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Non-typhoid salmonella septic arthritis in dual living liver transplant recipient: a case report.

Choi KM, Park CS, Song GW, Lee SG - Korean J Hepatobiliary Pancreat Surg (2014)

Bottom Line: In some patients, however, this arthritis spears to be chronic in nature.We describe herein a living-donor liver transplant recipient who experienced non-typhoid Salmonella-triggered arthritis in the left hip.The patient recovered uneventfully after 6-month-long antibiotics treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.

ABSTRACT
Non-typhoid salmonellosis is an infectious disease caused by Salmonella species other than Salmonella typhi. Although the usual clinical course of non-typhoid salmonellosis is a benign self-limiting gastroenteritis, these bacteria are especially problematic in immunocompromised individuals, including patients with malignancies, human immunodeficiency virus, or diabetes, and those receiving corticosteroids or other immunotherapy agents. In addition to enteric symptoms, Salmonella species give rise to extra-intestinal complications, including self-limiting arthritis, which appears 1 to 3 weeks after the onset of infection and lasts from a few weeks to several months. In some patients, however, this arthritis spears to be chronic in nature. We describe herein a living-donor liver transplant recipient who experienced non-typhoid Salmonella-triggered arthritis in the left hip. The patient recovered uneventfully after 6-month-long antibiotics treatment. Clinicians involved in transplantation should be aware of the possibility that transplant recipients, like other immunocompromised individuals, are at risk of salmonellosis and therefore require careful clinical and microbiological evaluation, with the goals of prevention and early recognition of infection.

No MeSH data available.


Related in: MedlinePlus

(A) Left Hip MRI 3 weeks after admission, showing slightly improved myositis and decreased joint effusion (arrow). (B) Left hip MRI after 6 months of antibiotic treatment, showing markedly improved myositis and abscess (arrow).
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Figure 2: (A) Left Hip MRI 3 weeks after admission, showing slightly improved myositis and decreased joint effusion (arrow). (B) Left hip MRI after 6 months of antibiotic treatment, showing markedly improved myositis and abscess (arrow).

Mentions: A 47-year-old man underwent a dual living-donor liver transplantation, consisting of the right lobe from his wife and the left lobe from his brother, due to hepatitis B, liver cirrhosis and hepatocellular carcinoma in February 2010. Postoperatively, he was treated with tacrolimus (initially 0.025 mg/kg/day intravenous injection switched into 3.5 mg per oral administration (per os) twice a day) and methyl prednisolone (initially 50 mg intravenous injection, every 6 hours switched into 12 mg per os twice a day). The serum level of tacrolimus was adjusted to 14.6 ng/ml (normal range, 5-20 ng/ml) and his graft function was excellent. He discharged in stable condition of day 24 with immunosuppressants (Tacrobel® 3.5 mg and methylon® 12 mg, twice a day), acyclovir (Zovirax® 200 mg, once a day) and trimethoprim-sulfamethoxazole (400 mg-80 mg, Septrin® 2 tablets, every other day) to prevent rejection and infection. One week after discharge, he presented at the emergency room with a high fever (39.1℃), watery diarrhea, severe pain and stiffness in the left hip for 4 days. Blood tests showed hemoglobin 11 g/dl, leukocyte count 4,400/mm3, platelet count 71,000/mm3 and normal liver function test but C-reactive protein (CRP) concentration was 4.39 mg/dl. Blood cultures yielded group D Salmonella, which was sensitive to ampicillin, cefixime, and ceftriaxone, and resistant to quinolone. The patient had no joint problems preoperatively. Bilateral hip joint magnetic resonance imaging (MRI) revealed pyomyositis involving the left iliopsoas and external obturator muscles with abscesses in the iliopsoas muscle as well as diffuse synovial enhancement with increased joint effusion in the left hip joint (Fig. 1). Subsequent culture of synovial fluid from the left hip joint revealed no bacterial growth. He was treated empirically with intravenous ceftriaxone 2 g per day and all immunosuppressive agents were stopped for 3 days. Over the next 10 days of intravenous antibiotic treatment, his diarrhea and fever resolved, but pain and limited range of movement of the left hip continued. Three weeks later, follow-up MRI showed that the abscesses in his muscles had decreased but myositis was still present. Diffuse synovial thickening had progressed but the amount of joint effusion had decreased in the left hip (Fig. 2A). He was maintained on intravenous antibiotics for an additional 3 weeks, following which he was switched from intravenous ceftriaxone to oral cefixime 400 mg per day and sulfamethoxazole-trimethoprim (400 mg/80 mg) 2 tablets per day. After 5 weeks of antibiotic treatment, his joint pain improved progressively and he discharged with a further antibiotic treatment plan for a total of 6 months. An additional MRI, performed after 6 months of antibiotic therapy, revealed myositis and arthritis were markedly improved (Fig. 2B). Six months following his infection, his left hip had clinically improved. He had no joint disability and his graft function has remained stable for 22 months after liver transplantation.


Non-typhoid salmonella septic arthritis in dual living liver transplant recipient: a case report.

Choi KM, Park CS, Song GW, Lee SG - Korean J Hepatobiliary Pancreat Surg (2014)

(A) Left Hip MRI 3 weeks after admission, showing slightly improved myositis and decreased joint effusion (arrow). (B) Left hip MRI after 6 months of antibiotic treatment, showing markedly improved myositis and abscess (arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4492329&req=5

Figure 2: (A) Left Hip MRI 3 weeks after admission, showing slightly improved myositis and decreased joint effusion (arrow). (B) Left hip MRI after 6 months of antibiotic treatment, showing markedly improved myositis and abscess (arrow).
Mentions: A 47-year-old man underwent a dual living-donor liver transplantation, consisting of the right lobe from his wife and the left lobe from his brother, due to hepatitis B, liver cirrhosis and hepatocellular carcinoma in February 2010. Postoperatively, he was treated with tacrolimus (initially 0.025 mg/kg/day intravenous injection switched into 3.5 mg per oral administration (per os) twice a day) and methyl prednisolone (initially 50 mg intravenous injection, every 6 hours switched into 12 mg per os twice a day). The serum level of tacrolimus was adjusted to 14.6 ng/ml (normal range, 5-20 ng/ml) and his graft function was excellent. He discharged in stable condition of day 24 with immunosuppressants (Tacrobel® 3.5 mg and methylon® 12 mg, twice a day), acyclovir (Zovirax® 200 mg, once a day) and trimethoprim-sulfamethoxazole (400 mg-80 mg, Septrin® 2 tablets, every other day) to prevent rejection and infection. One week after discharge, he presented at the emergency room with a high fever (39.1℃), watery diarrhea, severe pain and stiffness in the left hip for 4 days. Blood tests showed hemoglobin 11 g/dl, leukocyte count 4,400/mm3, platelet count 71,000/mm3 and normal liver function test but C-reactive protein (CRP) concentration was 4.39 mg/dl. Blood cultures yielded group D Salmonella, which was sensitive to ampicillin, cefixime, and ceftriaxone, and resistant to quinolone. The patient had no joint problems preoperatively. Bilateral hip joint magnetic resonance imaging (MRI) revealed pyomyositis involving the left iliopsoas and external obturator muscles with abscesses in the iliopsoas muscle as well as diffuse synovial enhancement with increased joint effusion in the left hip joint (Fig. 1). Subsequent culture of synovial fluid from the left hip joint revealed no bacterial growth. He was treated empirically with intravenous ceftriaxone 2 g per day and all immunosuppressive agents were stopped for 3 days. Over the next 10 days of intravenous antibiotic treatment, his diarrhea and fever resolved, but pain and limited range of movement of the left hip continued. Three weeks later, follow-up MRI showed that the abscesses in his muscles had decreased but myositis was still present. Diffuse synovial thickening had progressed but the amount of joint effusion had decreased in the left hip (Fig. 2A). He was maintained on intravenous antibiotics for an additional 3 weeks, following which he was switched from intravenous ceftriaxone to oral cefixime 400 mg per day and sulfamethoxazole-trimethoprim (400 mg/80 mg) 2 tablets per day. After 5 weeks of antibiotic treatment, his joint pain improved progressively and he discharged with a further antibiotic treatment plan for a total of 6 months. An additional MRI, performed after 6 months of antibiotic therapy, revealed myositis and arthritis were markedly improved (Fig. 2B). Six months following his infection, his left hip had clinically improved. He had no joint disability and his graft function has remained stable for 22 months after liver transplantation.

Bottom Line: In some patients, however, this arthritis spears to be chronic in nature.We describe herein a living-donor liver transplant recipient who experienced non-typhoid Salmonella-triggered arthritis in the left hip.The patient recovered uneventfully after 6-month-long antibiotics treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea.

ABSTRACT
Non-typhoid salmonellosis is an infectious disease caused by Salmonella species other than Salmonella typhi. Although the usual clinical course of non-typhoid salmonellosis is a benign self-limiting gastroenteritis, these bacteria are especially problematic in immunocompromised individuals, including patients with malignancies, human immunodeficiency virus, or diabetes, and those receiving corticosteroids or other immunotherapy agents. In addition to enteric symptoms, Salmonella species give rise to extra-intestinal complications, including self-limiting arthritis, which appears 1 to 3 weeks after the onset of infection and lasts from a few weeks to several months. In some patients, however, this arthritis spears to be chronic in nature. We describe herein a living-donor liver transplant recipient who experienced non-typhoid Salmonella-triggered arthritis in the left hip. The patient recovered uneventfully after 6-month-long antibiotics treatment. Clinicians involved in transplantation should be aware of the possibility that transplant recipients, like other immunocompromised individuals, are at risk of salmonellosis and therefore require careful clinical and microbiological evaluation, with the goals of prevention and early recognition of infection.

No MeSH data available.


Related in: MedlinePlus