Feder, Henry M. Jr MD; Zempsky, William MD
Division of Infectious Disease, Connecticut Children's Medical Center, Hartford, CT.
Address correspondence and reprint requests to Henry M. Feder Jr, MD, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-2918. E-mail: email@example.com.
Abstract: Salmonella rarely causes focal genital infections. We report a neonate who was hospitalized with fever and a tender erythematous scrotum. Blood cultures were positive for Salmonella. After 4 days of appropriate antibiotic therapy, 5 mL of pus was drained from under the tunica vaginalis of each testicle and was culture-positive for Salmonella. The culprit for bringing the Salmonella into the home was most likely a Savannah monitor. Reptiles pose a risk for causing human Salmonella infections, especially in infants, and should not be kept as pets in households with children younger than 5 years.
Focal infections with nontyphoidal Salmonella are rare.1,2 The following is a case report of Salmonella orchitis in a neonate who had an unusual exposure.
A 24-day-old boy was hospitalized with fever, irritability, and a tender red scrotum (Fig. 1). He had been circumcised without incident at 1 day of age and was discharged from the hospital on day 3 after birth. He had been exclusively breastfed and thriving throughout his first 23 days of life. Then on his 24th day of life, he decreased his feeding and developed fever. Everyone else at home was well. On admission, the infant's vital signs were normal except for a temperature of 38.9°C. His physical examination was positive for a swollen, tender, red scrotum. His white blood cell count was 13,400/mm3 with a normal differential; his urinalysis was normal (and urine culture was sterile), and his cerebrospinal fluid was normal. An ultrasound revealed echogenic fluid around each testicle. He was initially treated with intravenous clindamycin, ampicillin, and cefotaxime. On hospital day 2, his blood culture was positive for Salmonella (later serotyped by the Centers for Disease Control and Prevention as Salmonella serotype Stellingen, an unusual human isolate). The Salmonella Stellingen was susceptible to ampicillin and cefotaxime. It was then learned that the family had a pet Savannah monitor (a 2-ft-long African lizard) who was cared for by the infant's mother. The infant's mother gave a history of diarrhea 2 weeks before the hospitalization. The infant had never come into direct contact with the lizard. On hospital day 4, the patient's scrotum was still red, swollen, and tender. He was taken to the operating room where 5 mL of pus was drained from between the tunica vaginalis and tunica albuginea of each testicle. Cultures from both testicles were positive for Salmonella Stellingen. Drains were left in place for 3 days. He was treated in the hospital with 7 days of intravenous ampicillin and cefotaxime. The infant never had diarrhea, and stool cultures were not done. He was then discharged and treated as an outpatient with 10 days of oral amoxicillin. A stool culture from the monitor could not be performed as the lizard had been given away to a reptile farm. Stool culture from the mother, whose diarrhea had resolved, was negative for Salmonella. It was the mother who cared for the monitor, and the monitor was kept in a cage. The cage was not available for culture (Salmonella can survive in the environment for weeks). It is likely that the lizard brought Salmonella into the family, and the infant got infected via his mother. At his 1-year well-child visit, the patient's testicles were normal.
Lizards and other reptiles were first recognized as Salmonella hazards in 1946. In the 1970 and 1971, more than 280,000 of the 2 million cases of human salmonellosis in the United States were linked to pet turtles.3 Carriage of Salmonella by turtles and other reptiles is common and is very difficult, if not impossible, to eradicate using antibiotics. Because of the Salmonella risk from pet turtles, in 1972, the US government curtailed their sale, and turtle-associated Salmonella cases fell to 77%.4 Families, however, continue to keep reptiles as pets.5-8
Infants, compared with adults, need a much smaller inoculum of Salmonella to cause clinical infection. This may be because of infants having gastric hypochlorhydria and rapid gastric emptying.9,10 In addition, infants, compared with adults, are more likely to develop nongastrointestional focal Salmonella infections including meningitis, osteomyelitis, or occasionally, orchitis. An infant with a positive blood culture for Salmonella should have a lumbar puncture to rule out meningitis, because in this age group, meningitis may not be clinically apparent. In 1987, Cohen et al1 reviewed the adult and pediatric literature of extraintestinal Salmonella infections. They found 651 cases of extraintestinal Salmonella infections of which 6 (0.9%) of 651 involved testicles and 9 (1.4%) of 651 involved ovaries. In 1977, Huang and Chuan11 reviewed 5 cases of Salmonella orchitis in infants younger than 3 months. In these 5 infants, the initial diagnoses were incarcerated hernias (2 patients), acute scrotal swelling (1 patient), and testicular torsion (2 patients). Reptile exposure was not reported in any of the cases. All patients needed drainage procedures, and at the time of drainage, all of the infants had positive cultures for Salmonella. The Salmonella orchitis was diagnosed at the time of surgery. Antibiotic treatment of these patients ranged from 10 to 24 days. In our infant, Salmonella was recovered from both testes 4 days after starting appropriate antibiotic therapy. The potential space between the tunica vaginalis and albuginea contains a small amount of fluid (a large amount of fluid defines a hydrocele, which was not present in our patient) which can get infected with Salmonella. Therefore, the Salmonella infection is around the testes, and the testes become secondarily inflamed.
In 2003, 1 state (Tennessee) has banned the pet store sale of turtles, 5 states (California, Connecticut, Maryland, Michigan, and New York) require that families buying turtles be warned about Salmonella, and 4 states (Colorado, Illinois, Kansas, and Texas) require that families buying turtles or reptiles be warned about Salmonella. Of the 1,200,000 United States cases of Salmonella infections in 1999, approximately 74,000 (6%) were caused by reptile or amphibian contact.7 The Centers for Disease Control and Prevention has published guidelines for preventing reptile/amphibian associated salmonellosis. Because infants are at high risk for developing serious Salmonella infections, the Centers for Disease Control and Prevention recommends that reptile/amphibian not be kept by families with children younger than 5 years.
Our case serves as a reminder that reptiles are inappropriate pets for families with infants. If an infant develops Salmonella orchitis, drainage may be necessary to resolve the infection.
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