Acute Abdomen Caused by Salmonella typhimurium
Infection in Children
By I. Serdar Arda, Funda Ergin, Birgül Varan, Beyhan Demirhan, Hande Aslan, and İpek Özyaylali
Ankara, Turkey
Salmonella spp. infections can be particularly challenging
when they manifest as acute abdominal problems and lead
to emergency surgery. Examples of such serious conditions
are Salmonella-related intestinal perforation, gallbladder in-
volvement, salpingitis, and peritonitis. Mesenteric lymphad-
enitis associated with Salmonella typhimurium mimics acute
appendicitis and can make it difficult to establish a timely
and definitive diagnosis in young patients who present with
right lower abdominal pain. Paralytic ileus is a fairly common
manifestation of Salmonella infection at all ages, but com-
plete intestinal obstruction requiring surgical intervention is
very rare. Because of the nature of the diagnostic process, a
significant number of patients with Salmonella infection
present with acute abdomen and undergo needless opera-
tions. This report describes the cases of 2 pediatric patients
I N CHILDREN, Salmonella spp. are always consid-
ered potential causal agents when the clinical picture
is acute abdomen.1-5 Mesenteric lymphadenitis caused by
Salmonella can manifest clinically as abdominal condi-
tions that mimic acute appendicitis or peritonitis.6-10
However, paralytic ileus is a common finding; complete
intestinal obstruction is a very rare occurrence.3
We encountered 2 pediatric cases that involved un-
usual presentations of Salmonella typhimurium infection,
both of which were diagnostically challenging. On ad-
mission, 1 patient had the clinical symptoms of acute
appendicitis and the other showed signs of complete
intestinal obstruction; however, we were unable to iden-
tify the exact cause of the problems during the initial
workup. Exploratory surgery found that the appendicitis-
like symptoms were caused by mesenteric lymphadeni-
tis, and that the complete intestinal obstruction had been
caused by adhesions between inflamed mesenteric lymph
nodes and adjacent intestinal segments.
CASE REPORTS
Case 1
A 12-year-old boy presented with the complaints of colicky abdom-
inal pain, fever, and vomiting of 3 days’ duration. The patient had no
diarrhea, constipation, or urinary symptoms. Physical examination
found tenderness and rigidity in the right lower quadrant of the
abdomen. We also noted pharyngeal hyperemia and keratitis caused by
herpes infection. His axillary temperature was 39.4°C, and the labora-
tory findings were as follows: hemoglobin level, 12.4 G/dL; white
blood cell count, 8,300/mm3; platelet count, 240,000/mm3, C-reactive
protein, 36.2 mg/dL (Normal, 0 to 6 mg/dL); erythrocyte sedimentation
Journal of Pediatric Surgery, Vol 36, No 12 (December), 2001: pp 1849-1852
who underwent surgery to address persistent pain in the
right lower abdominal quadrant and complete intestinal ob-
struction, respectively. The first patient had inflamed mesen-
teric lymph nodes that caused appendicitislike symptoms,
and the second had dense adhesions between the mesentery
and the terminal segments of the ileum that led to intestinal
blockage. Serology results showed that both patients’ titers
for BO (“B and O agglutinating [BO]”) antibodies rose to
1:640 in the week after their admission to hospital, a pattern
and level that is indicative of S typhimurium infection.
J Pediatr Surg 36:1849-1852. Copyright © 2001 by W.B.
Saunders Company.
INDEX WORDS: Salmonella typhimurium, mesenteric
lymphadenitis, appendicitis, intestinal obstruction.
rate, 44 mm/h; urine sediment examination normal. Abdominal ultra-
sonography (USG) showed enlarged lymph nodes in the ileocecal
region and thickening of the intestinal wall in that area, but the
appendix vermiformis could not be visualized. A tuberculin test yielded
a 7-mm reactive area. Widal’s test showed that the patient was positive
for BO antibodies, with a titer of 1:20. Abdominal computerized
tomography (CT) showed the same findings as USG. A stool culture
was negative for enteric pathogens. On the basis of the symptoms and
the initial test results, we started the patient on a course of intravenous
ceftriaxone at 100 mg/kg/d.
With no improvement in the patient’s condition after 2 days, we felt
that exploratory surgery was indicated. At laparotomy, we found a
mass of firmly adhered lymph nodes adjacent to the cecum and
extending to the posteromedial aspect of the ascending colon. The
appendix was mildly edematous and appeared inflamed on gross
examination. There was no free fluid in the abdominal cavity, and the
rest of the intestinal tract appeared normal. We excised 3 lymph nodes
and performed an appendectomy.
Histopathologic examination of the excised nodes showed reactive
hyperplasia (Fig 1). The appendix wall was thickened and exhibited the
same findings of inflammatory reaction. The patient’s temperature had
normalized by the third postoperative day. On the sixth day after
admission the blood culture results showed isolation of S typhimurium,
with sensitivity to ceftriaxone. A Widal’s test repeated on day 7 showed
From the Departments of Pediatric Surgery, Clinical Microbiology
and Infectious Diseases, Pediatrics, Pathology, and General Surgery,
Baskent University Faculty of Medicine, Ankara, Turkey.
Address reprint requests to I. Serdar Arda, MD, Pediatric Surgeon,
Baskent University Faculty of Medicine, Department of Pediatric
Surgery, Fevzi Çakmak caddesi 10. Sokak No: 45, 06490 Bahcelievler,
Ankara, Turkey.
Copyright © 2001 by W.B. Saunders Company
0022-3468/01/3612-0027$35.00/0
doi:10.1053/jpsu.2001.28867
1849
1850 ARDA ET AL

days of hospitalization. He completed a 14-day course of ceftriaxone

treatment.

DISCUSSION
Salmonella infections usually are self-limiting ill-
nesses confined to the gastrointestinal system and are
best known as a common cause of gastroenteritis. How-
ever, in some cases the organisms escape the small
intestine through the lymphatics and may cause hyper-
plasia in the Peyer’s patches, as well as mesenteric
lymphadenopathy, splenomegaly, and changes in the
liver parenchyma. This type of infection also can mani-
fest as acute abdomen and lead to emergency surgery.
Surgical interventions for Salmonella-related small
Fig 1. Reactive lymph node shows prominent sinus histiocytosis.
bowel perforation, gallbladder involvement, salpingitis,
(H&E, original magnification, ⴛ50.)
and peritonitis all have been documented in the litera-
ture.4,11,12 Salmonella spp. also have been isolated as
that the patient’s titer for BO antibodies had risen to 1:640. The patient causes of osteomyelitis and brain abscess, but such
encountered no complications, was discharged on day 10 postsurgery, findings are rare.2,3 Salmonella spp. also can cause true
and completed 14 days of the antibiotic treatment. appendicitis or appendicitislike symptoms.5-10 Overall,
the spectrum of associated pathology is broad, ranging
Case 2
from lymphoid hyperplasia of the appendix to lymphad-
A 14-year-old boy presented with abdominal cramps and bilious enitis of adjacent nodes, and from ileitis with or without
vomiting of 2 days’ duration. On physical examination, the patient’s
abdomen was distended and was tender in all four quadrants, and bowel appendicitis to suppurative appendicitis.13,14 In some
sounds were decreased. His axillary temperature was 38.7°C. The cases, the infection presents with paralytic ileus.2
laboratory findings were as follows: hemoglobin level, 14.6 G/dL; It often is hard to differentiate acute appendicitis from
white blood cell count, 3,300/mm3; platelet count, 370,000/mm3; blood Salmonella infection in the lower ileum. Reports state
urea nitrogen level, 20 mg/dL; creatinine level, 0.8 mg/dL; sodium, 132
that Salmonella infection mimicking appendicitis usually
mEq/L; potassium level, 3.2 mEq/L; chloride, 105 mEq/L; urine
sediment examination normal. A plain abdominal x-ray showed large occurs in the first 2 decades of life.15 Corbeira et al16
based air-fluid levels in the abdomen, with no gas in the pelvic area, found that patients who have mesenteric lymphadenitis
signs indicative of complete intestinal obstruction. USG showed en- and a clinical picture of an appendicitislike syndrome
larged lymph nodes in the right iliac fossa. There was no evidence of often have enlarged and erythematous lymph nodes at
intraperitoneal infection caused by intestinal leakage or of any mass
the root of mesentery and a normal appendix. They noted
that might be causing the obstruction. CT examination showed that the
wall of the terminal end of the small bowel was thickened, and also that histopathologic examination of these nodes typically
showed numerous enlarged lymph nodes, as seen on USG. show reactive lymphadenitis or follicular hyperplasia. In
Based on these initial findings, we started the patient on intravenous cases of mesenteric adenitis caused by Salmonella, the
ceftriaxone (100 mg/kg/d) and ornidazole (20 mg/kg/d). Further combination of clinical presentation and radiologic and
workup with a Widal’s test showed that the patient was positive for BO
laboratory assessment may not always show the extent of
antibodies with a 1:40 titer. We placed a nasogastric tube, and collected
bilious drainage material in amounts of 3,000 mL, 2,500 mL, and 2,000
mL on days 1, 2, and 3 after admission, respectively.
Since the patient’s fever, abdominal tenderness, and intestinal ob-
struction remained unchanged under medical treatment, we operated on
him using a right paramedian approach. On opening the abdomen, we
found that the terminal small intestine was severely distended and
noted some clear fluid in the pelvic cavity. There were numerous
inflamed lymph nodes in the mesentery near the ileocecal junction, and
these were associated with dense adhesions between the mesentery and
the intestine. The intestinal wall in the affected area was intact. After
releasing the adhesions, we performed an appendectomy and excised
some of the inflamed nodes.
Histopathologic examination found microabscess formation in the
reactive lymph nodes (Fig 2) and normal appendix tissue. A culture of
the peritoneal fluid was negative. The patient’s bowel motility resumed
on the second postoperative day, and a stool culture isolated S typhi-
murium. We repeated the Widal’s test on day 7 postadmission and
found that the patient’s titer for BO antibodies had risen to 1:640. There Fig 2. Neutrophilic microabscess in the reactive lymph node.
were no surgical complications, and the patient was discharged after 7 (H&E, original magnification, ⴛ230.)
ACUTE ABDOMEN AND SALMONELLA INFECTION
the underlying pathology.10 The common USG findings
in patients with bacterial enteritis of the ileocecal region
are enlarged mesenteric lymph nodes and mural thicken-
ing in the terminal ileum and cecum, with no visualiza-
tion of the appendix.17 CT is another tool for diagnosing
mesenteric adenitis mimicking appendicitis, and a typical
scan in these cases shows enlarged mesenteric lymph
nodes and a normal appendix.18
The diagnosis of Salmonella enteritis usually is con-
firmed by isolating the Salmonella strain involved. Blood
cultures are positive in 40 to 60% of patients who are
seen early in the course of the disease, and stool and
urine cultures become positive after a 1-week incubation
period. Serologic tests also are of diagnostic value for
identifying Salmonella organisms, but the sensitivity of
serology is limited because up to one-third of infected
patients show insignificant antibody titers and no evi-
dence of titer rise. The readily available Widal’s test
detects significant titer increases in agglutinating anti-
bodies in paired serum specimens. Titer changes may be
noted as early as 1 week after disease onset, as we
observed in both our cases. A single titer of 1:320 or
higher for O antibody, especially in a child, should alert
the physician to the possibility of Salmonella spp. infec-
tion.2,3
Published reports indicate that bacterial enteritis in the
ileocecal region has resulted in many unnecessary lapa-
rotomies and appendectomies. Van Noyen et al5 reported
having isolated the same enteric pathogen from the stool
of 72.5% of patients who had a culture-positive appen-
dix. They stated that a positive stool culture for Salmo-
nella spp. in a patient with suspected appendicitis, if
consistent with sonographic and clinical findings, should
be considered strong evidence against the existence of
true appendicitis in that individual. However, in cases in
which the definitive diagnosis cannot be established,
even with USG and CT, appendectomy is indicated and
appropriate because of the high morbidity and mortality
associated with untreated appendicitis.
In the first case presented in this report, although we
did not strongly suspect acute appendicitis, the patient’s
persistent pain in the right lower abdominal quadrant and
continued fever made surgery a logical and necessary
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step. The patient’s appendix was affected secondarily,
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