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International Journal of Medical Microbiology 297 (2007) 123–126 www.elsevier.de/ijmm
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Case report: Parotid abscess due to Salmonella enterica serovar Enteritidis in an immunocompetent adult Eleni Moraitoua, Ioannis Karydisb,c, Dimitra Nikitad, Matthew E. Falagasb,c,e, a
Department of Microbiology, Sotiria Hospital, Athens, Greece Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece c Department of Medicine, Henry Dunant Hospital, Athens, Greece d Department of Microbiology, Henry Dunant Hospital, Athens, Greece e Department of Medicine, Tufts University School of Medicine, Boston, MA, USA b
Received 26 May 2006; received in revised form 14 September 2006; accepted 30 November 2006
Abstract There are reports of increasing incidence of focal extra-intestinal infections from non-typhoidal salmonellae during the past two decades. We present the first case of a parotid abscess caused by Salmonella enterica serovar Enteritidis (S. Enteritidis) in an apparently immunocompetent adult without other abnormality of the parotid glands. A 58-yearold man was admitted to our hospital because of a 3-day history of fever and painful swelling of the right parotid gland. His medical history was unremarkable. A CT scan revealed an abscess of the right parotid. S. Enteritidis was isolated from a sample of fluid aspirated from the parotid abscess under ultrasound guidance. The stool, urine, and blood cultures were negative. The patient was treated with ciprofloxacin 500 mg per os every 12 h for 10 days, with complete remission of symptoms. The infection did not recur during 3 years of follow up. Our case report adds to the literature regarding the extra-intestinal infections with S. Enteritidis, a common non-typhoidal salmonellosis. r 2006 Elsevier GmbH. All rights reserved. Keywords: Non-typhoidal salmonellosis; Salmonella Enteritidis; Parotid abscess; Suppurative parotitis; Immunocompetence
Introduction Non-typhoidal salmonellae comprise many different serovars (Tindall et al., 2005) among which Salmonella Typhimurium (S. Typhimurium), S. Enteritidis, S. Heidelberg, S. Hadar, S. Newport, S. Agona, S. Montevideo, S. Poona, S. Javiana, S. Thomson are the most
Corresponding author. Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, GR-151 23 Marousi, Greece. Tel.: +30 694 6110 000; fax: +30 210 6839 605. E-mail address:
[email protected] (M.E. Falagas).
1438-4221/$ - see front matter r 2006 Elsevier GmbH. All rights reserved. doi:10.1016/j.ijmm.2006.11.005
prevalent (CDC, 1996). They are found in a wide range of animal hosts, especially poultry, and can be transmitted by food, mainly meat and eggs and their products. Among them S. Enteritidis is the major eggassociated pathogen and is frequently associated with ice cream consumption (Rice et al., 2003; Rabsch et al., 2001). Non-typhoidal salmonellae produce clinical symptoms mainly in neonates, infants, aged, and immunocompromised patients. Hematogenous dissemination may occur in complicated cases whereas the formation of abscesses is rare. Both seem to be related to the immunological status of the host. Brain (Wessalowski et al., 1993) and neck (Ray
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et al., 1997), lung (Ridha et al., 1996), liver (Vidal et al., 2003), splenic (Liang et al., 1995), pancreatic (Masclans et al., 1994), and thigh abscesses (Bjo¨rkman et al., 2002) have been reported in case reports, most of which involved immunocompromised patients or neonates. The parotid is a rare site of non-typhoidal Salmonella abscess formation: There are two case reports in the literature of parotid abscesses in immunocompromised patients (Georgilis et al., 1994; Moser et al., 1995) and one case report in a patient with a history of parotid masses (Kosnik et al., 2002). We present the first case of an otherwise healthy, immunocompetent 58-year-old man with a right parotid abscess caused by S. Enteritidis and review its clinical features.
Case report A 58-year-old man was admitted to Henry Dunant Hospital complaining of a 3-day history of fever, malaise and a painful swelling of the right parotid gland. For 2 days before his admission, he had been taking amoxicillin and metronidazole, as the swelling was thought to be related to dental infection, by his general practitioner. His medical history was unremarkable, including the absence of diabetes mellitus, HIV infection, and malignancy. The patient did not suffer from any immune or endocrine disease and had not taken any other medication in the past. He did not mention any history of diarrhea, vomiting, abdominal pain, joint pain, or joint swelling. He was living in Athens suburbs, working as a civil servant. He did not have any exposure to pets or personal contact with ill persons. As the symptoms seemed to persist, the patient was referred to our hospital for evaluation. At physical examination, a firm mass was palpable at the right parotid, and the patient was admitted for further investigation. No evidence of palpable regional lymph nodes was noted and no other clinical findings could be revealed. The chest X-ray showed no abnormalities. His white blood count was 9250/mm3 (69.7% neutrophils, 17.2% lymphocytes, and 6.8% monocytes), hematocrit 48.5%, hemoglobin level 16.1 g/dl, platelet count 267,000/mm3, C-reactive protein 8.3 mg/dl (normal values up to 0.5 mg/dl), and erythrocyte sedimentation rate 70 mmHg/1st hour. A CT scan revealed an abscess of the right parotid, with no evidence of malignancy (Fig. 1). The patient underwent fine-needle aspiration of the abscess, under ultrasound guidance, and the pus aspirated was sent to our microbiological laboratory for culture. After 24-h incubation, S. Enteritidis was isolated from the sample. The stool, urine, and blood cultures were negative. The patient was treated with ciprofloxacin 500 mg po every 12 h for 10 days, with complete remission of
Fig. 1. CT scan showing an abscess in the right parotid gland (arrow).
symptoms. He was discharged from the hospital 15 days later after complete resolution of the infection. He did not have any recurrence of the disease during 3 years of follow up.
Discussion In this paper, we present a case of an otherwise healthy immunocompetent adult with a parotid abscess due to infection with S. Enteritidis. The first case of parotid infection with S. Enteritidis that appeared in the literature was that of a parotid abscess in a patient with acute promyelocytic leukemia (Georgilis et al., 1994) and the second one was a case of suppurative parotitis in a patient with insulin-dependent diabetes mellitus and a history of chronic alcohol abuse (Moser et al., 1995). A third report of a right parotid abscess caused by S. Enteritidis involved an immunocompetent patient with a long history of parotid masses thought to correspond to Warthin’s tumor. However, right superficial parotidectomy subsequently revealed basal cell adenoma (Kosnik et al., 2002). It should be noted that glucose-6-phosphate dehydrogenase (G6PD) deficiency has been associated with increased incidence of Salmonella infection and dissemination and it is fairly common in people of Greek heritage. We did not perform the corresponding laboratory test to exclude G6PD deficiency during the hospitalization of the patient. However, testing for G6PD deficiency is usually performed during childhood in Greece because of associated hemolysis occurring in the setting of fava bean consumption, which is common in the country. The patient’s history was free of G6PD
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deficiency. Moreover, there was no evidence of hemolysis in the setting of S. Enteritidis infection in our patient. S. Enteritidis was the sole microbe that grew in the culture of the obtained pus sample. Nevertheless, we cannot exclude the remote possibility of it being a contaminant or the presence of a mixed infection since we did not perform further sophisticated diagnostic techniques, such as immunofluorescence microscopy analysis. The in vitro antimicrobial susceptibility testing of the isolate showed that S. Enteritidis was susceptible to ciprofloxacin. However, the panel of antimicrobials of the in vitro susceptibility testing used did not include amoxicillin. Since resistance of S. Enteritidis isolates to ampicillin up to 13.5% has been reported (Simango and Mbewe, 2000), we chose to treat the patient with ciprofloxacin. Many adults infected with non-typhoidal salmonellae become bacteremic after invasion of the bacteria and subsequent extra-intestinal organ involvement is frequent (Shimoni et al., 1999). In immunocompromised hosts bacteremia may occur in up to 80%. Focal extraintestinal infections from non-typhoidal salmonellae have increased in incidence during the past two decades. They can manifest as urinary tract infections, heart or arterial infections, osteomyelitis, bacterial arthritis, soft tissue infections or meningitis, frequently complications of bacteremia or enteric fever (Ispahani and Slack, 2000). Soft tissue infections occur mostly in patients with chronic underlying conditions and immune deficiency. Cancer, diabetes mellitus, human immunodeficiency virus infection, and drug-induced immunosuppression are the most common predisposing conditions for systemic Salmonella infections. Salmonella infections in otherwise healthy individuals are mostly foodborne, or due to direct contact with infected animals, but there is evidence of household contamination as well. The severity and the outcome of a systemic Salmonella infection depend on the ‘‘virulence’’ of the bacteria, on the infectious dose as well as on the genetic makeup and immunological status of the host (Mastroeni, 2002). In immunocompetent patients, S. Enteritidis is the most frequent strain associated with Salmonella infections in the European Union (de Jong and Ekdahl, 2006). This strain has developed sophisticated mechanisms for adaptation to its host milieu (Rhen and Dorman, 2005). The first stage of infection in our patient was thought to be acute bacterial parotitis, which subsequently progressed to parotid abscess. In our patient, the parotid abscess most probably originated from contaminated food and infected the parotid directly, or during a transient and silent bacteremic episode.
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In conclusion, we present the first case of a parotid abscess caused by S. Enteritidis in an apparently immunocompetent adult without other abnormality of the parotid glands.
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