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The Brief Case: Salmonella enterica Serovar Typhi in a Central American Refugee

CASE An unvaccinated teenage male with no known past medical history presented to the emergency department (ED) with complaints of headache, back and neck pain, and fever with chills for 2 days before presentation. In addition, he reported constipation (bowel movement only every 3 days), rhinorrhea, and congestion. He denied abdominal pain, shortness of breath, or photophobia. Social history revealed that he had traveled alone from Central America to the United States and had spent ;7 days in the Sonoran Desert of Mexico and southern Arizona with only crackers, apples, and small amounts of water (source unknown). The patient had been in United States Border Patrol custody for ;2weeks before presenting to the ED. The patient’s vital signs at presentation revealed a temperature of 37.1°C, heart rate of 71 beats/minute, respiratory rate of 19 breaths/minute, blood pressure of 114/ 68mm Hg, and an oxygen saturation of 95%. A thorough physical exam was unremarkable. His complete blood count, including white blood cells, was normal; and his electrolyte panel showed hyponatremia of 126mmol/liter, hypochloremia of 90mmol/liter, and hypocalcemia of 8.4mg/dl. Additionally, the patient’s transaminases were elevated (aspartate transaminase 144 IU/liter, alanine aminotransferase 73 IU/liter, and alkaline phosphatase 83 IU/liter). The patient was admitted for management of hyponatremia and additional workup. On the evening of the 1st day of admission, the patient had a fever of 40.5°C and heart rate of 82 beats/minutes, as well as new diarrhea and continuing headache and chills. The patient’s first set of blood cultures was drawn during this febrile episode. Treatment with cefepime (2 g every 8 h) was initiated on the 2nd day of admission, when both the aerobic and anaerobic blood culture bottles were flagged positive by the BD Bactec FX system. Gram stain of the positive blood culture broth revealed Gram-negative rods. Molecular testing of the positive blood culture broth via the Verigene Gram-negative blood culture panel (Luminex Corporation, Austin, TX) did not identify the pathogen. After a report of the patient’s positive blood culture with Gramnegative rods and because of the patient’s new-onset diarrhea, a BioFire FilmArray gastrointestinal pathogen panel (BioFire Diagnostics, LLC, Salt Lake City, UT) was ordered on a stool specimen, with Salmonella spp. and Shigella/enteroinvasive Escherichia coli isolates detected. Subculture of the positive blood culture broth revealed gray nonhemolytic colonies on 5% sheep’s blood agar and lactose-nonfermenting colonies on both MacConkey II agar (clear colonies) and Hektoen enteric agar (green colonies with slight H2S production [Fig. 1A]). The isolate tested spot indole and oxidase negative. Matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) identification of the isolate via Vitek MS (bioMérieux, Durham, NC) identified Salmonella enterica Citation Addams J, Lainhart W. 2021. The Brief Case: Salmonella enterica serovar Typhi in a Central American refugee. J Clin Microbiol 59: e01359-20. https://doi.org/10.1128/JCM.01359-20. Editor, Carey-Ann D. Burnham, Washington University School of Medicine Copyright © 2021 American Society for Microbiology. All Rights Reserved. Address correspondence to William Lainhart, wlainhart@pathology.arizona.edu. For answers to the self-assessment questions and take-home points, see https://doi.org/10 .1128/JCM.01360-20 in this issue. Published 20 April 2021