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Infectious Diseases in Obstetrics and Gynecology 1:46-48 (I 993) (C) 1993 Wiley-Liss, Inc. Maternal and Neonatal Infection With Salmonella heidelberg: A Case Report Kevin A. Ault, Maureen Kennedy, Muhieddine A.-F. Seoud, and Rosemary Reiss Department ofGynecology and Obstetrics, University ofKansas Medical Center, Kansas City, KS (K.A.A., M.A.-F.S.) and Department of Obstetrics and Gynecology, Ohio State University, Columbus, o4 (M.I., ..) ABSTRACT Maternal and neonatal infections with Salmonella typhi have been well documented. There are only two previous case reports ofintrauterine infection with non-typhoidal species. This paper presents a third case of maternal septicemia followed by neonatal sepsis with Salmonella heidelberg. (C) 1993 Wiley-Liss, Inc. KEY WORDS Amnionitis, salmonella, premature rupture of membranes almonella is a gram-negative bacillus ofthe fam- ily Enterobacteriaceae. Salmonella species are ubiquitous common pathogens in both humans and animals. Types of infection include asymptomatic carriage, gastroenteritis, enteric fever, meningitis, osteomyelitis, and septicemia. Transmission is fe- cal-oral, and the peak incidence occurs in infants aged 2 through 6 months. Neonatal infections due to Salmonella are well documented.2 The spread is typically epidemic, with premature infants at higher risk, and the in- dex case is often a mother. Vertical transmission during pregnancy has been documented with iden- tification ofSalmonella typhi in the amniotic fluid.3 Case reports of typhoid fever in pregnant women reflect the serious nature and lengthy differential diagnosis of this illness.4-7 Serious, non-typhoidal Salmonella infections in mothers appear to be less common. Roberts and Wilkins reported the results of screening over 30,000 women for Salmonella upon their presenta- tion for delivery, s Sixty (0.2%) women were Sal- monella excreters; the majority were asymptomatic. Two cases of intrauterine infection with presumed transplacental spread have been reported.9'1 We report here an unusual case of maternal bacteremia with subsequent neonatal infection due to Salmo- nella heidelberg.

ta- tion for delivery, s Sixty (0.2%) women were Sal- monella excreters; the majority were asymptomatic. Two cases of intrauterine infection with presumed transplacental spread have been reported.9'1 We report here an unusual case of maternal bacteremia with subsequent neonatal infection due to Salmo- nella heidelberg. CASE REPORT The patient was a 25 year old black woman, gravida four, para two, abortus one, at 28 weeks of gestation. Her chief complaint was leakage of fluid per vagina for 2 days with fever and chills. Her antenatal course was otherwise unremarkable. Her rectal temperature on admission was 39C, and her pulse was 124. She denied any cough, abdominal pain, diarrhea, or neck stiffness. No localizing signs of infection were found on physical examina- tion, and the uterus was noted to be non-tender. Sterile speculum examination confirmed the rup- ture of membranes, and her cervix appeared closed. The initial leukocyte count was 11,800/ mm3, with 85% segmented neutrophils and 5% Address correspondence/reprint requests to Dr. Kevin A. Ault, Department of Gynecology and Obstetrics, University of Kansas School ofMedicine, 3901 Rainbow Blvd., Kansas City, KS 66160-7316. Received October I, 1992 Obstetrics Case Report Accepted November 17, 1992 MATERNAL AND NEONATAL SALMONELLA AULT ET AL. bands; the hemoglobin was 10.9 g/dl. One hour later, her rectal temperature was 43C, and she continued to have chills. She was presumed to have prolonged rupture of membranes with choriam- nionitis. After obtaining urinary, cervical, and blood cultures, she was started on gentamicin and clindamycin intravenously, as well as acetamin- ophen and a cooling blanket; labor was induced with dilute oxytocin. Ampicillin was not given sec- ondary to a penicillin allergy. Labor progressed rapidly, and 6 hours later she delivered vaginally a live male neonate weighing 1,240 g. Apgar scores were 5 and 5 at and 5 minutes, respectively, and an umbilical vein pI-I was 7.33. The mother was noted to be afebrile at the time ofdelivery. The preliminary report on the blood cultures was Salmonella. The human immu- nodeficienc virus (HIV) test was negative, and hemoglobin electrophoresis was consistent with sickle cell trait. At the advice of an infectious dis- ease consultant, the antibiotic was changed to oral trimethoprim-sulfamethoxazole. The patient de- veloped diarrhea on postpartum day 2. Cultures of the placenta, maternal blood, and stool were posi- tive for Salmonella, serogroup B.

trophoresis was consistent with sickle cell trait. At the advice of an infectious dis- ease consultant, the antibiotic was changed to oral trimethoprim-sulfamethoxazole. The patient de- veloped diarrhea on postpartum day 2. Cultures of the placenta, maternal blood, and stool were posi- tive for Salmonella, serogroup B. She remained afebrile and was discharged on the fourth postpar- tum day. The newborn was admitted to the neonatal inten- sive care unit, intubated, placed on a ventilator, and given gentamicin and ampicillin. He was given artificial surfactant in the first few hours of life. Initial chest x-ray showed opacification bilater- ally. Initial blood and respiratory cultures were negative, and the newborn was weaned from the ventilator slowly over the first week of life. Intra- venous antibiotics were given for 10 days and then stopped. The newborn was extubated on day 10. Twelve hours after stopping the antibiotics, he de- veloped bradycardia, apnea, and hypoxemia, re- quiring ventilatory assistance. Leukocytosis was noted, and blood cultures, along with lumbar puncture, were performed. Chest x-ray showed no consolidations. Intravenous ampicillin and genta- micin were started. Twenty-four hours after blood cultures were done, gram-negative rods were de- tected. Eventually, blood, cerebrospinal fluid, and stool all grew Salmonella, serogroup B. The antibi- otics were changed to intravenous ceftazidime with ampicillin. The infant gradually improved on this regimen and was soon re-extubated. He eventually developed hydrocephaly, which required a shunt, and bilateral hydroceles requiring herniorrhaphy and orchidopexy. The child was released from the hospital after approximately 3 months. All fol- low-up cultures were negative for Salmonella. Samples of the bacteria from the maternal and neonatal blood cultures were sent to the local public health department and the Centers for Disease Con- trol and Prevention in Atlanta, GA. The serotype was identified as S. heidelberg. In retrospect, the mother reported eating partially cooked chicken several days prior to admission, and this chicken had been purchased directly from a local farm. DISCUSSION Salmonella typhi has been shown to cause serious maternal infection, with transplacental spread to the fetus. Systemic disease in adults is often due to S. typhi andparatyphi, whereas childhood disease is due to a wider variety of serotypes.

on, and this chicken had been purchased directly from a local farm. DISCUSSION Salmonella typhi has been shown to cause serious maternal infection, with transplacental spread to the fetus. Systemic disease in adults is often due to S. typhi andparatyphi, whereas childhood disease is due to a wider variety of serotypes. 2 Most of these childhood infections are cases of bacteremia and gastroenteritis in the first year of life. We have previously reported on maternal and neonatal infection with S. typhi.7 Both vertical and horizontal transmission have been hypothesized, and positive amniotic and cervical cultures have been reported.3 The placenta in this case did not show inflammation of membranes; however, it showed suppurative villitis. Scialli et al. 1 pre- sented a case ofsecond-trimester fetal loss associated with group C1 Salmonella. Dalaker et al. 9 also reported a case of septic abortion due to S. enteriti- dis. It is likely our case represents maternal sepsis from an enteric source with transplacental spread to the fetus. The neonatal infection on day 10 of life was felt to be secondary to an incompletely treated neonatal septicemia acquired in utero. The infant was in strict enteric isolation throughout the first several weeks of life. There were no other tempo- rally related cases ofSalmonella in the intensive care unit. Scialli et al.l recommend that pregnant women with diarrhea illness be screened for Salmo- nella. We agree with this conclusion, but we realize the difficulty in finding an etiological agent for infectious diarrhea. However, in the setting of ma- ternal sepsis with or without gastrointestinal com- plaints, it is prudent to consider all Salmonella spe- cies in the differential diagnosis. Identifying a history of ingestion of contaminated food or possi- bly a history of immunodeficiency or hemoglobin- INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 47 MATERNAL AND NEONATAL SALMONELLA AULT ET AL. opathy may help identify mothers at risk for Salmo- nella sepsis and lead to prompt and appropriate therapy. REFERENCES 1. Hyams JS, Durbin WA, Grand RI, Goldman DA: Sal- monella bacteremia in the first year of life. Pediatrics 96:57-59, 1980. 2. Remington DS, Klein S: Microorganisms responsible for neonatal diarrhea. In: Infectious Diseases ofthe Fetus and Newborn Infant. WB Saunders Company, Philadelphia, PA. 1990, third edition: 920-6. 3. Awadalla SG, Mercer LJ, Brown LG: Pregnancy com- plicated by intra-amnionitic infection by Salmonella typhi.

59, 1980. 2. Remington DS, Klein S: Microorganisms responsible for neonatal diarrhea. In: Infectious Diseases ofthe Fetus and Newborn Infant. WB Saunders Company, Philadelphia, PA. 1990, third edition: 920-6. 3. Awadalla SG, Mercer LJ, Brown LG: Pregnancy com- plicated by intra-amnionitic infection by Salmonella typhi. Obstet Gynecol 65:305-315, 1985. 4. Amster R, Lessing JB, Daffa AJ, Peyser MR: Case re- port: Typhoid fever complicating pregnancy. Acta Obstet Gynecol Scand 64:685-686, 1985. 5. Dildy GA, Martins MG, Faro S, Lee W: Typhoid fever in pregnancy; a case report. J Reprod Med 35:273-276, 1990. 6. Duff P, Engelsgjerd B; Typhoid fever on an obstetrics and gynecology service. Am J Obstet Gynecol 145:113- 114, 1983. 7. Seoud M, Saade G, Uwaydah M, Azoury R: Typhoid fever in pregnancy. Obstet Gynecol 71:711-714, 1988. 8. Roberts C, Wilkins EGL: Salmonella screening of preg- nant women. J Hosp Infect 10:67-72, 1987. 9. Dalaker K, Andersen M, Louslett K, Reuhaug A, Berdal B: Case report--septic abortion caused by Salmonella en- teritidis. Acta Obstet Gynecol Scand 67:185-186, 1988. 10. Scialli A, Rarick T: Salmonella sepsis and second trimes- ter pregnancy loss. Obstet Gynecol 79:820-821, 1992. 48 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY