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  Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 2  |  Page : 311-313
 

Isolation of Salmonella typhi from high vaginal swab in a case of septic abortion


Department of Microbiology, Dr. Baba Saheb Ambedkar Hospital, Government of NCT of Delhi, New Delhi, India

Date of Web Publication5-Jul-2017

Correspondence Address:
Renu Gur
Department of Microbiology, Dr. Baba Saheb Ambedkar Hospital, Government of NCT of Delhi, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_16_180

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 ~ Abstract 

Salmonella Typhi can be a significant cause of morbidity and mortality in pregnant females with adverse outcomes. Risk of infections increases manifold during pregnancy due to hormonal changes and immunological phenomena. S. Typhi has the ability to cross placenta (vertical transmission) resulting in miscarriage, stillbirth or premature labour. We report a case of a pregnant female who was admitted to emergency department with fever, missed abortion and hypovolaemic shock. Subsequently, S. Typhi was isolated from her high vaginal swab and blood cultures. Follow-up cultures were negative for S. Typhi, and the patient was discharged after 10 days. The possibility of salmonellosis should be considered if a pregnant woman residing in an endemic area presents with high-grade fever. Furthermore, it should be promptly treated to prevent foetal loss.


Keywords: High vaginal swab, Salmonella Typhi, vertical transmission


How to cite this article:
Jena PP, Duggal SD, Kumar A, Bharara T, Sharma A, Gur R. Isolation of Salmonella typhi from high vaginal swab in a case of septic abortion. Indian J Med Microbiol 2017;35:311-3

How to cite this URL:
Jena PP, Duggal SD, Kumar A, Bharara T, Sharma A, Gur R. Isolation of Salmonella typhi from high vaginal swab in a case of septic abortion. Indian J Med Microbiol [serial online] 2017 [cited 2017 Sep 26];35:311-3. Available from: http://www.ijmm.org/text.asp?2017/35/2/311/209573



 ~ Introduction Top


 Salmonella More Details can cause a variety of disease in both humans and animals.[1]Salmonella Typhi can be a significant cause of morbidity and mortality in pregnant females with adverse outcomes. More than 60 years ago, Sir Medawar had explained the immunological paradox during pregnancy, in which the body tolerates and accepts an allogeneic foetus but increases a woman's susceptibility to infection.[2] Before antibiotic era, typhoid fever in pregnancy carried a 60%–80% risk of abortion and premature labour, as well as a 15% maternal mortality rate.[3] Chances of foetal loss are 50%–60% if infection is acquired before 16 weeks of gestation and 10%–15% if acquired later.[4] The intention of this report is to share our knowledge about typhoid fever complicating pregnancy and discuss about pregnancy outcomes in such cases.


 ~ Case Report Top


A 23-year-old married female presented to the emergency department in our hospital with amenorrhoea for 2 months and intermittent fever with chills, headache, malaise, vague abdominal pain and loose motions for 1 week. She was admitted in the Obstetrics and Gynaecology Department with provisional diagnosis of septic abortion. The patient was multiparous, non-smoker, with no history of drug/alcohol intake. On physical examination, she was febrile, conscious; blood pressure was low 60/40 mm Hg, pulse rate was 120/min, her chest was clear and abdomen was soft and non-tender. No hepatomegaly or splenomegaly was seen. The uterus was 8–10 weeks in size, immobile, bulky, bilateral free, with copious pus discharge from vagina but no foul smell.

Her haemoglobin was low i.e., 10.6 mg/dl and white blood cell count was high i.e., 22,500/cumm with a predominance of neutrophils - 91%. Serum sodium was low i.e., 13.8 mEq/L, calcium was low i.e., 7.7 mg/dl and serum glutamic-oxaloacetic transaminase elevated i.e., 165 IU/ml. Blood sugar, serum urea and creatinine, potassium, total serum bilirubin and direct bilirubin and platelet count were within normal limits.

Upon admission, her high vaginal swab (HVS), blood and urine samples were sent for culture. She was seronegative for human immunodeficiency virus 1 and 2. C-reactive protein was 12.8 mg/dl, Widal test was reactive for S. Typhi antibody TO-Somatic antigen (TO) at a dilution of 1:320, S. Typhi antibody Flagellar antigen (TH) at a dilution of 1:640. Within 24 h, HVS and blood cultures grew S. Typhi. S. Typhi was identified on standard biochemical tests and confirmed by slide agglutination with specific antisera (Denka Seiken Co. Ltd.). Both isolates were sensitive to ampicillin, ceftriaxone, cefixime, chloramphenicol and co-trimoxazole but resistant to nalidixic acid and intermediate sensitive to ciprofloxacin.

Empiric treatment for sepsis was initiated with meropenem and metronidazole. Dilatation and curettage was performed. Foetus was expelled en masse with placenta. Shortly after the procedure, she was transferred to Intensive Care Unit because of respiratory distress. Patient was put on assisted ventilation and on inotropes but was weaned off the next day. Based on culture report, the antibiotic therapy was changed to ceftriaxone for 14 days. Follow-up blood and HVS cultures at 1 week and blood counts were unremarkable. Urine and stool cultures did not grow S. Typhi. However, the products of conception were not sent for culture. The patient was discharged after 10 days of beginning therapy.


 ~ Discussion And Conclusion Top


Worldwide, there are estimated 22 million cases of enteric fever, with 200,000 deaths annually. The incidence is highest in India (>100 cases/100,000 population/year). A high incidence of enteric fever correlates with poor sanitation and lack of access to clean drinking water. In endemic regions, it is more common in urban areas and amongst young children and adolescents.[1] Genitourinary infections due to Salmonella enterica serotype Typhi accounts for <1% of cases.[5]S. Typhi is a facultative anaerobic Gram-negative enteric rod that causes a wide variety of human infections on ingestion with contaminated food or water. The incubation period may range from a few days to months. The bacteria invade the small intestinal mucosa leading to transient bacteraemia. Further intracellular multiplication of bacteria in phagocytic cells cause episodes of secondary bacteraemia.

In fowls, Salmonella infection in the offspring occurs as a result of its localisation in the ovaries and upper oviducts or may be transmitted to the forming egg before shell deposition.[6] In humans, transfer of infection from mother to foetus occurs through the transplacental route. Cases of vertical transmission by Salmonella have been reported in India [7],[8],[9],[10] as described in [Table 1].[7],[8],[9],[10],[11],[12],[13],[14]
Table 1: Review of cases of vertical transmission of Salmonella

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Placenta is a chimeric organ made of maternal and foetal cells. It nourishes and protects the foetus. The invasive extravillous trophoblasts (EVT) of the placenta provide anchorage with the uterine implantation site and also restructure the maternal arteries to facilitate blood flow to the foetus. The syncytium in these villi mediates nutrient and gas exchange between maternal and foetal tissues and protects the offspring from blood–borne pathogens.[15] The EVT strongly expresses human leucocyte antigen-G which downregulates natural killer cell function. Uterine decidual and placental cells produce a huge array of cytokines which, in part, contribute to the deviation of the immune response from Th1 (cell mediated immunity) to Th2 (humoral immunity). This may leave the mother more open to infection whose control is Th1-dependent i.e., intracellular organisms. This bias in cytokines and hormonal effects on the thymus and B cells may also contribute to the suppression of autoimmune responses and changes in circulating and local T-cell subsets in pregnancy.[16]Salmonella can trigger the formation of membrane ruffles in normally non-phagocytic epithelial cells leading to bacteria-mediated endocytosis by specialised Type III secretion system. In Gram-stain of placental tissue, numerous colonies of Gram-negative bacilli can be seen within the fibrin meshwork of the placental villi. This picture confirms to true villitis in case of haematogenous infection.[13]

Risk of foetal loss is more in early pregnancy. Hence, in an endemic area,  Salmonellosis More Details should be considered in differential diagnosis of fever. The antenatal clients should be educated about adverse events in pregnancy and advised to report to the healthcare centre in case of ill health. Clinician must consider geographic risk as well as microbiological clues to establish proper diagnosis. Vaginal swabs, blood and products of conception must be sent for culture in case of septic abortion to aid in establishing final diagnosis. Susceptibility testing is also important considering the changing trends.[17],[18]

Salmonellosis is an enteric infection that can be prevented by simple measures such as hand hygiene, avoidance of eating roadside uncovered food, water and contaminated animal food products. Hygiene at every level is the cornerstone for prevention of salmonellosis. Efficacy of killed vaccines has not yet been established in pregnancy. Prevention of typhoid fever is well within the scope of modern public health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
Lesser CF, Miller SI. Salmonellosis. In: Fauci SA, Longo LD, Casper LD, Jameson LJ, Hauser LS, editors. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill Medical Publishing Division; 2012.  Back to cited text no. 1
    
2.
Medawar PB. Some immunological and endocrinological problems raised by the evolution of viviparity in vertebrates. Symp Soc Exp Biol 1953;7:320-38.  Back to cited text no. 2
    
3.
Villarama A, Galang JS. Typhoid fever in pregnancy. Phillippine Isl Med Assoc 1930;10:311-5.  Back to cited text no. 3
    
4.
Carles G, Montoya Y, Seve B, Rakotofananina T, Largeaud M, Mignot V. Typhoid fever and pregnancy. J Gynecol Obstet Biol Reprod (Paris) 2002;31:495-9.  Back to cited text no. 4
    
5.
Huang DB, DuPont HL. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype typhi infection. Lancet Infect Dis 2005;5:341-8.  Back to cited text no. 5
    
6.
Koneman EW, Winn WC Jr. Koneman's Colour Atlas and Textbook of Diagnostic Microbiology. 6th ed. Baltimore: Lippincott Williams & Wilkins, Wolters Kluwer Company; 2006. p. 250.  Back to cited text no. 6
    
7.
Mohanty S, Gaind R, Sehgal R, Chellani H, Deb M. Neonatal sepsis due to Salmonella typhi and paratyphi A. J Infect Dev Ctries 2009;3:633-8.  Back to cited text no. 7
    
8.
Ravneet K, Purabi B. A case of Salmonella typhi infection leading to miscarriage. J Lab Physicians 2011;3:61-2.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Kaistha N, Singla N, Bansal N, Chander J. Salmonella typhi isolation in a pregnant woman: determining the importance. J Clin Diagn Res 2013;7:2100-1.  Back to cited text no. 9
    
10.
Poonia S, Satia MN, Torame VP, Natraj G. Vertical transmission of Salmonella typhi. JPGO 2015;2. Available from: http://www.jpgo.org/2015/01/vertical-transmission-of-salmonella.html. [Last accessed on 2016 May 24].  Back to cited text no. 10
    
11.
Seoud M, Saade G, Uwaydah M, Azoury R. Typhoid fever in pregnancy. Obstet Gynecol 1988;71:711-4.  Back to cited text no. 11
    
12.
Gluck B, Ramin KD, Ramin SM. Salmonella typhi and pregnancy: a case report. Infect Dis Obstet Gynecol 1994;2:186-9.  Back to cited text no. 12
    
13.
Coughlin LB, McGuigan J, Haddad NG, Mannion P. Salmonella sepsis and miscarriage. Clin Microbiol Infect 2003;9:866-8.  Back to cited text no. 13
    
14.
Vigliani MB, Bakardjiev AI. First trimester typhoid fever with vertical transmission of Salmonella typhi, an intracellular organism. Case Rep Med 2013;2013:973297.  Back to cited text no. 14
    
15.
Weetman AP. The immunology of pregnancy. Thyroid 1999;9:643-6.  Back to cited text no. 15
    
16.
Zeldovich VB, Bakardjiev AI. Host defense and tolerance: unique challenges in the placenta. PLoS Pathog 2012;8:e1002804.  Back to cited text no. 16
    
17.
Singhal L, Gupta PK, Kale P, Gautam V, Ray P. Trends in antimicrobial susceptibility of Salmonella typhi from North India (2001-2012). Indian J Med Microbiol 2014;32:149-52.  Back to cited text no. 17
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18.
Chande CA, Chopdekar KA, Pradnya V, Unnati R, Jyoti B, Ritesh S, et al. Current trend of antibiotic sensitivity of Salmonella typhi and other Salmonellae in Mumbai: A 5 years study. Indian J Med Microbiol 2016;34:115-6.  Back to cited text no. 18
[PUBMED]  [Full text]  



 
 
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