Short scientific article Zdrav Vestn | Maj – June 2017 | Volume 86 Metabolic and hormonal disorders id

Short scientific article

Acute gastroenterocolitis caused by Salmonella Chester

Tajda Keber,1 Eta Mijoč,2 Neda Hudopisk,3 Marjana Simetinger,3 Klemen Mojškerc1

Abstract 1 Department of internal Turtles are common pets and represent a known reservoir for salmonellosis. There are few epidemic medicine, Slovenj Gradec General Hospital, Slovenj outbreaks of salmonellosis linked to ingestion of undercooked turtle meat described in the literature. Gradec A few cases of pet turtle borne infection and infection due to aquarium water contamination have been described. We present two female patients hospitalized d with acute gastroenterocolitis caused 2 Department of paediatrics, Slovenj by Salmonella Chester, and give an epidemiological report of the events related to the infection out- Gradec General Hospital, break. The infection was transmitted from the water of a private aquarium housing two pet turtles. Slovenj Gradec 3 Regional Unit Ravne Cite as: Zdrav Vestn. 2017; 86:207–11. na Koroškem, National Institute of Public Health, Ravne na Koroškem

Correspondence: 1. Introduction 2. Case reports Tajda Keber, e: tajda.keber@gmail. com Turtles are popular pets, widely acces- 2.1. Group 1 sible in pet stores. Reptiles are common Key words: Salmonella salmonellosis reservoir, because they A 55-yearold female with the diag- Chester; turtles; carry Salmonella spp. as part of com- nosis of Raynaud’s phenomenon, hiatal gastroenterocolitis; mensal flora in their intestines.Salmo - , reflux oesophagitis type A, and nella spp. were found in 50–90 % of their mixed connective tissue disease treated Cite as: faeces samples (1,2).Children are often with methylprednisolone, (Patient 1) Zdrav Vestn. 2017; infected because they spend a lot of time was hospitalized with a 5-day history of 86:207–11. in close contact with their pets (3). and diarrhoea. She passed at Received: 23. 10. 2016 The paper describes two patients (Pa- least ten green watery stools a day. She Accepted: 9. 2. 2017 tients 1 and 2) who were hospitalized had diffuse abdominal pain relieved with acute gastroenterocolitis caused by by defecation. She had a headache and Salmonella Chester transferred from the a temperature of up to do 38 °C. Three water contaminated by yellow-necked to four days before the outbreak of her turtles. An epidemiological report on symptoms her granddaughter fell ill the events associated with the infection with vomiting and diarrhoea. The pa- is given. tient was febrile (37,9 °C) and tachy-

Acute gastroenterocolitis caused by Salmonella Chester on line edition Metabolic and hormonal disorders

cardic; on palpation her abdomen was onset of diarrhoea she vomited 10 to 15 painful in the lower quadrants. Labora- times, and then the vomiting stopped. tory measurements showed high levels She had up to 20 watery stools without of C-reactive protein and procalcitonin traces of blood a day. Her body weight without leucocytosis or lactate elevation. decreased by 0.5 kg per day. She had a Laboratory criteria for dehydration with temperature of up to 39.5 °C. The day impaired renal function were present. before hospitalization she refused food Abdominal ultrasound showed signs of and water intake. Her younger sister gastroenterocolitis with a thickened hy- had similar symptoms, which lasted for poechoic colonic wall, especially in the two days; her grandmother was hospi- right hemicolon. During the first days talized for the same symptoms (Patient of hospital stay she was febrile (tem- 1). Her mother presented with vomiting perature of up to 39,6 °C) and had low for two days; her father was nauseous blood pressure (around 90/60 mmHg). but had no other symptoms. On exami- Low blood pressure returned to nor- nation the girl showed no clinical signs mal after parenteral hydration. The pa- of dehydration; she had of 38.8 °C, tient complained of moderate headache. tachycardia, and diffuse abdominal pain After four days of antibiotic treatment on palpation Laboratory tests showed el- with ciprofloxacin and azithromycin evated C-reactive protein, hypokalaemia her inflammatory markers levels were and dehydration. She received parenteral normalized. She received antibiotics for hydration with potassium supplements; ten days. After parenteral hydration her since day two of hospitali stay her oral renal function returned to normal. Hae- water intake has been sufficient. During mocultures remained sterile. Salmonella her stay in the hospitali we once noticed Chester, sensitive to all the tested anti- a small amount of blood in her stool. Her biotics (ampicillin, cefotaxime, ceftriax- haemocultures remained sterile. Salmo- one, ciprofloxacin, trimethoprim with nella Chester, sensitive to all the tested sulfamethoxazole) was isolated from antibiotics (ampicillin, cefotaxime, cef- stool samples. Before bacteria isolation, triaxone, ciprofloxacin, trimethoprim there was suspicion of an infectious dis- with sulfamethoxazole) was isolated ease outbreak because several family from stool samples. The patientwas dis- members experienced the same symp- charged after eight days of hospitaliza- toms. On reviewing the patient’s history tion. She had fever for 15 days and di- we connected the outbreak of symptoms arrhoea for 16 days. Salmonella Chester with exposure to new family pets- two persisted in stool samples of our patient yellow-necked turtles. The Regionaland her younger sister after three and six Unit of the National Institute of Public weeks, respectively.Other family mem- Health was notified about the outbreak, bers had negative stool samples at that and epidemiological monitoring was time. Stool samples of the affected girls performed. were negative after nine weeks.

2.2. Group 2 3. Epdemiological report

A 4.5-year-old female (Patient 2) was After the notification of the suspect- admitted to hospital with a 4-day his- ed infectious disease outbreak in a fam- tory of abdominal pain, diarrhoea and ily, we performed an epidemiological high temperature. One day before the survey following the infectious bowel on line edition Zdrav Vestn | Maj – June 2017 | Volume 86 Short scientific article

diseases protocol. Six family members, the pet shop was performed; none of the five females and one male,, aged two to employees fell ill. 56 years were admitted to hospital. Five Three of the persons with symptoms presented with the signs of gastroen- (Patients 1 and 2 and the younger sister terocolitis (two sisters, the mother and of Patient 2) had confirmed Salmonella the grandmother). Two of them, i.e. the Chester infection. grandmother and the granddaughter- were hospitalized. 4. Discussion The survey showed that the affected persons lived in the same house with The literature mentions turtle meat separate and occasionally common as a reservoir for Salmonella infections. household. None of them worked in During reptile breeding their meat be- food industry, health, school or kinder- comes contaminated. It depends on the garten services. accommodation and feeding hygiene A few days before the onset of symp- conditions. The quality of water in con- toms they had bought two yellow- tact with the aquatic animal is also im- necked turtles in a pet store. They had portant (2). In the 1970s precautions no direct contact with turtles except were taken in several countries around when cleaning the aquarium. In view of the world to reduce the transmission of the time course and connection between turtle-borne infections; from banning symptoms and new pets there was a the sale of turtles as pets to testing tur- high suspicion of animal-human disease tles for the presence of bacterial coloni- transmission. We consulted the Admin- sation (4). istration of the Republic of Slovenia for Several examples of minor epidemic Food Safety, Veterinary Sector and Plant outbreaks have been described in con- Protection (UVHVVR) and a local vet- nection to consuming raw or poorly erinary station. heat-treated meat and offal of turtles (2). The local veterinarian checked the An example of the transmission of Sal- health status of turtles and sent the turtle monella infection from the turtle aquar- cloaca for further testing to the Leipzig ium water was described, but the type of IDEXX laboratory. After receiving nega- Salmonella was different than that in our tive cloaca results, samples of aquarium case (1). water were sent for analysis. Water sam- Salmonella Chester was isolated from ples were positive for Salmonella Ches- sea turtle meat and water in a restaurant ter. in Australia, with 36 people infected, but UVHVVR contacted the turtle dis- the investigators were unable to connect tributor and warned them about possi- the infections with the ingestion of turtle ble animal-human disease transmission. as the diseased had several common risk Data from pet shop showed that four factors for the disease (2,5). yellow-necked turtles of the Testudo In the past, Salmonella infections species had been delivered to the shop transmitted from pets were common, in one shipment. Two buyers bought two but there is no evidence in the literature turtles each. One buyer was the member that such infections were caused by Sal- of the diseased family. Another buyer monella Chester (4). was contacted and alerted, but never re- Salmonellosis usually presents with sponded. Cleaning and disinfection of gastroenterocolitis, the illness lasts three

Acute gastroenterocolitis caused by Salmonella Chester on line edition Metabolic and hormonal disorders

to seven days, most people recover with- Empirical antibiotic therapy is con- out specific treatment. traindicated in immunocompetent chil- Infection can lead to septicaemia or dren without known pathogen isolated complications outside of the intestines. from stool samples because of the pos- Complications are more common in sibility of haemolytic-uremic syndrome people over the age of 50 years, in chil- development (8). Retrospective studies dren under three months of age, in pa- in children show that short-term anti- tients with associated chronic illnesses, biotic therapy prolonged carrying the diabetes, artificial heart valves, artificial pathogens in stool, and is indicated only joints, vascular implants, in cancer pa- in a group of children at risk of compli- tients and in immunocompromised pa- cations (6,9). tients (1,3,6). In Salmonella-induced diarrhoea Patient 1 belonged to a group of elder- these pathogens can occur in stools for ly patients with immunodeficiency and several weeks (in adults on average for was treated with methylprednisolone. four to five weeks and in children for up Etiological diagnosis is based on stool to seven weeks), which can be danger- sampling and cultivation, which is posi- ous when the diseased are involved in tive in approximately 6 % of patients the preparation and distribution of food. with acute disease (3). The carriage lasts longer in patientstreat- In our study, the diagnosis was etio- ed with antibiotics. Up to 4 % of patients logically confirmed in three of five pa- remain permanent carriers (3,9). tients. Contrary to the literature data, the In highrisk groups of patients and/ antibiotic-treated Patient 1 no longer or in patients with a severe course of the excreted Salmonellas in the stool after a disease the treatment of infectious diar- month. Patient 2 and her sister remained rhoea empirically begins with one of the carriers after three and six weeks, respec- quinolones (3). Patient 1 received anti- tively. Their stool cultures were negative biotics because of immunodeficiency, for the pathogen as late as after nine whereas the rest of the patients had no weeks. antibiotic therapy. Because of initially In micro-epidemic outbreaks of acute etiologically unexplained diarrhoea, she gastroenterocolitis the source of infec- was put on combination therapy with tion is not always obvious. Our paper ciprofloxacin and azithromycin, as cam- demonstrates that pets can be disease pylobacters as a possible cause of gastro- carriers. The paucity of literature data can be resistant to cipro- strongly suggests that these diseases are floxacin (7). commonly overlooked.

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Acute gastroenterocolitis caused by Salmonella Chester on line edition