Medico-Legal Update - An International Journal

Volume 22 Number 3 July-September 2022

Salmonella Paratyphi B Meningitis in an Infant;

The First Report in Indonesia

Prastiya Indra Gunawan1, Riza Noviandi2

1
PhD Pediatric Neurology Lecturer, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga,
Dr Soetomo General Acdemic Hospital, Surabaya, Indonesia
2
MD Pediatric Neurology Lecturer, Department of Pediatrics, Faculty of Medicine, Universitas Airlangga,
Dr Soetomo General Acdemic Hospital, Surabaya, Indonesia

How to cite this article: Prastiya Indra Gunawan, Riza Noviandi et al Salmonella Paratyphi B Meningitis in
an Infant; The First Report in Indonesia. Volume 22 | Number 3 | July-September 2022

Abstract

A 7-month-old, previously healthy Indonesian baby was referred with chief complaint of several general seizures, fever
and diarrhea. The baby was irritable with positive pathological reflexes. Head CT scan suggesting meningoencephalitis.
CSF culture resulted Salmonella spp and biochemical test supported Salmonella paratyphi B. The baby was treated with
ampicillin and chloramphenicol for two weeks. The patient was discharge without neurological complication. Salmonella
paratyphi B in infant is a rare entity and it is the first case that ever reported in Indonesia. Proper management with
adequate antibiotics resulted satisfactory outcome.

Keywords: Salmonella Paratyphi B, meningitis, infant

Introduction morbidity presenting variable complications4. It is

associated with significant neurological sequelae in
Meningitis is described as inflammation of the those who survive, and a high relapse rate4-6.
membranes that encompass the brain and spinal
cord1. Salmonella meningitis is an uncommon form The purpose of this paper is to report a rare case of
and approximately 1% or less of acute bacterial Salmonella paratyphi B meningitis infection in infant
meningitis in developed countries. The first case of that successfully treated with conventional therapy.
Salmonella meningitis stated by Ghon in the year
1908 was due to Salmonella Paratyphi B2,3. Case Report
The previous reports suggested that Salmonella A 7-month-old, previously healthy Indonesian male
meningitis was associated with a high mortality rate baby was referred to Soetomo Hospital, Surabaya,
of up to 50-70% and high prevalence (50-90%) of Indonesia with chief complaint of several general

Corresponding author:
Prastiya Indra Gunawan
Institution affiliation: Department of Child Health, Universitas Airlangga, Faculty of Medicine
Address: Jl. Prof Dr Moestopo 6-8 Surabaya Indonesia 60286
Email: prastiya-i-g@fk.unair.ac.id
Telephone +628113429476
64

seizures that lasted for 10-15 minutes. The baby Paratyphi B. CSF analysis through lumbar puncture
presented with 5 days fever, diarrhea and stable (LP) is the most important laboratory diagnostic
hemodynamic. No history of ear discharge and test, and routine laboratory techniques can usually
thypoid fever in the family. The baby was anemic identify the pathogen. In infants and young children
and irritable. Meningeal sign was negative, otherwise globally, Streptococcus pneumoniae, Haemophilus
pathological reflexes were positive in both extremities. influenzae type b and Neisseria meningitides are
the most common causes of bacterial meningitis7,8.
Complete blood count showed white blood
Salmonella meningitis is an unusual manifestation
cells of 29.810 cells/mcL, haemoglobine level of
of salmonellosis. Humans acquire Salmonella by
8.7 g/dl, platelet count of 405.000 cells/mcL and
ingestion of contaminated water or food, furthermore
C-Reactive Protein was 136.65 mg/dL. Head CT
gastroenteritis remains the most common clinical
Scan with contrast showed leptomeningeal and
presentation. Intracranial infections follow bacteremia,
gyral enhancement on bilateral temporoparietal lobe
which occurs as a result of migration of the organisms
suggested of meningoenchepalitis.
across the gastrointestinal tract into the bloodstream9.
The liquor cerebrospinal analysis was cloudy in A CDC report showed that a third of patients yielding
appearance, cell count was 4558/µL consisting of Salmonella isolates from the CSF were younger than 3
53.5% polymorphonuclear cell, nonne and pandy months, besides more than half were younger than 1
test were positive, decreased glucose concentration year. Many reasons, including an undeveloped blood
(11 mg/dl) and increased total protein (97 mg/dl). brain barrier and a inadequately developed immune
Cerebrospinal fluid (CSF) culture resulted Salmonella system, have been postulated for why young children
spp in which sensitive with cefotaxime, ampicillin and are most susceptible, but no single explanation is
chloramphenicol. Biochemical tests demonstrated adequate9.
that indole was negative and citrate was positive.
Treatment of salmonella meningitis is very difficult,
Triple sugar iron produced abundant H2S as the
and has never been standardized5. Salmonella is
characteristic of Salmonella Paratyphi B. Blood
being a facultative intracellular micro-organism. The
culture resulted no growth of bacteria.
drug penetration is inadequate, which may result
Based on the antibiotic sensitivity test, the patient in the progression of the infection and also, there is
put on ampicillin 100 mg/kg/day intravenously an evidence of an increasing resistance against the
and chloramphenicol 50 mg/kg/day intravenously conventionally used antibiotics such as ampicillin,
for two weeks. Phenytoin was added to control the chloramphenicol, cotrimoxazole and cephalosporins.
seizures. The baby condition was improve, and then The treatment protocol for salmonella meningitis can
discharge in a good condition after being hospitalized be adjusted depending upon the sensitivity pattern of
for three weeks. No complication was observed. The the organism and the clinical response to the antibiotic
ambulatory EEG was normal. in use. Duration of treatment varied between two
to eight weeks2-4,10 . In our case, combination of
Discussion chloramphenicol and ampicillin for 14 consecutive
days resulted in a good response.
The clinical signs and symptoms of bacterial
The prognosis and the course of Salmonella
meningitis in children vary depending on the age
meningitis is varies. Salmonella meningitis tends to
of the child and duration of disease. Classical signs
cause a high percentage of neurological abnormalities.
of meningitis such as nuchal rigidity, bulging
Coma on admission is related with a worse prognosis
fontanelle, photophobia, and a positive Kernig’s or
than a child presenting with irritability or lethargy
Brudzinski’s sign (usually in children older than 12
alone6. In our case, the baby was fully recovered and
to 18 months) may also be present. Focal neurological
had no obvious complication after the treatment .
signs may also be observed, as well as reduced level
of consciousness. In our case, the baby was irritable,
fever with positive pathological reflexes suggesting Summary
an intracranial infection.
Meningitis in infants is rarely caused by Salmonella
From CSF Salmonella spp was isolated. Manual paratyphi B. This is the first case that ever reported in
biochemical test showed the species was Salmonella Indonesia. The children who experienced Salmonella

MLU/ Volume 22 / Number 3 / July-September 2022

 Medico-Legal Update - An International Journal 65

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MLU/ Volume 22 / Number 3 / July-September 2022