Salmonella abscess in a Failed Transplanted Kidney

Abstract

An abscess in the kidney is due to salmonellae are rare in the literature and rarer in kidney-transplant patients. The etiology of such abscesses can be difficult to decipher. Salmonella enteric subspecies I serotypes can cause disease in a range of hosts depending on their adaptations. Human host restricted serotypes of typhi, paratyphi A and sendai tend to cause more systemic infections as they are thought to be more adapted to their host. Unrestricted host Salmonella species usually include typhirium and enteritidis and mostly cause self-limited gastroenteritis symptoms but in a range of higher vertebrates [1]. The CDC estimates there are 1.2 million Salmonella infections per year with surveillance data indicating Salmonella serovar enteritidis being the most common serotype followed by Salmonella serovar typhimurium and Salmonella serovar newport. Chicken eggs are known source of these salmonellae outbreaks [2,3]. The patient's history presents a compelling possibility of a previous systemic infection of Salmonella prior to presentation that could have seeded her kidney transplant leading its destruction via abscess. Although full sero typing was not completed, O antigen reactivity did not indicate it was from one of the common subspecies found on surveillance data. Successful treatment included systemic antibiotics with percutaneous drainage. This case report details the rare possibility of a systemic Salmonella infection seeding and destroying a failed kidney graft with subsequent management. Case Presentation53-year-old Jamaican woman with history of hypertension, diabetes mellitus type 2 and end-stage renal disease presented to an outside hospital in December 2013. The patient was admitted with altered mental status, fevers, abdominal pain, fatigue and anorexia ongoing for two months, but without diarrhea. Her graft history dates to 2007 after receiving a deceased donor kidney transplant but failed after graft rejection and resumed hemodialysis in February 2013. Her remaining immunosuppression at time of presentation was prednisone. After resuscitation, she recovered mental status, but abdominal pain persisted which prompted imaging with an MRI showing a fluid collection and air pockets in the right lower quadrant of the abdomen, abutting the right psoas muscle. The patient was started on vancomycin at that time due to concern for Staphylococcus aureus. CT guided abscess drainage on day 5 of hospitalization retrieved 20mL of purulent material that was sent for gram stain and culturing. Gram stain showed 5-10 WBCs (1+) and rare 1-2 gram positive cocci per slide; however, despite no gram negative rods in the smear, few colonies of Salmonella grew from automated aerobic cultures on proprietary media. The patient was changed to ciprofloxacin 200mg BID IV on approximately day 8 th based on Salmonella sensitivities. She was a febrile for the remainder of her hospital course. Final sero typing on day 16 indicated Salmonella enterica subspecies sero type Group O: 47, 48, or 50. Unfortunately due to time and outs...