Salmonellosis in patients with neoplastic disease. A review of 100 episodes at Memorial Cancer Center over a 13-year period

Clinical presentation and outcomes of non-typhoidal Salmonella infections in patients with cancer

Background

Non-typhoidal Salmonella (NTS) infection is thought to be more severe in cancer patients, but this has not been studied since the development of new cancer therapies, increasing antibiotic resistance and the introduction of new antibiotics. We sought to describe the demographic characteristics, microbiological findings, clinical manifestations, and outcomes of NTS infections in cancer patients at our institution.

Methods

We reviewed microbiology laboratory records and identified patients who had cancer and from whom NTS organisms were recovered between January 1, 2000 and December 31, 2013, at a comprehensive cancer center in Houston, Texas. Descriptive statistics were used to summarize patient characteristics, clinical presentation and outcomes.

Results

We identified 110 isolates from 82 patients with 88 episodes of NTS infection (including five relapses [6%] in four patients, and two consecutive episodes in one patient). Fifty-five patients (67%) had hematologic malignancies. Most NTS isolates were susceptible to the commonly prescribed antimicrobials. Sixty-nine percent of patients had sepsis and one-third had severe sepsis or septic shock. Gastroenteritis, bacteremia, or both were present in 69% of patients, and the rest had focal infection. Mortality at 30 days was low (8%). Relapses occurred only in patients receiving ≤ 10 days of antibiotic therapy.

Conclusions

NTS affects predominantly patients with hematologic malignancies, followed by gastrointestinal and genitourinary cancers. Invasive disease, sepsis, and septic shock are common presentations among admitted patients. Antimicrobial prophylaxis may not prevent NTS infection. Thirty-day mortality and attributable mortality rates were low in our series compared to older case series. Early appropriate antibiotic therapy may have had a role in decreasing mortality. Relapses occurred in patients receiving ≤ 10 days of therapy, suggesting the need for longer duration of antibiotic therapy in cancer patients with uncomplicated NTS infections.

Recurrent Meningitis and Subarachnoid Hemorrhage Due to Salmonella in an HIV+ Patient: Case Report and Mini-Review of the Literature

Meningitis due to non-typhi salmonella is infrequent in HIV-positive adults.

We report a case of a patient with >300 CD4+ cells/mm3 who presented with five episodes of recurrent meningitis, focal subarachnoid hemorrhage and cerebral vasculitis ultimately attributed to Salmonella choleraesuis infection. Even within the cART era invasive salmonellosis can occur in unusual ways in HIV-infected patients.

A case of back pain caused by Salmonella spondylitis -A case report-

Salmonella spondylitis is a rare illness, and it generally occurs in patients who have already had sickle cell anemia, and it is even rarer in patients who are without sickle cell anemia. A 61-year-old male patient was hospitalized for the evaluation of his renal function and then treatment was started for his back pain. His back pain had developed about 2 months previously without any specific trauma. Only a bulging disc was detected on the initial lumbar MRI. Regarding his fever, it was diagnosed as possible atypical pneumonia, scrub typhus, etc., and multiple antibiotic therapy was administered. At the time of transfer, the leucocytes and hs-CRP were normal and the ESR was elevated. A diagnostic epidural block was performed for his back pain, but his symptoms were not improved. Lumbar MRI was performed again and it showed findings of infective spondylitis. Salmonella D was identified on the abscess culture and so he was diagnosed as suffering from Salmonella spondylitis. After antibiotic treatment, his back pain was improved and the patient was able to walk.

Salmonella meningitis in an adult with type B viral hepatitis and an incidental schwannoma

Salmonella meningitis is an unusual complication of Salmonella sepsis that occurs almost exclusively in infants and young children. Cases that do occur in adults are associated with a high morbidity and mortality. The present study concerns a rare case of Salmonella meningitis, the first to be reported in Qatar, in a previously healthy young adult man who was admitted with fever, headache and nuchal rigidity. Cerebrospinal fluid (CSF) culture produced Salmonella paratyphi A, although cultures of blood were negative. The patient was admitted to the medical intensive care unit (MICU) and assisted with mechanical ventilation for 1 week, then transferred to the medical ward where he exhibited progressive improvement on treatment with meropenam for 3 weeks. The patient was found to have an incidental schwannoma causing right-sided hydronephrosis, and hydroureter, treated with double J stent insertion. He was discharged in good condition without any neurological sequelae.

Nosocomial nontyphoidal salmonellosis after antineoplastic chemotherapy: reactivation of asymptomatic colonization?

An increased frequency of nontyphoidal salmonellosis is well established in cancer patients, but it is unclear whether this represents increased susceptibility to exogenous infection or opportunistic, endogenous reactivation of asymptomatic carriage. In a retrospective study, a simple case definition was used to identify the probable presence of reactivation salmonellosis in five cancer patients between 1996 and 2002. Reactivation salmonellosis was defined as the development of nosocomial diarrhea >72 h after admission and following the administration of antineoplastic chemotherapy in an HIV-seronegative cancer patient who was asymptomatic on admission, in the absence of epidemiological evidence of a nosocomial outbreak. Primary salmonellosis associated with unrecognized nosocomial transmission or community acquisition and an unusually prolonged incubation period could not entirely be ruled out. During the same time period, another opportunistic infection, Pneumocystis pneumonia, was diagnosed in six cancer patients. Presumably, asymptomatic intestinal Salmonella colonization was converted to invasive infection by chemotherapy-associated intestinal mucosal damage and altered innate immune mechanisms. According to published guidelines, stool specimens from patients hospitalized for longer than 72 h should be rejected unless the patient is neutropenic or >or=65 years old with significant comorbidity. However, in this study neutropenia was present in only one patient, and four patients were <65 years old. Guidelines should thus be revised in order not to reject stool culture specimens from such patients. In cancer patients, nosocomial salmonellosis can occur as a chemotherapy-triggered opportunistic reactivation infection that may be similar in frequency to Pneumocystis pneumonia.

Salmonella enterica pneumonia in a patient with lung cancer

A case of life-threatening Salmonella enterica serotype Enteritidis pneumonia in a febrile patient with lung cancer is described. The organism was isolated from the sputum, the protected specimen brush material of bronchial secretions, and the stool. Despite the early administration of appropriate and adequate treatment, the patient died 7 days after the onset of the infection.

Typhoidal focal suppurative lymphatic abscess

We describe a submandibular suppurative lymphatic abscess caused by Salmonella typhi in an 8-year-old child. The diagnosis was confirmed by repeated isolation of S. typhi from the abscess. A literature search found no previous report of a similar nature and this therefore seems to be the first case report of focal suppurative typhoidal lymphatic abscess. The child responded to cephalexin and surgical drainage.

Extra-intestinal non-typhoidal Salmonella infections in children

Extra-intestinal non-typhoidal Salmonella (NTS) infections are uncommon in developed countries but common in developing ones. The risk factors, clinical features and outcome of children admitted to the Department of Paediatrics, University of Malaya Medical Center, Kuala Lumpur from 1978 to 1998 with extra-intestinal NTS infections were reviewed. All positive cultures of NTS, blood, cerebrospinal fluid, urine, synovial, pericardial and other body secretions (except stools), were included. Of the 98 cases reviewed, 56 were boys and 42 girls. The mean age was 2.1 years (range: newborn to 14 years). Twenty-seven children were severely immunocompromised and 21 had underlying chronic medical disorders. Bacteraemia was the most commonly detected type of infection and meningitis the commonest focal infection. The overall mortality rate was 15%. An immunocompromised state or underlying chronic medical disorder was associated with increased mortality. The three serotypes most commonly isolated were S. enteritidis, S. paratyphi B and S. typhimurium. Most isolates were sensitive to antibiotics commonly used in salmonellosis.

Emergence of new pathogens as a function of changes in host susceptibility

A pathogen may emerge as an important public health problem because of changes in itself or its transmission pathways. Alternatively, a microorganism may emerge as a pathogen or acquire new public health importance because of changes in host susceptibility to infection. Factors influencing host susceptibility within the population as a whole include increases in the number of immunocompromised patients; increased use of immunosuppressive agents, particularly among persons receiving cancer chemotherapy or undergoing organ transplantation; aging of the population; and malnutrition. In considering the emergence of foodborne pathogens and designing interventions to limit their spread, the susceptibility of these population subgroups to specific infections should be taken into account.

A malignant pleural effusion infected with Salmonella enteritidis

A patient is described with a unilateral pleural effusion persistently infected with Salmonella enteritidis. The infection was eventually eradicated with ciprofloxacin. A computed tomographic scan and mediastinal lymph node biopsy demonstrated an underlying small cell bronchogenic carcinoma.

Commentary: pleural empyema and malignancy--another dimension

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Salmonella infections in a cancer center

Data concerning 40 patients hospitalized in a cancer center and Salmonella infection were analyzed. Hematological malignancy was present in 24 patients (60%) and solid tumor in 14 patients (35%). Among the predisposing factors, antineoplastic chemotherapy was the most frequent (60%) followed by antacid use (47.5%), corticosteroids (37.5%), granulocytopenia below 500 neutrophils/microliters (15%), surgery (10%) and splenectomy (2.5%). Bacteremia was the most frequent clinical syndrome accounting for 42.5% of the patients. Focal infection, enteritis and carrier state accounted for the remaining 30%, 20% and 7.5% respectively. Salmonella typhimurium and S. dublin represented 65% of the isolates, with clear association between serotype dublin and bacteremia. All S. dublin isolates were resistant to chloramphenicol. Among dublin and typhimurium serotypes, 20% the isolates were resistant to the traditional antibiotics used in salmonellosis (ampicillin, chloramphenicol, cotrimoxazole). All strains were susceptible in vitro to cephalosporins. The frequency of relapse was 15% and the overall mortality (within 30 days) attributed to Salmonella infection was 15%.

The Salmonella typhimurium virulence plasmid increases the growth rate of salmonellae in mice

The virulence plasmids of Salmonella typhimurium and other invasive Salmonella serovars have long been associated with the ability of these bacteria to cause systemic infection beyond the intestines in orally inoculated animals. Genetic analysis of virulence genes on the high-molecular-weight plasmids has revealed that no more than five genes spanning a 6.2-kb region are sufficient to replace the entire plasmid for conferring virulence. However, the exact virulence function(s) encoded by these genes has not been elucidated. In this report, we measured the possible effect of the virulence plasmid on the growth rate of S. typhimurium in mice by two complementary procedures. The first procedure used segregation of a temperature-sensitive plasmid in vivo to provide a measure of bacterial divisions and the number of recovered marker plasmid-containing salmonellae as a measure of killing. In the second procedure, aroA deletions were transduced into virulence plasmid-containing and plasmid-cured S. typhimurium. Since AroA- salmonellae are inhibited for growth in vivo, if the virulence plasmid affected only growth rate, no difference in the recoveries of the paired AroA- strains would be seen. Virulence plasmid-containing S. typhimurium segregated the marker plasmid more rapidly than did the virulence plasmid-cured strain, and AroA- derivatives of both strains were recovered equally from mice. Therefore, the S. typhimurium virulence plasmid increased growth rate but had no detectable effect on killing or bacterial movement into deep tissues. To examine whether the plasmid accomplished this function by affecting the intracellular/extracellular location of bacteria, orally infected mice were injected with gentamicin to kill the extracellular bacteria. Wild-type and plasmid-cured S. typhimurium strains were equally resistant to gentamicin in vivo and hence most likely located intracellularly to equal degrees. When wild-type and plasmid-cured S. typhimurium strains were sequestered within peritoneal chambers in mice, the resulting extracellular growth was equal. Therefore, the virulence plasmid increases the growth rate of S. typhimurium in mice, probably within mouse cells.

Molecular evolutionary genetics of the cattle-adapted serovar Salmonella dublin

An electrophoretic analysis of allelic variation at 24 enzyme loci among 170 isolates of the serovar Salmonella dublin (serotype 1,9,12[Vi]:g,p:-) identified three electrophoretic types (Du 1, Du 3, and Du 4), marking three closely related clones, one of which (Du 1) is globally distributed and was represented by 95% of the randomly selected isolates. All but 1 of 114 nonmotile isolates of serotype 1,9,12:-:- recovered from cattle and swine in the United States were genotypically Du 1. The virulence capsular polysaccharide (Vi antigen) is confined to clone Du 3, which apparently is limited in distribution to France and Great Britain. For all 29 isolates of Du 3, positive signals were detected when genomic DNA was hybridized with a probe specific for the ViaB region, which contains the structurally determinant genes for the Vi antigen; and 23 of these isolates had been serologically typed as Vi positive. In contrast, all 30 isolates of Du 1 tested with the ViaB probe were negative. These findings strongly suggest that the ViaB genes were recently acquired by S. dublin via horizontal transfer and additive recombination. The clones of S. dublin are closely similar to the globally predominant clone (En 1) of Salmonella enteritidis (serotype 1,9,12:g,m:-) in both multilocus enzyme genotype and nucleotide sequence of the fliC gene encoding phase 1 flagellin. Comparative sequencing of fliC has revealed the molecular genetic basis for expression of the p and m flagellar epitopes by which these serovars are distinguished in the Kauffmann-White serological scheme of classification.

Multiple Salmonella enteritidis leg abscesses in a patient with systemic lupus erythematosus

We describe a 19 year old woman with systemic lupus erythematosus on corticosteroid therapy, who developed bilateral, multiple, gas-forming Salmonella enteritidis leg abscesses and osteomyelitis mimicking deep vein thrombosis. The infection was treated successfully by a combination of surgical drainage and intravenous ceftriaxone, followed by prolonged oral pefloxacin. This rare case of gas-producing S. enteritidis emphasizes the difficulty in diagnosing such complications in active systemic lupus erythematosus.

Salmonella arizona infections in Latinos associated with rattlesnake folk medicine

In 1987 two Los Angeles County (California) hospitals reported four Latino patients with serious Salmonella arizona (Salmonella subgroup 3) infections who gave a medical history of taking rattlesnake capsules prior to illness. Capsules supplied by the patients or household members grew Salmonella arizona. We reviewed surveillance data for this Salmonella species and conducted a case-control study to determine the magnitude of this public health problem. Eighteen (82 percent) of the 22 Latino cases in 1986 and 1987 who were questioned reported ingesting snake capsules compared to two (8 percent) of 24 matched Latino controls with non-subgroup 3 salmonellosis or shigellosis (matched pair odds ratio = 18.0, CI = 4.2, 76.3). An average of 18 cases per year of Salmonella arizona were reported in the county between 1980 and 1987. In this investigation the majority of S. arizona cases reporting snake capsule ingestion had underlying illnesses such as acquired immunodeficiency syndrome (AIDS), diabetes, arthritis, cancer. The capsules were obtained primarily from Tijuana, Mexico and from Los Angeles, California pharmacies in Latino neighborhoods. Despite publicity and attempts to remove the capsules from sale in California, Salmonella arizona cases associated with snake-capsule ingestion continue to occur.

Oral ciprofloxacin treatment for Salmonella typhimurium infection of normal and immunocompromised mice

Oral treatment of Salmonella typhimurium infection with ciprofloxacin was compared with conventional chemotherapy with ampicillin or chloramphenicol in normal (CFW1) and immunocompromised (C57BL/6) mice. Administration of the antibiotics for 12 days reduced the number of bacteria in livers and the mortality of C57BL/6 mice significantly. Ciprofloxacin was considerably more effective than ampicillin in prolongation of the mean survival time of these mice. Similar to conventional chemotherapeutic agents, ciprofloxacin did not prevent fatal disease in most C57BL/6 mice when the treatment lasted 12 days only. On the other hand, ciprofloxacin cured lethal S. typhimurium illness in immunocompromised mice after long-term oral chemotherapy for 26 days at a dosage of 100 mg/kg twice a day. This was not achieved by either ampicillin or chloramphenicol. In normal mice, 12 days of therapy with ciprofloxacin was sufficient for a significant decrease in both the number of viable bacteria in livers and the mortality of lethally infected mice. The results provide a basis for an alternative antibiotic treatment by the oral route in immunocompromised hosts with systemic infections.

Perioperative dissemination of Salmonella

A hypophyseal adenoma was operated on in a patient who was a carrier of Salmonella typhimurium. A chronic salmonella osteitis developed in her calvarium at the site of operation. Our case and reported experience emphasise that asymptomatic carriers of salmonella should be given perioperative antibiotic prophylaxis, especially if they are immunosuppressed.

Recurrent salmonella infection with a single strain in the acquired immunodeficiency syndrome. Confirmation by plasmid fingerprinting

Five weeks before the development of acquired immunodeficiency syndrome (AIDS), a 38-yr-old homosexual man had symptomatic gastroenteritis that resolved without antibiotic treatment. His stool culture was positive for Salmonella typhimurium at that time. The patient subsequently developed Pneumocystis carinii pneumonia and received a 10-day course of intravenous trimethoprim-sulfamethoxazole. He developed salmonella bacteremia 4 months later. The salmonella isolates from the stool and blood were susceptible to trimethoprim-sulfamethoxazole. Comparison of cryptic plasmids showed a pattern identical to the initial salmonella infection, so infection with a new strain did not cause the bacteremia. This finding illustrates the utility of plasmid fingerprinting as a diagnostic tool, and suggests that persons with AIDS, or those at high risk with prodromal symptoms, should receive prompt, effective therapy for nontyphoidal salmonella gastroenteritis.

Person-to-person spread of Salmonella typhimurium after a hospital common-source outbreak

In September, 1973, diarrhoea caused by Salmonella typhimurium developed in 32 people in a Maine hospital. Both epidemiological and microbiological evidence indicated that raw egg beaten in milk ("egg-nog") was responsible for the infection. However, 6 patients and 8 employees had not had egg-nog, and their illness developed after the source of infection had been recognised and removed. Most of these people had had direct contact with an infected patient, and presumably acquired the infection by person-to-person spread. It is concluded that person-to-person spread of S. typhimurium can occur in hospitals and can be a hazard to patients and staff.