1350 | Case Report Salmonella Typyhi Isolated From Urine Cul- ture before Percutaneous Nephrolithotomy: A Case Report Tansu Değirmenci,1Alpay Arı,2 Zafer Kozacıoğlu,1Bumin Örs,1Bülent Günlüsoy1 Keywords: nephrostomy, percutaneous; urinary tract infections; microbiology; salmonella ty- phimurium; salmonella infections. INTRODUCTION Typhoid fever is the most common illness caused by Salmonella typhi (S. typhi). (1) S. typhi bacteriuria can be seen following a recent episode of typhoid fever, or in chronic carrier state involving the urinary system, especially with local abnormalities of uri- nary tract.(2) However, S. typhi bacteriuria with renal stone disease has rarely been reported.(2) We presented a rare case of a kidney stone with Salmonella infection and discussed the treat- ment approaches in the light of literature. CASE REPORT A 58 years old man with right flank pain and frequent urination was presented to our outpatient clinic. There was hematuria and leukocyturia in dipstick urinalysis. Intravenous urography findings were 25 mm stone located in the right pelvis with multiple lower calyx stones and severe hydronephrosis of the right kidney (Figure 1). Noncontrast computed tomography re- vealed severe hydronephrosis, parenchymal loss and in the renal pelvis and lower pole hyper dense appearance of 25 mm millimeter stones (Figure 2). In technetium-99m-diethylenetri- aminepentacetic acid (99mTc-DTPA) renal scintigraphy, renal functions for the right and left kidneys were measured as 29% and 71%, respectively. Serogroup D Salmonella was isolated from the first midstream urine culture. Findings of the vital signs were normal but erythrocyte sedimentation rate was 44 mm/h (0-20 mm) and C-re- Corresponding Author: Tansu Değirmenci, MD Izmir Bozyaka Eğitim ve Arastirma Hastanesi, Uroloji Klinigi, Bozyaka, 35360, Izmir, Turkey. Tel: + 90 532 3631611 Fax: + 90 232 250 29 97 E-Mail: tansudegirmenci@hotmail. com Received June 2012 Accepted August 2011 1 İzmir Bozyaka Education and Research Hospital, Urology Department, Izmir, Turkey. 2 İzmir Bozyaka Education and Research Hospital, Infectious Disease and Clinical Microbiol- ogy Department, Izmir, Turkey. CASE REPORT 1351Vol. 11 | No. 01 | Jan-Feb 2014 |U R O LO G Y J O U R N A L Salmonella Typyhi in Urine Culture | Değirmenci et al active protein was 14.18 mg/dL (0-5 mg/dL). Microbiologi- cal workup resulted positive for S. typhi H antigen (1/100) and S. serogroup D. There was no significant infection ac- cording to the stool culture. Ceftriaxone (2g every 12 hours, intravenously) was administered thereafter. On the third day of the antibiotic therapy the patient underwent percutaneous nephrolithotomy. We obtained pyuric urine samples from the renal pelvis. The obstructive pelvis and lower calyx stones were cleared. Stone culture samples were taken. The urinary catheter and the nephrostomy tube were retrieved on the first and third postoperative day, respectively. On the first and the second postoperative day, 38.5°C fever was measured. S. typhi was isolated from the intraoperative pelvic urine and stone culture. Preoperative antibiotic treatment was contin- ued for 7 days and the patient was discharged with oral cip- rofloxacin therapy (750 mg twice daily) after 11 days of hos- pitalization. Ciprofloxacin was discontinued after 3 months of use. Outpatient evaluation of third months was negative for urine culture. At six months, 99mTc-DTPA renal scin- tigraphy revealed the percentages of distribution of the total renal function as 31% and 69% for the right and left kidney, respectively. DISCUSSION Salmonellae are facultative anaerobic, non-spore-forming, gram-negative bacilli.(1) The bacilli have been classified into 2541 serotype by the Kaufmann-White scheme based on the O and H antigens.(1) The laboratories perform a few sim- ple agglutination reactions that define specific O antigens into serogroups, designated as groups A, B, C1, C2, D and E Salmonella.(1) S. enteritidis and S. typhi are both group D. Our patient’s midstream urine, pelvic urine and stone culture yielded Salmonella group D. Isolation of S. typhi from urine is rare even where this infec- tion is endemic.(1) It is believed that the bacilli are shed in urine following a recent typhoid fever as part of the natural history of this disease or in chronic carrier states.(3,4) Dur- ing asymptomatic bacteriuria, cystitis or pyelonephritis can be seen clinically.(1,2,5) But interstitial nephritis and renal micro abscesses can develop as important complications in the course of the disease.(1) The incidence of bacteriuria is reported as 0.6%.(1) This condition occurs in patients both with and without local abnormalities of the urinary tract. Up to 50% of patients with S. typhi urinary tract infection Figure 1. The stone located in right kidney pelvis on intravenous urography. Figure 2. Noncontrast computed tomography shows a stone in the renal pelvis with severe hydronephrosis and parenchymal loss. 1352 | Case Report (UTI) had urinary calculi.(3) This bacteriuria was related with predisposing factors such as urinary tract abnormalities or immunosuppression.(4) In case of a UTI associated with anatomic obstructive abnormalities, surgical correction may be required in addition to prolonged antimicrobial therapy (≥ 6 weeks) to eradicate infection.(1) S. typhi bacteriuria is asymptomatic in the majority of patients and probably is as- sociated with a recent typhoid fever in patients. Although S. typhi bacteriuria is rare even where it’s endemic, this specific infection should be kept in mind in patients who have an uni- dentified chronic UTI. CONFLICT OF INTEREST None declared. REFERENCES 1. Pegues DA, Miller SI. Salmonella Species, Including Salmonella Ty- phi. Mandell, Douglas, and Bennett's Principles and Practice of In- fectious Diseases, Editors: Gerard Mendel, Johhn Bennett, Raphael Dolin. Seven edition, Philadelphia, Churchill Livingstone; 2009. p. 2887-903. 2. Mathai E, John TJ, Rani M, et al. Significance of Salmonella typhi bac- teriuria. J Clin Microbiol. 1995;33:1791-2. 3. Kapoor R, Tewari A, Dhole TN, Ayyagiri A. Salmonella typhi urinary tract infection: a report of two cases. Indian J Urol. 1992;8:94-95. 4. Gagnon J, Labbe R, Laroche B. Salmonella urinary tract infection: a vascular emergency. Can J Surg. 2007;50:221-2. 5. Ramos JM, Aguado JM, García-Corbeira P, Alés JM, Soriano F. Clinical spectrum of urinary tract infection due to nontyphoidal Salmonella species. Clin Infect Dis. 1996;23:388-90.