CASE 19

A 48-year-old man presents to the emergency room with 2 days of crampy

abdominal pain, nausea, vomiting, diarrhea, and fever.
He has not had any blood in his stool. He denies contact with anyone with similar
symptoms recently. He has not eaten any raw or unprocessed foods recently. The
only food that he did not prepare himself in the past week was a breakfast of eggs
sunny-side up and bacon that he had at a diner the day before his symptoms
started.
On examination, he is tired appearing; his temperature is 37.7C (99.9F); and his
heart rate is 95 beats per minute while he is lying down, but it increases to 120 beats
per minute when he sits up. His blood pressure is 145/85 mm Hg while lying down
and 110/60 mm Hg when sitting. The physician interprets this as a positive tilt
test, indicating significant volume depletion.
His mucous membranes appear dry. His abdominal exam is notable for diffuse
tenderness but no palpable masses, rebound, or guarding. A rectal exam reveals only
heme-negative watery stool.

What is the most likely etiologic agent of this infection?

What are the most common sources of human infections with this organism?
ANSWERS TO CASE 19
Salmonella AND Shigella
Summary: A 48-year-old man with acute gastroenteritis has fever, a positive tilt test,
abdominal pain, and diarrhea after eating eggs a day before.

Most likely etiology of infection: Salmonella

Most common sources of infection: Undercooked poultry, eggs, dairy products,

or foods prepared on contaminated work surfaces

CLINICAL CORRELATION
This individual has the acute onset of diarrhea and vomiting. The first priorities as
with any patient are the ABCs: airway, breathing, circulation. Circulatory status is

assessed by monitoring the pulse rate and blood pressure, which may be normal at
rest, but abnormal on changing of position.
This patient had a rise in 10 beats per minute heart rate from the lying to the sitting
position, and a fall of 10 mm Hg of blood pressure. This constitutes a positive tilt
test and may indicate a volume depletion of 1025 percent. Thus, the first
therapeutic goal would be volume repletion, such as with intravenous normal saline.
In humans, most cases of nontyphoidal Salmonella result from ingesting
contaminated food products. Poultry, eggs, dairy products, or other foods prepared
on contaminated work surfaces are the most common sources. Fecal-oral spread is
common among children. Live animals, especially exotic pets such as reptiles, have
also been identified as sources of infection.
Host gastric acid is a primary defense against the organism, and conditions or
medications that reduce gastric acidity may predispose to infection. The primary site
of invasion of Salmonella is the M (microfold) cells in the Peyers patches of the
distal ileum. M cells internalize and transfer foreign antigens from the intestinal
lumen to macrophages and leukocyte. The infection can then spread to adjacent cells
and lymphoid tissue. Host inflammatory responses usually limit the infection to the
gastrointestinal (GI) tract, but bacteremia can occur. Bacteremia is more common in
the children, elderly patients, or those with immune deficien- cies, such as AIDS.
Gastroenteritis is the most common clinical manifestation of Salmonella infection.
Nausea, vomiting, nonbloody diarrhea, fever, and abdominal cramps starting 848
hours after ingestion of contaminated food are typical. The illness is generally
selflimited and will last from 2 to 7 days.
Enteric fever, or typhoid fever, is a more severe form of gastroenteritis with
systemic symptoms that are caused by either Salmonella typhi or Salmonella
paratyphi. Symptoms include chills, headache, anorexia, weakness, and muscle
aches; and later fever, lymphadenopathy, and hepatosplenomegaly; and in a third of
patients a maculopapular rash (rose spots). Symptoms persist for a longer period of
time than nontyphoidal gastroenteritis as does the carrier state in a small percentage
of infected patients.
Gastroenteritis caused by Salmonella can mimic the signs and symptoms of other
forms of infections such as Shigella.
Infection with Shigella produces predominantly diarrhea, sometimes grossly bloody
as a result of invasion of the mucosa. The infection is also usually selflimited;
however, dehydration can occur if diarrhea is severe.

APPROACH TO SUSPECTED
Salmonella AND Shigella INFECTION
Objectives
1. Know the structure, characteristics, and clinical diseases associated with
salmonella. 
2. Know the virulence, epidemiology, and pathogenesis of salmonella infections. 
3. Know the structure, characteristics, and clinical diseases associated with shigella. 
4. Know the virulence, epidemiology, and pathogenesis of shigella infections. 

Definitions
Rose spots: Papular rash usually on the lower trunk leaving a darkening of the skin,
characteristic of typhoid fever.
Fecal leukocytes: White blood cells found in the stool, nonspecific finding of an
invasive process.
Hepatosplenomegaly: Enlargement of both the liver and the spleen which can be a
feature of many diseases, including typhoid fever.

DISCUSSION
Characteristics of Salmonella and Shigella
Salmonella are motile, facultative anaerobic, nonspore-forming, gram- negative
bacilli that are part of the family Enterobacteriaceae. The genus Salmonella consists
of more than 2400 serotypes capable of infecting almost all animal species.
However, S. typhi and S. paratyphi only colonize humans. Salmonella is protected
from phagocytic destruction by two mechanisms: an acid tolerance response
gene, which protects it both from gastric acid and from the acidic pH of the
phagosome, and Salmonella-secreted invasion pro- teins (Sips or Ssps). These
rearrange M-cell actin, resulting in membranes that surround and engulf the
Salmonella and enable intracellular replication of the pathogen with subsequent host
cell death.
Shigella is a nonmotile gram-negative bacilli that is also part of the fam- ily
Enterobacteriaceae. There are 40 serotypes of Shigella that are divided into four
groups or species, based on biochemical reactivity. Shigella dysenteriae is group A,

Shigella flexneri is group B, Shigella boydii is group C, and Shigella sonnei is group
D. Virulence mechanisms of Shigella include their ability to invade the intestinal
mucosa and production of shiga toxin, which acts to destroy the intestinal mucosa
once the organism has invaded the tissue. Some strains of Escherichia coli are
closely related to Shigella species and are also capable of producing shiga toxin.

Diagnosis
The diagnosis of gastroenteritis is based on the patients age, risk factors, exposures,
and symptoms. Collection of stool and blood cultures, if fever and other systemic
symptoms are present, is necessary for the definitive diagnosis. A direct exam for
fecal leukocytes and occult blood may initially help narrow down the differential
diagnosis. For example, blood in the stools usu- ally indicates invasive bacterial
infection. In cases of bacterial gastroenteritis, final diagnosis is made by culture of
the stool for enteric pathogens such as Campylobacter, Shigella, and Salmonella.
Although culture of Campylobacter requires specialized media and incubation
conditions, both Salmonella and Shigella grow rapidly on routine microbiologic
media. Because of the fact that stool contains many organisms that are normal flora,
stools are also cultured onto selective media to aid in more rapid diagnosis.
Both Salmonella and Shigella are nonlactose fermenters that appear as clear colonies
on MacConkey agar. The use of a medium that contains an indicator for production
of H2S helps differentiate the two genera. Shigella does not produce H2S and
appears as clear or green colonies on a media such as Hektoen enteric (HE)
agar, whereas Salmonella appears black as a result of production of H2S. This is
only presumptive and further biochemical testing needs to be performed because
other organisms also produce black colonies on HE agar. The diagnosis of Shigella
can also be made by testing for Shiga toxin directly in the stool. This cannot
differentiate Shigella from the entero- hemorrhagic E. coli that also produce shiga
toxin and are associated with hemolytic uremic syndrome.

Treatment and Prevention

Nontyphoid Salmonella gastroenteritis is usually not treated because it is a
selflimited disease, and antibiotics have not been shown to alter the course of the
infection. Primary treatment should be supportive including fluid replace- ment if
necessary.
Antibiotic treatment is recommended for treatment of bacteremia, long-term
carriers, or typhoid fever. Amoxicillin, sulfamethoxazole and trimethoprim (SMXTMP), or, in areas where antibiotic resistant strains are prevalent (India, Asia and
Africa), quinolones can be used. The specific choice of antimicrobial agent should
be based on susceptibility testing of the patients isolate.

In the case of infection caused by Shigella, antibiotic therapy has been shown to
be useful, especially in the prevention of person-to-person spread of the disease.
Quinolones can also be used to treat, although Shigella therapy should be based on
antimicrobial susceptibility testing of the isolate.
Prevention of disease caused by enteric pathogens is based on control of the
contaminated source in the environment and good personal hygiene. The thorough
cooking of poultry and cooking eggs until the yolk is hard can kill Salmonella and
prevent infection. A vaccine does exist for prevention of typhoid fever, which is
useful for travelers to endemic areas of the world. The efficacy of the vaccine is
thought to be between 50 and 80 percent.

COMPREHENSION QUESTIONS
1. In which of the following sites is S. typhi most likely to be found dur- ing the
carrier state? A
 . BloodB. Gallbladder C. KidneyD. LiverE. Spleen 
2. A 4-year-old has fever and diarrhea. Blood culture grows a gram- negative rod.
This is most likely to be which of the following? A
 . Group B Streptococcus
B. Listeria speciesC. Salmonella speciesD. Shigella species 
3. Whichofthefollowingisafrequentcauseofosteomyelitisinpatients with sickle cell
anemia? A
 . Group A StreptococcusB. Group B StreptococcusC. Salmonella
speciesD. Streptococcus pneumoniae 
4. Which of the following is mismatched?

a. Ecthyma gangrenosum Pseudomonas aeruginosa 

b. Halophilic Salmonella typhi 
c. K1 antigen neonatal meningitis caused by Escherichia coli 
d. Red pigment Serratia marcescens 
e. Severe dehydration Vibrio cholerae