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CASE REPORT
Year : 2002  |  Volume : 20  |  Issue : 4  |  Page : 219-220
 

Cranial vault salmonella osteomyelitis leading to extradural abscess - A case report


Department of Microbiology, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh, India

Correspondence Address:
Department of Microbiology, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh, India

 ~ Abstract 

A case of rarely encountered Salmonella typhi osteomyelitis of left occipital bone leading to extradural abscess, is reported. The causative organism was not suspected until the culture report was obtained. The patient responded promptly to surgical drainage and antibiotic therapy.

How to cite this article:
Thakur K, Singh D V, Goel A. Cranial vault salmonella osteomyelitis leading to extradural abscess - A case report. Indian J Med Microbiol 2002;20:219-20


How to cite this URL:
Thakur K, Singh D V, Goel A. Cranial vault salmonella osteomyelitis leading to extradural abscess - A case report. Indian J Med Microbiol [serial online] 2002 [cited 2020 Oct 28];20:219-20. Available from: https://www.ijmm.org/text.asp?2002/20/4/219/6961


Apart from a classical presentation,  Salmonellosis More Details may present as localised infection at almost any site in the body including bones and brain.[1],[2] Most of the patients develop  Salmonella More Details abscess during the course of infection or even following it.[3] In this communication, we report a case of  Salmonella More Details osteomyelitis of the left occipital bone with extradural collection of pus, for its uncommon presentation. The  Salmonella More Details etiology was never suspected preoperatively.

 ~ Case Report Top

A 55 year old female was admitted with complaints of fever and headache for two months. She was treated at a local hospital for fever. After one month, the patient developed fever again and noticed swelling in the occipital region of the scalp. The fever was high grade (101-1020F), and continuous type and accompanied with chills. There was no history of convulsions, local trauma, surgery, discharge from ear, paranasal sinus infection or diabetes mellitus. No abnormal finding was detected on general physical and systemic examination including central nervous system. Local examination of scalp revealed 8x6 cystic, fluctuating swelling with normal overlying skin in the occipital region. The investigations done earlier at primary health centre were haemoglobin (Hb)-10.5 gm%, total leukocyte count (TLC) 8500/cmm, differential leukocyte count (DLC)-P 65% L 32%, M 3%, and ESR-10mm in first hour. The investigations done on admission revealed Hb-10 gm%, TLC-8400/cmm, DLC-P 65%, L3%, M%, ESR-20mm in first hour, blood urea-25mg%, blood sugar-100 mg%, negative peripheral blood smear for malarial parasites with normal morphology of RBC, negative blood, urine and stool cultures, and sputum negative for AFB. Widal test revealed titers of TO and TH as 160 and 320 respectively. Serological tests for HIV1 and HIV2 were non-reactive. X-ray chest and skull were normal. Contrast CT scan of skull revealed extradural soft tissue edema with collection of fluid, dural enhancement and minimal destruction of inner table of left occipital bone, suggestive of osteomyelitis [Figure]. Frank creamy pus was aspirated and cultured on MacConkey agar and blood agar. On MacConkey agar, colonies were non-lactose fermenting, 2mm in size, low convex, smooth, translucent with typical vine leaf appearance and easily emulsifiable. On blood agar, colonies were grayish and non-haemolytic. Rest of the characteristics were same as on MacConkey agar. The isolated organism was identified by biochemical reactions. The biochemical reactions were that of  S.typhi  . It was further confirmed by slide agglutination test with appropriate antisera i.e., poly O and O9 as S.typhi.[4]
Antibiotic susceptibility testing was done on Mueller-Hinton agar by modified Kirby Bauer technique as described by National Committee for Clinical Laboratory Standards (NCCLS)[5] which revealed isolated organism to be sensitive to ampicillin, cotrimoxazole, chloramphenicol, nalidixic acid, ciprofloxacin, cefuroxime and ceftriaxone. The patient was treated with surgical intervention and antibiotic therapy. Operative findings were consistent with osteomyelitis of left occipital bone with extradural abscess formation. Left occipital craniotomy, excision of osteomyelitic bone, removal of extradural pus, soft tissue debridement was done. Ceftriaxone (2gm) was given once a day for 2 weeks during hospitalization followed by oral administration of cefuroxime (1gm thrice per day) for further 2 weeks. Patient made uneventful recovery and was discharged on request from hospital after 15 days. Chest X-ray and CT scan of skull could not be done as patient did not turn up for follow up.

 ~ Discussion Top

 Salmonella More Details species usually cause gastroenteritis and enteric fever. However,  Salmonellosis More Details can also lead to bacteraemia and focal infections in various tissues including bones and brain.[1],[2]  Salmonella More Details osteomyelitis is an occasional complication of enteric fever in less than 1% of cases. It is especially likely to occur in patients with sickle cell haemoglobinopathy, SLE, haematologic neoplasm, immunosuppressive therapy, cranial surgery, trauma, prolonged exposure to the organism, impaired cell mediated immune response as in AIDS.[6],[7],[8] However, many cases have not had any precipitating factors. Usually it affects long bones or body of vertebrae, but any bone may be involved. The onset is usually during the convalescent stage of the disease i.e., 4th week onwards.[9] The management consists of establishing the diagnosis, antibiotic therapy and surgery. The culture of microorganism from blood remains the gold standard for early diagnosis. The blood cultures are often positive in  Salmonella More Details osteomyelitis. The most common isolate is  Salmonella More Details typhimurium.[10] In our patient, the precipitating factor was presumably inadequate treatment of previous bacteraemic illness resulting in prolonged exposure to the organism. The aspirated pus grew S.typhi but blood culture was sterile. Though there are controversies regarding the diagnostic value of Widal test, it still remains the only practical test where facilities for culture are not available especially in smaller hospitals. The high or rising titer in Widal test may give some clue in the diagnosis of  Salmonellosis More Details in cases of negative culture report. The antibiotic therapy in  Salmonella More Details osteomyelitis must be given for an extended period of time, initially parenterally and subsequently orally. With emergence of multidrug resistant (MDR) S.typhi, either quinolones or third generation cephalosporins are currently recommended for empirical antibiotic treatment. Quinolones can not be administered below 17 years of age because of cartilage damage and arthropathy in this age group and also resistance to these drugs is emerging. Ceftriaxone, a third generation cephalosporin is the best choice for  Salmonella More Details osteomyelitis. It is recommended in a dosage of 1-2 gms for 4-6 weeks. No other drug has been found as rapidly acting or as effective as ceftriaxone. The relapse rate is also low with this antibiotic.[10] The surgical intervention in the management of  Salmonella More Details osteomyelitis may include craniotomy, removal of sequestra, drainage and removal of extradural pus and granulation tissue.
In summary, we would like to bring attention to this unusual skull bone infection. All patients of PUO with or with out bone involvement should be adequately investigated for  Salmonella More Details etiology so as to reduce morbidity and mortality due to  Salmonellosis More Details

 ~ References Top

1.Cohen JI, Bartlett JA, Corey GR. Extra intestinal manifestations of Salmonella infections. Medicine 1987;4:349-388.  Back to cited text no. 1    
2.Jain KC, Mahapatra AK. Subdural empyema due to Salmonella infection. Paediatr Neurosurg 1998;28:89-90.  Back to cited text no. 2    
3.Herbert D, Ruskin J. Salmonella typhi epidural abscess occurring 47 years after typhoid fever. Case report. J Neurosurg 1982;57:719-721.  Back to cited text no. 3    
4.Barrow GI, Feltham RKA. (Eds.) Characters of Gram negative bacteria. Chapter 7. In: Cowan and Steel's manual for the identification of medical bacteria. 3rd ed. (Cambridge University Press, Cambridge) 1993:140-142.  Back to cited text no. 4    
5.National Committee for clinical laboratory standards. Performance standards for antimicrobial susceptibility tests-Sixth Edition; Approved standards Vol. 17:M2-A6, 1997, Pennysylvania, USA.  Back to cited text no. 5    
6.Hook EW, Campbell CG, Weens HS, Cooper GR. Salmonella osteomyelitis in patients with sickle-cell anaemia. N Eng J Med 1957:257:403.  Back to cited text no. 6    
7.Hook EW. Salmonella species (including Tyhpoid fever). In: Principles and Practice of Infectious Disease. 3rd ed. Mandell GL, Douglas RG, Bennett JE. Eds. (Churchill Livingstone Inc., New York) 1990:1700-1716.  Back to cited text no. 7    
8.Harry F, Chambers MD. Salmonellosis. In: Current Medical Diagnosis and Treatment, 40th ed. Lawerence M, Tierney Jr, Stephen J, McPhee, Maxine A. Eds. (Mc Graw-Hill, New York) 2001:1370-1372.  Back to cited text no. 8    
9.Phillips W. Essentials of Orthopaedics. (J & A Churchill Ltd, Gloucester Place) 1951:354-372.  Back to cited text no. 9    
10.Lesser CF, Miller SI. Salmonellosis. In: Harrison's Principles of Internal Medicine. 14th ed. Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Eds. (MC Graw-Hill, New York) 2001 Vol. I:970-975.  Back to cited text no. 10    
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