Non-Typhoidal Salmonella Aortitis in a Transplant Patient

Nauman Tarif; Anass El Abboud El Kheder; Mohammed Najeeb Azam; Ahmad H Mitwalli; Jamal S Al-Wakeel

Home

Instructions

Users online: 405

CASE REPORT

Year : 2002 | Volume : 13 | Issue : 4 | Page : 501-505

Non-Typhoidal Salmonella Aortitis in a Transplant Patient

Nauman Tarif¹, Anass El Abboud El Kheder², Mohammed Najeeb Azam¹, Ahmad H Mitwalli¹, Jamal S Al-Wakeel¹
¹ Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
² Department of Medicine, Dallah Hospital, Riyadh, Saudi Arabia

Click here for correspondence address and email

Abstract

Non-typhoidal salmonella bacteremia may result in extra gastrointestinal localization of infection. Aortitis due to non-typhoidal salmonella was reported to be the cause of 38-42.5% of all infected abdominal aortitis. Underlying atherosclersis is a frequent site for salmonella aortitis. We describe here a case of possible salmonella aortitis in a renal transplant patient.

Keywords: Non-typhoidal salmonella, Aortitis, Renal transplant

How to cite this article:
Tarif N, El Kheder AE, Azam MN, Mitwalli AH, Al-Wakeel JS. Non-Typhoidal Salmonella Aortitis in a Transplant Patient. Saudi J Kidney Dis Transpl 2002;13:501-5

How to cite this URL:
Tarif N, El Kheder AE, Azam MN, Mitwalli AH, Al-Wakeel JS. Non-Typhoidal Salmonella Aortitis in a Transplant Patient. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2022 Jul 6];13:501-5. Available from: https://www.sjkdt.org/text.asp?2002/13/4/501/33106

Introduction

Renal transplant patients are susceptible to infection with a wide range of organisms secondary to immunosuppression.^[1] Non typhoidal Salmonellosis ^{More Details} has been described in renal transplant patients resulting in enteritis, urinary tract infection and focal involvement of other organs (septic arthritis, pneumonia, lung abscess, mycotic aneurysms etc).^{[2],[3],[4],[5],[6],[7],[8]} Specifically, aortitis has only been described in two of such patients.^[9],[10]

We describe here a patient who had aortitis complicated by aneurysm formation and succumbed to sepsis.

Case History

A 50 year-old man underwent a living unrelated renal transplantation five years ago in India His renal failure was secondary to diabetic nephropathy. Post transplantation, he was found to be reactive to HCV antibody and positive for hepatitis B surface antigen. He had stable renal function on cyclosporine 100 mg daily and prednisolone 5 mg daily.

Four months before presentation to our hospital, he developed low-grade fever with intermittent spikes. He was also anorexic and complained of vague abdominal pain.

He was evaluated by repeated blood, stool and urine cultures with no yield. The patient was treated with various courses of antibiotics to which he responded with variable afebrile periods. He continued to lose weight and complained of fatigue, vague abdominal and low back pain. During this time, he was evaluated in two different hospitals with at least one abdominal ultrasound that was unrevealing.

On examination, the patient was afebrile, normotensive, pale and mildly jaundiced. Cardiovascular examination was unremarkable. Abdomen was soft, without tenderness, organomegaly or bruits. Few basal crepitations were auscultated on chest examination.

Initial investigations revealed mild leukocytosis of 14,000 with 73% neutrophils and nomochronic normocytic anemia (Hemoglobin: 105 g/L). Serum albumin was only 17 g/L, total bilirubin 25 mmol/L with normal liver enzymes. Creatinine was mildly elevated to 131 µmol/L, which was the average stable value post-renal transplant.

Urinalysis was normal. Urine culture did not grow any organisms. The initial blood cultures grew non-typhoidal Salmonella ^{More Details} (group B) after 24 hours that was sensitive to ceftriaxone.

Serology was negative for Brucella ^{More Details} and CMV IgG was 1:10. Chest X-ray showed basal atelectasis. Transesophageal echocardiogram was negative for any vegetations and abdominal ultrasound was reported as unremarkable. The patient was started on ceftriaxone 1 gram daily but he continued to spike fever and repeated blood cultures were negative. Abdominal CT scan showed a heterogenous dense area surrounding the proximal abdominal aorta immediately below the diaphragm. Intravenous contrast enhancement revealed two lumina of the abdominal aorta suggesting dissection or aneurysm, and atherosclerotic calcifications [Figure - 1]. An urgent coronary angiogram for preoperative assessment along with the abdominal aortogram revealed triple vessel coronary artery disease and a seven-cm abdominal aortic aneurysm with a short wide neck [Figure - 2]. Urgent surgical intervention was considered, however the patient's general condition deteriorated, developing acute myocardial infarction along with septic shock and expired.

Discussion

Salmonella are gram-negative motile, facultative anaerobic bacilli of the family Enterobacteriaciae. Since reported by Salmon and Smith in 1886, it has been recognized as a common human pathogen.^[11] Clinically, salmonellosis is can be typhoidal and nontyphoidal. Typhoidal salmonella, namely S. typhi and S. paratyphi infect only humans. Non-typhoidal salmonella are ubiquitous and human disease is transmitted with food, commonly dairy products.

Non-typhoidal salmonella infection is selflimited in healthy patients, while it may have serious sequelae in renal transplant patients.^{[2],[3],[4],[5],[6],[7],[8],[9],[10]} In USA, the incidence of non typhoidal salmonellosis in renal transplant patients was 3.9%,^[12] while in Saudi Arabia, Dhar et al reported an incidence of 3.4% among 592 renal transplant patients.^[5]

Salmonella infection usually manifests as gastroenteritis, enteric fever, bacteremia, localized infections, or the chronic carrier state. Bacteremia may result in infection of the vascular tree forming mycotic aneurysms. Abdominal aorta is the commonest site involved; 2.6% of all abdominal aortic aneurysm is the result of infections and 38 42.5% of these was due to salmonella.^{[13],[14],[15]}

Most patients with aortitis due to salmonella have preexisting atherosclerotic disease at the site of the subsequent aneurysm.^[16] In a study of patients with salmonella bacteremia, 25% of those more than 50 years of age developed endothelial infection.^[17] SoraviaDunand et al have recently reviewed 140 cases of salmonella aortitis;^[18] the review revealed non-typhoidal salmonella as the almost exclusive organism. Moreover, all but one of their 10 patients had risk factors for atherosclerosis, such as being elderly, hypertensive and/or diabetic.

Only two renal transplant patients with salmonella aortitis have been described in the medical literature.^[9],[10] Since the review by Soravia-Dunand et al in 1999 no new cases of salmonella aortitis in a renal transplant patient has been published. We believe our patient is the third reported case that succumbed to this dreadful complication. Previous presence of aneurysm and secondary infection cannot be ruled out entirely, however, the presentation of undiagnosed fever, abdominal and back pain with positive non-typhoidal salmonella bacteremia is highly suggestive. Furthermore, the mean duration before the actual diagnosis of salmonella aortitis was reported to be one month,^[18] which coincides with the duration of the disease in our patient.

Renal transplant patients have a higher tendency for atherosclerosis due to renal failure, diabetes, hypertension, hyperlipidemia and immunosuppressive medications.^[19] Our patient was diabetic, hypertensive and was in his fifth year post renal transplantation on immunosuppressive medications. He also had evidence of atherosclerotic calcification in the abdominal aorta [Figure - 1]. All these factors were probably responsible for the salmonella induced aortitis in him; whether there was a preexisting aneurysm is speculative.

Only the initial blood culture at presentation to our hospital was positive, which was possibly due to empiric intermittent antibiotic courses. Furthermore, only 85% of the blood cultures may be positive, which can add to the difficulty of early diagnosis of the infection. Nevertheless, one of the renal transplant patients with salmonella aortitis had recurrent bacteremia and successful streilization was achieved only after excision of the infected aorta.^[9],[18]

Commonly, the reported non-typhoidal species causing aortitis are Salmonella enteritidis, Salmonella cholerauis and Salmonella group D. However, geographical variation is evident in different reports.^[18] Dhar et al reported 31 episodes of nontyphoidal salmonellosis among 592 renal transplant patients from Saudi Arabia.[^5] Group B was the third commonest organism isolated in 6/31 cultures; it was the same type of organism cultured in our patient.

Considering the risk factors in renal transplant patients, it is important that prolonged fever with vague abdominal signs and symptoms prompt investigation for occult infection such as aortitis. Abdominal ultrasound, CT scan, MRI and nuclear imaging like Gallium or white blood cell indium labeled scan can be utilized.

Early diagnosis has a therapeutic implication. Soravia-Dunand et al found in their review that early diagnosis and surgical intervention decreased mortality from 96% to 40%.^[18] Bactericidal antibiotics should be continued for at least 6 weeks in patients undergoing surgical reconstruction.^[15],[8] Even longer duration of suppression with oral antibiotics has been recommended.^[20]

In conclusion, non-typhoidal salmonella bacteremia associated with prolonged and vague clinical features in a renal transplant patient should be evaluated for unusual sites of infection especially aortits. Once aortitis is diagnosed, early surgical intervention followed by prolonged antibiotic course may result in better prognosis.

References

1.	Kubak BM, Holt CD. Infectious complications of kidney transplantation and their management. In: Danovitch GM [ed]. Handbook of Renal transplantation. Boston, New York, Toronto, London. Little Brown and Company 1996;187-213.
2.	Anderson RJ, Schafer LA, Olin DB, Eickhoff TC. Septicemia in renal transplant recipients. Arch Surg 1973;106:692-4. [PUBMED]
3.	Dupuis F, Vereerstraeten P, Geertruyden J, Van Kinnaert P, Schoutens E, Toussaint C. Salmonella typhimurium urinary infection after kidney transplantation. Report of seven cases. Clin Nephrol 1974;2:131-5.
4.	Mussche MM, Lameire NH, Ringoir SM. Salmonella typhimurium infections in renal transplant patients. Report of five cases. Nephron 1975;15:143-50.
5.	Dhar JM, Al-Khader AA, Al-Sulaiman M, Al-Hasani MK. Non-typhoid salmonella in renal transplant recipients: a report of twenty cases and review of the literature. Q J Med 1991;78:235-50. [PUBMED] [FULLTEXT]
6.	Hussein MM, Mooij JM, Roujouleh HM, Hamour OA, Felemban H. Non-typhoid salmonella septicemia and visceral leishmaniasis in a renal transplant patient. Transplantation 2001;71(3):479-81.
7.	Ramos JM, Garcia-Corbeira P, Aguado JM, Plaza JJ, Soriano F. Non-typhoid salmonella extraintestinal infections in renal transplant recipients. Nephron 1995;71(4):489-90.
8.	Huang JY, Huang CC, Lai MK, Chu SH, Chuang CK. Salmonella infection in renal transplant recipients. Transplant Proc 1994; 26(4):2147.
9.	Smith EJ, Milligan SL, Eilo RS. Salmonella mycotic aneurysm after renal transplantation. South Med J 1981;74:1399-401.
10.	Kessler M, Gamberoni J, Renoult E. Nontyphoid salmonellosis in renal transplant patients. Report of a case with colonization of a vascular prosthesis. Nephron 1988;48:234.
11.	Salmon DE, Smith T. The bacterium of swine plague. Am Mon Microsc J 1886; 7:204-5.
12.	Gueco I, Saniel M, Mendoza M, Alano F, Ona E. Tropical infections after renal transplantation. Transplant Proc 1989;21:2105-7. [PUBMED]
13.	Carreras M, Larena JA, Tabernero G, Langara E, Pena JM. Evolution of salmonella aortitis towards the formation of abdominal aneurysm. Eur Radiol 1997;7:54-6. [PUBMED] [FULLTEXT]
14.	Oz MC, Brener BJ, Buda JA, et al. A ten year experience with bacterial aortitis. J Vasc Surg 1989;10:439-49. [PUBMED]
15.	Luo CY, Yang YJ. Surgical experience with salmonella-infected aneurysms of the abdominal aorta. J Formos Med Assoc 1997;96:346-52. [PUBMED]
16.	Oskoui R, Davis WA, Gomes MN. Salmonella aortitis. A report of a successfully treated case with a comprehensive review of the literature. Arch Intern Med 1993;153:517-25.
17.	Cohen SS, O'Brien TF, Schoenbaum SC, Medeiros AA. The risk of endothelial infection in adults with salmonella bacteremia. Ann Intern Med 1978;89:931-2.
18.	Soravia-Dunand VA, Loo VG, Salit IE. Aortitis due to salmonella: report of 10 cases and comprehensive review of the literature. Clin Infect Dis 1999;29:862-8. [PUBMED]
19.	Hilbrands LB, Demacker PN, Hoitsma AJ, Stalenhoef AF, Koene RA. The effects of cyclosporine and prednisone on serum lipid and (apo) lipoprotein levels in renal transplant recipients. J Am Soc Nephrol 1995;5:2073-81. [PUBMED]
20.	Donabedian H. Long-term suppression of salmonella aortitis with an oral antibiotic. Arch Intern Med 1989;149:1452. [PUBMED]

Correspondence Address:
Jamal S Al-Wakeel
Department of Medicine (38), College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461
Saudi Arabia