An unusual case of Salmonella enterica subtype Typhi causing pneumonia, synpneumonic effusion, and septic shock in an immunocompetent pregnant patient

Arun Agarwal; Pooja Parab; Madan Mohan Sharma

doi:10.4103/jacp.jacp_15_19

CORRESPONDENCE

Year : 2020 | Volume : 8 | Issue : 1 | Page : 33-36

An unusual case of Salmonella enterica subtype Typhi causing pneumonia, synpneumonic effusion, and septic shock in an immunocompetent pregnant patient

Arun Agarwal, Pooja Parab, Madan Mohan Sharma
Department of Internal Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan, India

Date of Submission	12-Apr-2019
Date of Decision	01-Oct-2019
Date of Acceptance	14-Oct-2019
Date of Web Publication	11-Feb-2020

Correspondence Address:
Arun Agarwal
Department of Internal Medicine, Fortis Escorts Hospital, Jaipur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jacp.jacp_15_19

Abstract

Salmonellosis may present with varying clinical manifestations ranging from fever, malaise, abdominal discomfort, and gastroenteritis to nonspecific symptoms related to febrile syndromes. Pneumonia, however, is an atypical site for Salmonellosis. More severe infections can invade into the blood stream and cause bacteremia with the possibility of disseminated focal infection. We report a case of a 29-year old pregnant immunocompetent patient with atypical extraintestinal symptoms in the first week of typhoid illness. She presented with high-grade fever with chills, dry cough, and breathlessness developing extensive lobar pneumonia along with synpneumonic effusion and shock. Her blood culture was positive for Salmonella enterica serotype Typhi. She was diagnosed with community-acquired pneumonia with pleural effusion due to Salmonella enterica serotype Typhi without any gastrointestinal symptoms.

Keywords: Pneumonia, pregnancy, Salmonella enterica serotype Typhi, synpneumonic effusion

How to cite this article:
Agarwal A, Parab P, Sharma MM. An unusual case of Salmonella enterica subtype Typhi causing pneumonia, synpneumonic effusion, and septic shock in an immunocompetent pregnant patient. J Assoc Chest Physicians 2020;8:33-6

How to cite this URL:
Agarwal A, Parab P, Sharma MM. An unusual case of Salmonella enterica subtype Typhi causing pneumonia, synpneumonic effusion, and septic shock in an immunocompetent pregnant patient. J Assoc Chest Physicians [serial online] 2020 [cited 2023 Apr 1];8:33-6. Available from: https://www.jacpjournal.org/text.asp?2020/8/1/33/278117

Introduction

Typhoid fever is a very common infective disease in India. It manifests with fever, headache, and abdominal pain, gastrointestinal symptoms like anorexia, nausea, vomiting, and constipation with or without any specific signs during the first week of illness. The common signs like relative bradycardia, hepatomegaly, splenomegaly, abdominal tenderness may develop in second week of illness. Complications like acute abdomen, intestinal perforation, pneumonia, psychosis, ataxia, altered sensorium, and nephritis are likely to develop in third to fourth week of illness.^[1],[2],[3] However, the classical presentation of typhoid fever has considerably changed now and this classic typhoid fever syndrome is no longer seen in clinical practice. Extra-intestinal complications of Salmonella ^{More Details} Typhi (S. Typhi) infection usually occur in endemic countries and in patients with underlying risk conditions.^[4] Pneumonia presenting within first week of typhoid illness in a pregnant immunocompetent patient has never been reported earlier. She had no underlying risk condition.

Case report

A 29-year old lady with six-month pregnancy and belonging to upper-middle class family was admitted on 15 February 2019 with complaints of dry cough, breathlessness, and fever of three days duration. It was associated with chills and high grade. She had no complaints of coryza, nausea, vomiting, diarrhea, rashes, or body aches. On admission her vitals were as follows: temperature 103.5 F, blood pressure 118/72 mm of Hg, pulse = 122/min, regular, respiratory rate 24/min, and peripheral capillary oxygen saturation (SpPO2) of 98% on room air. On systemic examination, patient was conscious and alert, had vesicular breath sounds bilaterally on auscultation of chest with occasional left-sided infrascapular crepitations. Per abdomen examination revealed uterus of 24 weeks palpable with fetal heart sounds present. Other systemic findings were essentially normal.

Past history of the patient reveals infection with Dengue virus, Malaria, and Salmonella Typhi ten years back. There was no other significant past history. Her last checkups were for routine antenatal visit and the latest one being for symptoms of dry cough and fever of which reports are mentioned in [Table 1]

Table 1 Pleural fluid analysis

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She was admitted on floor and investigated. She refused for X-ray chest. She was started on empirical treatment with Ceftriaxone 2 gram twice daily intravenously (IV) and other supportive management. Ultrasound imaging revealed single, live fetus of 24 weeks 4 days with cephalic presentation. Patient tested positive for serum Legionella pneumophila

IgM antibody (Qualitative) and Injection Azithromycin 500 mg iv 24 hourly was added to her treatment. However, her Legionella Pneumophila antigen detection in urine and sputum culture was negative. On day 2 of admission, she developed bothersome cough, breathlessness, tachypnea and chest discomfort with SpO₂ of 98% on room air. Patient was shifted to medical ICU. Patient was stabilized but eventually required O₂ support to maintain adequate oxygen saturation. She had continuous fever and bilateral basal coarse crepitations on lung auscultation. X-ray chest [Figure 1]A was done with lead shield wrapped around abdomen after counseling of the patient and family. Over next 36 hours she developed marked cough, breathlessness with tachypnea, hypoxemia and required non-invasive ventilation (NIV), and oxygen support. Her subsequent X-rays are shown in [Figure 1]B, 1C and 1D. She rapidly developed left-side lobar consolidation with pleural effusion and left hemithorax was almost opaque by 21 February 2019. On 18 February 2019, blood culture was reported positive for Salmonella Typhi and antibiotics were up titrated to intravenous Meropenem 1 gram 8 hourly along with intravenous Azithromycin 500 mg twice daily. Ultrasonography (USG) of chest was performed which revealed minimal right pleural effusion and 200–300 ml of left pleural effusion with underlying left lower lobe consolidation. USG-guided thoracentesis under local anesthesia was done and sent for investigations. Fluid was transudate with predominant neutrophils. The details of pleural fluid examination are shown in [Table 1]. Her serology profile (Hepatitis B surface antigen, Human Immunodeficiency Virus 1/2 antibodies), malaria antigen test, Dengue NS 1 antigen, pleural fluid culture, salmonella typhi IgM antibodies were negative. Oxygen requirement of patient increased gradually with requirement of intermittent NIV support by day 5 of admission. She also had hypotension and required vasopressor noradrenaline infusion. Her symptoms gradually resolved over next few days and she was weaned off NIV, oxygen, and vasopressor support by 23 February 2019. She was discharged on 26 February 2019 on oral antibiotics.

Figure 1 X-ray chest AP views. A: 16 Feb 2019; B: 18 Feb 2019 ; C: 21 Feb 2019 ; D: 24 Feb 2019.

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Discussion

The term “enteric fever” is a collective term for both typhoid and paratyphoid fever, and “typhoid” and “enteric fever” are often used interchangeably. The organism classically responsible for the enteric fever syndrome is S. enterica serotype Typhi also formerly known as S. typhi. S. enterica serotype Typhi causes disease only in humans and has no known animal reservoir. Infection therefore implies direct contact with an infected individual or indirect contact via contaminated food or water. She did not have any such underlying history. Once ingested these organisms survive exposure to gastric acid in stomach before gaining access to the small bowel, where they penetrate the epithelium, enter the lymphoid tissue, and disseminate via the lymphatic or hematogenous route. The routine use of proton pump inhibitors (PPI) these days could further facilitate survival of these organisms to gastric acid.

Besides classic presentation of enteric fever, other protean extra-intestinal manifestations have been reported to varying degrees. Cough has been observed in approximately 20–45 percent.^[5],[6] Our patient had bothersome dry cough. Other extra-intestinal manifestations, including involvement of the hepatobiliary, cardiovascular, respiratory, genitourinary, musculoskeletal, and central nervous systems, have been described as a result of bacteremic seeding, but are observed infrequently.^[7]

Our patient developed synpneumonic effusion along with pneumonia. Thoracentesis was done under USG guidance and was found to be transudate and sterile on culture. Diagnostic/therapeutic aspiration is advised to rule out other associated conditions like tuberculosis and other infection in cases who present with atypical and rapidly developing symptoms. It further helps in classifying pleural effusion into synpneumonic effusion (sterile pleural effusion due to pneumonia), parapneumonic effusion (pleural effusion as a result of a pneumonia, lung abscess, or bronchiectasis with same organism grown on culture), and metapneumonic effusion (effusion and pneumonia co-exist, but effusion is not due to pneumonia).^[8]

We do not consider Legionella pneumophilia as a possible etiology or co-infection in the case presented. PCR is the preferred test for the diagnosis of Legionnaires’ disease. It could not be done due to inability to obtain adequate sputum sample. Testing for upper respiratory samples by PCR is also an alternative, but was not done as its sensitivity is low.^[9] The Legionella urinary antigen test is a commonly used alternative test and can be detected in urine as early as one day after symptom onset and persist for days to weeks. Its sensitivity ranges from 70 to 80 percent and the specificity approaches 100 percent in patients with Legionnaires’ disease caused by L. pneumophila serotype 1.^[10],[11] However, Legionella urinary antigen was not detected in our patient. Indirect immunofluorescent IgM antibody was available and it was reported positive. However, it has poor sensitivity and cross-reacts with other respiratory pathogens.

Typhoid fever during pregnancy with atypical presentation in first week is a difficult diagnosis for clinicians. It can be complicated by uteroplacental infection, miscarriage, and vertical intrauterine transmission leading to neonatal typhoid.^[12],[13] Pregnancy is associated with certain risk factors for typhoid fever like decreased gastrointestinal motility, delayed gastric emptying, esophageal reflux with use of acid-reducing or neutralizing medicines, modulation of cell-mediated immunity, and changes in appetite and food selection including pica.^[14] Our patient was also taking acid-reducing medicine pantoprazole. Antibiotic resistance among salmonellae and potential risks of many antimicrobial agents in pregnancy makes the choice of antibiotics for initial treatment of infection difficult before cultures and sensitivities are reported. She responded well to azithromycin and meropenem.To conclude, atypical manifestations do not necessarily mean a worse prognosis in typhoid fever. However, a high index of suspicion is needed in such cases especially in pregnancy. Patients having high fever presenting with pneumonia, early encephalopathy, early diarrhea, or bone marrow depression in a typhoid endemic area should be suspected for Salmonellosis ^{More Details}.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

Authors have declared that no competing interests exist.

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