Salmonella paratyphi C osteomyelitis: report of two separate episodes 17 years apart

A rare case of Salmonella Paratyphi C osteomyelitis: A genetic analysis and review of Salmonella osteomyelitis in England

Salmonella osteomyelitis is rare in patients without sickling hemoglobinopathies. Invasive disease caused by Salmonella Paratyphi C is rarer still with only one case reported in the United Kingdom in the last 15 years. We report a case of relapsing S. Paratyphi C osteomyelitis in a newly diagnosed diabetic patient from Ghana. Our patient was initially treated successfully with surgical debridement followed by 6 weeks of IV ceftriaxone before recrudescence 9 months later. Due to the rarity of S. Paratyphi C and the lack of recent travel, genomic analysis was undertaken to assess possible sources with the closest related strain being from Cote d'Ivoire. The patient had likley picked up the strain several years before presentation. We review current Salmonella osteomyelitis literature and audit all cases referred to the England and Wales Salmonella national reference laboratory over the last 15 years.

Spondylodiscitis due to Salmonella Typhi: a series of four cases

Salmonella Typhi is very rarely associated with focal bone and joint complications. Classically, they are described in patients with risk factors such as haemoglobinopathies. We report four cases of spondylodiscitis, where the aetiology was found to be Salmonella Typhi. All four cases were treated successfully with variable duration of ceftriaxone followed by cotrimoxazole. We report these cases to highlight the importance of obtaining a microbiological diagnosis and the possibility of a rare infection in endemic settings.

Salmonella osteomyelitis: A rare differential diagnosis in osteolytic lesions around the knee

Salmonella osteomyelitis in immunocompetent adults is uncommon. It usually has a diaphyseal location or present as spondylitis. Metaphyseal affection is extremely rare. A 51-year-old male presented with refractory knee pain. Plain X-rays showed a rounded osteolytic lesion in the proximal tibia without marginal sclerosis. A minimal C-reactive protein elevation and a normal leucocytic count were present. Further imaging raised suspicion of malignancy so that a biopsy was done. After fenestering the lesion, 15-ml turbid fluid was evacuated. Microbiological examination showed Salmonella enteritidis. Repeated debridements were done and antibiotic therapy with ciprofloxacin was initiated. The cavity was then filled with synthetic bone graft leading to progressive healing. Although rare, Salmonella bone infection usually lacks the typical periosteal reaction and the laboratory evidence of infection of pyogenic osteomyelitis. It should therefore be considered in the differential diagnosis of osteolytic neoplastic lesions.

WITHDRAWN: Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever)

BACKGROUND

Review status: Current question - no update intended. Azithromycin treatments are included in the review: Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). (Thaver D, Zaidi AKM, Critchley JA, Azmatullah A, Madni SA, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004530. DOI: 10.1002/14651858.CD004530.pub3.)   This latter review is being updated, and will be published in late 2011.Enteric fever (typhoid and paratyphoid fever) is potentially fatal. Infection with drug-resistant strains of the causative organism Salmonella enterica serovar Typhi or Paratyphi increases morbidity and mortality. Azithromycin may have better outcomes in people with uncomplicated forms of the disease.

OBJECTIVES

To compare azithromycin with other antibiotics for treating uncomplicated enteric fever.

SEARCH STRATEGY

In August 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched conference proceedings, reference lists, and contacted researchers and a pharmaceutical company.

SELECTION CRITERIA

Randomized controlled trials comparing azithromycin with other antibiotics for treating children and adults with uncomplicated enteric fever confirmed by cultures of S. Typhi or Paratyphi in blood and/or stool.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed the risk of bias. Dichotomous data were presented and compared using the odds ratio, and continuous data were reported as arithmetic means with standard deviations and were combined using the mean difference (MD). Both were presented with 95% confidence intervals (CI).

MAIN RESULTS

Seven trials involving 773 participants met the inclusion criteria. The trials used adequate methods to generate the allocation sequence and conceal allocation, and were open label. Three trials exclusively included adults, two included children, and two included both adults and children; all were hospital inpatients. One trial evaluated azithromycin against chloramphenicol and did not demonstrate a difference for any outcome (77 participants, 1 trial). When compared with fluoroquinolones in four trials, azithromycin significantly reduced clinical failure (OR 0.48, 95% CI 0.26 to 0.89; 564 participants, 4 trials) and duration of hospital stay (MD -1.04 days, 95% CI -1.73 to -0.34 days; 213 participants, 2 trials); all four trials included people with multiple-drug-resistant or nalidixic acid-resistant strains of S. Typhi or S. Paratyphi. We detected no statistically significant difference in the other outcomes. Compared with ceftriaxone, azithromycin significantly reduced relapse (OR 0.09, 95% CI 0.01 to 0.70; 132 participants, 2 trials) and not other outcome measures. Few adverse events were reported, and most were mild and self limiting.

AUTHORS' CONCLUSIONS

Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.

A case of relapsing Salmonella osteomyelitis in a thalassaemia trait patient

We report a case of chronic relapsing osteomyelitis caused by Salmonella Stanley in a β-thalassaemia trait patient who is otherwise normal. The importance of obtaining definitive bacteriological diagnosis and timely intervention to treat bone infection effectively is emphasised here.

Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever)

BACKGROUND

Enteric fever (typhoid and paratyphoid fever) is potentially fatal. Infection with drug-resistant strains of the causative organism Salmonella enterica serovar Typhi or Paratyphi increases morbidity and mortality. Azithromycin may have better outcomes in people with uncomplicated forms of the disease.

OBJECTIVES

To compare azithromycin with other antibiotics for treating uncomplicated enteric fever.

SEARCH STRATEGY

In August 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched conference proceedings, reference lists, and contacted researchers and a pharmaceutical company.

SELECTION CRITERIA

Randomized controlled trials comparing azithromycin with other antibiotics for treating children and adults with uncomplicated enteric fever confirmed by cultures of S. Typhi or Paratyphi in blood and/or stool.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed the risk of bias. Dichotomous data were presented and compared using the odds ratio, and continuous data were reported as arithmetic means with standard deviations and were combined using the mean difference (MD). Both were presented with 95% confidence intervals (CI).

MAIN RESULTS

Seven trials involving 773 participants met the inclusion criteria. The trials used adequate methods to generate the allocation sequence and conceal allocation, and were open label. Three trials exclusively included adults, two included children, and two included both adults and children; all were hospital inpatients. One trial evaluated azithromycin against chloramphenicol and did not demonstrate a difference for any outcome (77 participants, 1 trial). When compared with fluoroquinolones in four trials, azithromycin significantly reduced clinical failure (OR 0.48, 95% CI 0.26 to 0.89; 564 participants, 4 trials) and duration of hospital stay (MD -1.04 days, 95% CI -1.73 to -0.34 days; 213 participants, 2 trials); all four trials included people with multiple-drug-resistant or nalidixic acid-resistant strains of S. Typhi or S. Paratyphi. We detected no statistically significant difference in the other outcomes. Compared with ceftriaxone, azithromycin significantly reduced relapse (OR 0.09, 95% CI 0.01 to 0.70; 132 participants, 2 trials) and not other outcome measures. Few adverse events were reported, and most were mild and self limiting.

AUTHORS' CONCLUSIONS

Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.

Typhoid and paratyphoid fever

Typhoid fever is estimated to have caused 21.6 million illnesses and 216,500 deaths globally in 2000, affecting all ages. There is also one case of paratyphoid fever for every four of typhoid. The global emergence of multidrug-resistant strains and of strains with reduced susceptibility to fluoroquinolones is of great concern. We discuss the occurrence of poor clinical response to fluoroquinolones despite disc sensitivity. Developments are being made in our understanding of the molecular pathogenesis, and genomic and proteomic studies reveal the possibility of new targets for diagnosis and treatment. Further, we review guidelines for use of diagnostic tests and for selection of antimicrobials in varying clinical situations. The importance of safe water, sanitation, and immunisation in the presence of increasing antibiotic resistance is paramount. Routine immunisation of school-age children with Vi or Ty21a vaccine is recommended for countries endemic for typhoid. Vi vaccine should be used for 2-5 year-old children in highly endemic settings.

Salmonella osteomyelitis in an otherwise healthy adult male-successful management with conservative treatment: a case report

A 21-year-old male presented with pain in the right thigh of insidious onset and 3 months' duration. He had a history of febrile illness lasting for 15 days, 2 months prior to the onset of pain. Examination revealed swelling over the lower lateral aspect of the right thigh with some induration and tenderness. Initial X-rays of the right femur and the computed tomography scan at 10 weeks after the onset of disease were normal. Magnetic resonance imaging scan showed signal alteration with minimal destruction of the anterior cortex in the mid-diaphyseal region of the right femur. A repeated X-ray taken at 15 weeks after the onset of illness showed erosive changes, along with periosteal reaction in the diaphyseal area. The Widal test was positive. Open biopsy of the lesion revealed inflammatory non-caseating tissue. Culture of the specimen grew Salmonella typhi. The patient was given antibiotic treatment. Both X-rays and the Widal titres were normal on subsequent follow-up at 3 months.

Multifocal simultaneous Salmonella typhi osteomyelitis in an immunocompetent adult

We report a case of Salmonella typhi osteomyelitis that presented as a pathologic fracture of the left femur and had additional silent manifestations in the right tibia and humerus in an otherwise healthy adult. This is the first report in the literature of multifocal simultaneous Salmonella osteomyelitis in an adult with no underlying medical condition.

Chronic relapsing salmonella osteomyelitis in an immunocompetent patient: case report and literature review

We present the first case of Salmonella virchow causing a relapsing bone infection at the same site 12 years apart in an otherwise healthy patient. Chronic relapsing osteomyelitis caused by a zoonotic salmonella may become increasingly important in view of the increased incidence of zoonotic salmonella infections. Based on this case, we recommend 3 months of therapy with a quinolone when treating a chronic relapsing zoonotic salmonella osteomyelitis.