Non-typhoidal salmonella: an unusual cause of spontaneous bacterial peritonitis in decompensated cirrhosis

An Unusual Instigator of Spontaneous Bacterial Peritonitis: Salmonella typhimurium

Salmonella is an unusual cause of spontaneous bacterial peritonitis (SBP). It is commonly seen in asymptomatic patients with normal or high ascitic fluid protein levels and an immunocompromised state such as AIDS and hematological and solid organ malignancies other than liver. SBP from non-typhoidal Salmonella species should be considered, even in the absence of underlying immunosuppression. Our patient presented with a history of high-grade fever and frequent loose stools with decompensated alcoholic liver cirrhosis. While evaluating the SBP etiology, ascitic fluid turned out positive for the non-typhoidal Salmonella species, which was red, turbid, and hemorrhagic due to portal vein and superior mesenteric vein thrombosis. We thus report an extremely rare case of SBP caused by Salmonella typhimurium in our patient.

Salmonella typhimurium as a causative agent of spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a common complication of liver cirrhosis and abdominal ascites, usually caused by organisms from the Enterobacteriaceae family. A woman in her 40s with a history of alcoholic liver cirrhosis presented to the hospital with dyspnoea, abdominal distention and diffuse abdominal pain. She was found to have sepsis and abdominal ascites, with elevated ascitic fluid neutrophil counts consistent with SBP. Culture of ascitic fluid revealed Salmonella typhimurium Further investigation revealed that the patient shared her home with a pet bearded dragon, a reptile known to carry Salmonella spp. She was treated with intravenous ceftriaxone and oral ciprofloxacin for a total of 14 days. S. typhimurium, likely transmitted to the patient from the pet reptile, is a rare pathogen in SBP and highlights the importance of environmental exposures in the management of this condition.

Spontaneous Bacterial Peritonitis Secondary to Salmonella spp. in a Patient With Decompensated Liver Cirrhosis

Spontaneous bacterial peritonitis (SBP) is a common and serious complication of cirrhosis, with gram-negative bacteria being the culprit in most cases. SBP secondary to Salmonella spp. is rare. Here, we report a case of Salmonellaenterica SBP in a patient with decompensated cirrhosis, diagnosed via paracentesis coupled with ascitic fluid analysis and culture. A high index of suspicion must be maintained for atypical causes of SBP, with prompt initiation of treatment.

Factors Affecting Mortality and Morbidity of Patients With Cirrhosis Hospitalized for Spontaneous Bacterial Peritonitis

OBJECTIVES

Spontaneous bacterial peritonitis, unless originating from surgery or an intra-abdominal source, is an infection diagnosed by neutrophil counts greater than 250/mm³ in ascites. Spontaneous bacterial peritonitis is the most common infection among patients hospitalized with cirrhosis, with a prevalence of 9% and a risk of development among all patients with cirrhosis within 1 year of 10%. No valid parameters have been defined to predict the mortality related to spontaneous bacterial peritonitis. Unless it is treated, the mortality rate as a result of spontaneous bacterial peritonitis is 50%, and serious complications may arise.

MATERIALS AND METHODS

Medical records from 29 patients on the deceased-donor transplant waiting list and receiving treatment at the Başkent University Hospital Gastroenterology Clinic for cirrhotic ascites infection between 1996 and 2013 were analyzed. Demographic information, paracentesis findings, clinical follow-up, and treatment results were reviewed and collected from patient medical records, with data recorded to the research form.

RESULTS

In our patient group, 72.4% were men and the average age was 46.6 years. Most of our patients were at advanced stage, with 55.2% having a Child-Pugh score of C and an average Model for End-Stage Liver Disease score of 17 ± 4.1. We found that 34.5% of the patients received prophylactic treatment for spontaneous bacterial peritonitis, 72.4% received a proton pump inhibitor, and 82.8% had treatment with intravenous albumin support at the time of diagnosis. Albumin treatment showed no effect on mortality. Mortality rate among patients with Child-Pugh score of C was 81.3%.

CONCLUSIONS

Existence of chronic renal failure, liver graft surgery, and hepatocellular cancer did not seem to have a significant effect on patient mortality. The albumin treatment protocol showed no significant difference despite common belief among physicians.