Monomicrobial Non-Neutrocytic Bacteriascites due to Salmonella enteritidis: A Case Report and Literature Review

Abstract

Spontaneous bacterial peritonitis (SBP) is diagnosed on the basis of neutrophilic leukocytosis in peritoneal fluid. In monomicrobial non-neutrocytic bacteriascites (MNB), bacterial cultures are positive in absence of neutrophilic leukocytosis (polymorphonuclear neutrophil (PMN) < 250/mm³). Salmonella is an uncommon cause of SBP and only one other case of Salmonella MNB has been reported. We report such a case of Salmonella MNB. A 70-year-old man with diabetes mellitus and cirrhosis was brought to the ED with irritability and confusion for 2 days. He had recovered from a diarrheal illness 3 days prior to presentation. Examination was notable for tachycardia, tachypnea, confusion, and ascites with diffuse abdominal tenderness. Pertinent investigations included creatinine 1.38 mg/dL, ammonia 142 mMol/L, and lactic acid 5.3 mMol/L. Diagnostic paracentesis revealed a nucleated cell count of 33/mm³. He was admitted to MICU for hepatic encephalopathy and severe sepsis and started on empiric vancomycin and cefepime. Salmonella enteritidis was isolated in the ascitic fluid culture on day 4. Repeat paracentesis was indicated but could not be performed because he was transferred to another hospital. Infection secondary to non-typhoidal Salmonella usually presents as a self-limited gastrointestinal disease. The diagnosis of MNB is made when ascitic fluid culture is positive but fluid PMN count is < 250/mm³. Thirty-eight percent of patients with MNB eventually progress to SBP, while in the rest, this represents spontaneous colonization resolving without antibiotic treatment. Mechanism of infection is translocation of bacteria across intestinal cells into the peritoneum, increasing according to the Child-Pugh classification. Treatment is recommended if patients continue to have positive ascitic fluid cultures on subsequent paracentesis or if they develop local or systemic signs of infection. MNB is a potentially life-threatening condition with mortality similar to SBP. Clinicians must follow ascitic fluid culture even when fluid PMN count is < 250/mm³.




J Med Cases. 2016;7(8):351-353
doi: http://dx.doi.org/10.14740/jmc2575w