Case Report

By Dr. Filiz Pehlivanoglu , Dr. Kadriye Kart Yasar , Dr. Gonul Sengoz
Corresponding Author Dr. Filiz Pehlivanoglu
Infectious Diseases and Clinical Microbiology, - Turkey 34300
Submitting Author Dr. Filiz Pehlivanoglu
Other Authors Dr. Kadriye Kart Yasar
Infectious Diseases and Clinical Microbiology, - Turkey 34300

Dr. Gonul Sengoz
Infectious Diseases and Clinical Microbiology, - Turkey 34300


S. Typhi, Carrier State, Treatment

Pehlivanoglu F, Kart Yasar K, Sengoz G. Relapse After Five Years in a Chronic Carrier Patient with Salmonellosis. WebmedCentral INFECTIOUS DISEASES 2011;2(4):WMC001887
doi: 10.9754/journal.wmc.2011.001887
Submitted on: 20 Apr 2011 05:54:01 PM GMT
Published on: 21 Apr 2011 02:14:27 PM GMT


S. Typhi is a bacteria, of which the sole resevoir is humans. The carrier state was shown to persist for many years in patients. Treatment is difficult and time-consuming. If there is an anatomical defect, treatment of the carrier state with antibiotics is not successful. We report a case of S.Typhi bacteremia and bacteriuria in a 53 years old male patient with recurrent infections within five years.


Typhoid fever is a life-threatening illness that is common in most parts of the world, especially in underdeveloped countries. Typhoid is associated with food, water and socio-economical conditions of a country, and is frequent in areas with insufficient infra-structure. S.Typhi enters the body by the fecal-oral route, with contaminated food and drinks. The sources of spread are patients with typhoid fever and carriers. There are millions of typhoid bacilli  (109-1011/g) in the feces of infected persons. Typhoid fever epidemics may occur as a result of contamination of drinking water and potable water from the sewer system. Typhoid epidemics are seen in summer and autumn seasons. Improvement in hygienic conditions in our country have enabled a decrease in yearly salmonella statistics from thousands to tens. But Salmonella enterica serovar Typhi infection is a severe illness and may be life-threatening in patients with an underlying disease. Also, their different locations may create problems in diagnosis.

Case Report

A 53 years old male patient was admitted at our outpatient clinics with complaints of left flank pain, fever, malaise, and back-pain. He was admitted at the division of urology 15 days before with complaints, and was given oral ciprofloxacin 500 mg BID with a diagnosis of urinary system infection. Skin eruptions had occurred on the 3rd day of this treatment, and he had stopped taking the medication.

A splenomegaly of two cm was detected in the physical examination. The leucocyte count was 5.800/mm3, and testing for Gruber-Widal S.Typhi H and O was positive at  1/160 dilution. S.Typhi was isolated from the urine culture, which was sensitive to ampicilline and ciprofloxacine. A grade two pelvic ectasia in the right kidney, multiple renal stones and grade three pelvic ectasia, and a mass of 75x41 mm were seen at the inferior portion of the left kidney in the ultrasonographic examination. Acute renal failure in the presence of chronic renal failure was detected. A treatment with IV ampicillin-sulbactam of 15 days was started, with dose adjustment according to creatinin clearence. Three months later, S.Typhi sensitive to ampicilline and ciprofloxacin was isolated from urine culture at the follow-up examination. Treatment with ampicillin-sulbactam was started again. The patient was operated for the renal stones by the urologic surgeons two months later.

The patient had a fever of 39°C, with a leucocyte count of 25.000/mm3 with 90% neutrophyls, 1280 leucocytes/mm3 in the urine, and a CRP of 172 mg/L when he was admitted at our hospital for urinary system complaints five years later. Compensatory hypertrophy and simple cortical cysts in the right kidney, cysts and stones in the left kidney, and also cholecystitis with gallbladder stones were detected in the ultrasonographic examination. Mitral valve prolapsus was seen in echocardiographic examination. Treatment with IV ceftriaxon 2 g BID and ciprofloxacin 400 mg BID was started. S.Typhi was isolated from the blood and urine in follow-up. Resistance to ciprofloxacin was detected with disc diffusion, and the MIC value was determined as 3 mcg/L and considered as decreased sensitivity. Leucocytes and erythrocytes were not seen in the microscopic examination of the feces and salmonella was not isolated by feces culture.


Typhoid fever is a bacterial disease, caused by Salmonella Typhi. It is transmitted through the ingestion of food or liquids contaminated by the faeces or urine of infected people. Typhoid fever is still common in the developing world, where it affects about 21.5 million persons each year [1]. Especially sensitive populations are at the the greatest risk of serious illness and mortality from water and food-borne enteric microorganisms. This group was found to include the very young, elderly, pregnant women, and the immunocompromised [2].

The clinical presentation of typhoid fever varies from a mild illness with low-grade fever, malaise, and a slight dry cough to a severe clinical picture with abdominal discomfort and multiple complications. 1-5% of the patients are in a carrier state, depending on age, chronic carriers harbouring S.typhi in the gallbladder [3].

Salmonella species are a rare cause of urinary tract infections. They have been associated with structural or functional abnormalities of the urinary tract or immunosuppressive status. Mathai et al. analyzed 18 patients with S. typhi bacteriuria during five years. Fourteen patients had localized urinary tract infection due to S. Typhi. Four others had bacteriuria, probably associated with typhoid fever. Local abnormalities encountered included urolithiasis, prostatic hypertrophy, and tuberculosis [4]. Our case has urolitiasis and gall bladder stones. The presence of stones, which may harbor organisms frequently, may provoke relapses or  development of chronic urinary carrier state.

The food handlers prominently play a role in disseminating typhoid bacilli through different food products and water. Asymptomatic typhoid carrier rate was 16% among food handlers in India. S.Typhi isolates were least resistant to oflaxacin, ciproflaxacin, gentamicin and nalidixic acid, while high resistance to tetracycline, rifampicin and chloramphenicol was also observed. It was concluded that drug resistance was found in the isolates from asymptomatic typhoid carriers [5].

The rate of resistance development in bacteria was found to be increasing. Resistance to antimicrobial agents, such as ampicillin, chloramphenicol, and trimethoprim-sulfonamide combinations, has emerged worldwide among Salmonella serotype Typhi strains [6]. No resistance to ciprofloxacin was found in a study in India in 1999, while the rate of resistance to ciprofloxacin was 13% six years later [7].

Crump et al. reported that patients infected with Salmonella serotype Typhi isolates with decreased ciprofloxacin susceptibility (MICs of 0.12 to 1 g/ml) need a longer time for resolution of fever and exhibit more frequent treatment failure. Nalidixic acid screening did not detect all isolates with decreased ciprofloxacin susceptibility [8]. In our study, the S.Typhi strain was resistant to ciprofloxacin with disc diffusion method, whereas it showed decreased ciprofloxacin susceptibility with E test.

Extra-intestinal infectious complications caused by S. Typhi are uncommon. But S. Typhi may affect other organ systems. Typhoid fever including extra-intestinal complications should be considered in a person with a compatible clinical picture, who has recently visited a typhoid-endemic region. In general fluoroquinolones and third-generation cephalosporins are the first-line therapy for infections with S. Typhi [9].


1. Centers for Disease Control and Prevention. Typhoid Fever. Availabl at: (Accessed April 10, 2011).

2. Gerba CP, Roseb JB, Haasc CH. Sensitive populations: who is at the greatest risk? Int J Food Microbiology 1996; 30: 113-123.

3. World Health Organization. Background document: The diagnosis, treatment and prevention of typhoid fever. Available at: (Accessed April 10, 2011).

4. Mathai E, John J, Rani M, Mathai D, Chacko N, Nath V, et al. Significance of Salmonella typhi Bacteriuria. J Clin Microbiol 1995; 33(7): 1791-1792.

5. Senthilkumar B, Prabakaran G. Multidrug Resistant Salmonella typhi in Asymptomatic Typhoid Carriers among Food Handlers in Namakkal District, Tamil Nadu. Indian J Med Microbiol 2005;23:92-4
6. Rowe B, Ward LR, Threlfal EJ. Multidrug-Resistant Salmonella typhi: A Worldwide Epidemic. Clin Infect Dis 1997; 24(Suppl 1): 106-9.
7. Kumar S, Rizvi M, Berry N. Rising prevalence of enteric fever due to multidrug-resistant Salmonella: an epidemiological study. J Med Microbiol 2008 Oct; 57(Pt 10):1247-50
8.  Crump JA,  Kretsinger K, Gay K, Hoekstra RM, Duc J, Vugia DJ, et al. Clinical Response and Outcome of Infection with Salmonella enterica Serotype Typhi with Decreased Susceptibility to Fluoroquinolones: a United States FoodNet Multicenter Retrospective Cohort Study. Antimicrob Agents Chemother 2008; 52(4): 1278-1284.
9. Huang DB, DuPont HL. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection. Lancet Infect Dis 2005; 5: 341-48.

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There are no any source of funding for our article.

Competing Interests

There are no any conflict interest between authors.


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