VIMS Journal: December 2016

Young Doctor's Corner

Case Report : A Case of in Vitro Sensitive But In-VivoResistant Culture Isolated Salmonella Typhi

Dr. Pramit Kumar Bhattacharyya, Dr. Abhirup Chatterjee , Dr. Debdatta Kar

Introduction :
Medical literature has endowed Typhoid feverthe fame of a historic disease entity. Typhoidbacillus has evolved over years according tocontemporary antibiotics. In Indian subcontinent,a highly endemic zone for typhoid fever,Ceftriaxone, Azithromycin and Fluoroquinoloneshave emerged at present as first line therapy forTyphoid fever. In a recent study among cultureisolated cases, 100% cases were resistant toCiprofloxacin, 3.12% against Ceftriaxone. Allcases were sensitive to Meropenem andImipenem. [1] In some previous studies in 2011-12, Ciprofloxacin resistance was reported in29.2% and Cephalosporin sensitivity was in morethan 96%. [2] In 2014, Singh et al show resistanceagainst Nalidixic acid and third generationCephalosporin with a tendency of decreasingsusceptibility to Ciprofloxacin. [3] More recentlycases have started being reported from variouspart of the subcontinent showing resistance ofTyphoid bacilli against Ceftriaxone. In a recentstudy conducted in Karnataka, 4 among 106culture positive typhoid fever cases (3.8%) werereported to be resistant to Ceftriaxone whereasCiprofloxacin resistance was found in 29.2%. [4]

A 16 yrs old male patient residing at DharmatalaRoad, Kasba, Kolkata, admitted to our hospitalon 13.12.16 with high grade intermittent type offever (maximum recorded axillary temperature101 0 F) for three days prior to admission withanorexia, nausea, vomiting and mild discomfortsometimes felt as pain in his left hypochondrium for last 10 days prior to admission. On clinicalexamination patient was febrile (recorded up to103 0 F), tachycardic (106/min), SPO2 95% inroom air, chest bilaterally vesicular breath sound,no wheeze or crepitus noted. Spleen palpable 2fingers below the left costal margin, soft inconsistency, mildly tender. No other abnormalitydetected on examination of other systems.

He was admitted in our hospital a week ago, forfever with jaundice and was discharged afterremission of fever and jaundice, with diagnosisof acute viral hepatitis due to infection withhepatitis E. At that time, he was treatedconservatively without any antibiotic.

After present admission, CBC was inconclusive.Tests for malaria came out to be negative.Dengue NS1 antigen was nonreactive. In LFT,Bilirubin was not significantly raised, neitherthe liver enzymes (TSB=1.7, conjugated 1.2mg/dl; AST/ALT=70/87). CRP was positive.USG whole abdomen shows 12.8cm sizedspleen, otherwise normal. No pus cell wasisolated in routine and microscopic examinationof urine. Blood culture and sensitivity was sentbut the report was pending.

Blood for Typhidot IgM was sent, and came outto be weakly positive. Widal test was positivefor TO and TH antigen of Salmonella typhi at1:240 titre.

Keeping in mind the high endemicity of typhoidfever, Injection Ceftriaxone IV 2gm/D with TabAzithromycin 500mg PO OD was started. In the mean time, Blood culture report turned outto be positive for Salmonella typhi, in vitrosensitive to Ceftriaxone (with an MIC of =1mg),Cefoperazone-Sulbactum, Cefepime, andCarbapenems and resistant to FQs, CefuroximeAxetil, AGs. Azithromycin was not tested forsensitivity. Patient kept on being febrile withseveral 2-4 spikes of high grade fever even tillfifth day of starting this antibiotic regimen.Another blood culture was sent which revealedsame antibiotic sensitivity pattern.

At this point of time the patient was clinicallynot responsive to IV Ceftriaxone and therefore was decided to be put on Injection IVMeropenem only.

Patient responded within two days, becameafebrile. Appetite improved, although hepersisted to have discomfort in his lefthypochondrium.

Conclusion: Resistant typhoid is not uncommonin our hospital, several cases were noted, andthis case has been highlighted to make awarenessabout the present scenario of antibiotic resistance.It needs further study to detect the prevalenceand to search reason behind this.

References
  1. Bulbul Hasan, Sabera Gul Nahar, Laila Akter, AhmedAbu Saleh; Antimicrobial sensitivity pattern ofSalmonella typhi isolated from blood culture in a referralhospital, Bangladesh J Med Microbiol 2011; 05 (01):16-20.

  2. Ashwini Kumar, Vinay Pandit, Seema Shetty, ChythraR Rao, Sanjay Pattanshett ,Charmaine M Samarasinghe;Study of Clinical Profile and Antibiotic Sensitivitypattern in Culture-positive Typhoid Fever Cases, IndianJournal of Community Medicine/Vol 37/Issue 4/October2012, doi: 10.4103/0970-0218.103475.

  3. L Singhal, PK Gupta, P Kale, V Gautam, P Ray Trendsin antimicrobial susceptibility of Salmonella typhifrom North India (2001-2012) Indian Journal ofMedical microbiology 2014, Volume: 32| Issue : 2 |Page : 149-152.

  4. Ranjana Hawaldar, Sadhna Sodani, Hemlata Bhilware;Antibiotic Sensitivity Pattern of Salmonella Typhi ina Stand Alone; Lab in Central Madhya Pradesh; IndianJ Microbiol Res 2016;3(1):31-36.

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