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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 166-169

Salmonella typhi septic sacroiliitis in a young Nigerian


1 Department of Medicine, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna State, Nigeria
2 Department of Radiology, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna State, Nigeria

Date of Submission20-Mar-2016
Date of Acceptance24-Aug-2016
Date of Web Publication19-Sep-2016

Correspondence Address:
Abdul Aziz Umar
Department of Internal Medicine, Ahmadu Bello University Teaching Hospital, PMB 06, Shika-Zaria, Kaduna State
Nigeria
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DOI: 10.4103/2384-5147.190863

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  Abstract 

Although infections are important cause of joint pathology in the tropics, Salmonella typhi rarely contributes significantly to this, with joint infection amounting to only 1% of its clinical manifestation. Infection of the sacroiliac joint is rare and mostly due to staphylococcal, streptococcal, and Pseudomonas species. Few cases of S. typhi septic sacroiliitis have been reported in literature. A rare case of sacroiliitis due to S. typhi in a young Nigerian is herein reported to heighten index of suspicion.

Keywords: Sacroiliitis, Salmonella typhi, septic


How to cite this article:
Umar AA, Ahmed M S, Tuko M T, Usman B O. Salmonella typhi septic sacroiliitis in a young Nigerian. Sub-Saharan Afr J Med 2016;3:166-9

How to cite this URL:
Umar AA, Ahmed M S, Tuko M T, Usman B O. Salmonella typhi septic sacroiliitis in a young Nigerian. Sub-Saharan Afr J Med [serial online] 2016 [cited 2019 Oct 16];3:166-9. Available from: http://www.ssajm.org/text.asp?2016/3/3/166/190863


  Introduction Top


Typhoid fever is a feco-oral infection caused by  Salmonella More Details typhi. Sixteen million cases of typhoid fever occur globally, resulting in 600,000 deaths. [1] The burden of disease is particularly high in the tropics and subtropics where the disease is endemic and poses a public health problem, with an estimated annual incidence of 540/100,000 population. [2] Poor personal hygiene, lack of safe drinking water, inadequate sanitary facilities, and the usage of untreated human excreta as local manure are factors that contribute to high disease burden in the tropics.

Septic arthritis is an inflammatory condition of the joint due to invasion by infective organism. Infective agents are a significant cause of joint pathology in the tropics. [3] Pathogens can gain access to the joint space via any of the following routes-hematogenous spread, lymphatic channels, from adjacent osteomyelitis or from joint penetration (iatrogenic or posttraumatic). The organisms that commonly cause septic arthritis are Staphylococcus aureus, streptococcal species, and Pseudomonas aeruginosa; the later occurring more commonly in intravenous drug abusers. [4] Pyogenic infection of the sacroiliac joints occurs less commonly compared to the peripheral joints, and when it occur, similar organisms are responsible. [4] S. typhi septic sacroiliitis is uncommon, with only few cases reported in the literatures. [5],[6],[7]] Localized bone and joint infections complicates <1% of all Salmonella infection, [8] and are more likely to occur in patients with background immune paresis due to human immunodeficiency virus (HIV) infection, systemic lupus erythematosus, sickle cell anemia, or those on immunosuppressive therapy. [3],[9],[10] Only few cases of S. typhi sacroiliitis have been observed in apparently healthy individuals. [5],[6],[7]] A case report of S. typhi sacroiliitis is presented herein because of its rarity and relevant literature search done.


  Case report Top


A 20-year-old male, day-secondary school student, presented to our hospital with 12 days history of high-grade fever associated with chills and rigors and a global throbbing headache, with no specific periodicity and had no meningeal symptoms. He had constipation for 3 days at the onset of his symptoms, which was succeeded by the passage of nonmucoid, nonbloody diarrheal stools and associated with vague, generalized abdominal pain, but no abdominal distension. He had generalized weakness at presentation but had no cardiopulmonary or genitourinary symptoms. The patient eats out during school hours. There were no similar symptoms in the patient's close contacts.

Physical examination revealed an acutely ill young patient who was restless, pale, dehydrated and febrile (38.9°C). He had no significant lymphadenopathy. His pulse rate was 120 beats/min, blood pressure was 120/70 mmHg, with a rapid 1 st and 2 nd heart sounds. He had paraumbilical tenderness on abdominal examination.

He was admitted as a suspected case of typhoid fever, and he presented with a high titer widal test result (H-1/64, O-1/64), done a day before presentation. He was started on intravenous amoxicillin 500 mg 8 hourly on the day of admission.

Two days into admission, he complained of the left hip/gluteal pain which was severe enough to limit his ambulation. He had no symptoms in other joints, no known history of contact with animals, and no precedent trauma. The patient was not previously diagnosed with arthritis or uveitis and not known to have sickle cell disease. He does not use recreational drugs.

He was febrile (38.4°C), had left sacroiliac compression and distraction tenderness, global restriction of his left hip range of motion, a positive flexion, abduction, external rotation sign, and the left antalgic gait.

A presumptive diagnosis of the left sacroiliitis complicating S. typhi sepsis was made, and on account of suspected sacroiliac joint affectation had his antibiotic changed to intravenous levofloxacin 500 mg daily, on the 3 rd day of admission. The patient had investigations done with results as follows: Packed cell volume (PCV) =20%, total white blood cell count = 7.8 × 10 9 /L, (neutrophil - 89%, lymphocytes - 10%, and eosinophils - 01%). Paired S. typhi serology done a week apart showed positive and rising titer (1 st sample - H titer >1:64, O titer >1: 64), (2 nd sample - H titer > 1: 128, O titer >1: 128). Urine and stool cultures for salmonella were negative; blood culture was positive for S. typhi with sensitivity to ciprofloxacin, ceftriaxone, and cefixime. Erythrocyte sedimentation rate (ESR) was 56 mm/h. Serologic screening for HIV and  Brucella More Details were negative, and hemoglobin electrophoresis showed AA genotype. The patient had normal urea and electrolyte and a random blood sugar of 4.8 mmol/L. His chest radiograph and abdominal ultrasound were unremarkable.

Sacroiliac radiograph revealed haziness of the left iliac bone, with loss of subcortical line, erosion, and pseudowidening of the left sacroiliac joint space [Figure 1].
Figure 1: Sacroiliac joint radiograph showing haziness, irregularity, loss of subchondral cortex, pseudowidening, and marginal erosion of the left sacroiliac joint

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For anemia (PCV 20%), the patient was transfused with 3 unit of packed red cells. Before the report of blood culture and sensitivity, the patient was started on intravenous levofloxacin 500 mg daily due to the excellent bone penetrability of the newer generations quinolones and the favorable response among Salmonella species. He had intravenous levofloxacin 500 mg daily for 2 weeks, thereafter, oral levofloxacin was given for a further 4 weeks; in addition to analgesics, with good clinical response, as evidenced by resolution of fever, reduced hip pain, and improved ambulation. He was counseled on basic hygiene and how to prevent reinfection and was discharged after 2 weeks. At 4 th and 6 th week of follow-up, the patient continued to show remarkable clinical response as he had no hip pain and had normal range of hip joint motion at 6 th week, with an ESR of 15 mm/h.


  Discussion Top


The most common presentation of Salmonella infection is with acute fever associated with gastrointestinal symptoms (acute enteritis). However, transient primary or secondary bacteremia may occur during the disease resulting in the dissemination of the organism and the development of focal lesions in almost any organ, with or without sepsis. S. typhi infection can manifest with arthritis; with joint involvement manifesting either as a reactive (sterile) arthritis or septic (pyogenic) arthritis. [7],[9]

S. typhi reactive arthritis is reported as usually occurring 1-4 weeks post infection, presenting as asymmetrical oligoarthritis, with predilection for the joints of the lower extremities, and mucocutaneous manifestation (cervicitis, conjunctivitis, and uveitis). [11],[12] Patients that develop S. typhi reactive arthritis are usually human leukocyte antigen B27 antigen positive, (50%-70%). [11],[12]

S. typhi septic sacroiliitis occurs less frequently, tends to affect adolescents and young adults and has predilection for the left sacroiliac joint. [13] The mean age at presentation of patients with typhoid sacroiliitis is said to be 18.8 years, [10] with no gender predilection. The index patient falls into the age group that is most commonly affected. Most patients affected usually have preceding gastrointestinal upset, with articular symptoms developing during the febrile period in all patients. [6],[7],[10] Clinical presentation is usually with fever, hip and/or gluteal pain, difficulty with ambulation, limping, with marked tenderness over the sacroiliac joint. [6],[7],[10] Most reported cases of S. typhi sacroiliitis had pulse-temperature dissociation at presentation (positive Faget's sign). [7],[10],[13] Our patient had significant tachycardia; this could be as a result of his presentation with severe anemia.

All reported cases of S. typhi sacroiliitis had high titer widal test, and positive culture for S. typhi (blood and or joint aspirate) and an elevated ESR for age. [6],[7],[10],[13]

Pelvic radiograph in patients with septic arthritis is usually normal at presentation, [5],[6],[7]],[9] with changes only becoming apparent within days to 2 weeks of onset of pyogenic arthritis. [14] Hence, the reliance on radionuclide bone scan and of recent, computerized tomography (CT) scan, or magnetic resonance imaging (MRI) in detecting early joint changes. [6],[7],[10] Where available and affordable, sacroiliac CT scan and MRI are now the modalities of choice in detecting early changes in the sacroiliac joint. [6],[7],[13] We were unable to do sacroiliac MRI or CT scan on the patient due to financial constraints.

The index case had a pelvic radiograph that showed features of the left sacroiliitis [Figure 1]. Although radiographic changes are uncommon in early pyogenic sacroiliitis, late or delayed presentation could allow enough time for changes to manifest. Plain radiograph features in septic sacroiliitis range from normal (most cases), haziness, irregularity, loss of subchondral cortex, widening of the sacroiliac joint space to frank erosion. [15] Radiographic changes usually start from the iliac portion of the sacroiliac joint as the sacral aspect is covered with a thick articular cartilage.

We upheld the diagnosis of septic arthritis because of the pattern of the patient's presentation: Monoarticular arthritis of the sacroiliac joint, occurrence of joint symptoms during the febrile period, positive blood culture for S. typhi, absence of mucosal affectation, and the patient's good response to antibiotics therapy.

The patient had favourable response to levofloxacin which was given intravenously for 2 weeks before switching to oral levofloxacin for 4 weeks. Previous reports have also pointed to good response to quinolones or 3 rd generation cephalosporins. [7],[13] Duration of treatment in studies ranged from 4 to 6 weeks, split into 1-2 weeks of intravenous antibiotics, depending on patient's response, and a further 3-4 weeks of oral antibiotics. [9],[10] Early initiation of effective antibiotics has been reported to result in good clinical response [10] and might obviate the need for CT-guided or open sacroiliac joint drainage.


  Conclusion Top


Given that S. typhi septic sacroiliitis is uncommon, clinicians should be aware of this manifestation in patients with S. typhi infection who develop features that are consistent with sacroiliitis. Changes can be detected on plain sacroiliac, especially in late presentation and treatment with quinolones or cephalosporins are generally effective.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ivanoff B. Typhoid fever: Global situation and WHO recommendations. South East Asian J Trop Med Public Health 1995;26 Suppl 2:1-6.  Back to cited text no. 1
    
2.
Okonko IO, Soleye FA, Eyarefe OD, Amusan TA, Abubakr MJ, Adeyi AO, et al. Prevalence of Salmonella typhi among patients in Abeokuta, South-Western Nigeria. Br J Pharmacol Toxicol 2010;1:6-14.  Back to cited text no. 2
    
3.
Onyemelukwe G, Sturrock RD. Septic arthritis in Northern Nigeria. Rheumatol Rehabil 1979;18:13-7.  Back to cited text no. 3
    
4.
Vyskocil JJ, McIlroy MA, Brennan TA, Wilson FM. Pyogenic infection of the sacroiliac joint. Case reports and review of the literature. Medicine (Baltimore) 1991;70:188-97.  Back to cited text no. 4
    
5.
Oka M, Möttönen T. Septic sacroiliitis. J Rheumatol 1983;10:475-8.  Back to cited text no. 5
    
6.
Alsoub H. Sacroiliitis due to Salmonella typhi: A report of two cases. Ann Saudi Med 1997;17:331-3.  Back to cited text no. 6
    
7.
Avcu S, Mentes O, Bulut MD, Sünnetçioglu M, Karahocagil MK. Sacroiliitis due to Salmonella typhi: A case report. N Am J Med Sci 2010;2:208-10.  Back to cited text no. 7
    
8.
Hook EW. Salmonella species (including typhoid fever). In: Mendel GL, Douglas RG, Bennett JE, editors. Principles and Practice of Infectious Diseases. Edinburgh: Churchill Livingstone; 1990. p. 1700-10.  Back to cited text no. 8
    
9.
Al Afraj A, Hassan N. Salmonella sacroilitis in a patient with systemic lupus erythematosus. Bahrain Med Bull 1995;17:83-5.  Back to cited text no. 9
    
10.
Ulug M, Celen MK, Geyik MF, Hosoglu S, Ayaz C. Sacroiliitis caused by Salmonella typhi. J Infect Dev Ctries 2009;3:564-8.  Back to cited text no. 10
    
11.
Carter JD. Reactive arthritis: Defined etiologies, emerging pathophysiology, and unresolved treatment. Infect Dis Clin North Am 2006;20:827-47.  Back to cited text no. 11
    
12.
Petersel DL, Sigal LH. Reactive arthritis. Infect Dis Clin North Am 2005;19:863-83.  Back to cited text no. 12
    
13.
Garg B, Madan M, Kumar V, Malhotra R. Sacroiliitis caused by Salmonella typhi: A case report. J Orthop Surg (Hong Kong) 2011;19:244-6.  Back to cited text no. 13
    
14.
William RG. Bacterial septic arthritis. In: Sterling GW, (editor) Rheumatology secrets. Philadelphia: Henley and Belfus Inc; 2002. p. 281-9.  Back to cited text no. 14
    
15.
George GB. Infectious arthritis. In George GB, John AA, Frank BV (editors). Imaging of Arthritis and related conditions. Philadelphia: Lippincott Williams and Wilkins; 2001. p. 190-209.  Back to cited text no. 15
    


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