- Email: [email protected]
A rare case of Salmonella typhi meningitis in a two-month-old infant: A case report
p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 4 ) 1 e2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pid
Case Report
A rare case of Salmonella typhi meningitis in a two-month-old infant: A case report J. Dinesh Kumar a,*, Padmanabhan Ramachandran b, S. Saji James c, P. Subbarao a, T. Kishore Kumar d a
Assistant Professor, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India Professor, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India c Associate Professor, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India d Junior Resident, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India b
article info
abstract
Article history:
Salmonella typhi as a cause of bacterial meningitis in infants is extremely rare. A two-
Received 12 April 2013
month-old child presented with clinical features of sepsis. Diagnosis of Salmonella typhi
Accepted 17 March 2014
meningitis was established based on CSF findings and blood culture. Child was treated
Available online xxx
with intravenous antibiotics for 6 weeks with good improvement. Child was also followed up for 1 year and was found to be doing well without any sequelae. The importance of
Keywords:
bacteriological diagnosis and prolonged antibiotic treatment for S. typhi meningitis is dis-
Salmonella typhi
cussed. High case fatality and serious neurological sequelae following S. typhi meningitis
Meningitis
are also highlighted. Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights
Infants
reserved.
1.
Introduction
Salmonella typhi is a rare cause of bacterial meningitis in infants accounting for 1% or less of cases. It has high morbidity and mortality rate and having greater potential for relapse when not treated with adequate and appropriate antibiotics.1 A wide variety of antibiotics have been used in the treatment of S. typhi meningitis with varying degrees of success. We report a 2-month-old child treated for S. typhi meningitis.
1.1.
Case presentation
A 2-month-old male infant was referred to our tertiary care hospital with history of fever for 2 days and vomiting, poor oral
intake and reduced activity for 1 day. There was no history of cough, jaundice, rashes, or ear discharge. Physical examination revealed a well-nourished infant with a temperature of 38 C. Feeding history revealed breast feeding and starting of bottle feeds 3 weeks ago. Cardiovascular and respiratory systems were normal. The liver was tipped and spleen was not enlarged. Suspecting sepsis, the child was started on intravenous ceftriaxone after taking the blood cultures. After stabilizing the child, lumbar puncture done on day 2 of admission showed turbid cerebrospinal fluid (CSF) with a glucose level of 33 mg/dl (Corresponding blood sugar 98 mg/dl) and a total white cell count of 25 cells mm.3 Protein was 205 mg/dl. CSF culture was sterile. Blood culture grew S. typhi susceptible to ceftriaxone. Urine culture was sterile. Hematological studies showed the white cell
* Corresponding author. Tel.: þ91 9841111009 (mobile). E-mail address: [email protected] (J. Dinesh Kumar). http://dx.doi.org/10.1016/j.pid.2014.03.004 2212-8328/Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved.
Please cite this article in press as: Dinesh Kumar J, et al., A rare case of Salmonella typhi meningitis in a two-month-old infant: A case report, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2014.03.004
2
p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 4 ) 1 e2
count to be 4830/mm3 with 68% neutrophils, 29%lymphocytes and 2.5% monocytes. On admission, the patient was commenced empirically on ceftriaxone given intravenously at 12-hourly intervals. The activity and oral intake of the child improved. A diagnosis of acute bacterial meningitis due to S. typhi was made on CSF findings and blood culture. Blood culture repeated after 7 days of Intravenous ceftriaxone yielded no growth. A lumbar puncture done after 14 days of intravenous antibiotics showed sugars of 45 mg/dl (corresponding blood sugar 96 mg/dl) and protein of 108 mg/dl. Intravenous antibiotics were continued for 6 weeks. Lumbar puncture done at the end of 6 weeks of treatment showed protein of 85 mg/dl and sugar of 55 mg/dl (corresponding blood sugar 90 mg/dl). CT brain was done, which was normal. Hearing evaluation by BERA was normal. Serial monitoring of the head circumference was done during the hospital stay which did not show any hydrocephalus. The infant was in our follow-up for 1 year. The infant recovered completely without any neurological deficit or sequelae and had normal developmental milestones.
2.
In a study of 5 cases, all aged below 6 months with salmonella meningitis treatment was given with Cefotaxime for 4 weeks. The results were mortality in two cases, CNS sequelae in two cases and one child recovered and was doing well with 6 months follow-up.6 There are several possible reasons for the high mortality and neurological damage. Salmonella is a facultative intracellular micro organism hence inadequate drug penetration may result in progression of infection.7 There are no clear guidelines for the management of S. typhi meningitis in infants. In our case we treated with intravenous ceftriaxone for 6 weeks based on the available guidelines suggesting a minimum of 4 weeks antibiotics. The child was followed up for 1 year and the child is free from any sequelae. In conclusion, S. typhi meningitis particularly in infancy remains a devastating disease with high mortality and a high prevalence of neurological damage. A definitive diagnosis was made possible because of blood culture prior to antibiotics though we could not do an LP before antibiotics. Without a definitive diagnosis of S. typhi meningitis we might have administered empiric antibiotics for only 2 weeks raising the risk of neurological sequelae and relapse.
Discussion
S. typhi meningitis was diagnosed based on CSF findings and blood culture as per WHO criteria.2 Salmonella meningitis accounts for a very small proportion of all bacterial meningitis. The serotypes commonly encountered include Salmonella typhimurium, Salmonella paratyphi B and S. typhi.3 Salmonella species are ubiquitous human and animal pathogens. They are motile, non-encapsulated Gram negative bacilli of the Enterobacteriaceae family. Infection is almost always by the feco-oral route. Salmonella spp., after invading the blood stream, have a unique capability of disseminating to cause a suppurative focus in almost any organ, most commonly bones and meninges. Focal infections including brain abscess and empyema have been reported.3 S. typhi meningitis differs considerably from other cases of pyogenic meningitis in children as 50e75% of cases occur in the first four months of life. The disease is characterized by a high incidence of complications, especially in neonates. Acute hydrocephalus, seizures, ventriculitis, abscesses, subdural empyema and long term neurological sequelae are known to occur in most cases.4 Antibiotics used for the treatment of Salmonella meningitis in children have not been as successful as those used to treat Escherichia. coli meningitis. The American academy of pediatrics now recommends that treatment for salmonella meningitis with cefotaxime or ceftriaxone should continue often for 4 weeks or more, although relapses have been reported with the use of cefotaxime therapy even with 4 weeks of treatment.1 Some others have recommended that salmonella meningitis should be treated with a third generation cephalosporin and the therapy should be prolonged for a minimum of three weeks.5
Conflicts of interest All authors have none to declare.
references
1. Pricea Elizabeth H, de Louvoisb John, rella workmanc M. Antibiotics for salmonella meningitis in children. J Antimicrob Chemother. 2000;46(5):653e655. 2. WHO/V&B/03.01. Immunization Surveillance, Assessment and Monitoring. WHO-Recommended Surveillance Standards for Surveillance of Selected Vaccine-Preventable Diseases. February 2003:4e10. 3. Nwadike VU, Fowotade A, Tuta KE, Olusanya OO. A rare case of Salmonella typhi meningitis in an eleven month old infant-case report. Ann Ibadan Postgrad Med. 2012;10(1):38e39. 4. Wu HM, Huang YW, Lee LM, Yang AD, Chaou KP, Hsieh LY. Clinical features, acute complications, and outcome of Salmonella meningitis in children under one year of age in Taiwan. BMC Infect. 2011;11:30. 5. Cooke FJ, Ginwalla S, Hampton MD, et al. Neonatal report of neonatal meningitis due to Salmonella enterica serotype Agona and review of breast milk-associated Salmonella infections. Clin Microbiol. 2009;47:30e45. 6. Abuekteish F, Daoud AS, Massadeh H, Rawashdeh M. Salmonella typhi meningitis in infants. Indian J Pediatr. 1996;33:1037e1039. 7. Kinsella TR, Yoger R, Shulman ST. Treatment of salmonella meningitis and brain abscess with the new cephalosporins: two case reports and a review of literature. Pediatr Infect Dis J. 1987;6:476e480.
Please cite this article in press as: Dinesh Kumar J, et al., A rare case of Salmonella typhi meningitis in a two-month-old infant: A case report, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2014.03.004
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pid
Case Report
A rare case of Salmonella typhi meningitis in a two-month-old infant: A case report J. Dinesh Kumar a,*, Padmanabhan Ramachandran b, S. Saji James c, P. Subbarao a, T. Kishore Kumar d a
Assistant Professor, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India Professor, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India c Associate Professor, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India d Junior Resident, Department of Pediatrics, Sri Ramachandra University, Chennai, Tamil Nadu 600116, India b
article info
abstract
Article history:
Salmonella typhi as a cause of bacterial meningitis in infants is extremely rare. A two-
Received 12 April 2013
month-old child presented with clinical features of sepsis. Diagnosis of Salmonella typhi
Accepted 17 March 2014
meningitis was established based on CSF findings and blood culture. Child was treated
Available online xxx
with intravenous antibiotics for 6 weeks with good improvement. Child was also followed up for 1 year and was found to be doing well without any sequelae. The importance of
Keywords:
bacteriological diagnosis and prolonged antibiotic treatment for S. typhi meningitis is dis-
Salmonella typhi
cussed. High case fatality and serious neurological sequelae following S. typhi meningitis
Meningitis
are also highlighted. Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights
Infants
reserved.
1.
Introduction
Salmonella typhi is a rare cause of bacterial meningitis in infants accounting for 1% or less of cases. It has high morbidity and mortality rate and having greater potential for relapse when not treated with adequate and appropriate antibiotics.1 A wide variety of antibiotics have been used in the treatment of S. typhi meningitis with varying degrees of success. We report a 2-month-old child treated for S. typhi meningitis.
1.1.
Case presentation
A 2-month-old male infant was referred to our tertiary care hospital with history of fever for 2 days and vomiting, poor oral
intake and reduced activity for 1 day. There was no history of cough, jaundice, rashes, or ear discharge. Physical examination revealed a well-nourished infant with a temperature of 38 C. Feeding history revealed breast feeding and starting of bottle feeds 3 weeks ago. Cardiovascular and respiratory systems were normal. The liver was tipped and spleen was not enlarged. Suspecting sepsis, the child was started on intravenous ceftriaxone after taking the blood cultures. After stabilizing the child, lumbar puncture done on day 2 of admission showed turbid cerebrospinal fluid (CSF) with a glucose level of 33 mg/dl (Corresponding blood sugar 98 mg/dl) and a total white cell count of 25 cells mm.3 Protein was 205 mg/dl. CSF culture was sterile. Blood culture grew S. typhi susceptible to ceftriaxone. Urine culture was sterile. Hematological studies showed the white cell
* Corresponding author. Tel.: þ91 9841111009 (mobile). E-mail address: [email protected] (J. Dinesh Kumar). http://dx.doi.org/10.1016/j.pid.2014.03.004 2212-8328/Copyright ª 2014, Indian Academy of Pediatrics, Infectious Disease Chapter. All rights reserved.
Please cite this article in press as: Dinesh Kumar J, et al., A rare case of Salmonella typhi meningitis in a two-month-old infant: A case report, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2014.03.004
2
p e d i a t r i c i n f e c t i o u s d i s e a s e x x x ( 2 0 1 4 ) 1 e2
count to be 4830/mm3 with 68% neutrophils, 29%lymphocytes and 2.5% monocytes. On admission, the patient was commenced empirically on ceftriaxone given intravenously at 12-hourly intervals. The activity and oral intake of the child improved. A diagnosis of acute bacterial meningitis due to S. typhi was made on CSF findings and blood culture. Blood culture repeated after 7 days of Intravenous ceftriaxone yielded no growth. A lumbar puncture done after 14 days of intravenous antibiotics showed sugars of 45 mg/dl (corresponding blood sugar 96 mg/dl) and protein of 108 mg/dl. Intravenous antibiotics were continued for 6 weeks. Lumbar puncture done at the end of 6 weeks of treatment showed protein of 85 mg/dl and sugar of 55 mg/dl (corresponding blood sugar 90 mg/dl). CT brain was done, which was normal. Hearing evaluation by BERA was normal. Serial monitoring of the head circumference was done during the hospital stay which did not show any hydrocephalus. The infant was in our follow-up for 1 year. The infant recovered completely without any neurological deficit or sequelae and had normal developmental milestones.
2.
In a study of 5 cases, all aged below 6 months with salmonella meningitis treatment was given with Cefotaxime for 4 weeks. The results were mortality in two cases, CNS sequelae in two cases and one child recovered and was doing well with 6 months follow-up.6 There are several possible reasons for the high mortality and neurological damage. Salmonella is a facultative intracellular micro organism hence inadequate drug penetration may result in progression of infection.7 There are no clear guidelines for the management of S. typhi meningitis in infants. In our case we treated with intravenous ceftriaxone for 6 weeks based on the available guidelines suggesting a minimum of 4 weeks antibiotics. The child was followed up for 1 year and the child is free from any sequelae. In conclusion, S. typhi meningitis particularly in infancy remains a devastating disease with high mortality and a high prevalence of neurological damage. A definitive diagnosis was made possible because of blood culture prior to antibiotics though we could not do an LP before antibiotics. Without a definitive diagnosis of S. typhi meningitis we might have administered empiric antibiotics for only 2 weeks raising the risk of neurological sequelae and relapse.
Discussion
S. typhi meningitis was diagnosed based on CSF findings and blood culture as per WHO criteria.2 Salmonella meningitis accounts for a very small proportion of all bacterial meningitis. The serotypes commonly encountered include Salmonella typhimurium, Salmonella paratyphi B and S. typhi.3 Salmonella species are ubiquitous human and animal pathogens. They are motile, non-encapsulated Gram negative bacilli of the Enterobacteriaceae family. Infection is almost always by the feco-oral route. Salmonella spp., after invading the blood stream, have a unique capability of disseminating to cause a suppurative focus in almost any organ, most commonly bones and meninges. Focal infections including brain abscess and empyema have been reported.3 S. typhi meningitis differs considerably from other cases of pyogenic meningitis in children as 50e75% of cases occur in the first four months of life. The disease is characterized by a high incidence of complications, especially in neonates. Acute hydrocephalus, seizures, ventriculitis, abscesses, subdural empyema and long term neurological sequelae are known to occur in most cases.4 Antibiotics used for the treatment of Salmonella meningitis in children have not been as successful as those used to treat Escherichia. coli meningitis. The American academy of pediatrics now recommends that treatment for salmonella meningitis with cefotaxime or ceftriaxone should continue often for 4 weeks or more, although relapses have been reported with the use of cefotaxime therapy even with 4 weeks of treatment.1 Some others have recommended that salmonella meningitis should be treated with a third generation cephalosporin and the therapy should be prolonged for a minimum of three weeks.5
Conflicts of interest All authors have none to declare.
references
1. Pricea Elizabeth H, de Louvoisb John, rella workmanc M. Antibiotics for salmonella meningitis in children. J Antimicrob Chemother. 2000;46(5):653e655. 2. WHO/V&B/03.01. Immunization Surveillance, Assessment and Monitoring. WHO-Recommended Surveillance Standards for Surveillance of Selected Vaccine-Preventable Diseases. February 2003:4e10. 3. Nwadike VU, Fowotade A, Tuta KE, Olusanya OO. A rare case of Salmonella typhi meningitis in an eleven month old infant-case report. Ann Ibadan Postgrad Med. 2012;10(1):38e39. 4. Wu HM, Huang YW, Lee LM, Yang AD, Chaou KP, Hsieh LY. Clinical features, acute complications, and outcome of Salmonella meningitis in children under one year of age in Taiwan. BMC Infect. 2011;11:30. 5. Cooke FJ, Ginwalla S, Hampton MD, et al. Neonatal report of neonatal meningitis due to Salmonella enterica serotype Agona and review of breast milk-associated Salmonella infections. Clin Microbiol. 2009;47:30e45. 6. Abuekteish F, Daoud AS, Massadeh H, Rawashdeh M. Salmonella typhi meningitis in infants. Indian J Pediatr. 1996;33:1037e1039. 7. Kinsella TR, Yoger R, Shulman ST. Treatment of salmonella meningitis and brain abscess with the new cephalosporins: two case reports and a review of literature. Pediatr Infect Dis J. 1987;6:476e480.
Please cite this article in press as: Dinesh Kumar J, et al., A rare case of Salmonella typhi meningitis in a two-month-old infant: A case report, Pediatric Infectious Disease (2014), http://dx.doi.org/10.1016/j.pid.2014.03.004