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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 4  |  Page : 732-734
Salmonella typhi sepsis and rhabdomyolysis with acute renal failure: A rare presentation of a common disease


1 Department of Internal Medicine, Christian Medical College and Hospital, Ludhiana, India
2 Department of Nephrology, Christian Medical College and Hospital, Ludhiana, India

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Date of Web Publication26-Jun-2010
 

   Abstract 

Typhoid is associated with a number of complications and is commonly seen in India. Rhabdomyolysis is rarely reported. We report herewith a patient with Salmonella typhi sepsis who presented with rhabdomyolysis and acute renal failure.

How to cite this article:
Jhawar M, George P, Pawar B. Salmonella typhi sepsis and rhabdomyolysis with acute renal failure: A rare presentation of a common disease. Saudi J Kidney Dis Transpl 2010;21:732-4

How to cite this URL:
Jhawar M, George P, Pawar B. Salmonella typhi sepsis and rhabdomyolysis with acute renal failure: A rare presentation of a common disease. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2018 Aug 15];21:732-4. Available from: http://www.sjkdt.org/text.asp?2010/21/4/732/64662

   Introduction Top


Rhabdomyolysis is a disease leading to des­truction of muscles and release of potentially toxic metabolites, muscle enzymes and myo­globin-heme pigment into the circulation. The association of rhabdomyolysis and acute renal failure with typhoid has been rarely reported and hence, this report. [1],[2]


   Case Report Top


A 64-year-old male was admitted with inter­mittent fever and loose stools, without blood or mucus, daily for a week. He also complained of severe generalized body pain and tremulous­ness. He denied having abdominal pain, vomi­ting, oliguria, hematuria or dysuria. There was no history of antibiotic treatment prior to ad­mission, illicit drug use or alcohol abuse.

Examination revealed pallor with dehydration and generalized muscle tenderness. His blood pressure was 90/60 mmHg and temperature was 101°F. No skin rash was noticed and sys­temic examination was normal. No muscular weakness was elicited.

Investigations revealed normal total leukocyte count, thrombocytopenia (74000/mm3) and re­nal failure (blood urea 98 mg/dL, serum crea­tinine 3.7 mg/dL); the serum potassium was 5.6 meq/dL. Rhabdomyolysis was considered and the serum muscle enzymes were found to be elevated [creatine phosphokinase (CPK) 9473 U/L, lactate dehydrogenase (LDH) 3071 U/L]. The serum and urine myoglobin was not done concomitantly but checked two days later and was not found to be significantly raised. Ultra­sonography of the abdomen was normal. Ma­larial parasite examination was negative as were the investigations for dengue and leptospirosis. He was rehydrated, piperacillin/tazobactam and metronidazole initiated and forced alkaline diuresis attempted. However, his urine output diminished and renal failure worsened (blood urea 126 mg/dL, serum creatinine 6.1 mg/dL) associated with severe metabolic acidosis, ne­cessitating urgent hemodialysis. The total leu­kocyte and platelet counts fell to 3200/mm 3 and 52000/mm 3 . The tube agglutination test (Widal) showed flagellar antigen titers up to 640 and blood culture grew  Salmonella More Details typhi. The urine, stool and CSF cultures were sterile. Cefoperazone was started according to the cul­ture and sensitivity and ciprofloxacin was added after improvement in muscle enzymes. However, after a week, the patient continued to have fever and was switched to imipenem­cilastin and ciprofloxacin was continued.

The muscle enzyme levels improved. Inter­mittent hemodialysis was provided for a period of three weeks following which the renal func­tions showed progressive improvement [Table 1]. He was discharged from hospital in a satis­factory condition and normalization of renal function was seen four weeks after the initial hospitalization.


   Discussion Top


Typhoid is a systemic disease caused by Sal­monella typhi and paratyphi. Transmission of typhoid is through contact with chronic carriers or acutely infected individuals. [3] It is a common disease in India, with incidence as high as 980 per 100,000 per year in New Delhi. [4]

Complications like gastrointestinal bleed, in­testinal perforation, pancreatitis, hepatitis, peri­carditis, endocarditis, orchitis, meningitis, myo­carditis, parotitis, pneumonia, arthritis and osteo­myelitis are associated with typhoid. [3]

Acute renal failure is a known complication of rhabdomyolysis and may be due to ischemic tubular changes, acute tubular necrosis and/or formation of toxic free radicals. [5] Formation of lysophospholipids due to activation of phos­pholipase A2 leads to muscle membrane da­mage. Increased cytosolic calcium and sodium influx as a consequence, results in muscle ne­crosis and release of muscle components into circulation. [6] An elevated serum CPK to at least five-times the normal value is diagnostic of rhabdomyolysis. [7]

The association of typhoid with rhabdomyo­lysis and renal failure is rarely reported. Acute renal failure in salmonella infection has been associated with salmonella endotoxemia cau­sing glomerular microangiopathy and intravas­cular coagulation, leading to fragmentation of red blood cells. [8] It has also been seen as an acute nephritic syndrome, [9] and as part of multi­organ involvement. [10] Salmonella typhi compli­cated with the hemolytic uremic syndrome, rhabdomyolysis and acute renal failure has also been reported. [1]

Rare cases have been reported of rhabdomyo­lysis associated with typhoid. Mechanism of salmonella-induced rhabdomyolysis has been thought to include tissue hypoxia caused by sepsis, toxin release, direct bacterial invasion of muscle and altered muscle metabolic capacity. [11]

In our patient, Salmonella typhi sepsis was found to be associated with rhabdomyolysis and acute renal failure. Other causes of rhab­domyolysis such as trauma, medications, illicit drugs, hemolytic uremic syndrome and, infec­tions like malaria, dengue and leptospirosis were ruled out. He did not have any muscular weak-ness on examination despite having ele­vated muscle enzymes, thereby, ruling out Sal­monella typhi-induced myopathy. Electromyogram (EMG) could not be done because of poor fitness for transport to the neurophysiology lab. Renal biopsy was similarly not done due to poor fitness for the procedure. The patient res­ponded to antibiotics and resolution of rhab­domyolysis and renal failure was seen within four weeks.

Rhabdomyolysis and acute renal failure in Salmonella typhi infection is rare. In a study of data spanning 40 years from Michigan, United States of America, 22 patients with Salmonella infection had associated rhabdomyolysis, of whom only two patients had Salmonella typhi infection. [2]

Data from India on this entity is not avai­lable. It is likely to be more common in view of the high incidence, under reporting, inade­quate culture and muscle enzyme assay faci­lities and empirical unregulated use of quino­lone antibiotics. A high index of suspicion may help in treating this reversible cause of acute renal failure in Salmonella typhi infection, especially if detected and appropriately ma­naged early in the illness with alkaline diu­resis, hydration and appropriate treatment with antibiotics.

 
   References Top

1.Gupta RK, Nampoory N, Johny KV. Fatal case of Salmonella infection with acute renal failure, hemolytic uremic syndrome and rhab­domyolysis. Kuwait Med J 2006;38:229-31.  Back to cited text no. 1      
2.Fisk DT, Bradley SF. Rhabdomyolysis induced by Salmonella enterica serovar Typhi bacte­remia. Clin Microbiol Infect 2004;10:595-7.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Lesser CF, Miller SI. Salmonellosis. In Har­rison's Principles of Internal Medicine. Vo­lume 1. 16 th Edition. Edited by: Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. New York: McGraw-Hill; 2005:898-9.  Back to cited text no. 3      
4.Sinha A, Sazawal S, Kumar R, et al. Typhoid fever in children aged less than 5 years. Lancet 1999;354:734-7.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Zager RA. Rhabdomyolysis and myohemo­globinuric acute renal failure. Kidney Int 1996; 49:314-26.  Back to cited text no. 5  [PUBMED]    
6.Jackson MJ, Jones DA, Edwards RH. Experi­mental skeletal muscle damage: the nature of the calcium activated degenerative processes. Eur J Clin Invest 1984;14:369-74.  Back to cited text no. 6  [PUBMED]    
7.Poels PJ, Gabreels FJ. Rhabdomyolysis: a review of the literature. Clin Neurol Neurosurg 1993;95:175-92.  Back to cited text no. 7      
8.Shibusawa N, Arai T, Hashimoto K. Fatality due to severe salmonella enteritis associated with acute renal failure and septicemia. Intern Med 1997;36:674-75.  Back to cited text no. 8      
9.Hayashi M, Kouzu H, Nishihara M, et al. Acute renal failure likely due to acute nephritic syn­drome associated with typhoid fever. Intern Med 2005;44:1074-7.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Huang GC, Chang CM, Ko WC, Huang YL, Chuang YC. Typhoid fever complicated by mul­tiple organ involvement: report of two cases. J Infect 2005;51:E57-60.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.Brncic N, Viskovic I, Sasso A, Kraus I, Zamolo G. Salmonella infection-associated acute rhab­domyolysis. Some pathogenic considerations. Arch Med Res 2002;33:313-5.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Pratish George
Department of Internal Medicine, Christian Medical College and Hospital, Brown Road, Ludhiana141 008, Punjab
India
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PMID: 20587882

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