing factors. Hematogenous dissemination from other foci of infection accounts for 30% of the cases, whereas 70% have no proven source, as was the case in our patient. Perinephric abscess due to Gram-negative bacteria commonly develops due to rupture of corticomedullary abscess or also can occur from ascending urinary tract infection.[2]

The management of perinephric abscess requires a combination of prolonged intravenous and oral antimicrobial agents course while percutaneous drainage is reserved for large abscess and if there is no clinical improvement.[1],[8] Some studies have documented that MIC of ciprofloxacin in the range of decreased susceptibility (0.125–0.5 µg/ml) have led to treatment failure.[1] Ceftriaxone, is being increasingly used to treat Salmonella infections, due to better response and less reported resistance; as was done for this patient.


  Conclusion Top


Extra-intestinal infection by Salmonella Typhi virtually can affect any organ system. Extra-intestinal complications such as localized abscesses may be considered in a person with compatible illness in the typhoid-endemic region. The duration of treatment depends on the infected organ and also on local resistance patterns of these bacteria. Treatment with third generation cephalosporins for a longer duration of 14–21 days is advisable for a perinephric abscess caused due to Salmonella Typhi. Diagnostic imaging and prompt management by percutaneous drainage in combination with appropriate antimicrobial treatment based on culture report will result in a better outcome in this clinical condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kumar A, Sanjeevan KV, Kavitha R, Dinesh P, Vinod V, Karim S. Primary perinephric abscess due to hydrogen sulfide producing variant of Salmonella Paratyphi A. J Clin Pract 2011;19:288-90.  Back to cited text no. 1
    
2.
Meng MV, Mario LA, McAninch JW. Current treatment and outcomes of perinephric abscesses. J Urol 2002;168 (4 Pt 1):1337-40.  Back to cited text no. 2
    
3.
Hutchison FN, Kaysen GA. Perinephric abscess: The missed diagnosis. Med Clin North Am 1988;72:993-1014.  Back to cited text no. 3
    
4.
Dembry LM. Renal and perinephric abscesses: Current treatment options. Infect Dis 2002;4:21-30.  Back to cited text no. 4
    
5.
D'Cruz S, Kochhar S, Chauhan S, Gupta V. Isolation of Salmonella Paratyphi A from renal abscess. Indian J Pathol Microbiol 2009;52:117-9.  Back to cited text no. 5
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6.
Kiliç S, Tevfik M, Ergin H, Baydinç C. Left perinephric abscess caused by Salmonella Enteritidis due to colon perforation. Am Urol Assoc 2003;170:1945-6.  Back to cited text no. 6
    
7.
Wickre CG, Major JL, Wolfson M. Perinephric abscess: An unusual late infectious complication of renal biopsy. Ann Clin Lab Sci 1982;12:453-4.  Back to cited text no. 7
[PUBMED]    
8.
Rai RS, Karan SC, Kayastha BA. Renal and perinephric abscesses revisited. Med J Armed Force India 2007;63:223-5.  Back to cited text no. 8
    
9.
Dalla Palma L, Pozzi-Mucelli F, Ene V. Medical treatment of renal and perirenal abscesses: CT evaluation. Clin Radiol 1999;54:792-7.  Back to cited text no. 9
    
10.
Mackie TJ, McCrtney JE. Practical Medical Microbiology. 14th ed., Ch. 21. New York: Churchill Livingstone; 1996. p. 385-402.  Back to cited text no. 10
    




 

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