Salmonella Infection in Emergency Medicine Clinical Presentation

  • Author: Michael D Owens, DO, FACEP, FAAEM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 23, 2012
 

History

Obtain the patient's dietary history. Inquire about potential restaurant sources, food preparation techniques, and exposure to potentially contaminated or nonchlorinated water sources. Note: In the United States, half of Salmonella outbreaks occur in restaurant settings.[22]

  • Obtain the patient's travel history. Typhoid fever is increasingly associated with international travel to developing nations.
  • Determine if other patient contacts have similar illnesses, food ingestions, or animal contacts.
  • Salmonella syndromes can be divided into gastroenteritis, enteric fever, bacteremia, localized infection, and a chronic carrier state.

Gastroenteritis

  • Incidence is highest during May through October in temperate climates.[6]
  • The incubation period is from 8-48 hours after the ingestion of contaminated food or water.
  • Symptoms are acute onset of fever and chills, nausea and vomiting, abdominal cramping, and diarrhea.
  • If a fever is present, it generally abides in 72 hours.
  • Diarrhea is usually self-limited, lasting 3-7 days and may be grossly bloody. Diarrhea lasting more than 10 days suggests another diagnosis.[6]

Enteric (typhoid) fever

  • The incubation period of enteric (typhoid) fever is 5-21 days.
  • Transmission is generally from contaminated water or animal products or contact with an infected person or carrier.
  • The initial prodrome lasting 7-10 days includes headache, cough, diaphoresis, anorexia, weakness, sore throat, malaise, abdominal pain, and constipation or "pea soup" diarrhea. Abdominal pain is present in 20-40% of patients.[6] Constipation is found in 10-38% of patients.[6]
  • These prodromal symptoms typically plateau as the fever increases in a stepwise fashion peaking in the second week of illness.
  • After the prodrome, splenomegaly, abdominal distention and pain, relative bradycardia, rash, meningismus, and mental confusion may occur. It may disseminate to lungs, gallbladder, kidneys, or CNS.
  • Untreated patients experience either complications or resolution by the fourth week. Intestinal perforation occurs in 3-10% of patients.[6] Other complications include endocarditis, pericarditis, pneumonitis, orchitis, and focal abscess.

Bacteremia

  • Bacteremia typically occurs in immunocompromised patients.
  • Prolonged or recurrent fevers may occur.
  • Focal infections may occur.
  • Mycotic abdominal aortic aneurysm may occur.

Localized infection

  • Localized infection occurs in 5-10% of persons with bacteremia.[6]
  • The endocardium, arteries, CNS (more commonly in infants), lungs, bones, joints, muscles, soft tissues, reticuloendothelial system, kidneys, and genital regions have all been documented sites of extraintestinal infection.

Chronic carrier state

  • Chronic carrier state is defined as Salmonella in the stool or urine for greater than 1 year.
  • A chronic carrier state occurs in 0.2-0.6% of patients with nontyphoid Salmonella.[6]
  • A chronic carrier state occurs in 1-4% of patients with untreated typhoid Salmonella.
  • Salmonella Typhi and Salmonella Paratyphi A are able to survive for protracted periods in the gallbladder and kidney in otherwise healthy people, resulting in long term fecal shedding.[20, 23]
Next

Physical

Physical findings of salmonellosis can vary depending on the clinical syndrome, serotype, and patient’s immune status. However, the physical findings in gastroenteritis, enteric (typhoid) fever, and bacteremia frequently overlap.

The chronic carrier state is asymptomatic.

Gastroenteritis

  • Fevers (temperature 38-39°C) are common.
  • Physical signs of dehydration may be found.
  • Stool examination findings can be negative to grossly bloody.
  • Diffuse nonfocal abdominal tenderness is commonly present.
  • In rare cases, Salmonella infection mimics inflammatory bowel disease or pseudoappendicitis.[6]

Enteric or typhoid fever

  • A stepwise increase in temperature that plateaus in the second week at 39-40°C may be noted.
  • Cervical adenopathy may occur.
  • Relative bradycardia occurs in fewer than 50% of cases.
  • Abdominal examination may reveal distention with pain on deep palpation.
  • Hepatosplenomegaly is found in 50% of patients.[6]
  • A rose spot rash that typically occurs in the second week of disease is seen in 30% of patients. This rash is described as a faint salmon-colored 2-3 mm papule lesion located primarily on the trunk that fades with pressure.
  • Findings of meningismus may appear after the early prodrome.

Bacteremia

  • Bacteremia is usually associated with a prolonged or recurrent fever.
  • Generally, it is associated with a localized infection.
  • It may be a part of a mixed Salmonella infection.[6]
Previous
Next

Causes

Currently, more than 2500 serotypes of Salmonellaenterica have been identified.[1, 2] Although clinical manifestations of each overlap, typhi and paratyphi, tend to cause enteric or typhoid fever and the more invasive form of the disease, whereas most others cause a self-limited form of gastroenteritis.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Michael D Owens, DO, FACEP, FAAEM  Assistant Professor of Military/Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Clinical Faculty, Emergency Medicine Residency, Naval Medical Center Portsmouth; Consulting Staff, Department of Emergency Medicine, Chesapeake Emergency Physicians, Inc, Chesapeake Regional Medical Center

Michael D Owens, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk A Warren, MD  Emergency Medicine Resident, Naval Medical Center Portsmouth

Dirk A Warren, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Emergency Physicians, and Society of United States Naval Flight Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark Louden, MD, FACEP  Assistant Medical Director, Emergency Department, Duke Raleigh Hospital

Mark Louden, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Robert A Barrali Jr, MD, to the development and writing of this article. We would like to acknowledge the assistance of Michelle Manfredi in researching this topic.

References

  1. Coburn B, Grassl GA, Finlay BB. Salmonella, the host and disease: a brief review. Immunol Cell Biol. Feb-Mar 2007;85(2):112-8. [Medline].

  2. Grassl GA, Finlay BB. Pathogenesis of enteric Salmonella infections. Curr Opin Gastroenterol. Jan 2008;24(1):22-6. [Medline].

  3. Chambers HF. McPhee SJ, Papadakis MA, Tierney LM, eds. Current Medical Diagnosis & Treatment. 47th ed. McGraw-Hill Co; 2008:1250-1252.

  4. Centers for Disease Control and Prevention. Vital signs: incidence and trends of infection with pathogens transmitted commonly through food--foodborne diseases active surveillance network, 10 U.S. sites, 1996-2010. MMWR Morb Mortal Wkly Rep. Jun 10 2011;60(22):749-55. [Medline].

  5. Linam WM, Gerber MA. Changing epidemiology and prevention of Salmonella infections. Pediatr Infect Dis J. Aug 2007;26(8):747-8. [Medline].

  6. Peques DA, Miller SI. Salmonella Species, Including Salmonella Typhi. In: Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. 7th ed. Elsevier; 2009:chap. 223.

  7. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food - 10 states, 2009. MMWR Morb Mortal Wkly Rep. Apr 16 2010;59(14):418-22. [Medline]. [Full Text].

  8. Croswell A, Amir E, Teggatz P, Barman M, Salzman NH. Prolonged impact of antibiotics on intestinal microbial ecology and susceptibility to enteric Salmonella infection. Infect Immun. Jul 2009;77(7):2741-53. [Medline]. [Full Text].

  9. Braden CR. Salmonella enterica serotype Enteritidis and eggs: a national epidemic in the United States. Clin Infect Dis. Aug 15 2006;43(4):512-7. [Medline].

  10. Jones TF, Ingram LA, Fullerton KE, et al. A case-control study of the epidemiology of sporadic Salmonella infection in infants. Pediatrics. Dec 2006;118(6):2380-7. [Medline].

  11. Centers for Disease Control and Prevention. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food--10 states, 2007. MMWR Morb Mortal Wkly Rep. Apr 11 2008;57(14):366-70. [Medline].

  12. Centers for Disease Control and Prevention. Multistate outbreak of human Salmonella infections caused by contaminated dry dog food--United States, 2006-2007. MMWR Morb Mortal Wkly Rep. May 16 2008;57(19):521-4. [Medline]. [Full Text].

  13. Centers for Disease Control and Prevention. Multistate outbreak of Salmonella infections associated with peanut butter and peanut butter-containing products--United States, 2008-2009. MMWR Morb Mortal Wkly Rep. Feb 6 2009;58(4):85-90. [Medline]. [Full Text].

  14. Voetsch AC, Van Gilder TJ, Angulo FJ, et al. FoodNet estimate of the burden of illness caused by nontyphoidal Salmonella infections in the United States. Clin Infect Dis. Apr 15 2004;38 Suppl 3:S127-34. [Medline].

  15. Weinberger M, Keller N. Recent trends in the epidemiology of non-typhoid Salmonella and antimicrobial resistance: the Israeli experience and worldwide review. Curr Opin Infect Dis. Dec 2005;18(6):513-21. [Medline].

  16. Harish BN, Menezes GA. Antimicrobial resistance in typhoidal salmonellae. Indian J Med Microbiol. Jul-Sep 2011;29(3):223-9. [Medline].

  17. Meltzer E, Schwartz E. Enteric fever: a travel medicine oriented view. Curr Opin Infect Dis. Oct 2010;23(5):432-7. [Medline].

  18. Boyle EC, Bishop JL, Grassl GA, Finlay BB. Salmonella: from pathogenesis to therapeutics. J Bacteriol. Mar 2007;189(5):1489-95. [Medline]. [Full Text].

  19. Sethuraman U, Kamat D. Management of child with fever after international travel. Clin Pediatr (Phila). Apr 2007;46(3):222-7. [Medline].

  20. Zaki SA, Karande S. Multidrug-resistant typhoid fever: a review. J Infect Dev Ctries. May 28 2011;5(5):324-37. [Medline].

  21. Heymann DL. Control of Communicable Diseases Manual. 18th ed. American Public Health Association; 2004:469-473.

  22. Hedican E, Hooker C, Jenkins T, et al. Restaurant Salmonella Enteritidis outbreak associated with an asymptomatic infected food worker. J Food Prot. Nov 2009;72(11):2332-6. [Medline].

  23. Parry CM, Wijedoru L, Arjyal A, Baker S. The utility of diagnostic tests for enteric fever in endemic locations. Expert Rev Anti Infect Ther. Jun 2011;9(6):711-25. [Medline].

  24. Hatta M, Smits HL. Detection of Salmonella typhi by nested polymerase chain reaction in blood, urine, and stool samples. Am J Trop Med Hyg. Jan 2007;76(1):139-43. [Medline].

  25. Bottieau E, Clerinx J, Van den Enden E, et al. Fever after a stay in the tropics: diagnostic predictors of the leading tropical conditions. Medicine (Baltimore). Jan 2007;86(1):18-25. [Medline].

  26. Abubakar I, Irvine L, Aldus CF, et al. A systematic review of the clinical, public health and cost-effectiveness of rapid diagnostic tests for the detection and identification of bacterial intestinal pathogens in faeces and food. Health Technol Assess. Sep 2007;11(36):1-216. [Medline].

  27. Kuhn KG, Falkenhorst G, Ceper TH, et al. Detecting non-typhoid Salmonella in humans by ELISAs: a literature review. J Med Microbiol. Jan 2012;61:1-7. [Medline].

  28. Sirinavin S, Garner P. Antibiotics for treating salmonella gut infections. Cochrane Database Syst Rev. 2000;CD001167. [Medline].

  29. Wistrom J, Jertborn M, Ekwall E, et al. Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish Study Group. Ann Intern Med. Aug 1 1992;117(3):202-8. [Medline].

  30. Centers for Disease Control and Prevention. National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS): Human Isolates Final Report, 2004. [Full Text].

  31. Grady R. Safety profile of quinolone antibiotics in the pediatric population. Pediatr Infect Dis J. Dec 2003;22(12):1128-32. [Medline].

  32. Crump JA, Mintz ED. Global trends in typhoid and paratyphoid Fever. Clin Infect Dis. Jan 15 2010;50(2):241-6. [Medline]. [Full Text].

  33. Threlfall EJ, de Pinna E, Day M, Lawrence J, Jones J. Alternatives to ciprofloxacin use for enteric Fever, United kingdom. Emerg Infect Dis. May 2008;14(5):860-1. [Medline]. [Full Text].

  34. Mølbak K. Human health consequences of antimicrobial drug-resistant Salmonella and other foodborne pathogens. Clin Infect Dis. Dec 1 2005;41(11):1613-20. [Medline].

  35. [Best Evidence] Thaver D, Zaidi AK, Critchley JA, Azmatullah A, Madni SA, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev. Oct 8 2008;CD004530. [Medline].

  36. Parry CM, Threlfall EJ. Antimicrobial resistance in typhoidal and nontyphoidal salmonellae. Curr Opin Infect Dis. Oct 2008;21(5):531-8. [Medline].

  37. Buchwald DS, Blaser MJ. A review of human salmonellosis: II. Duration of excretion following infection with nontyphi Salmonella. Rev Infect Dis. May-Jun 1984;6(3):345-56. [Medline].

  38. Gündüz GT, Gönül SA, Karapinar M. Efficacy of myrtle oil against Salmonella Typhimurium on fresh produce. Int J Food Microbiol. Mar 31 2009;130(2):147-50. [Medline].

  39. Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. Jul 8 2006;333(7558):78-82. [Medline]. [Full Text].

  40. Torok TJ, Tauxe RV, Wise RP, et al. A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. JAMA. Aug 6 1997;278(5):389-95. [Medline].

  41. Adhikari B, Besser TE, Gay JM, et al. Introduction of new multidrug-resistant Salmonella enterica strains into commercial dairy herds. J Dairy Sci. Sep 2009;92(9):4218-28. [Medline].

  42. Amieva MR. Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective. Pediatr Clin North Am. Jun 2005;52(3):749-77, vi. [Medline].

  43. Connor BA, Schwartz E. Typhoid and paratyphoid fever in travellers. Lancet Infect Dis. Oct 2005;5(10):623-8. [Medline].

  44. Hoffman SL, Punjabi NH, Kumala S, et al. Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone. N Engl J Med. Jan 12 1984;310(2):82-8. [Medline].

  45. Parry CM, Hien TT, Dougan G, White NJ, Farrar JJ. Typhoid fever. N Engl J Med. Nov 28 2002;347(22):1770-82. [Medline].

  46. Perera N, Geary C, Wiselka M, Rajakumar K, Andrew Swann R. Mixed Salmonella infection: case report and review of the literature. J Travel Med. Mar-Apr 2007;14(2):134-5. [Medline].

  47. Punjabi NH, Hoffman SL, Edman DC, et al. Treatment of severe typhoid fever in children with high dose dexamethasone. Pediatr Infect Dis J. Aug 1988;7(8):598-600. [Medline].

 
Previous
Next
 
Under a moderately high magnification of 8000X, this colorized scanning electron micrograph (SEM) revealed the presence of a small grouping of gram-negative Salmonella typhimurium bacteria that had been isolated from a pure culture. Image courtesy of the Centers for Disease Control and Prevention, Bette Jensen, and Janice Haney Carr.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.