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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References

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  Table of Contents  
Year : 2013  |  Volume : 31  |  Issue : 4  |  Page : 409-411

Unusual manifestation of Salmonella enterica serotype enteritidis infection in a case of langerhans cell histiocytosis

1 Department of Gastrointestinal Sciences, Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission30-Mar-2013
Date of Acceptance31-May-2013
Date of Web Publication25-Sep-2013

Correspondence Address:
I Praharaj
Department of Gastrointestinal Sciences, Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.118873

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 ~ Abstract 

Nontyphoidal Salmonella (NTS) are established foodborne pathogens, most commonly reported in cases of gastroenteritis. These pathogens are however, increasingly being implicated in cases of bacteraemia and other extraintestinal manifestations. We report a case of a scalp abscess due to Salmonella enterica serotype Enteritidis, which is a serotype of NTS, in a child suffering from a haematologic malignancy. The child was on steroid and anticancer chemotherapy and developed the abscess secondary to bacteraemia with Salmonella Enteritidis. The abscess was drained and resolved following a course of intravenous antibiotic treatment.

Keywords: Immunosuppression, malignancy, Salmonella

How to cite this article:
Praharaj I, Sujatha S, Parija S C, Mahadevan S. Unusual manifestation of Salmonella enterica serotype enteritidis infection in a case of langerhans cell histiocytosis. Indian J Med Microbiol 2013;31:409-11

How to cite this URL:
Praharaj I, Sujatha S, Parija S C, Mahadevan S. Unusual manifestation of Salmonella enterica serotype enteritidis infection in a case of langerhans cell histiocytosis. Indian J Med Microbiol [serial online] 2013 [cited 2020 Nov 23];31:409-11. Available from:

 ~ Introduction Top

Non-typhoidal  Salmonella More Details (NTS) are pathogens, which are most commonly reported in cases of gastroenteritis. Focal infections and bacteraemia due to NTS are however also reported, especially in patients with underlying immunosuppression. This immunosuppression might be due to infection with the human immunodeficiency virus (HIV) or it may be due to treatment with steroids or other immunosuppressive drugs in patients with certain malignancies. [1] Extraintestinal focal infections due to NTS species may occur in up to 10% of all patients with Salmonella bacteraemia and such infections may involve diverse sites such as skin and soft tissue, liver, brain and other unusual sites.  Salmonella enteritidis Scientific Name Search is one of the most commonly isolated serotypes of NTS worldwide and is most commonly associated with cases of gastroenteritis due to intake of infected poultry products. [2],[3] There have however also been reports of extraintestinal infections due to this pathogen. Many of these infections are associated with steroid therapy or some underlying malignancy. [4],[5] We report here an unusual case of scalp abscess due to S. Enteritidis in a child with Langerhans cell histiocytosis (LCH) who was on treatment with corticosteroids and antineoplastic chemotherapy.

 ~ Case Report Top

A 1½-year-old male child with a 3 month history of LCH (Type 3), on treatment with vinblastine and corticosteroids (prednisolone) presented with fever of 1 week duration and painful swelling on the right temple. The patient had not suffered from any bouts of gastroenteritis in the recent past.

On examination, the child was found to be febrile (38°C) with pallor. A swelling was noted on the right temple area of the scalp. The swelling measured around 5 cm × 5 cm. It was found to be fluctuant, cystic and was warm to touch. Tenderness was associated with the swelling. Laboratory findings of the patient included a haemoglobin level of 9 g/dl, total white blood cells count of 16000 cells/, platelet count of 4,05,000/ and lymphocytosis. The patient was empirically started on cloxacillin, incision and drainage was performed on the swelling and pus was drained. The pus was sent for pyogenic culture and sensitivity. Blood sample from the child was also sent for culture. Gram staining of the pus sample revealed plenty of pus cells and gram negative rods. The sample was inoculated on to blood agar and MacConkey agar and incubated at 37°C for 24 hours. Pure growth of moist non-haemolytic colonies on blood agar and corresponding non-lactose fermenting colonies with irregular margins were observed on MacConkey agar. The colonies were identified as those of Group D Salmonella species based on standard biochemical tests and agglutination with Salmonella polyvalent O antiserum and Salmonella O9 antiserum (Denka Seiken Co Ltd, Japan). Antibiotic susceptibility testing was performed on Mueller Hinton agar by the Kirby Bauer disk diffusion method and the isolate was found to be sensitive to ciprofloxacin, chloramphenicol, ampicillin, ceftriaxone and co-trimoxazole. The strain was resistant to nalidixic acid. Further typing and confirmation of the isolate was performed at the National Salmonella Reference Centre, Kasauli, Himachal Pradesh, India. The isolate was identified as Salmonella enterica subspecies enterica serotype Enteritidis after agglutination with specific antisera (1, 9, 12:g, m:-). Blood culture from the patient also yielded the same organism. However, Salmonella species was not grown in stool or urine cultures during the period.

Patient was subsequently treated with ceftriaxone and considerable clinical improvement was noted. The abscess healed completely after 2 weeks of intravenous antimicrobial therapy.

 ~ Discussion Top

Presence of underlying malignancies is an established risk factor for Salmonella infections including soft tissue infections. [1] Wolfe et al. found a significant relationship between  Salmonella typhimurium Scientific Name Search bacteraemia and malignancies such as leukaemias and lymphomas. [6] Among other significant risk factors is HIV infection, which has been found to increase the risk of acquiring Salmonella infections by as much as 20 times. NTS are among the most common isolates from the blood of febrile patients, both adults and children in parts of sub-Saharan Africa where the rates of prevalence of HIV infection are high. [7]

Bacteraemia and focal infections due to NTS are commonly associated with preceding episodes of gastroenteritis due to these pathogens and as much as 5% of all cases of NTS gastroenteritis develop bacteraemia. However, in some conditions such as leukopenia and immunosuppression, patients can present with bacteraemia and focal infections due to NTS in the absence of gastroenteritis. [8] The development of Salmonella bacteraemia and focal Salmonella infections in the absence of preceding gastrointestinal symptoms has been considered to be an ominous sign by experts and is considered to be indicative of immunosuppression of some kind or some pre-existing anatomical abnormality and is more commonly seen in individuals at extremes of ages. [1],[9] In the case that has been described here, there were no gastrointestinal symptoms preceding the abscess and bacteraemia due to S. Enteritidis. However, the patient was suffering from a haematological malignancy for which he was being treated with steroids and other anticancer drugs. Although focal seeding of Salmonella infection may occur in any anatomical location and progress to a local infection, skin and soft-tissue infections due to Salmonella are comparatively rare and in most cases follow trauma or some kind of immunosuppression. [10]

Scalp abscesses due to Salmonella species have rarely been reported. Baliga et al. reported a case of scalp abscess due to Salmonella serotype Typhimurium in a 4-year-old child suffering from acute lymphoid leukaemia. [11] To the best of our knowledge, there have been no reported cases of scalp abscess due to S. Enteritidis until date. However, serovar Enteritidis has been reported to cause abscesses at other unusual sites such as retro-orbital space, [12] retromammary space (breast abscess), [13] parapharyngeal space, [14] site of melanoma metastasis etc. [15] Cases of intracranial abscess and epidural empyema due to S. Enteritidis have been reported in patients suffering from intracranial malignancies. [16],[17] In most of these cases of abscesses due to S. Enteritidis, patients have some underlying malignancy. [15],[16],[17]

In the present case, the patient described was immunosuppressed due to administration of corticosteroids and antineoplastic drugs as part of treatment for a haematological malignancy. The patient developed a scalp abscess secondary to bacteraemia due to S. Enteritidis and was managed with appropriate duration and dose of antibiotic treatment along with surgical drainage of the abscess. This particular case highlights the fact that NTS can be etiologic agents of focal infections, more so in patients with underlying immunosuppression.

 ~ References Top

1.Hohmann EL. Nontyphoidal salmonellosis. Clin Infect Dis 2001;32:263-9.  Back to cited text no. 1
2.Mølbak K, Neimann J. Risk factors for sporadic infection with Salmonella Enteritidis, Denmark, 1997-1999. Am J Epidemiol 2002;156:654-61.  Back to cited text no. 2
3.Patrick ME, Adcock PM, Gomez TM, Altekruse SF, Holland BH, Tauxe RV, et al. Salmonella Enteritidis infections, United States, 1985-1999. Emerg Infect Dis 2004;10:1-7.  Back to cited text no. 3
4.Shamiss A, Thaler M, Nussinovitch N, Zissin R, Rosenthal T. Multiple Salmonella Enteritidis leg abscesses in a patient with systemic lupus erythematosus. Postgrad Med J 1990;66:486-8.  Back to cited text no. 4
5.Gill GV, Holden A. A malignant pleural effusion infected with Salmonella Enteritidis. Thorax 1996;51:104-5.  Back to cited text no. 5
6.Wolfe MS, Louria DB, Armstrong D, Blevins A. Salmonellosis in patients with neoplastic disease. A review of 100 episodes at memorial cancer center over a 13-year period. Arch Intern Med 1971;128:546-54.  Back to cited text no. 6
7.Feasey NA, Dougan G, Kingsley RA, Heyderman RS, Gordon MA. Invasive non-typhoidal Salmonella disease: An emerging and neglected tropical disease in Africa. Lancet 2012;379:2489-99.  Back to cited text no. 7
8.Dhanoa A, Fatt QK. Non-typhoidal Salmonella bacteraemia: Epidemiology, clinical characteristics and its' association with severe immunosuppression. Ann Clin Microbiol Antimicrob 2009;8:15.  Back to cited text no. 8
9.Ramos JM, García-Corbeira P, Aguado JM, Alés JM, Soriano F. Classifying extraintestinal non-typhoid Salmonella infections. QJM 1996;89:123-6.  Back to cited text no. 9
10.Pegues DA, Miller SI. Salmonella species, including Salmonella typhi. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. 7 th ed. Philadelphia: Churchil Livingstone Elsevier; 2010. p. 2887-903.  Back to cited text no. 10
11.Baliga S, Shenoy S, Saldanha DR, Prashanth HV. Scalp abscess due to Salmonella Typhimurium. Indian J Pathol Microbiol 2010;53:572-3.  Back to cited text no. 11
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12.Spiritus T, Surmont I, Deruytter M, Aerts P, Stuer A. A case of an abscess due to Salmonella serotype Enteritidis behind the eye: A unique event as part of a growing food-borne problem in Belgium? Clin Microbiol Infect 2002;8:246-7.  Back to cited text no. 12
13.Brncic N, Gorup L, Strcic M, Abram M, Mustac E. Breast abscess in a man due to Salmonella enterica serotype Enteritidis. J Clin Microbiol 2012;50:192-3.  Back to cited text no. 13
14.Ray J, Shotton JC, Lobo VJ. A rare case of Salmonella neck abscess. J Laryngol Otol 1997;111:489-90.  Back to cited text no. 14
15.Forschner A, Autenrieth IB, Fierlbeck G. Soft-tissue abscess caused by Salmonella enterica serovar Enteritidis at the site of melanoma metastasis. Clin Microbiol Infect 2004;10:86-7.  Back to cited text no. 15
16.Sait M, Rahmathulla G, Chen TL, Barnett GH. Rare case of intracranial Salmonella enteritidis abscess following glioblastoma resection: Case report and review of the literature. Surg Neurol Int 2011;2:149.  Back to cited text no. 16
17.Blázquez D, Muñoz M, Gil C, Ruibal JL, El Knaichi F, Aleo E. Brain abscess and epidural empyema caused by Salmonella enteritidis in a child: Successful treatment with ciprofloxacin: A case report. Cases J 2009;2:7131.  Back to cited text no. 17

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1 Prednisolone/vinblastine
Reactions Weekly. 2015; 1543(1): 185
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