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Year : 2012  |  Volume : 30  |  Issue : 4  |  Page : 474--476

Recurrent meningitis due to Salmonella enteritidis: A case report from Kashmir India

BA Fomda1, BA Charoo2, JA Bhat1, N Reyaz1, P Maroof1, MI Naik1,  
1 Department of Microbiology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, India
2 Department of Neonatology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, India

Correspondence Address:
B A Fomda
Department of Microbiology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar
India

Abstract

Recurrent bacterial meningitis in children is potentially life-threatening and induces psychological trauma to the patients through repeated hospitalization. Here we report a case of recurrent meningitis in a one month old baby. The CSF and blood culture grew Salmonella enteritidis. Injection ciprofloxacin and ceftriaxone were given for 3 weeks. Baby became symptomatically better and was afebrile at discharge. Twenty eight days after discharge baby got readmitted with complaints of fever and refusal of feeds. Blood and CSF culture again showed growth of Salmonella enteritidis. Physicians should be educated about the possibility of recurrence which may occur days or even weeks after apparent successful antibiotic treatment.

How to cite this article:
Fomda B A, Charoo B A, Bhat J A, Reyaz N, Maroof P, Naik M I. Recurrent meningitis due to Salmonella enteritidis: A case report from Kashmir India.Indian J Med Microbiol 2012;30:474-476

How to cite this URL:
Fomda B A, Charoo B A, Bhat J A, Reyaz N, Maroof P, Naik M I. Recurrent meningitis due to Salmonella enteritidis: A case report from Kashmir India. Indian J Med Microbiol [serial online] 2012 [cited 2020 Nov 24 ];30:474-476
Available from: https://www.ijmm.org/text.asp?2012/30/4/474/103776

Full Text

 Introduction



Human salmonellosis is a major public health problem worldwide with an estimated 1.4 million cases occurring annually in the United States alone. [1] In industrialized countries, non-typhoidal salmonella (NTS) constitute a well recognized public health problem. In healthy subjects it causes self-limited gastroenteritis however, in immunocompromised and debilitated hosts, NTS can become invasive, leading to bacteremia, sepsis and focal infections like meningitis. [2],[3] The incidence of salmonellosis is highest among children of 1-4 years of age and is associated with high morbidity and mortality. [4] Even if the meningitis is not fatal, sequelae such as epilepsy, cranial nerve palsies, and hydrocephalus can occur. Recurrence of bacterial meningitis in children is not only potentially life-threatening but also involves or induces psychological trauma to the patients through repeated hospitalization and multiple invasive investigations if the underlying cause remains undetected. An extensive search through PubMed revealed few case reports of meningitis caused by Salmonella enteritidis and no published article on recurrent meningitis due to Salmonella enteritidis from India. [5],[6],[7] Here we report a case of recurrent meningitis caused by Salmonella enteritidis in a one month old child.

 Case Report



One month old female child, second in birth order, product of Consanginous marriage born by normal vaginal delivery at trust hospital SKIMS with no history of any perinatal insult. Baby was on exclusive breast feeding and presented with one day history of refusal to feed, fever and irritability. The child had right focal seizure at presentation that was managed and controlled by loading dose of phenytoin (20 mg/kg body weight). The child had received vaccination (BCG and DPT) two days prior to admission. On examination child was looking sick and febrile. Capillary filling time was<3 seconds, heart rate 144/minute and respiratory rate 46/minute, Chest, CVS and Abdominal examination was normal. Central nervous system examination revealed level anterior fontanelle, tone was normal, child had weak suck and cry, spontaneous activity was decreased and moros reflex was positive. Complete white blood cell count (CBC) showed total leukocyte count (TLC) 4.28,P 16%, L30%, atypical cells 54%, platelets 225 and RBC 3.57. Kidney function test/Liver Function test (KFT/LFT) showed urea 36, Serum creatinine 0.29,total protein 6.21,albumin 4.0,and calcium 10.9. CSF examination showed WBCs 3200, mostly polymorphs, protein 240 mg/dl,sugar 48 mg/dl. CT scan of brain was normal. With this clinical presentation and base line investigations diagnosis of bacterial meningitis was made. Gram stained smear of CSF revealed plenty of pus cells and gram negative bacilli. The culture from CSF and blood grew a non-lactose fermenting gram negative motile organism which was identified biochemically and confirmed by agglutination with specific antisera as Salmonella enteritidis. The isolates were subjected to antimicrobial susceptibility testing by the Kirby-Bauer disk diffusion method according to Clinical Laboratory Standards Institute (CLSI) guidelines. [8] The antimicrobial disks used were ampicillin 10 μg, chloramphenicol 30 μg, ciprofloxacin 5 μg and ceftriaxone 30 μg (Hi-Media,Mumbai, India). The isolates were sensitive to all antibiotics including ceftriaxone and ciprofloxacin. The baby was managed in hospital by IV fluids and subsequent breast feeds. Injection ciprofloxacin (10 mg/kg twice daily) and ceftriaxone (100 mg kg/day) were given for 3 weeks. Convulsions were managed by maintenance dose of phenytoin. CSF analysis was done after 3 weeks which showed cell count of 50/ cumm predominantly lymphocytes. Stool culture of baby after treatment showed bacterial growth of no significance. Mother had history of fever during pregnancy and her widal test showed titer TO 1:160, TH 1:80. Mother's blood and breast milk culture were sterile. Stool culture of mother revealed bacterial growth of no significance. Baby became symptomatically better, accepted feeds well and was afebrile at discharge.

Twenty eight days after discharge baby got readmitted with complaints of fever, refusal of feeds and discharge from both ears. Investigations this time revealed CRP positive, blood sugar 239 mg/dl,Serum creatinine 0.3, CSF examination revealed WBC 1700 mostly polymorphs, protein 325 mg/dl and sugar 35 mg/dl. Blood and CSF culture showed growth of Salmonella enteritidis sensitive to ampicillin, chloramphenicol, ciprofloxacin, ceftriaxone, ofloxacin. Pus culture from ear showed growth of mixed bacterial flora. CT scan of brain was normal. Baby had repeated episodes of right focal seizures during hospital stay. Baby was managed by phenytoin and phenobarbitone loading and subsequent maintenance doses. Baby was managed by injection ceftriaxone100 mg/kg/day and ciprofloxacin 10 mg/kg twice daily for 6 weeks. After 6 weeks of treatment CSF and blood culture were sterile. MRI was done after completion of treatment showed normal study. The baby is under regular follow up and is attaining normal developmental mile stone without any focal deficit.

 Discussion



Salmonella meningitis in infants and neonates has a wide spectrum of morbidity and acute complications, leading to complicated hospital course and subsequently a high prevalence of permanent adverse outcome. Thus early recognition of acute complications of Salmonella meningitis and a follow-up plan for early developmental assessment of survivors are vital. Meningitis by Salmonella enteritidis has not been previously reported from this region. In India and worldwide, only few cases of meningitis caused by Salmonella enteritidis have been reported. [5],[6],[7],[9],[10],[11],[12] We here report the first case of recurrent meningitis due to Salmonella enteritidis in one month old baby.

Bacterial migration, along congenital or acquired pathways from the skull or spinal dural defects, gains entrance into the central nervous system (CNS) and should be taken into consideration when a child has recurrent bacterial meningitis. However, CT scan and MRI were normal in present case thus excluding the possibility of congenital and acquired defects. Salmonella meningitis or brain abscess if treated incompletely or inadequately lead to recrudescence, relapse or recurrence of bacterial meningitis. [13] The isolate was sensitive to ampicillin, chloramphenicol, ceftriaxone, and ciprofloxacin. The baby was treated with injection ciprofloxacin (10 mg/ kg twice daily) and ceftriaxone 100 mg kg/day) only for 3 weeks. No controlled studies of treatment of meningitis due to Salmonella species are available. Treatment with conventional agents like ampicillin, chloramphenicol and trimethoprim-sulfamethoxazole has never been satisfactory. [14] The advent of third generation cephalosporin reduced the mortality and relapse rates dramatically; however, relapse rate remains the highest among these for meningitis caused by bacterial organisms. [14] Salmonella species are facultative intracellular organisms and have ability to survive in the presence of extracellular antibiotics. Ceftriaxone a bactericidal antibiotic has poor intracellular penetration and enter the intercellular compartment that contains engulfed bacteria only by diffusion. In such a case the intracellular ability of the antibiotics is dependent on the extracellular concentration achieved. Thus for successful treatment of meningitis caused by Salmonella species high dose of the third generation cephalosporin's should be used and the therapy should be continued for 4 weeks to ensure complete killing of the organism and to prevent relapse. [15] The American academy of Pediatrics now recommends that treatment for Salmonella meningitis with cefotaxime or ceftriaxone should continue often for 4 weeks or more. [16] The source of infection and mode of transmission in our patient is not clear. Non typhoidal salmonella infection is frequently associated with animal reservoir and infection usually originates from food products. [17] The patient was from a remote village where people keep animals and poultry in close vicinity of their house. Acquiring infection by direct contact of infant with animal reservoir is not a possibility. However, fecal-oral transmission from an infected adult including the mother in the household is a possibility. Neonates are at particular risk of infection because of reduced gastric acidity and peristalsis. Breast milk, blood and stool culture of mother were negative. Since the infant was fed with breast milk and mother has history of fever during pregnancy and her widal test titers were raised suggest the possibility of contaminated milk as source of infection. Infection can occur via direct nursing by mother with or without mastitis. [18] The infant was breast fed for one month and breast milk culture was done after we isolated Salmonella from CSF and blood culture of infant. It is possible that the mother had recovered completely after infecting the infant. The source of infection related to use of banked human milk, and use of raw eggs have been reported. Nevertheless, breast milk that was improperly collected and left at room temperature for a long period before the storage has accounted for several outbreaks in neonatal intensive care unit. [19] Thus the use of the correct procedure for collection and storage of breast milk is crucial to prevent bacteria from proliferating to infectious level. In conclusion clinicians should be alerted to the possibility of meningitis when they are evaluating an infant with salmonella in stools, urine or blood. They need to be aware of the invasive nature of this pathogen which could cause serious complications and sequelae, including brain abscesses. Salmonella infection is prone to recurrence and resistance to multiple antibiotics therefore proper treatment and regular follow up till patients completely recover is mandatory. After an apparent satisfactory clinical response to antibiotics, including the CSF returning to its normal appearance in cell counts and sugar contents, physicians and parents should be educated about the need for symptomatic self-diagnostic vigilance because of the possibility of relapse. This may occur days or even weeks after apparent successful antibiotic treatment.

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