Q J Med 2000; 93: 389-390
© 2000 Association of Physicians
Correspondence |
Acute cholecystitis and septic shock due to Salmonella virchow
Hôpital Laënnac, Creil, France
Sir,
Nontyphoidal salmonella (NTS) are a rare cause of infective cholecystitis with a rate of isolation that may not exceed 0.6% following cholecystectomy.1–4 Recently, McCarron and Love found only three cases of acute cholecystitis (5.8%) in a cohort of 52 consecutive patients treated for NTS enterocolitis.1 Salmonella virchow, which accounts for one of the less invasive NTS serotypes, has rarely been reported to cause cholecystitis.1,3,5 We describe a case of acute cholecystitis due to S. virchow complicated by septic shock and subsequent multiple organ failure.
A 72-year-old non-alcoholic and non-HIV-infected man was admitted to the hospital with a 24-h history of diarrhoea, vomiting and abdominal pain. His medical history was remarkable for myocardial necrosis 14 years ago, and rheumatoid arthritis treated with non-steroidal anti-inflammatory agents. He was apyretic but dehydrated and oliguric. Laboratory studies revealed normal leucocyte count with 84% neutrophils, creatinine 860 µmol/l, blood urea nitrogen 29 mmol/l, and protein 80 g/l. Despite intravenous fluid recsucitation, the patient rapidly worsened and developed severe hypotension needing mechanical ventilation. He was then admitted to the intensive care unit. A Swan-Ganz catheter was inserted for hemodynamic monitoring. Intravenous colloids infusion, albumin, and dopamine were administered to maintain adequate blood pressure. Antibiotherapy with ceftazidime, metronidazole and amikacin was begun. An abdominal CT scan showed the presence of gallstones within an enlarged gallbladder. Laparotomy was performed, and a markedly inflamed and friable gall bladder was removed. Histological studies showed an acute cholecystitis with thickening of the connective tissue of the gall bladder. Cultures of the bile and faeces rapidly grew S. virchow which was susceptible to the antibiotics. Blood cultures taken prior to cholecystectomy and antibiotherapy were negative. Despite hemodialysis and agressive rescucitation, the patient continued to worsen, with development of an adult respiratory distress syndrome. Chest X-ray studies showed several bilateral areas of pulmonary consolidation, and blood gas analysis while breathing pure oxygen revealed pH 7.20, PaO2 50 mmHg and PaCO2 52 mmHg. Repeated cultures of specimens obtained bronchoscopically by protected catheter brushing were negative. Laboratory studies showed development of disseminated intravascular coagulation, pancytopenia and rhabdomyolysis. The patient died from multiple organ failure on the third hospital day.
NTS usually cause only local enterocolitis by attacking the mucous membrane of the ileum without destroying it.6,7 However, this may result in a generalized or more invasive infection, with secondary septicaemia in approximately 3–14%.6,7 Acute cholecystitis remains however extremely rare, with a maximal rate of isolation of 0.6%.2–4 The incidence of infection with these organisms seems however to be increasing during the last three decades with a proportional increase in the frequency of acute cholecystitis.7–9 Actually, this incidence arose 5.8% of all of cases of NTS enterocolitis in a recent study.1 Predisposing factors include age of the patients (extremes of life), underlying chronic diseases such as lymphoproliferative disorders or diabetes mellitus, organ transplantation and immunosuppressive therapy, pointing to the role of cellular immunity in the defense against NTS invasion.6,7
S. virchow, which is not found to harbour a virulence plasmid, is one of the less invasive NTS serotypes.5,10 It was not mentioned in the ten most frequently reported salmonella serotypes from human sources.11,12 However, its incidence has increased during the last decade, with a substantial increase in its invasive potential, particularly in children.7,9,13 Numerous cases of meningism and septicaemia have been described, almost all of them occuring during sporadic outbreaks of food-poisoning.7,8,14 Notably, no case of acute cholecystis was reported before 1981.8 Since then, only three other cases have been described, with a sex ratio of 1.1,6,15 Three cases occurred in adults aged from 21 to 55 years,1,8,15 and one in a child of 3
years.6 Although the pathogen was recovered from stools in all the patients, only two presented with enterocolitis secondary to a food poisoning during travelling.1,15 One of these patients developed concomitant septicaemia,15 and the course was complicated by a biliary peritonitis in another.1
In contrast to our case, none of these patients died. Immunosuppressive conditions such as connective tissue diseases and non-steroidal anti-inflammatory medication may have predisposed our patient to a more severe infection. Development of septic shock, acute respiratory distress syndrome and subsequent multiple organ failure may have been major negative prognostic factors leading to death. To our knowledge, this is the first lethal reported case.
Cholecystitis may have occurred following a bacteraemic illness, as in the case reported by James et al.,15 or after direct invasion of the biliary system from the bowel.1,6,8 Decreased gastric acidity, immaturity of the gut-associated lymphoid tissue or other undetermined virulence factors may have contributed to the invasive potential of the bacteria in these patients.7 Although cholecystitis was associated with gallstones in only three of the five patients (including our case), some authors say that pre-existing gallstones have been a contributing factor for infection.8,15
Management of such cases does not differ from cholecystitis due to other pathogens. As S. virchow is susceptible to most of the antibiotics, antibiotic therapy may be a sufficient treatment.15 However, surgery may be necessary in cases of chronic cholecytolithiasis or complicated courses with perforation of the gallbladder and/or intraperitoneal infection.1,6,8
In conclusion, our case illustrates the potential severity of infection with S. virchow. With the increased frequency of its isolation from human samples in recent decades, this case should alert clinicians to the possibility of severe systemic spread of infection, and the need for early appropriate antibiotherapy.
References
1. McCaron B, Love WC. Acalculous nontyphoidal salmonellal cholecystitis requiring surgical intervention despite ciprofloxacin therapy: report of three cases. Clin Infect Dis1997; 24:707–9.[ISI][Medline]
2.
Lalitha MK, John R. Unusual manifestations of salmonellosis-a surgical problem. Q J Med1994; 87:301–9.
3. Fukunaga FH. Gallbladder bacteriology, histology and gallstones. Study of unselected cholecystectomy specimens in Honolulu. Arch Surg1973; 106:169–71.[ISI][Medline]
4. Keighley MRB, Graham NG. Infective cholecystitis. J Coll Surg Edinb1973; 18:213–20.
5.
Threlfall EJ, Hall MLM, Rowe B. Salmonella bacteraemia in England and Wales 1981–1990. J Clin Pathol1992; 45:34–6.
6. Beiler HA, Kuntz Ch, Eckstein TM, Daum R. Cholecystolithiasis and infection of the biliary tract with Salmonella virchow. A very rare case in early childhood. Eur J Pediatr Surg1995; 5:369–71.[ISI][Medline]
7. Shimoni Z, Pitlik S, Leibovici L, et al. Nontyphoid salmonella bacteraemia: Age-related differences in clinical presentation, bacteriology, and outcome. Clin Infect Dis1999; 28:822–7.[ISI][Medline]
8. Billingham JD, Slack MPE. Cholecystitis and subphrenic abscess caused by Salmonella virchow. Postgrad Med J1981; 57:308–9.[ISI][Medline]
9. Norris PG. Meningism following Salmonella virchow food poisoning. Postgrad Med J1986; 62:621–2.[Abstract]
10. Guiney DG, Fang FC, Krause M, Libby S, Buchmeier NA, Fierer J. Biology and clinical significance of virulence plasmids in Salmonella serovars. Clin Infect Dis1995; 21:S146–51.
11. Salmonella surveillance summary for 1986. Atlanta, Centers for Diseases Control, 1988.
12. Khakhria R, Woodward D, Johnson WM, Poppe C. Salmonella isolated from humans, animals and other sources in Canada, 1983–92. Epidemiol Infect1997; 119:15–23.[Medline]
13. Ruiz J, Nunez ML, Sempere MA, Diaz J, Gomez J. Systemic infections in three infants due to lactose-fermenting strains of Salmonella virchow. Eur J Clin Microbiol Infect Dis1995; 14:454–56.[ISI][Medline]
14. Todd WTA, McC Murdoch J. Salmonella virchow: a cause of significant bloodstream invasion. Scot Med J1983; 28:176–78.
15. James RA, Morris G, Winter R, Keston-Jones M. Acalculous cholecystitis due Salmonella virchow. Br J Clin Pract1990; 44:767–8.[ISI][Medline]
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