Associates' Presentations
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An unusual organism causing spontaneous bacterial peritonitis in a 69 year old man with liver cirrhosis.
Monika Rolek, M.D. (Associate), Marshfield Clinic/St. Joseph's Hospital, Marshfield, WI
Salmonella species are infrequently implicated pathogens in spontaneous bacterial peritonitis (SBP). Medline search from 1982 to present reveals less than 10 such cases in the English language literature.
CASE. A 69 year old man with cryptogenic liver cirrhosis, secondary ascites and hepatic encephalopathy, presented with a two day history of lower abdominal pain, anorexia and diarrhea. The patient's past medical history was remarkable for documented Salmonella (group B) gastroenteritis 10 years earlier. On physical exam he appeared jaundiced, lethargic and chronically ill. Lung auscultation revealed bibasilar rales, heart-tachycardia, and abdomen was distended and diffusely tender with positive shifting dullness. Laboratory findings included: WBC 5,000/mm3 with 20% band forms; albumin 2.2 g/dl; total bilirubin 3.8 mg/dl; AST 71 U/L; and Na 128 mmol/L. On day 1 he underwent a diagnostic paracentesis, which showed cloudy yellow fluid containing over 31,000 WBC/mm3 with 88% polymorphonuclear leukocytes and Gram negative bacilli identified as Salmonella typhimurium. Blood, urine and stool cultures were negative. Repeated CT scan of the abdomen failed to show any new intraabdominal pathology. Cefriaxone with metronidazole, and subsequently ciprofloxacin alone, was used. Despite the achievement of ascitic fluid sterilization on day 4, the patient developed intractable hyponatremia and died from cardiorespiratory failure on day 13.
DISCUSSION. SBP is a life threatening complication occurring in up to 30% of cirrhotic patients. The mechanism involves the bacterial seeding of ascitic fluid during transient bacteremia. Cirrhotic patients are found to have longer and more frequent episodes of bacteria. E coli, Klebsiella pneumonia and Streptococcus sp. are the most commonly responsible organisms for SBP. Salmonella has rarely been implicated. The number of patients reported is too small to recommend any specific antimicrobial treatment. Cefotaxime, routinely effective in SBP, has good in vitro activity against Salmonella. More experience with quinolone therapy is needed before it can be universally used in this setting.
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