Paratyphoid Sepsis V.S. Randhawa1, Ajay Kumar2, Arvind Saili2, Vikram Datta2, Charu Agrawal1 and Geeta Mehta1 2 Department of Pediatrics, 1Department of Microbiology, Lady Hardinge Medical College & associated Kalawati Saran Children Hospital, New Delhi
ABSTRACT A large for gestational age male baby was born to a healthy young primigravida, on L-thyroxime, at 40 weeks by caesarean delivery in a tertiary care hospital. The baby had episodes of hypoglycemia during his immediate four postnatal days in the nursery that were successfully managed with intravenous glucose administration. The baby became unwell on day 5 and had a positive sepsis-screening test. Blood culture revealed a multidrug susceptible S. Paratyphi A strain, which he probably acquired on the first or second postnatal day from the contaminated expressed breast milk or the formula feed. [Indian J Pediatr 2007; 74 (2) : 197-198] E-mail : [email protected]
Key words : Sepsis; S. paratyphi A; Paratyphoid
CASE REPORT A male baby weighing 4 Kg (large for gestational age) was born to a 23-year-old primigravida at 40 weeks by caesarean delivery at Lady Hardinge Medical College, New Delhi. The Apgar score of the newborn at 1, 5, and 10 mins was 9, 9, and 9 respectively. The indication for caesarean was a good-sized baby with borderline maternal pelvis. The mother had history of hypothyroidism and was on L- thyroxine. Her pregnancy was uneventful except that she was diagnosed as gestational diabetic three days prior to delivery. Her blood sugar was controlled by diet only. The mother’s family belonged to a lower middle socio-economic status and lived in a congested locality of New Delhi. There was no recent history of diarrhea or fever in family members or close contacts. The male baby was admitted to nursery for monitoring of blood glucose. The new born developed hypoglycemia (20 mg%) at half hour of age, for which intravenous bolus of ten percent glucose was given; followed by glucose infusion at the rate of 6 mg/Kg/min. The newborn remained healthy till about second day (26 hrs) of life, when he had another episode of hypoglycemia; which again required intravenous glucose bolus plus an increase in the glucose infusion rate to 8 mg/Kg/min. Due to this, his oral feeds were omitted. Subsequently; his stay at the nursery was uneventful and so on day 4 was initiated
Correspondence and Reprint requests : Dr. V.S. Randhawa, Department of Microbiology, Lady Hardinge Medical College, New Delhi 110001.
Indian Journal of Pediatrics, Volume 74—February, 2007
with formula feeds and expressed breast milk. On day five he became unwell, sluggish and refused oral feeds. His blood was sent for culture, sepsis screen and simultaneously intravenous Ofloxacin and Amikacin were started. The CSF examination done at this stage was within normal limits but low counts of blood leucocytes (4540/cu.mm.) and platelets (79X10 3/cu.mm.) with an increased C-reactive protein levels [>24 µg/dl] indicated a positive sepsis screen test. In view of maternal hypothyroidism, a thyroid profile of the neonate was performed; which was within normal limits. The blood culture showed growth of Salmonella species. His condition continued to improve and the antibiotics were continued. On day seven, the formula feeds and expressed breast milk was restarted. Serotyping was performed on the bacterial isolate and it was identified as Salmonella enterica serotype Paratyphi A in the National Salmonella Phage Typing Laboratory of Lady Hardinge Medical College. Antimicrobial susceptibility of the isolate was performed by NCCLS method (Disc Diffusion method) and the strain was found to be sensitive to all the antibiotics tested, namely, Trimethoprim-Sulfamethoxazole, Cefotaxime, Ciprofloxacin, Gentamicin, Ampicillin, Chloramphenicol, Amikacin and Ofloxacin. The MIC of the strain to Ciprofloxacin, detected with E- test (AB BIODISK), was found to be 0.5 µg/ml. The reference strain used for the tests was E. coli ATCC 25922. Other samples cultured in view of the newborn blood revealing S. Paratyphi A, such as neonate’s urine & stool and mother’s blood, stool & milk, didn’t yield any significant growth. The newborn received the antibiotics for 10 days and was discharged subsequently. The neonate was thriving well on follow up at 1 month. 197
V.S.Randhawa et al DISCUSSION Sepsis remains a significant cause of morbidity & mortality in newborns especially in the developing countries 1 . This is the first report of a Salmonella Paratyphi A sepsis in a neonate. There has been a report of S. Paratyphi A causing meningitis in a 10-day-old breast-feeding baby in north Pakistan but the organism couldn’t be isolated from the blood.2 Other Salmonellae as S. Typhimurium, S. Anatum, S. Senftenberg, and S. Newport have already been incriminated as pathogens in neonatal sepsis. Clinically, the picture of enteric fever in this case was like that of any other sepsis in the newborn. The newborn in this study is likely to have acquired the infection on the first or second postnatal day. The incubation period of Paratyphoid fevers is less than in Typhoid fever and may be so short so as to lead to a suspicion of food poisoning.3, 4 The source of this infection couldn’t be ascertained despite infection surveillance activity of the health personnel and environment, including the labor room, where the mother delivered and the nursery, where the baby was admitted. Stool culture of the health personnel of the nursery didn’t yield growth of any pathogens. However, this test couldn’t be done on the family members having attended the mother and baby due to non- compliance. The organism may have gained access to the expressed milk or formula feed from hands of an infected family person or contamination of the milking utensil. S. Paratyphi A infections are on the rise these days.5,6 These may be attributed to the selective usage of the S. Typhi vaccine [Ty 21a or Vi]. The use of the combined acetone killed vaccine of the past, as T.A. [having S.
Typhi, S. Paratyphi A], is on the decline. Drug resistant S. Paratyphi A is on the rise, however in this case the isolate was sensitive to multiple drugs7. Due to the increasing incidence of multidrug resistant S. Paratyphi A, this infection must be as judiciously treated; as we treat S. Typhi infections.8 REFERENCES 1. Baltimore RS. Perinatal bacterial and fungal infections. In Jenson HB & Baltimore RS, eds. Pediatric Infectious Diseases- Principles & Practice. 2nd edn; 2002. 1119-1134. 2. Bhutta ZA, Farooqui BJ, Sturm AW. Eradication of multiple drug resistant Salmonella Paratyphi A causing meningitis with Ciprofloxacin. J Infect 1992; 25(2): 215-219. 3. Sillkier JH and Gabis DA. Salmonellosis. In Balows A, Hausler WJ, Ohashi M and Turano A, eds. Laboratory diagnosis of infectious diseases- Principles and Practice. Vol 1, Springer Verlag; 1988; 448-465. 4. MF Parker. Enteric infections: Typhoid and Paratyphoid fever. In Smith GR, Easmon CSF, eds. Topley and Wilson’s Principle of bacteriology, Virology and Immunology. 8th edn. Vol 3 (Bacterial diseases). Edward Arnold, 1990; 423- 446. 5. Mendiratta DK, Deokale V. Enteric fever due to Salmonella Paratyphi A- an emerging problem. Indian J Med Microbiol 2004; 22(3) : 196. 6. Walia M, Gaind R, Mehta R, Paul P, Aggarwal P, Kalaivani M. Current perspectives of enteric fever: a hospital based study from India. Ann Trop Paediatr 2005; 25(3) : 161-174. 7. Sekar U, Srikanth P, Kindo AJ, Babu VP, Ramasubramaniam V. Increase in minimum inhibitory concentration to Quinolones and Ceftriaxone in Salmonellae causing enteric fever. J Commun Dis 2003; 35(3) : 162- 169. 8. Renuka K, Kapil A, Kabra SK, Wig N, Das BK, Prasad VV, Chaudhary R, Seth P. Reduced susceptibility to Ciprofloxacin and gyrase gene mutation in North Indian strains of Salmonella enterica serotype Typhi and serotype Paratyphi A. Microb Drug Resist 2004; 10(2) : 146-153.
Indian Journal of Pediatrics, Volume 74—February, 2007