Bovier, P.

Girardin, F.

Hächler, H.

Mezger, N.

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Eur J Clin Microbiol Infect Dis (2006) 25: 272–274DOI 10.1007/s10096-006-0122-2BRIEF REPORTF. Girardin . N. Mezger . H. Hächler . P. A. BovierSalmonella serovar Give: an unusual pathogencausing splenic abscessPublished online: 25 March 2006# Springer-Verlag 2006Salmonella enterica subsp. enterica serovar Give is anenteric serotype frequently isolated from ruminants andpigs but rarely found in human hosts [1]. Between Apriland June 2004, an unusual increase was observed in thenumber of S. ser. Give isolates identified by severalEuropean national reference laboratories [2]. In 11countries, 103 cases were detected, and only a minorityof these infections was related to travel. Further Europeandata suggest a recent increase in the prevalence andpathogenicity of S. ser. Give. For example, from March toJuly 2004, 115 cases of gastroenteritis caused by S. ser.Give were identified in Germany and these were mainlyresponsible for the increased number of cases reported inthe Enter-net data of the international surveillance networkfor enteric infections during the second quarter of 2004 [3].This nationwide outbreak was strongly associated withhuman consumption of raw minced pork (OR, 8.0; 95%CI,2.3–27.7; p=0.001), and common outbreak strains wereisolated from patients and pork samples. Compared topatients infected by S. ser. Enteritidis, the most commonserovar in Germany, infections caused by S. ser. Give led toa higher hospitalization rate in patients older than 60 years(S. ser. Give 55%, S. ser. Enteritidis 33%; OR, 2.5; 95%CI,1.1–5.4; p=0.02) [3]. The higher hospitalization rateobserved for S. ser. Give possibly indicates this serotypehas a higher virulence compared to other non-typhoidalSalmonella spp. Reported here is a clinical case of animmunocompetent patient presenting with splenic abscessdue to S. ser. Give, which was possibly associated withconsumption of raw minced meat.In March 2004, a 24-year-old Caucasian male returningfrom a vacation in southern Thailand with his family wasadmitted to our walk-in clinic with increasing fever,dyspnea and left shoulder pain. He had no medical historyof note. He had been well until February 2004, when hesuddenly developed a high fever, malaise, nausea, drycough and increasing dyspnea. He received intramuscularpenicillin G injections for 2 days without any improve-ment, then a combination of oral amoxicillin and clavulanicacid (625 mg tid) over 7 days for suspected bronchopneu-monia of the left lower lobe. Five days following initiationof the second antibiotic therapy, the patient felt better andfever disappeared. Following completion of the antibioticregimen, however, symptoms relapsed, with fever up to40°C, chills, abdominal discomfort and unbearable leftshoulder pain triggered by deep inspiration and coughing.Two days after completion of the oral regimen, the patientreturned for further investigations.Physical examination revealed a body temperature of38°C, dyspnea and polypnea (28/min), tachycardia (122/min), diffuse subcutaneous edema, dull percussion at theleft inferior thoracic base and hepatosplenomegaly. Labo-ratory tests revealed a raised C-reactive protein level(301 mg/l), leukocytosis (15×109/l) with a left shift (8%),thrombocytosis (804×109/l), hypoalbuminemia (17 g/l),and elevated liver enzymes (alanine aminotransferase 80,aspartate aminotransferase 37 U/l, gamma-glutamyl trans-peptidase 288 U/l). Chest radiographs showed a raised andthickened left diaphragm with signs of an expanding masswith air fluid level and stomach compression in the leftF. Girardin (*)Department of Community Medicine and Service of ClinicalPharmacology and Toxicology, Geneva University Hospitals,Micheli-du-Crest 24,1205 Geneva, Switzerlande-mail: francois.girardin@hcuge.chTel.: +41-22-3055397Fax: +41-22-3055309N. Mezger . P. A. BovierDepartment of Community Medicine,Geneva University Hospitals,Micheli-du-Crest 24,1205 Geneva, SwitzerlandH. HächlerNENT/NANT, Institute for Veterinary Bacteriology,University of Bern,3001 Bern, SwitzerlandPresent address:H. HächlerLeiter NENT, Institut für Medizinischen Mikrobiologie,Zentrum für Labormedizin, Kantonsspital,6000 Luzern 16, Switzerlandabdominal quadrant (Fig. 1). A splenic abscess wasconfirmed by computed tomography, which revealed ahuge hypodense mass in the spleen with gas formationdisplacing adjacent organs (Fig. 2). Considering thelocation and extent of the abscess, as well as the risk of asplenic rupture and septic complications following drain-age, splenectomy was performed.Stool and blood cultures, blood slides and serologicaltests were negative for melioidosis, malaria, amoebiasis(ELISA, 0.00 OD), and helminthiasis (ELISA, 0.00 OD fortrichinellosis, toxocariasis, Echinococcus granulosus,Echinococcus multilocularis, fascioliasis, schistosomiasis,anguilluliasis, and filariasis). Postoperative samples of thesplenic abscess were positive for S. ser. Give. The strainwas susceptible to piperacillin/tazobactam, ceftazidime,ciprofloxacin, cotrimoxazole, imipenem, gentamicin, ne-tilmicin, amikacin, nitrofurantoin, and colistin. However, italso demonstrated intermediate resistance to amoxicillin/clavulanic acid and resistance to ampicillin, ticarcillin,ticarcillin/clavulanic acid, cephalothin, chloramphenicol,kanamycin, streptomycin, spectinomycin, and tetracycline.This resistance profile could explain the unfavorablecourse of the administered antimicrobial therapy.The patient had a non-penetrating trauma as a single riskfactor: he remembered having fallen on slippery stairs andexperiencing subsequent transient pain of the left flank5 weeks before the first symptoms appeared. He alsomentioned a transient episode of non-bloody diarrhea thatoccurred around the same time following consumption ofraw minced meat. It is thus probable that intestinal S. ser.Give spread to a hematoma arising from the accident-related injury during transient bacteremia, which thencaused the splenic abscess. The patient’s left shoulder paincould be explained by the infradiaphragmatic irritation. Wepostulate that this clinical picture is a result of secondaryinfection and suppuration of the previously contusedspleen. To our knowledge, this is the first report of a caseof splenic abscess due to S. ser. Give.Splenic abscesses are more prevalent in males and inyounger age groups. Most of them are preceded byinfections elsewhere in the body, which act as a focus fordissemination of microorganisms, unless the spleen isinfected primarily through direct penetration [4, 5]. Strep-tococci and staphylococci, Escherichia coli, Bacterioidesspp, enterococci and Salmonella Typhi are frequentlycultured organisms: fungi and mycobacteria and, especiallyin Asia, Burkholderia pseudomallei are also reported tocause splenic abscess [6–9]. Immunosuppression, intrave-nous drug abuse, HIV, non-penetrating abdominal traumaand hemoglobinopathies are considered as predisposingfactors.Splenic abscess must be considered in a large number ofdifferential diagnoses, especially in febrile patients withsymptoms of polymorphic pain. Left upper quadranttenderness with fever and leukocytosis are the mostcommon clinical features. Computed tomography remainsthe gold standard and the most sensitive tool for thedefinitive diagnosis of splenic abscess [10]. Splenectomy isconsidered the treatment of choice by most authors, whilepercutaneous drainage and antimicrobial therapy can beconsidered as therapeutic alternatives for select clinicalconditions and when the pathogen has been clearlyidentified.References1. Higgins R, Desilets A, Cantin M, Messier S, Khakhria R,Ismail J, Mulvey MR, Daignault D, Caron H (1997) Outbreakof Salmonella Give in the province of Quebec. Can Vet J38:780–7812. Enter-Net. International surveillance network for the entericinfections. Salmonella, VTEC O157 and Campylobacter. http://www.hpa.org.uk/hpa/inter/enter-net_reports.htm. Cited Sept20043. Jansen A, Frank C, Prager R, Oppermann H, Stark K (2005)Bundesweiter Ausbruch durch Salmonella Give in Deutschlandim Jahr 2004 [Nationwide outbreak of Salmonella Give inGermany, 2004]. Z Gastroenterol 43:707–713Fig. 1 Chest radiograph showing signs of a prominent splenicabscess with air fluid level and stomach displacementFig. 2 Computed tomography confirming the presence of aprominent splenic abscess with air fluid level2734. Torres JR, Gotuzzo E, Isturiz R, Elster C, Wolff M, NorthlandR, Christenson B, Clara L (1994) Salmonellal splenic abscessin the antibiotic era: a Latin American perspective. Clin InfectDis 19:871–8755. Chun CH, Raff MJ, Contreras L, Varghese R, Waterman N,Daffner R, Melo JC (1980) Splenic abscess. Medicine 59:50–656. Lambotte O, Debord T, Castagne C, Roué R (2001) Unusualpresentation of typhoid fever: cutaneous vasculitis, pancreatitis,and splenic abscess. J Infect 42:161–1627. Smyrniotis V, Kehagias D, Voros D, Fotopoulos A, Lambrou A,Kostopanagiotou G, Kostopanagiotou E, Papadimitriou J(2000) Splenic abscess. An old disease with new interest. DigSurg 17:354–3578. Sangchan A, Mootsikapun P, Mairiang P (2003) Splenicabscess: clinical features, microbiologic finding, treatmentand outcome. J Med Assoc Thai 86:436–4419. Hayashi M, Yamawaki I, Okajima K, Tomimatsu M, Ohkawa S(2004) Tuberculous liver abscess not associated with lunginvolvement. Intern Med 43:521–52310. Liang JT, Lee PH, Wang SM, Chang KJ (1995) Splenicabscess: a diagnostic pitfall in the emergency department. Am JEmerg Med 13:337–343274

Salmonella serovar Give: an unusual pathogen causing splenic abscess

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Salmonella serovar Give: an unusual pathogen causing splenic abscess

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