Septicemia caused by Salmonella infection: an overlooked complication of sickle cell disease

OBJECTIVE: To describe the characteristics of salmonella infections in sickle cell disease and to compare the features of osteomyelitis and those with bacteremia/septicemia without obvious bone changes. To search for risk factors for osteomyelitis, and to draw attention to the frequency and significance of salmonella bacteremia/septicemia. STUDY DESIGN:A retrospective review of all salmonella isolations from the blood, pus, or aspirates during a 22-year period. SETTING: The sickle cell clinic at the University Hospital of the West Indies, Kingston, Jamaica. SUBJECTS: Patients with all genotypes of sickle cell diseases. Incidence data and the frequency of associated cholelithiasis were derived for the cohort study based on follow-up of all children detected by neonatal screening. MAIN OUTCOME MEASURES: Osteomyelitis and bacteremia/septicemia. RESULTS: Of 55 patients with salmonella infections, 25 initially had osteomyelitis and 27 had bacteremia/septicemia. Three of the first group later had bacteremias for a total of 30 episodes of bacteremia/septicemia, and 4 of the second group later had osteomyelitis for a total of 32 episodes of osteomyelitis. The incidence of salmonella infection was 8.6 percent by 15 years and 96 percent of infections occurred before the age of 10 years. Preceding episodes of avascular necrosis of bone were frequent (p < 0.006) in patients with osteomyelitis. Patients with osteomyelitis were not more prone to gallstones. High fever (temperature > or = 40 degrees C or 104 degrees F) occurred in 41 percent, and occasionally marked bone marrow suppression mimicked the aplastic crisis. Twenty Salmonella serotypes were isolated; Salmonella enteritidis accounted for 36 percent of infections, but no serotype difference occurred between those with osteomyelitis and those with bacteremia/septicemia. There were no deaths in the 32 patients with osteomyelitis, but 7 (23 percent) of 30 patients with septicemia died. CONCLUSIONS: Anti-salmonella prophylaxis requires assessment in the management of bone necrosis. Anti-salmonella agents may be indicated in undiagnosed septic conditions in sickle cell disease pending culture results.(AU)

Two different forms of homozygous sickle-cell disease - abstract

Haematological, clinical and some molecular genetic features have been compared in two groups of patients with homozygous sickle-cell (SS) disease in Saudi Arabia, 33 patients from the Eastern Province (eastern) and 30 from the South Western Province (Western). Eastern patients all had the Asian haplotype of DNA polymorphisms within the beta globin gene cluster whereas Western patients were more variable but predominantly of the Benin haplotype. Eastern patients had significantly more deletional alpha thalassaemia, higher levels of total haemoglobin and foetal haemoglobin, and lower of HBA, mean volume reticulocytes, and platelets. Clinically, Eastern patients had a greater persistence of splenomegaly, less dactylitis, less acute chest syndrome, a more normal body build and greater subscapular skin fold thickness. Painful crises occurred with equal frequency in both groups. Avascular necrosis of the femoral head was common in both groups. The disease in the Eastern province has many mild features consistent with the higher HbF levels and more frequent alpha thalassaemia but bone pathology (painful crises, avascular necrosis of the femoral head, osteomyelitis) remains common. The disease in the West is more severe, consistent with the Benin haplotype suggesting an African origin (AU)

Systemic salmonella infections in sickle cell anaemia

Salmonella infections remain a significant cause of morbidity and mortality in patients with sickle cell disease. In Jamaica, 16 episodes of systemic Salmonella infection were recognised in 308 children with sickle cell disease followed prospectively in a cohort study from birth. There were eight cases with osteomyelitis, seven with septicaemia, and one with meningitis. Salmonella dactylitis and dactylitis owing to avascular bone necrosis showed that children with osteomyelitis had significantly higher fever, prolonged history and fluctuant swelling. Fever above 38.5§C occurred in four of five children with Salmonella dactylitis, but in only one of 59 with uncomplicated dactylitis (P=0.01). Chloramphenicol and co-trimoxazole were both effective for systemic infection, and ampicillin alone was inadequate. Three deaths occurred, two from septicaemia and one from meningitis. (AU)

Hyperbaric oxygen initial experience with a new treatment modality in Barbados - abstract

The Decompression Chamber of the Barbados Defence Force has been used since February, 1987 for Hyperbaric Oxygen (HBO) treatment of accepted medical and surgical conditions. The treatments are administered in the chamber and are carried out at various pressures as recommended by the HBO sub-committee of the Undersea and Hyperbaric Medical Society. Thirty patients have been treated and the epidemiological details and results are reported. Improved - 25 patients, 84 percent; No change - 3 patients, 10 percent; Deteriorated - 1 patient, 3 percent; Discountinued treatment - 1 patient, 3 percent. Improvement was judged by clinical, radiological and bacteriological criteria. The results indicate that, whilst not a complete form of therapy by itself, HBO is a valuable adjunctive modality of treatment in speeding the resolution and healing of various conditions, e.g., chronic osteomyelitis, chronic leg ulcers and burns. This is in agreement with previously published studies. Barbados is fortunate in being able to provide this valuable form of therapy. HBO facilities are available in other Caribbean areas and greater use should be made of this treatment modality (AU)

Multiresistance Salmonella Ohio infections at the University Hospital of the West Indies

During 1982-83 there was a substantial increase in the number of S. ohio infections at the University Hospital of the West Indies, which coincided with the appearance of strains resistance to chloramphenicol, cotrimoxazole, ampicillin, neomycin and carbenicillin. Multiresistance strains of S. ohio accounted for 19.3 percent of all salmonella isolates during this period and all of 40 strains tested were able to transfer resistance determinants to E. coli K12 J 53-2. S. ohio was cultured from stool (60), blood (5), wounds and abscesses (4) and postmortem material (2). Eighty-six percent of S. ohio infections occurred in children of 3 years old or less. There was a high incidence of gastroenteritis in malnourished children, a 14 percent incidence of localizing infections and a 7 percent incidence of septicaemia. Two infants with severe gastroenteritis and bronchopneumonia died. There were a number of unusual infections including two cases of septicaemia in children receiving chloramphenicol for Haemophilus infleunzae meningitis, a scrotal abscess secondary to extravastion of urine and infected scabies in a child with marasmic kwashiorkor.(Summary)

Early splenomegaly in homozygous sickle-cell disease: an indicator of susceptibility to infection

135 children with homozygous sickle-cell (SS) disease diagnosed at birth have been followed for 1-5 years. Severe bacterial infections were confined to those in whom the spleen was first palpable at or before 1 year of age and were commonest in those in whom the spleen was first palpable at or before age 6 months. Regular follow-up of children with SS disease diagnosed at birth will identify children particularly at risk of severe infections. (Summary)

Pyogenic osteomyelitis of the spine - an important differential diagnosis of tuberculosis of the spine - abstract

Pyogenic osteomyelitis of the spine can very easily be confused with tuberculosis of the spine. It is important that these two conditions be differentiated and this can be done by a careful assessment of the clinical and radiological features of each. 18 cases of pyogenic osteomyelitis of the spine seen at the University Hospital of the West Indies over the last 10 years are reviewed. The age incidence varied from 23 years to 65 years with an average age of 54 years. There were 14 males and 4 females. The lesions were distributed as follows - 13 lumbar, 4 thoracic and 1 cervical. There was an associated urinary tract pathology or surgical intervention on the urinary tract in 11 cases. There was only 1 case with diabetes and none with abnormal haemoglobin. There were no cases of typhoid osteomyelitis. There were no local abnormalities of the spine, apart from mild osteoarthritic changes and osteoporosis consistent with the age of the patient. Pyogenic osteomyelitis of the spine is a fairly rare condition. The chief aetiological factor in the development of this condition is urinary tract infection (AU)

Conditions of the hip associated with hemoglobinopathies

In the Western hemisphere where malaria and parasitic infection is rare, the complications of the abnormal hemoglobins are those essentially of infarction. Hyperplastic changes never reach the extent seen in West Africa, infection is a less serious problem, patients survive into adult life and the hip joint produces a large proportion of the orthopedically crippled. Treatment follows the same lines which would be adopted in a patient with avascular necrosis of the femoral head with normal hemoglobin. The prognosis is worse because the age of onset is usually later resulting in slower and less complete restoration to normalcy. Special care in the general management of patients during operations is essential, particularly the avoidance of excessive blood loss or anoxia which may precipitate a crisis (summary)

Osteomyelitis: A study of the aetiological agents responsible for acute osteomyelitis at the University Hospital of the West Indies, 1966-1968

It is shown from a review of 50 cases of acute osteomyelitis from 1966-68 that:- 1) Infecting organism is Staph. pyogenes (coag.+ve)-86 percent of cases. 2) They claim that no toxic effects have been observed with chlorophenicol when they use it. However, this is based on no scientific study and is in conflict with most other reports. 3) They argue that less than 5 percent of the organisms involved are sensitive to penicillin. This has shown to be a gross underestimate. 4) They argue that chloramphenicol is cheap. However, pencillin is also cheap and in any case cost of treatment must be balanced against quality of treatment. 5) Finally, they argue that chloramphentic is convenient to administer. However, convenience must also be balanced against quality of treatment and in many cases it is not known wether the chlorampheticol is taken as ordered. (Summary)

Acute haematogenous osteomyelitis

Twenty-one cases of acute haematogenous osteomyelitis and eight cases of chronic osteomyelitis admitted to the Paediatric Surgical Ward of the University Hospital of the West Indies during 1962 have been reviewed. Eighty-six per cent of those with the acute disease responded to penicillin therapy with or without additional surgical drainage. Three children (14 percent) had a fulminating variety of the disease and it was these three who were found to have a penicillin resistant organism and required immediate drainage. Early treatment with antibiotics gave the best chance of cure without requiring drainage in the less severe form of the disease. It was found that drainage to be useful, had to be carried out promptly and not later than 36 hours after the start of antibiotic treatment (AU)

Osteomyelitis and fibrous dysplasia of the jaw in the negro (abstract only)

During the last three years six cases of Sclerosing Osteomyelitis of the jaws came under observation. They showed clinically and rontgenologically a uniform picture of sclerotic areas in the mandible and sequester formation. The cases described in the literature and all our cases are negroes, women and fortyfive (45) years old and older. No general disease as cause could be found - sickle cell anaemia was excluded. The histo-pathological survey by John Arneaud points out similarities with Fibrous Dysplasia and the possibility of these lesions being different stages of the same process (AU)

The bone changes in sickle cell anaemia and its genetic variants

The bone changes are described in fifty-one cases of sickle cell anaemia, nineteen cases of sickle cell haemoglobin C disease and two cases of sickle cell thalassaemia. Avascular necrosis of the head of the femur has been found in all three types of sickle cell disease. These responded to treatment. The changes found in six cases of Perthes' disease in the negro compared with the changes in avascular necrosis of the head of the femur in sickle cell disease. Hyperplastic bone changes are seen only in true sickle cell anaemia and not in the variants. Secondary osteomyelitis appears to be fairly common in sickle cell anaemia. Organisms of the salmonella group have often been found in these cases (Summary)

Paratyphoid C osteomyelitis

The first case of paratyphoid C infection in Jamaica is reported as a paratyphoid C osteomyelitis complicated by sickle cell crisis. The epidemiological implication of the above finding is of importance in view of the omission of paratyphoid organisms from the vaccine used in Jamaica. The high invasiveness and pathogenicity of Salmonella paratyphi C is noted. (AU)