Case Study: Salmonella Typhimurium Meningitis in an infant, hitherto unreported in Eastern India

Summary

The enterobacteriaceae family, especially non-typhoidal salmonella, as the etiological agent for pyogenic meningitis in infants is scarce. Most reports of S. typhimurium meningeal infection are confined to neonates. An instance of S. typhimurium meningitis in a 1-month and 16-day-old infant is being reported for the first time from the eastern part of India.

Background

Meningitis is a condition where the meninges – the protective membranes of the brain and spinal cord – become inflamed. Haemophilus influenzae type b, pneumococcus, and meningococcus are well-known to cause pyogenic meningitis in children outside the neonatal period , and they also cause about 85% of total cases of neonatal pyogenic meningitis(1).

In 1908, the first case of Salmonella meningitis was reported by Ghon. Salmonella causes less than 1% of cases of bacterial meningitis in infants, (2,3) but these cases are more likely to have complications, relapse, or high mortality, compared to those with E. coli or another typical bacterium. (4) Very few cases caused by Salmonella have been reported, but nearly all of them occur in neonates5,6). Very scanty reports of meningitis are available beyond the neonatal period, especially from the eastern part of India. This particular case is reported on account of its utmost rarity.

Case Presentation

An infant at one month and 16 days old was admitted with the history of fever and repeated convulsions throughout the day. There was no history of diarrhea before the convulsions. The incidence of repeated convulsions per day was pretty alarming.
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Investigations

Both the patient’s blood and CSF was sent for routine analysis and culture. The blood sample showed a normal report with all the counts within the permissible limits. On the other hand, CSF had a total WBC count of 1600/cu mm, 40% of which were neutrophils; 60% were lymphocytes; protein was elevated to 765 mg/100 ml; glucose decreased to 5 mg/100 ml; RBC was 250/mm3; and chloride was 94 mEq/100 ml. In the culture, CSF showed the growth of Salmonella typhimurium within 24 hours of incubation. The organism was identified by the VITEK® 2 Compact system, along with the determination of MIC (Minimum Inhibitory Concentration) values for this particular organism. It was found to be a very sensitive strain as it showed sensitivity to all the antibiotics.

Treatment

The antibiotic was then de-escalated; the patient was initially treated with meropenem (120mg IV TDS) and vancomycin (45mg IV TDS), but later on, after the diagnosis of the causative organism and determination of its MIC value, the treatment was done by ofloxacin (30mg IV BD) and ceftriaxone (150mg IV BD) with MICs ≤1. The treatment was continued for three weeks and four days, showing gradual improvement in the patient.

Outcome and Follow Up

The patient was finally discharged after doing a repeat of CSF routine analysis, which showed all the parameters within the normal level. We followed up for the next 3 months, with no symptoms or neurological sequelae showing up.

Discussion

Salmonella has versatile pathogenicity – enteric fever, septicaemia, and gastroenteritis. Invasion of blood stream and focal complications can occur, but infection of meninges is very rare (7). Infection can occur from contaminated pasteurized milk, especially in developed countries(8). However the scenario is totally different in Asia. Meningitis beyond the neonatal period has seldom been reported. The infection is almost always by faeco-oral route and the source of infection remains obscure.

Meningitis differs from other cases of pyogenic meningitis. The disease is characterized by a high incidence of complications and long-term neurological sequelae in most cases (9). Treatment with the 3rd-generation cephalosporin is recommended for a minimum of 3 weeks(10) followed by regular observation and routine follow-up.

Key Point

S. typhimurium, besides being an important cause of gastroenteritis, can also cause meningitis, leading to various complications.

About The Author

Mandal
Dr. Subhranshu Mandal, currently working as Consultant Microbiologist in Suraksha Diagnostic Pvt. Ltd. Salt Lake, Kolkata.

 

 

References (click to show/hide)

  1. Klein JO, Feigin RD, McCracken GH., Jr.Report of the Task Force on the Diagnosis and Management of Meningitis. Pediatrics. 1986;78:959-982.
  2. de Louvois, J. (1991). Neonatal meningitis. In Infections of the Central Nervous System (Lambert, H. P., Ed), pp. 161-74. Edward. Arnold, Sevenoaks, UK.
  3. Synott, M.B., Morse, D.L. & Hall, S.M. (1994). Neonatal Meningitis in England and Wales: A Review of Routine National Data. Archives of Disease in Childhood 71, F75-80.
  4. Anonymous. (2000). Baby Dies of Salmonella Poona Infection Linked to Pet Reptiles. Communicable Disease Report CDR Weekly 10,161.
  5. Puri V, Thirupuram S, Khalil A, Vargheese A, Gupta S. Nosocomial Epidemic in a Neonatal Special Care Unit. Ind J Pediatric 1980;17:233-239.
  6. Sasidharan CK, Rajagopal KC, Panicker CK. Epidemic in a Newborn Nursery. Ind J Pediatr 1983;50:599-605.
  7. Nelson J, Granoff D. Salmonella Gastroenteritis in the First Three Months of Life: A Review of Management and Complications. Clin Pediatr 1982,21:709-712.
  8. Ryan CA, Nickels MK, Hargett-Bean NT, et al. Massive Outbreak of Antimicrobial Resistant Salmonellosis Traced to Pasteurized Milk. JAMA 1987;258:3269-3274.
  9. Cohen JI, Bartlett JA, Corey GR. Extraintestinal Manifestations of Salmonella Infection. Medicine (Baltimore) 1987;66:349-388.
  10. Kinsella TR, Yogev R, Shulman ST, et al. Treatment of Salmonella Meningitis and Brain Abscess With the New Cephalosporins: Two Case Reports and Review of the Literature. Pediatr Infect Dis J 1987;6:476-480.


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One Comment

  1. Agni Saha
    Posted Feb 2014 at 10:20 am | Permalink

    This article just reminds me – during our MD PG years – way back in 1996-97 – we had an epidemic of S. typhimurium sepsis +/- meningitis in the NICU of R G Kar Medical College with considerable mortality. They were all culture proven and were sensitive to third generation Cephalos – which were the latest antibiotics in those years. However, we never thought of publishing them – so they went un-reported. Thanks to Dr. Mandal for refreshing that memory.
    Dr. Agni Sekhar Saha

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