[Cholangitis with hepatic microabscesses caused by Salmonella enterica serovar choleraesuis].

HISTORY AND ADMISSION FINDINGS: A 71-year-old man was admitted to the emergency unit of another hospital with a mild gastroenteritis and high fever. On admission g-GT and C-reactive protein (CRP) levels were markedly elevated. Under nonspecific antibiotic therapy with ampicillin/sulbactam the fever persisted and for the first time, on day 5, the patient complained of right-sided abdominal pain. An increase in the laboratory values indicated cholestasis. After changing the antibiotics to ceftriaxon and metronidazole, acute cholangitis being suspected, the fever subsided immediately and the CRP level decreased. The patient was discharged after seven days of antibiotic treatment. But he was once more admitted after four weeks to another hospital because of severely reduced general condition and mild fever. He was transferred to our unit after two weeks.

INVESTIGATIONS AND DIAGNOSIS: The test values indicated cholestasis and CRP was markedly elevated, while aminotransferase activity was slightly increased and normocytic normochromic anemia developed. Viral hepatitis, autoimmune and metabolic liver diseases, toxic liver damage, extrahepatic cholestasis and an endocarditis were excluded. Bile was aspirated by endoscopic retrograde cholangiopancreatography and added to blood culture bottles. Salmonella enterica serovar choleraesuis var. Kunzendorf was isolated.

TREATMENT AND FURTHER COURSE: The patient was treated with ciprofloxacin, 2 x 250 mg by mouth for a total of five weeks. After 17 days of treatment no Salmonella bacteria were grown from a newly aspirated bile sample and the patient became free of fever.

CONCLUSION

Salmonella infections do not always present as gastroenteritis. Bacteremia should be considered in the differential diagnosis of such infections. If cholangitis persists, the aspiration of bile for microbiological tests can be a rational diagnostic step and facilitates treatment. Prolonged administration of antibiotics is necessary to avoid relapse. and follow-up is very important when treatment is finished.