Hydatid disease of the liver complicated by salmonellosis

674 TRANSACTIONS OFTHEROYALSOCIETYOF TROPICALMEDICINE ANDHYGIENE(1993) 87, 674-675

1Short Report 1 Hydatid disease of the liver complicated by salmonellosis David Sadhul, Booshanam V. Moses], Ranjit John* and M. K. Lalitha** ‘Department of Surgery Unit 3 and *Department of Microbiology, Christian Medical College Hospital, Vellore, 632004, South India Salmonella SKI. are resnonsible for a wide range of infections, both & primary-and secondary aetiolo$cal factors (COHEN et al.. 1987). Salmonellosis comnlicating hvdatid disease of tge liver is exceedingly rare ~HERB&&N et al., 1959; MATOSSIAN & NAJJAR, 1968; SITARAM et al., 1990). Secondary infection of hydatid cysts is associated with increased morbidity and mortality despite the tremendous advances made in antimicrobial therapy. We report a case of salmonellosis complicating hydatid disease of the liver and review the literature on the combined presence of these 2 infectious entities. Case Report A 19 year old woman was admitted in August 1991 to Surgery Unit 3 at the Christian Medical College Hospital, Vellore, South India with pain in the right upper abdomen of 3 months duration. There was no other presenting complaint. Abdominal examination demonstrated marked tenderness in the right hypochondrium. There was no hepatosplenomegaly. Systemic examination was normal. Laboratory investigation results included: haemoglobin 11.5 g%, erythrocyte sedimentation rate 94 mm (1 h), total white blood cell count 12 000/mm3 with a differential count of 82% polymorphonuclear cells and 18% lymphocytes. A chest X-ray showed an irregular calcific density within the liver shadow. Ultrasonography of the abdomen revealed a focal lesion 7 x 7 cm in size in the postero-inferior part of the right lobe of the liver. Areas of calcification were seen, together with hypo-echoic areas. Based on the clinical and radiological findings, a diagnosis of hvdatid disease of the liver was made. Laparoiomy revealed a large hydatid cyst in the postero-inferior aspect of the right lobe of the liver. Other abdominal viscera were normal. Purulent fluid was aspirated from the cyst following which 40 mL of 0.5% cetrimide were injected into the cvst. The hvdatid cyst was then excised. Bacteriological examination of the aspirate showed manv pus cells and few Gram-negative bacilli. Culture grew Shlmonella typhi which was s&ceptible to chloramnhenicol and co-trimoxazole. The Widal test results here: anti-o, +20; anti-H, +40 (others negative). The patient was treated with chloramphenicol and albendazole. She had an uneventful recovery and was discharged on the seventh post-operative day. Discussion Salmonella spp. have been well recognized as causative agents of several unusual infections, especially in endemic areas. They have been reported to be primary aetiological agents in infections such as abdominal abscess, soft tissue infections, arthritis, pericarditis, and meningitis. Salmonella is also responsible for causing secondary infections in pre-existing sites of pathological and microbiological disease; these include aneurysms, cholelithiasis, arthritic joints, amoebic abscess, urolithiasis, malignancy, and various cystic diseases (COHEN et al., 1987). *Author for correspondence.

In areas endemic for sahnonellosis, these agents should always be considered for both primary and secondary infections. Failure to recognize and treat such infections may result in prolonged morbidity in surgical patients. The incidence of sunnurative infection in hvdatid disease of the liver is repdried to be S-37% (PAPA~)IMITRIOU & MANDREKAS, 1970;. AL-HASHIMI, .1971; LANGER, 1984). Secondarv infectlons of hvdatid cvsts are associated ‘with increased morbidity anh mortality. It is essential to treat these infections with appropriate antibiotics. The common organisms causing secondary infection in hydatid disease are Escherichia coli, staphylococci and streptococci (MATOSSIAN & NAJJAR, 1968). There have been 4 previous reports of salmonellosis complicating an intact hydatid cyst (Table). The most likely source of Table.

Salmonellosis

Reference

complicating

hepatic

hydatid

disease”

Salmoneila

Age (years)Treatment

species

HERBSMANer al. (1959)

21

External drainage, antibiotics

St Paul

MATOSSIAN & NAJJAR (1968) 35 Excision, antibiotics S. MATOSSIAN & NAJJAR (1968) 37 Excision, antibiotics S. SITARAMet al. (1990) 13 External drainage, S. antibiotics 19 Excision, antibiotics S. Present case

pararyphi B typhi typhi typhi

‘All patients recovered.

Salmonella infection is via the biliary tract, though haematogenous spread cannot be excluded (HERBSMAN et al., 1959). In addition, 2 cases of post-operative infection of the cavity of the hydatid cyst caused by S. typhi and S. typhimurium have been reported (BAYKAL & BELGIN, i977). Both infections werecured using appropriate antibiotics. Pre-operative diagnosis of salmonellosis complicating hydatid disease may be possible if secondary infection of a hvdatid cvst if susnected. followed bv isolation of Salmonella from’the stooi. However, the rahty of this combination makes this unlikely. Salmonellosis may be associated with other parasitic infections, the most well recognized being schistosomiasis. Schistosomiasis may be associated with a chronic urinary Salmonella carrier state as well as with prolonged Salmonella bacteraemia. The fibrotic and obstructive changes induced by schistosomiasis in the urinary tract are believed to be the focus of Salmonella infection. In 2 studies in Egypt, S. paratyphi A was the most common strain resoonsible for infection. while S. tvbhi and S. paratyphi ‘B were also isolated @ARID et al,* 1970; HATHOUT et al., 1966). However, in Brazil, S. cholerasuis and S. typhi were the organisms responsible for prolonged Salmonella bacteraemia in patients with schistosomiasis (ROCHA et al., 1971). Salmonella has also been reported to cause secondary infection of an amoebic liver abscess (MARR & HAFF, 1971). Salmonellosis should always be considered as a possible aetiological agent in various infections in endemic areas. Adequate antibiotic treatment, as shown in this review, is essential in preventing post-operative morbidity in surgical patients. References Al-Hashimi, M. (1971). Intra-biliary rupture of hydatid cyst of the liver. British Iournal ofSureerv. 58.228-232. Baykal, M. & BeI&, E. (1977). [Foit:op&ative focal Salmonella infections of hydatid cysts.] Mikrobiyologii Bulzeni, 11, 425426.

Cohen, J. I., Bartlett, J. A. &Corey, J. R. (1987). Extra-intestinal manifestations of salmonella infections. Medicine, 66, 349-387.

Farid, Z., Bassily, S., Kent, D. C., Sandborn, W. R.,, Hassan, A., Abdel-Wahab, M. F. & Lehman, J. S., jr (1970). Chronic urinary Salmonella carriers with intermittent bacter-

675 aemia. Journal of Tropical Medicine and Hygiene, 73, 153156. Hathout, S. E., El-Ghaffar, Y. A., Awny, A. Y. & Hassan, K. (1966). Relation between urinary schistosomiasis and chronic enteric carrier state among Egyptians. American Journal of Tropical Medicine and Hygiene, 15, 156-161. Herbsman, H., Tanaka, A. M. & Stuckey, J. H. (1959). The first case report of an Echinococcus liver cyst infected with Salmonella Saint Paul. Annals of Surgery, 149,565-571. Langer, J. C. (1984). Diagnosis and management of hydatid cysts in the liver. Annals of.Surgety, 199,412--117. Marr, J. J. & Haff, R. C. (1971). Superinfection of an amoebic abscess by Salmonella enteritidis. Archives of Internal Medicine, 128,291-294.

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Leprosy in an Italian tourist the tropics

Matossian. R. M. & Naiiar. F. (1968). Suonurative salmonellosis in human hepa& hydatih cysfs. Akals of Tropical Medicine and Parasitology, 62, 143-146. Papadimitriou, J. & Mandrekas, A. (1970). The surgical treatment of hydatid disease of the liver. British Journal of Surgery,68,474-476. Rocha, H., Kirk, J. W. & Hearey, C. D., jr (1971). Prolonged Salmonella bacteremia in patients with Schistosoma mansoni infection. Archives of Internal Medicine, 128,254-256. Sitaram, V., Lalitha, M. K. & Mathew, G. (1990). Salmonella &phi infection of hydatid cyst. Indian Journal of Pathology and Microbiology, 33,7475. Received 14 December 1992; revised 16 February accepted for publication I7 Februa y I993

MEDICINE

AND HYGIENE

visiting

Paolo Fiallol, Enrico Nunzil, Giuseppe Bisighini* and Centre for Research on Leprosy and Giovanni Vaccariz Tropical Dermatology (CIRLEP), University of Genoa, Genoa, Italy; *Divisione di Dertnatologia, Arcispedale ‘S. Maria Nuova’, Reggio Emilia, Italy

With an estimated world prevalence of 5.5 million cases (NORDEEN et al.. 1992). lenrosv is one of the most important infectious diseases ‘in humans. Despite a long history of study, several questions about leprosy are still unanswered. Over the years leprologists have universally agreed that ‘prolonged intimate’ contact with infectious cases is essential for transmission of the disease (BADGER, 1964); however, the expressions ‘prolonged’ and ‘intimate’ are rather indefinite. We report a case of leprosy acquired by a tourist during shortvacations to thhtropics. A 38 vears old Italian male was first seen bv us in February 1592. The patient had lived in Italy *(in an area where autochthonous leprosy has never been reported) since his birth, except for time spent abroad on vacations. He reported no leprosy case among his family and denied contact with immigrants from countries endemic for leprosy. He reported visiting tropical regions 4 times in the past. He had been twice in Ceylon (1980 and 1981), once in southern India (1987) and once in Cuba (1988), each time spending 20-30 d in each country. During his visits he travelled by public transport and stayed in hotels etc. used by local people. He denied sexual intercourse with the population. The man was reportedly healthv until September 1989, when he started complaining of paraesthesja of the ulnar side of the right hand followed bv sensorv imoairment of the right median nerve. In spite of surgical i;tervention to relieve pressure on the nerves, pain, sensory impairment and motor deficits became progressively worse. In November 1991 he presented with an erythematous annular lesion on the right buttock,. followed by the deAddress for correspondence: Dr Paolo Fiallo, Institute of Dermatology, University of Genoa, Viale Benedetto XV 8, 16132 Genoa, Italy.

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velopment of another on the face and several on both legs. On admission to our facility in February 1992, all blood examinations (including human immunodeficiency virus testing) were either negative or within the normal range. Histological examination of a skin biopsy from one of the lesions showed periadnexal and perineural granulomas composed of epithelioid cells, giant cells and lymphocytes. Carbol-fuchsin staining revealed acid-fast bacilli within cutaneous nerves and histiocvtes. On the basis of clinical, microbiol&gical and histopatholoeical findings. a diagnosis of borderline-tuberculoid leprosy was esta&hed aid proper therapy was administered. The peculiarity of this case was the occurrence of leprosy in a person visiting an endemic country as a tourist, with apparently no history of ‘contact’. Such an event is not unusual in highly endemic areas, where most leprosy patients fail to report contacts with known cases (NORDEEN,

1985).

Other authors have reported military personnel contracting leprosy after shbrt spells of duty in endemic countries (BADGER, 1964; FELDMAN & STURDIVANT, 1976), but‘little attention has been paid to the possibility of contracting leprosy as a visitor. Our patient was affected with paucibacillary leprosy, the incubation period of which is estimated to be between 2.9 and 5.3 years (NORDEEN, 1985). Thus the man probably contracted the disease during his vacations in India or Cuba. Inferences based on a single case should be made with extreme caution. A report such as this does not mean that people visiting the tropics are at significant risk of acquiring the disease. It means only that leprosy must be considered as a communicable disease that can be transmitted even by casual contact in the right set of circumstances. References

Badger, L. F. (1964). Epidemiology. In: Leprosy in Theoy and Pracrice, Cochrane, R. G. & Davey, T. F. (editors). Bristol: John Wright and Sons, pp. 69-97. Feldman, R. A. & Sturdivant, M. (1976). Leprosy in the United States: an epidemiological review. Southern Medical Journal, 69,970-979.

Noordeen, S. K. (1985). The epidemiology of leprosy. In: Leprosy, Hastings, R. C. (editor). Edinburgh: Churchill Livingstone, pp. 15-30. Noordeen, S. K., Lopez Bravo, L. & Sundaresan, T. K. (1992). Estimated number of leprosy casesin the world. Leprosy Review, 63,282-287. Received 23 December 1992; revised 1.5 February accepted for publication I7 Februa y 1993

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