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Salmonella Lithiasis
Vol. 115, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
SALMONELLA LITHIASIS A. I. HASHAM*·
t
AND DAVID T. UEHLING
From the Division of Urology, University of Wisconsin Hospitals, Madison, Wisconsin
A case of Salmonella lithiasis in a 60-year-old woman is presented and the relevant literature is discussed. Nephrectomy instead of pyelolithotomy was undertaken to eliminate the carrier state, and cholecystectomy and exploration of the common bile duct were required. chronic pyelonephritis with multiple microabscesses and nephrolithiasis. Stone analysis revealed calcium, oxalate, magnesium and phosphates as the constituents.
With the current methods of pasteurization, packaging of foods and chlorination of water, previously prevalent infectious diseases tend to be forgotten. Herein we describe a case of Salmonella lithiasis in a carrier.
DISCUSSION
CASE REPORT
A 60-year-old woman presented with urinary frequency and dysuria. History revealed that while on a camping trip in Utah in 1973 she had suffered from an episode of diarrhea, malaise and headache, which lasted about 2 days and was followed by recurrent urinary tract infections. In November 1973 she had had fever, chills and backache and was treated in her community. No cultures were obtained. Thirty years ago the patient had had right upper quadrant pain, flatulence, dyspepsia and icterus. Two months after this episode she passed a small renal stone and had remained asymptomatic until now. Laboratory studies included hematocrit 36 per cent, white blood count 4.5 cm., serum calcium 9.4 mg. per cent, phosphorous 3.2 mg. per cent, blood urea nitrogen 16 mg. per cent, uric acid 4.9 mg. per cent, creatinine 0.8 mg. per cent, cholesterol 297 mg. per cent, alkaline phosphatase 11.4 units, lactic dehydrogenase 129 units and serum glutamic pyruvic transaminase 38 units. Urine and stool cultures yielded Salmonella group C2. A large calcified mass was noted in the region of the right kidney on the preliminary film of an excretory urogram (IVP) (see figure). On a subsequent IVP the mass was within the right collecting system. There was no delay in function of the right kidney. An intravenous cholangiogram showed radiolucent stones in the common bile duct and the gallbladder was not visualized. After the cultures were confirmed a second time the patient was started on 2 gm. ampicillin daily. This was abandoned 3 days later when a severe drug reaction developed despite denial of any form of penicillin allergy prior to commencement of therapy. The patient was then treated successfully with 2 gm. chloramphenicol daily for 10 days. A right nephrectomy was performed. The renal pelvis was dilated but no definite ureteropelvic junction obstruction was demonstrated. The kidney contained more than 100 smooth, round stones in the right collecting system. Some of the stones formed a loosely bound calcareous mass in a fibrinous matrix. Stone cultures and a wedge section of renal parenchyma yielded Salmonella group C2. Postoperative urine and stool cultures were negative. The latter may have been owing to preoperative antibiotic therapy. The patient was rehospitalized 4 weeks later and a successful cholecystectomy and exploration of the common bile duct were done. Bile culture at exploration yielded Salmonella group C2 and enterococci. Repeat urine and stool cultures have not yielded Salmonella. Histological examination of the kidney showed acute and Accepted for publication June 27, 1975. * Requests for reprints: Division of Urology, University of Wisconsin Hospitals, 1300 University Ave., Madison, Wisconsin 53706. . t Current address: 112-0 Lofton Drive, Fayetteville, North Carolma 28301.
Salmonella organisms are subdivided into group A, B, C and D on the basis of their somatic O antigens. Groups A and Bare associated with typhoid and paratyphoid, while groups C and D are mainly responsible for enteritis. Group C is usually an animal pathogen, and organisms are maintained in animal species and transmitted through fomites. C2 organisms, as well
as Salmonella Cl, are liable to cause bacteremia and miliary abscesses in addition to gastroenteritis. If there is no underlying pathology the carriers clear spontaneously. Transient bacilluria has been shown to occur in 20 to 40 per cent of Salmonella enteritis in the pre-chloramphenicol era. 1 Focal Salmonella glomerulonephritis and microscopic miliary abscesses are more common in persons with pre-existing renal changes such as nephrolithiasis, hydronephrosis, kidneys displaying anatomical anomalies (duplication), ureteropelvic
110
111
SALMON~LLA LITHIASIS
!
.I
I
junction obstruction and in areas where urinary schistosomiasis is endemic. 2 In a summary of 2,000 autopsies of fatal typhoid fever Holscher found only 42 cases of renal involvement. 3 Flexner noted the relative absence of overt renal lesions where bacilli were grown from kidneys on fatal typhoid patients. 4 Urinary tract infection occurring as late as 26 years after the original typhoid infection has been reported in 4 cases.5 In 1897 Rovsing 6 and in 1916 Melchior 7 postulated that stones preceded the Salmonella infection. However, in 1900 Young presented a case and argued that the calculi were secondary to Salmonella infection. 8 In a study of 489 renal calculi Rovsing found Salmonella in only 3 cases.• Houston has drawn attention to the paucity of intestinal symptoms, especially in children with Salmonella enteritis and secondary renal infection. 1 ° Children are more commonly temporary or permanent carriers. Urinary tract manifestations in Salmonella infection are uncommon. When they do occur they run the gamut of transient bacilluria, perinephric abscess, pyelonephritis, nephrolithiasis and cystitis. It is difficult in our case to deny the existence of previous stones or to pinpoint the date of Salmonella infection. Multiplicity and size of stones would favor their development secondary to infection in an already damaged kidney. Nephrectomy was done rather than stone removal to be sure of eliminating the carrier state. Despite negative urine and stool cultures preoperatively renal stones, renal parenchyma and bile cultures yielded Salmonella.
REFERENCES
1. Patch, F. S.: J. Urol., 14: 199, 1925. 2. Melzer, M., Altmann, G., Rakowszcyk, M., Yosipovitch, Z. H. and Barsilai, B.: J. Urol., 94: 23, 1965. 3. Holscher, J.: Miinch. Med. Woch., p. 43, 1891. 4. Flexner, I.: Johns Hopkins Hosp. Report, 2: 343, 1895. 5. Yosipovitch, Z. H.: Thesis, The Hebrew University Hadassah Medical School, Jerusalem, 1957. 6. Rovsing, T.: Ann. des Mal. des Organ. Genito-Urin., September 1897. 7. Melchior, E.: Zeit. fur Urol., 10: 129, 1916. 8. Young, H. H.: Johns Hopkins Hosp. Reports, 8: 401, 1900. 9. Rovsing, T.: Zeit. fur Urol. Chir., Orig., 12: 377, 1923. 10. Houston: Brit. Med. J., p. 78, 1899.
COMMENT Is nephrolithiasis the cause or the result of Salmonella infection of the urinary tract? Opinions vary. Melzer and associates reported on 6 patients with clinically significant Salmonella urinary tract infections associated with nephrolithiasis. 2 The authors reasoned, and we would agree, that the pre-existence of stones, deformities or local tissue damage predisposed to the development of chronic Salmonella infection of the kidney. The vital clinical point is that in patients with S1gl!!QllfilULcarrier state15acilruria will not be permanently elimtmlted by treatmentwITflantiliiotics oved,~s corrected an diseased renru_tissue.-i&-resecled. S.S. .
THE JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
SALMONELLA LITHIASIS A. I. HASHAM*·
t
AND DAVID T. UEHLING
From the Division of Urology, University of Wisconsin Hospitals, Madison, Wisconsin
A case of Salmonella lithiasis in a 60-year-old woman is presented and the relevant literature is discussed. Nephrectomy instead of pyelolithotomy was undertaken to eliminate the carrier state, and cholecystectomy and exploration of the common bile duct were required. chronic pyelonephritis with multiple microabscesses and nephrolithiasis. Stone analysis revealed calcium, oxalate, magnesium and phosphates as the constituents.
With the current methods of pasteurization, packaging of foods and chlorination of water, previously prevalent infectious diseases tend to be forgotten. Herein we describe a case of Salmonella lithiasis in a carrier.
DISCUSSION
CASE REPORT
A 60-year-old woman presented with urinary frequency and dysuria. History revealed that while on a camping trip in Utah in 1973 she had suffered from an episode of diarrhea, malaise and headache, which lasted about 2 days and was followed by recurrent urinary tract infections. In November 1973 she had had fever, chills and backache and was treated in her community. No cultures were obtained. Thirty years ago the patient had had right upper quadrant pain, flatulence, dyspepsia and icterus. Two months after this episode she passed a small renal stone and had remained asymptomatic until now. Laboratory studies included hematocrit 36 per cent, white blood count 4.5 cm., serum calcium 9.4 mg. per cent, phosphorous 3.2 mg. per cent, blood urea nitrogen 16 mg. per cent, uric acid 4.9 mg. per cent, creatinine 0.8 mg. per cent, cholesterol 297 mg. per cent, alkaline phosphatase 11.4 units, lactic dehydrogenase 129 units and serum glutamic pyruvic transaminase 38 units. Urine and stool cultures yielded Salmonella group C2. A large calcified mass was noted in the region of the right kidney on the preliminary film of an excretory urogram (IVP) (see figure). On a subsequent IVP the mass was within the right collecting system. There was no delay in function of the right kidney. An intravenous cholangiogram showed radiolucent stones in the common bile duct and the gallbladder was not visualized. After the cultures were confirmed a second time the patient was started on 2 gm. ampicillin daily. This was abandoned 3 days later when a severe drug reaction developed despite denial of any form of penicillin allergy prior to commencement of therapy. The patient was then treated successfully with 2 gm. chloramphenicol daily for 10 days. A right nephrectomy was performed. The renal pelvis was dilated but no definite ureteropelvic junction obstruction was demonstrated. The kidney contained more than 100 smooth, round stones in the right collecting system. Some of the stones formed a loosely bound calcareous mass in a fibrinous matrix. Stone cultures and a wedge section of renal parenchyma yielded Salmonella group C2. Postoperative urine and stool cultures were negative. The latter may have been owing to preoperative antibiotic therapy. The patient was rehospitalized 4 weeks later and a successful cholecystectomy and exploration of the common bile duct were done. Bile culture at exploration yielded Salmonella group C2 and enterococci. Repeat urine and stool cultures have not yielded Salmonella. Histological examination of the kidney showed acute and Accepted for publication June 27, 1975. * Requests for reprints: Division of Urology, University of Wisconsin Hospitals, 1300 University Ave., Madison, Wisconsin 53706. . t Current address: 112-0 Lofton Drive, Fayetteville, North Carolma 28301.
Salmonella organisms are subdivided into group A, B, C and D on the basis of their somatic O antigens. Groups A and Bare associated with typhoid and paratyphoid, while groups C and D are mainly responsible for enteritis. Group C is usually an animal pathogen, and organisms are maintained in animal species and transmitted through fomites. C2 organisms, as well
as Salmonella Cl, are liable to cause bacteremia and miliary abscesses in addition to gastroenteritis. If there is no underlying pathology the carriers clear spontaneously. Transient bacilluria has been shown to occur in 20 to 40 per cent of Salmonella enteritis in the pre-chloramphenicol era. 1 Focal Salmonella glomerulonephritis and microscopic miliary abscesses are more common in persons with pre-existing renal changes such as nephrolithiasis, hydronephrosis, kidneys displaying anatomical anomalies (duplication), ureteropelvic
110
111
SALMON~LLA LITHIASIS
!
.I
I
junction obstruction and in areas where urinary schistosomiasis is endemic. 2 In a summary of 2,000 autopsies of fatal typhoid fever Holscher found only 42 cases of renal involvement. 3 Flexner noted the relative absence of overt renal lesions where bacilli were grown from kidneys on fatal typhoid patients. 4 Urinary tract infection occurring as late as 26 years after the original typhoid infection has been reported in 4 cases.5 In 1897 Rovsing 6 and in 1916 Melchior 7 postulated that stones preceded the Salmonella infection. However, in 1900 Young presented a case and argued that the calculi were secondary to Salmonella infection. 8 In a study of 489 renal calculi Rovsing found Salmonella in only 3 cases.• Houston has drawn attention to the paucity of intestinal symptoms, especially in children with Salmonella enteritis and secondary renal infection. 1 ° Children are more commonly temporary or permanent carriers. Urinary tract manifestations in Salmonella infection are uncommon. When they do occur they run the gamut of transient bacilluria, perinephric abscess, pyelonephritis, nephrolithiasis and cystitis. It is difficult in our case to deny the existence of previous stones or to pinpoint the date of Salmonella infection. Multiplicity and size of stones would favor their development secondary to infection in an already damaged kidney. Nephrectomy was done rather than stone removal to be sure of eliminating the carrier state. Despite negative urine and stool cultures preoperatively renal stones, renal parenchyma and bile cultures yielded Salmonella.
REFERENCES
1. Patch, F. S.: J. Urol., 14: 199, 1925. 2. Melzer, M., Altmann, G., Rakowszcyk, M., Yosipovitch, Z. H. and Barsilai, B.: J. Urol., 94: 23, 1965. 3. Holscher, J.: Miinch. Med. Woch., p. 43, 1891. 4. Flexner, I.: Johns Hopkins Hosp. Report, 2: 343, 1895. 5. Yosipovitch, Z. H.: Thesis, The Hebrew University Hadassah Medical School, Jerusalem, 1957. 6. Rovsing, T.: Ann. des Mal. des Organ. Genito-Urin., September 1897. 7. Melchior, E.: Zeit. fur Urol., 10: 129, 1916. 8. Young, H. H.: Johns Hopkins Hosp. Reports, 8: 401, 1900. 9. Rovsing, T.: Zeit. fur Urol. Chir., Orig., 12: 377, 1923. 10. Houston: Brit. Med. J., p. 78, 1899.
COMMENT Is nephrolithiasis the cause or the result of Salmonella infection of the urinary tract? Opinions vary. Melzer and associates reported on 6 patients with clinically significant Salmonella urinary tract infections associated with nephrolithiasis. 2 The authors reasoned, and we would agree, that the pre-existence of stones, deformities or local tissue damage predisposed to the development of chronic Salmonella infection of the kidney. The vital clinical point is that in patients with S1gl!!QllfilULcarrier state15acilruria will not be permanently elimtmlted by treatmentwITflantiliiotics oved,~s corrected an diseased renru_tissue.-i&-resecled. S.S. .