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| Year : 2010 | Volume
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| Issue : 4 | Page : 732-734 |
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| Salmonella typhi sepsis and rhabdomyolysis with acute renal failure: A rare presentation of a common disease |
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Manmeet Jhawar1, Pratish George1, Basant Pawar2
1 Department of Internal Medicine, Christian Medical College and Hospital, Ludhiana, India
2 Department of Nephrology, Christian Medical College and Hospital, Ludhiana, India
Click here for correspondence address and email
| Date of Web Publication | 26-Jun-2010 |
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 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 2022 Aug 16];21:732-4. Available from: https://www.sjkdt.org/text.asp?2010/21/4/732/64662 |
| Introduction | |  |
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 | | |
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 | | |
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 | | |
| 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.  |
| 2. | Fisk DT, Bradley SF. Rhabdomyolysis induced by Salmonella enterica serovar Typhi bacteremia. Clin Microbiol Infect 2004;10:595-7. [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. |
| 4. | Sinha A, Sazawal S, Kumar R, et al. Typhoid fever in children aged less than 5 years. Lancet 1999;354:734-7. [PUBMED] [FULLTEXT] |
| 5. | Zager RA. Rhabdomyolysis and myohemoglobinuric acute renal failure. Kidney Int 1996; 49:314-26. [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. [PUBMED] |
| 7. | Poels PJ, Gabreels FJ. Rhabdomyolysis: a review of the literature. Clin Neurol Neurosurg 1993;95:175-92. |
| 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. |
| 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. [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. [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. [PUBMED] [FULLTEXT] |
Correspondence Address:
Pratish George
Department of Internal Medicine, Christian Medical College and Hospital, Brown Road, Ludhiana141 008, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 20587882 
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