Salmonella typhimurium: A Rare Cause of Colonic Ulceration and Perforation in Infancy By Chan Hon Chui, V.T. Joseph, and Chia Yin Chong Singapore A rare case of a healthy infant with colonic ulcers caused by Salmonella typhimurium infection that presented with co- lonic perforation, hypovolemic, and septicemic shock is dis- cussed. It stresses the importance of considering an infective process such as salmonellosis in the differential diagnosis of colonic ulceration in an infant and illustrates the unique histologic finding of colonic inflammatory changes with sparing of the small intestine. J Pediatr Surg 35:1494-1495. Copyright © 2000 by W.B. Saunders Company. INDEX WORDS: Salmonella typhimurium, colonic ulceration, colonic perforation. S ALMONELLA TYPHIMURIUM causing colonic ul- cers is described rarely in infants. Because most of the patients with salmonellosis recover without compli- cations, ulcerations rarely are discovered unless visual- ized through endoscopy or after gut resection when complicated by hemorrhage or perforation. Salmonella infection is known to occur primarily in the small intes- tine. 1,2 Few reports have illustrated colonic inflammatory changes with sparing of the small intestine on histolo- gy. 2-4 We report on a healthy infant with colonic ulcers caused by S typhimurium infection that presented with colonic perforation. CASE REPORT A 9-month-old Chinese girl, 8 kg, presented to the Children’s Emergency Department in hypovolemic and septicemic shock. Before her admission, she had fever for a duration of 7 days. This was associated with vomiting on the first day of her illness and diarrhea on the third day of illness. On the day of admission, she had copious vomiting and became very lethargic and unresponsive to call. She had no previous significant medical illnesses. Clinically, she was toxic, and her peripheries were cold and clammy. Blood pressure was 94/27 mm Hg, pulse rate was 198 beats per minute, thready. Respiratory rate was 40 per minute. Abdomen was distended with generalized tenderness and absence of bowel sounds. Periumbil- ical erythema was noticed. Metabolic acidosis was apparent on arterial blood gas. She responded to resuscitation with crystalloids. Abdominal x-ray showed a pneumoperitoneum and dilated bowel loops. Hemoglobin level was 11.3 g/dL, total white cell count was 11.6  10 9 /L, granulocytes were 80%, and lymphocytes were 9%, with shift to left and toxic granulations. Platelet count was 430  10 9 /L, and serum electrolytes showed hyponatremia at 122 mmol/L, which im- proved with resuscitation. The results of cultures were not available at the time of surgery and did not contribute to the preoperative diagnosis. Intravenous ceftriax- one and metronidazole were given preoperatively after blood cultures were taken. Emergency laparotomy findings showed a 0.5-cm  0.5-cm cecal perforation with multiple areas of impending perforations in the ascending colon. There also was extensive fecal soilage and purulent fluid in the peritoneal cavity. Primary repair of the cecal perforation was performed with absorbable sutures. Impending perfo- rations were reinforced with seromuscular sutures. The blood and stool cultures grew S typhimurium. Peritoneal fluid cultures grew Enterobacter cloacae, Escherichi coli, and Klebsiella species. She was continued on ceftriaxone and metronidazole and was stable for the next 4 days. On the fifth postoperative day, she had fecal soilage through the right paracolic gutter drain. She underwent a second laparotomy and an ascending colon perforation, and multiple other areas of impending perforations were found. Previous sites of repaired perforations were intact. Right hemicolectomy was performed. Stool culture was repeated and continued to grow S typhimurium, and an earlier discharge from the drain site grew E clocae and Acinetobactor baumanni, which were sensitive to meropenem and amikacin. The antibiotics were changed to intravenous meropenem and amikacin. The specimen was opened up, and multiple punched-out ulcers were found in the right colon. These were swabbed for herpes simplex virus (HSV) immunoflouresence, cytomegalovirus (CMV) culture, smears for fungus, and acid-fast bacillus, results of which were negative. Amoebic antibodies were less than 1 of 64. Blood HSV CF and CMV CF antibodies were less than 8 and CMV IgM Ab EIA also was negative. Human immunodeficiency virus screening was nonreactive. Gross examination of the specimen found multiple small ulcers on the colonic mucosa (Fig 1), the largest measured 3 cm  1 cm and is present in the cecum. The ulcers appeared to be situated in a transverse fashion and show punched-out edges with necrotic base. Microscopic examination showed multiple acute ulcers of varying depths of pene- tration, including one that has perforated through the entire colonic wall. The ulcer base showed necrotic slough with fibrinous exudates containing debris and neutrophils overlying the underlying submucosa, which showed presence of foamy histiocytes, lymphocytes, and plasma cells. No granulomas were seen. The paracecal lymph nodes were tiny and unremarkable. The mucosa of the small intestine was nonulcerated and showed occasional scattered foci of histiocytes. Special stains for acid-fast bacilli and fungi were negative. Neither amoeba nor viral inclusions were identified. Postoperatively, she was started on total parenteral nutrition. As she continued to improve, she started feeding on the seventh postoperative day. Wound infection occurred on the eighth postoperative day. She From the Division of Paediatric Surgery, KK Women’s and Chil- dren’s Hospital, Singapore. Address reprint requests to V.T. Joseph, MBBS, FRCSEd, FRACS, M. Med (Surgery), FAMS, Division of Paediatric Surgery, KK Wom- en’s and Children’s Hospital, 100 Bukit Timah Rd, Singapore 229899. Copyright © 2000 by W.B. Saunders Company 0022-3468/00/3510-0021$03.00/0 doi:10.1053/jpsu.2000.16422 1494 Journal of Pediatric Surgery, Vol 35, No 10 (October), 2000: pp 1494-1495