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SALMONELLA INFECTIONS IN A TEACHING HOSPITAL OVER T

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EN YEARS

Katherine STURGESS1, Robert KINGSLEY2 and Fiona COOKE1,2

1HPA Clinical Microbiology and Public Health Laboratory, Addenbrooke’s Hospital, Cambridge, United Kingdom, 2Wellcome Trust SangerInstitute, Cambridge, United Kingdom

Introduction: Salmonella infections vary in severity from mildgastroenteritis to potentially fatal enteric fever. Despite highstandards of sanitation and awareness of prevention methods,Salmonella continues to cause considerable morbidity in thedeveloped world. We investigated the burden of disease in a UKteaching hospital.Methods: We reviewed all Salmonella infections diagnosed in theClinical Microbiology and Public Health Laboratory at Addenbrooke’sHospital between 1.1.1999 e 31.12.2008. Patient demographics,serotype and additional relevant details (travel history, resistance-type and phage-type) were recorded. Stool isolates and invasiveisolates were considered separately.

Results:

Stool isolates: 1003 episodes of Salmonella gastroenteritis wereconfirmed by stool culture, representing 88 serotypes. Enteritidis(59%), Typhimurium (4.7%), Virchow (2.6%), Newport (1.8%) andBraenderup (1.7%) were most common.Invasive isolates: The 37 invasive Salmonella infections comprised32 blood cultures, 4 tissue samples and 1 CSF. Ten of the 11 entericfever patients (6 S. Typhi; 4 S. Paratyphi A; 1 S. Paratyphi B), hadvisited the Indian subcontinent. Most S. Typhi were Ciprofloxacinsensitive (MIC range 0.016-0.75 mg/L). Six of 21 patients with non-typhoidal Salmonella bacteraemia (9 S. Enteritidis; 4 S. Typhimuriumand 7 other) were immunosuppressed.Discussion: This descriptive study provides useful data aboutthe different Salmonella serotypes circulating within a smalldefined geographical area of the UK. Prospective molecularanalysis of these serotypes by multi-locus sequence typing(MLST) and single nucleotide polymorphism (SNP) detection willdetermine the geo-phylogenetic relationship of isolates withinour region.

METHOD

Introduction: Salmonella infections vary in severity from mildgastroenteritis to potentially fatal enteric fever. Despite high

standards of sanitation and awareness of prevention methods,Salmonella continues to cause considerable morbidity in thedeveloped world. We investigated the burden of disease in a UKteaching hospital.Methods: We reviewed all Salmonella infections diagnosed in theClinical Microbiology and Public Health Laboratory at Addenbrooke’sHospital between 1.1.1999 e 31.12.2008. Patient demographics,serotype and additional relevant details (travel history, resistance-type and phage-type) were recorded. Stool isolates and invasiveisolates were considered separately.

RESULTS

Results:

Stool isolates: 1003 episodes of Salmonella gastroenteritis wereconfirmed by stool culture, representing 88 serotypes. Enteritidis(59%), Typhimurium (4.7%), Virchow (2.6%), Newport (1.8%) andBraenderup (1.7%) were most common.Invasive isolates: The 37 invasive Salmonella infections comprised32 blood cultures, 4 tissue samples and 1 CSF. Ten of the 11 entericfever patients (6 S. Typhi; 4 S. Paratyphi A; 1 S. Paratyphi B), hadvisited the Indian subcontinent. Most S. Typhi were Ciprofloxacinsensitive (MIC range 0.016-0.75 mg/L). Six of 21 patients with non-typhoidal Salmonella bacteraemia (9 S. Enteritidis; 4 S. Typhimuriumand 7 other) were immunosuppressed.

CONCLUSIONS

Discussion: This descriptive study provides useful data about thedifferent Salmonella serotypes circulating within a small definedgeographical area of the UK. Prospective molecular analysis of theseserotypes by multi-locus sequence typing (MLST) and singlenucleotide polymorphism (SNP) detection will determine the geo-phylogenetic relationship of isolates within our region.

HANSEN AND THE TWO IN ONE RULE

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Elinor MOORE and Diana LOCKWOODHospital for Tropical Diseases, University College Hospital, London, United Kingdom

MJ is a 21 year old Sri Lankan man who complained of a 2 yearhistory of worsening skin lesions. This started with a smalllesion on his back that gradually enlarged, and subsequentlynew lesions on his face and ears, which had become red. Overthe last 6 months he had experienced weakness and numbnessin his legs. Examination revealed a large annular geographiclesion with an erythematous edge on his back plus multiplesmaller inflamed plaques and nodules on his face, earlobes andarms. His nerves were minimally enlarged but non-tender withnormal function and sensation.

Slit skin smears revealed acid fast bacilli with a high bacillaryindex of 4.3. MJ was diagnosed with lepromatous leprosy witha type 1 immunological reaction downgrading from the initialborderline lesion on his back. He commenced multibacillaryleprosy treatment (rifampicin, dapsone, clofazimine) for 24months with prednisolone for the Type 1 reaction. 5 months intotreatment his lesions were less inflamed and still no evidence ofperipheral nerve damage.Six months into treatment, MJ developed high fevers and a drycough with a mild hypoxia (pO2 10.4kp). On examination he had

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numerous new painful erythematous skin spots on his legs, armsand at the edge of the original large borderline lesion on his back.Otherwise the examination was normal (including chest).Investigations revealed a high CRP (86) and a raised white cellcount (15.3, predominant neutrophilia). Multiple investigationswere negative: Blood cultures, malaria films, HIV test, chest x-ray.

METHOD

The methods for this clinical case are outlined in the abstract.

RESULTS

The results of the investigations for this clinical case are as follows;a high CRP (86) and a raised white cell count (15.3, predominantneutrophilia). Multiple investigations were negative: Blood cultures,malaria films, HIV test, chest x-ray.

CONCLUSIONS

The conclusions of this clinical case are given as a clinical lesson inthe second accompanying abstract as instructed

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HANSEN AND THE TWO IN ONE RULE

Elinor MOORE and Diana LOCKWOODHospital for Tropical Diseases, University College Hospital, LOndon, United Kingdom

Covering letter

METHOD

this abstract accompanies the principle abstact of the same title.

RESULTS

clinical pictures of the skin lesions will be presented.The patient was diagnosed with a type 2 immunological reactionwithin his leprosy treatment. He was managed effectively with theaddition of thalidomide to his treatment.

CONCLUSIONS

The clinical lesson learnt from this patient with leprosy is thatalthough having both a type 1 and a type 2 immunological reaction israre, it is possible and needs to be identified to manage patientseffectively. The case highlights well how to interpret the clinicalsigns to classify leprosy patients correctly. It also illustrates how type2 reactions can present with systemic upset that may be misleadingin reaching the correct diagnosis.

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ACUTE HEPATITIS E IS MORE COMMON THAN HEPATITIS A AMONG RETURNING TRAVELLERS PRESENTING TOSECONDARY CARE.

Catherine COSGROVE, Michael BROWN, Margaret ARMSTRONG and Justin DOHERTYThe Hospital for Tropical Diseases, London, United Kingdom

Introduction. Acute viral hepatitis is a common cause of hospitalattendance after foreign travel. Travellers and doctors are generallyaware of hepatitis A and pre-travel immunisation is available andefficacious. No vaccine is available for hepatitis E and the number ofcases caused by hepatitis E has increased recently.Methods. We examined the prevalence and aetiology of acute viralhepatitis among all patients presenting to the Hospital for TropicalDiseases between 2000-2008. Travel destination, demographics andlaboratory features of patients with hepatitis A and hepatitis E werecompared.Results. Sixty- eight patients presented in the last 8 years. Theannual incidence of hepatitis A has remained stable, while that ofhepatitis E has increased. Hepatitis E was associated with older age,travel to Indian Subcontinent and visiting friends and relativesstatus. Peak ALT was similar, but as many as 40% developeda prolonged INR (20% of hepatitis A patients) and hospital admissionwas 4 days longer.Conclusion. Hepatitis E is now the commonest cause of viralhepatitis in returning travellers in our centre, and is associated withlaboratory features suggestive of more severe liver necrosis andlonger hospital stay. In the absence of an effective vaccine, pre-

travel advice to prevent infection and early investigation aftersymptom onset, are advised.

METHOD

Patients presenting to the Hospital for Tropical Diseases wereprospectively coded for presenting problem between August 2000 toAugust 2008. Demographic, travel, laboratory and clinical data wascollected from a prospective questionnaire filled in by the physicianin attendance and additional retrospective data collected from casenotes and electronic records. A case of hepatitis was diagnosed as anALT >500 and/ or confirmatory laboratory tests revealing positiveviral hepatitis serology in the appropriate clinical context. Allinpatient cases of hepatitis were reviewed as well as all outpatientcases of hepatitis A and hepatitis E.

RESULTS

Hepatitis E was the commonest cause of patients presenting to theHTD with hepatitis. There were 26 cases in total with 68 cases ofhepatitis.