Digestive Diseases and Sciences, Vol. 37, No. 11 (November 1992), pp. 1772-1775
CASE REPORT
Acalculous Acute Cholecystitis due to
Salmonella typhi M A R T I N E. A V A L O S , MD, M A U R I C E A. C E R U L L I , MD, and R I C H A R D S. L E E , M D KEY WORDS: acalculous caolecystitis; Salmonella typhi; typhoid fever; HIDA scan; cholecystectomy.
Salmonella infections are an important health problem in the United States and in m a n y countries abroad, mainly those with p o o r sanitary conditions. In t h e United States, despite i m p r o v e m e n t s in sanitation involving food processing, outbreaks of salmonella infections still o c c u r (1). With the increase of immigrants, foreign travel (2, 21), and the A I D S epidemic (3, 4) m o r e cases will soon be reported. Salmonellosis can o c c u r in several different forms: g a s t r o e n t e r i t i s (the m o s t c o m m o n syndrome), enteric f e v e r (typhoid f e v e r and paratyphoid fever), b a c t e r e m i a , chronic carrier state, and localized infections. Localized salmonella infections m o s t frequently o c c u r as a result of bacteremia but m a y also o c c u r during the course of episodes of enteric f e v e r or gastroenteritis (5, 6). In this paper, we describe a case of localized salmonella infection: acalculous acute cholecystitis during an episode o f typhoid fever. Acute cholecystitis associated with Salmonella typhi is not rare in the p r e s e n c e of gallbladder stones. Nevertheless, its o c c u r r e n c e without cholelithiasis is very rare and is m o s t c o m m o n l y reported with salmonella serotypes other than Salmonella typhi.
CASE REPORT A 30-year-old Hispanic housewife from the Dominican Republic was admitted to the hospital because of a one-week history of nausea, vomiting, headaches, fight upper quadrant abdominal pain, and fever. Her past medical history was unremarkable except for a similar episode diagnosed as typhoid fever four months ago in
Manuscript received October 23, 1991; revised manuscript received February 25, 1992; accepted March 19, 1992.
From the Department of Medicine, Gastroenterology Division, The Brooklyn Hospital Center, Brooklyn, New York. Address for reprint requests: Dr. Martin E. Avalos, Department of Medicine, Division of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, New York 11201.
1772
another hospital. There was also a history of episodic diarrhea a few days before the admission. Physical examination was unremarkable except for a temperature of 38~ C as well as severe tenderness and guarding in the fight upper quadrant of the abdomen. There were no palpable masses or liver enlargement. The Murphy sign was positive. The white cell blood count was 5300/mm3 with 55% polymorphonuclear leukocytes and 15% bands. The platelet count was 230,000/ixl. Total bilirubin level was 0.6 mg/dl (normal 0.2-1.2 mg/dl), alkaline phosphatase level was 138 units/liter (normal 30-115 units/liter), serum glutamic oxaloacetic transaminase level (AST) was 174 units/liter (normal 5-37 units/ liter), serum glutamic piruvic transaminase level (ALT) was 161 units/liter (normal 5-40 units/liter), serum amylase was 60 units/liter (normal up to 110). A urinalysis showed a small amount of bilirubin, trace blood, and urobilinogen of 0.2 units/dl. There were 8-10 red blood cells/high-power field and 4-5 white blood cells/highpower field. Blood and urine cultures were obtained. An abdominal sonogram showed a normal-appearing liver and spleen as well as a normal pancreas. The gallbladder was also normal with no stones. There was no biliary dilation, and the common bile duct was normal in caliber. Over the next 24 hr her temperature rose to 39~ C and an intravenous antibiotic, ampicillin 1 g every 6 hr was started. A gallbladder nuclear scan (HIDA) showed nonvisualization of the gallbladder consistent with acute cholecystitis (Figure 1). After 48 hr of intravenous antibiotics, her temperature decreased to 37.5~ C and her general condition improved markedly. The abdominal pain subsided considerably. A white blood ceU count was 4400/mm 3 with 57% polymorphonuclear leukocytes and no bands. Total bilirubin level was 0.5 mg/dl, alkaline phosphatase was 192 units/liter, AST was 621 units/liter, and ALT was 461 units/liter. Hepatitis serology was negative for hepatitis A, hepatitis B, and hepatitis C. Iron studies were normal as were antinuclear antibody and antimithocondrial antibody titers. A ceruloplasim level was also within the normal limits. The abnormal liver function tests were thought to be caused by reactive hepatitis due to infection. After 72 hr in the hospital, blood cultures taken on admission were reported positive for Salmonella typhi in four different culture bottles. The patient was continued on oral antibiotics and was discharged after 11 days of hospitalization. A repeated abdominal sonogram was Digestive Diseases and Sciences, Vol. 37, No. 11 (November 1992)
0163-2116/92/1100-1772506.50/09 1992PlenumPublishingCorporation
ACALCULOUS ACUTE CHOLECYSTITIS
Fig 1. Hepatobiliary scan (HIDA scan). Delayed images obtained up to 2 1/2 hr after injection demonstrate most of the activity in the small bowel without visualization of the gallbladder consistent with acute cholecystitis. (Anteroposterior and right lateral views.)
again reported as normal and on a repeated nuclear scan the gallbladder was well visualized (Figure 2). Repeated liver function tests upon discharge showed improvement: alkaline phosphatase 183 units/liter, AST 95 units/liter, and ALT 150 units/liter. DISCUSSION Salmonella infections occur throughout the abdomen but most commonly affect the hepatobiliary system and the spleen (8). Almost half of all patients with salmonella intrabdominal infections have preexisting anatomic anomalies including biliary tract stones, intrahepatic cholestasis, biliary cirrhosis or have infections after endoscopic procedures, mainly ERCP (8). Other predisposing conditions include abdominal tumors, sickle cell disease, history of previous typhoid fever, ethanol abuse, and gastric achlorhydria. Digestive Diseases and Sciences, Vol. 37, No. 11 (November 1992)
Cohen et al (8), in a review of previous studies concerning extraintestinal manifestations of salmonella infections, described the clinical features of salmonella abdominal infections in over 50 patients averaging 35 years of age with almost equal sex distribution. Their mean duration of symptoms before diagnosis was 13 days. In 10 of these patients, acute cholecystitis was the main manifestation. The most common predisposing conditions were anatomical abnormalities of the hepatobiliary system, and biliary stones were found in seven of 10 patients. The most common sites were: gallbladder stones in five patients, stones in the common bile duct in one patient, and intrahepatic stones in one patient. The most common clinical manifestations were fever, abdominal pain, and tenderness in over 50% of patients. Acute cholecystitis due to salmonella has been the most frequent intrabdominal
1773
AVALOS ET AL
Fig 2. Hepatobiliary scan (HIDA scan). Images obtained at 30 and 35 min after injection demonstrate a well outlined liver with adequate extrahepatic excretion through the common hepatic and common bile ducts. The gallbladder is well visualized and small intestinal activity is noted consistent with a normal study. (Anteroposterior and right lateral views.)
manifestation reported in several studies (9-11). Acute cholecystitis in the setting of typhoid fever occurs in up to 3% of patients (7), and most cases occur in the presence of gallbladder stones. Only a few cases of acalculous salmonella cholecystitis have been reported and most of them involved a
1774
variety of serotypes other than Salmonella typhi (12-14). In our case, a patient with an episode of relapse of typhoid fever complicated with acute cholecystitis, gallstones were not found in two ultrasound examinations performed, and the patient responded promptly Digestive Diseases and Sciences, Vol. 37~No. 11 (November 1992)
A C A L C U L O U S A C U T E CHOLECYSTITIS
to medical treatment. Medical treatment with various oral antibiotics such as ampicillin, amoxicillin, ciprofloxacin, and trimethoprim sulfametoxasole for six weeks is recommended if no gallstones are found (16-20). Some authors have suggested prolonged oral therapy up to three months before considering surgery for the patient with stones in the gallbladder (19). Cholecystectomy has been recommended for the chronic cartier state (defined as the excretion of salmonella organisms in the stools for more than a year), which occurs in 3-5% of patients with associated gallstones (15). The patient with salmonella acute cholecystitis who requires surgery is more prone to have multiple postoperative complications. The most common being reported are postoperative wound infections, postoperative bacteremia and, rarely, subphrenic abscess or cholangitis due to recurrent stones (13, 14, 22-27). Our patient most likely had a relapse of typhoid fever, which is reported to be as high as 20% after the first episode. This relapse may occur in patients who receive early and proper antibiotic therapy, which may inhibit the development of an adequate immune response (19). Foreign travel to the Dominican Republic was a predisposing factor for acquiring the infection, and it is related mainly to poor hygiene concerning food and water handling. It is important to note that the patient denied risk factors for AIDS and a serological test for the immunodeficiency virus was refused. In summary this case illustrates the rare complication of acute acalculous cholecystitis associated with an episode of typhoid fever which resolved medically. Surgery was not required. REFERENCES 1. Centers for Disease Control: Update: Milk-borne salmonellosis. MMWR 34:215-216, 1985 2. Taylor DN, Pollard RA, Blake PA: Typhoid in the United States and the risk for the internationaltraveler: J Infect Dis 148:599-603, 1983 3. Glaser JB, Morton-Kute L, Berger SR, Wever J, Siegel FP, Lopez C, Robbins W, Landesman SH: Recurrent Salmonella typhimurium bacteremia associated with AIDS. Ann Intern Med 102:189-193, 1985 4. Jacobs SL, Gold JW, Murray HW, Roberts RB, Armstrong D: Salmonella infections in patients with AIDS. Ann Intern Med 102:186-188, 1985 5. Black PH, Kunz LJ, Swartz MN: Salmonellosis: A review of some unusual aspects. N Engl J Med 262:811-817, 864-870, 921-927, 1960
Digestive Diseases and Sciences, Vol. 37, No. 11 (November 1992)
6. Rubin RH, Weinstein L: Salmonellosis: Microbiologic, Pathologic and Clinical Features. New York, Stratton Intercontinental Medical Book Corp, 1977 7. Stuart BM, Pullen RS: Typhoid: Clinical analysis of three hundred and sixty cases. Arch Intern Med 78:629-661, 1976 8. Cohen JI Bartlett JA, Corey GR: Extra intestinal manifestations of Salmonella infections. Medicine 66:349-388, 1987 9. Koshi G: Uncommon manifestations of Salmonella infections. Indian J Med Res 64:314-321, 1976 10. Saphra I, Wasserman M: Salmonella cholerasuis: A clinical and epidemiological evaluation of 329 infections. Am J Med Sci 228:525-533, 1954 11. Seligmann E, Saphra I, Wassermann M: Salmonella infections in the United States. A second series of 2000 human infections recorded by the New York Salmonella Center. J Immunol 54:68-87, 1947 12. Bonta JA, Lovingood CG: Acute cholecystitis in childhood. Surgery 31:309-311, 1952 13. Campbell CW, Eckman MR: Acute cholecystitis caused by Salmonella indiana. JAMA 233:815, 1975 14. Cooper D: Acute non calculous cholecystitis: A case report. Med J Austr 2:669, 1975 15. Dinbar A, Altman G, Tulcinsky D: The treatment of chronic biliary salmonella carriers. Am J Med 47:236-242, 1969 16. Johnson W, Hook E, Linsey E, Kaye D: Treatment of chronic typhoid carriers with ampicillin. Antimicrob Agents Chemother 3:439-440, 1973 17. Musher D, Rubenstein A: Permanent carriers of non typhosa salmonella. Arch Intern Med 132:869-872, 1973 18. Dichler H, Knothe H, Spitzy K, Vielkind G: Treatment of chronic carriers of Salmonella typhi and Salmonella paratyphi with trimethoprim sulfametoxasole. J Infect Dis 128(suppl):743-744, 1973 19. Keusch GT: Salmonellosis. In Harrison's Principals of Internal Medicine, 12th ed. JD Wilson, E Braunwald, KJ Isselbacher, RG Petersdoff, JB Martin, AS Fauci, RK Root (eds). New York, McGraw-Hill, 1991, Chap. 113, pp 609613 20. Ferreccio C, Morris JG, Valdivieso C, Prenzel I, Sotomayor V, Drusano GL, Levine MM: Efficacy of ciprofloxacin in the treatment of chronic typhoid carriers. J Infect Dis 157:1235, 1988 21. Ryan CA, Hargrett-Bean NT, Blake PA: Salmonella typhi infections in the United States 1975-1984: Increasing role of foreign travel. Rev Infect Dis 11:1, 1989 22. Altemeier WA: Postoperative infections. Surg Clin North Am 25:1202-1228, 1945 23. Langenskiold A: Salmonella paratyphi B in suppurating silk granulomas after cholecystectomy for cartier state. Acta Chir Scand 106:187-191, 1953 24. Penistan JL: Surgical wound infection by salmonella. Can Med Assoc J 97:30-31, 1967 25. Reisig G, Schalfner W: Postoperative detection of Salmonella typhi. Arch Surg 104:349-350, 1972 26. Saik RP: Wound dehiscence after cholecystectomy and salmonella infection. Am Surg 42:350-351, 1976 27. Soley RL, Garloch JH: Unusual wound complications following cholecystectomy for typhoid gallbladder. J Mt Sinai Hosp NY 30:241-245, 1963
1775
CASE REPORT
Acalculous Acute Cholecystitis due to
Salmonella typhi M A R T I N E. A V A L O S , MD, M A U R I C E A. C E R U L L I , MD, and R I C H A R D S. L E E , M D KEY WORDS: acalculous caolecystitis; Salmonella typhi; typhoid fever; HIDA scan; cholecystectomy.
Salmonella infections are an important health problem in the United States and in m a n y countries abroad, mainly those with p o o r sanitary conditions. In t h e United States, despite i m p r o v e m e n t s in sanitation involving food processing, outbreaks of salmonella infections still o c c u r (1). With the increase of immigrants, foreign travel (2, 21), and the A I D S epidemic (3, 4) m o r e cases will soon be reported. Salmonellosis can o c c u r in several different forms: g a s t r o e n t e r i t i s (the m o s t c o m m o n syndrome), enteric f e v e r (typhoid f e v e r and paratyphoid fever), b a c t e r e m i a , chronic carrier state, and localized infections. Localized salmonella infections m o s t frequently o c c u r as a result of bacteremia but m a y also o c c u r during the course of episodes of enteric f e v e r or gastroenteritis (5, 6). In this paper, we describe a case of localized salmonella infection: acalculous acute cholecystitis during an episode o f typhoid fever. Acute cholecystitis associated with Salmonella typhi is not rare in the p r e s e n c e of gallbladder stones. Nevertheless, its o c c u r r e n c e without cholelithiasis is very rare and is m o s t c o m m o n l y reported with salmonella serotypes other than Salmonella typhi.
CASE REPORT A 30-year-old Hispanic housewife from the Dominican Republic was admitted to the hospital because of a one-week history of nausea, vomiting, headaches, fight upper quadrant abdominal pain, and fever. Her past medical history was unremarkable except for a similar episode diagnosed as typhoid fever four months ago in
Manuscript received October 23, 1991; revised manuscript received February 25, 1992; accepted March 19, 1992.
From the Department of Medicine, Gastroenterology Division, The Brooklyn Hospital Center, Brooklyn, New York. Address for reprint requests: Dr. Martin E. Avalos, Department of Medicine, Division of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, New York 11201.
1772
another hospital. There was also a history of episodic diarrhea a few days before the admission. Physical examination was unremarkable except for a temperature of 38~ C as well as severe tenderness and guarding in the fight upper quadrant of the abdomen. There were no palpable masses or liver enlargement. The Murphy sign was positive. The white cell blood count was 5300/mm3 with 55% polymorphonuclear leukocytes and 15% bands. The platelet count was 230,000/ixl. Total bilirubin level was 0.6 mg/dl (normal 0.2-1.2 mg/dl), alkaline phosphatase level was 138 units/liter (normal 30-115 units/liter), serum glutamic oxaloacetic transaminase level (AST) was 174 units/liter (normal 5-37 units/ liter), serum glutamic piruvic transaminase level (ALT) was 161 units/liter (normal 5-40 units/liter), serum amylase was 60 units/liter (normal up to 110). A urinalysis showed a small amount of bilirubin, trace blood, and urobilinogen of 0.2 units/dl. There were 8-10 red blood cells/high-power field and 4-5 white blood cells/highpower field. Blood and urine cultures were obtained. An abdominal sonogram showed a normal-appearing liver and spleen as well as a normal pancreas. The gallbladder was also normal with no stones. There was no biliary dilation, and the common bile duct was normal in caliber. Over the next 24 hr her temperature rose to 39~ C and an intravenous antibiotic, ampicillin 1 g every 6 hr was started. A gallbladder nuclear scan (HIDA) showed nonvisualization of the gallbladder consistent with acute cholecystitis (Figure 1). After 48 hr of intravenous antibiotics, her temperature decreased to 37.5~ C and her general condition improved markedly. The abdominal pain subsided considerably. A white blood ceU count was 4400/mm 3 with 57% polymorphonuclear leukocytes and no bands. Total bilirubin level was 0.5 mg/dl, alkaline phosphatase was 192 units/liter, AST was 621 units/liter, and ALT was 461 units/liter. Hepatitis serology was negative for hepatitis A, hepatitis B, and hepatitis C. Iron studies were normal as were antinuclear antibody and antimithocondrial antibody titers. A ceruloplasim level was also within the normal limits. The abnormal liver function tests were thought to be caused by reactive hepatitis due to infection. After 72 hr in the hospital, blood cultures taken on admission were reported positive for Salmonella typhi in four different culture bottles. The patient was continued on oral antibiotics and was discharged after 11 days of hospitalization. A repeated abdominal sonogram was Digestive Diseases and Sciences, Vol. 37, No. 11 (November 1992)
0163-2116/92/1100-1772506.50/09 1992PlenumPublishingCorporation
ACALCULOUS ACUTE CHOLECYSTITIS
Fig 1. Hepatobiliary scan (HIDA scan). Delayed images obtained up to 2 1/2 hr after injection demonstrate most of the activity in the small bowel without visualization of the gallbladder consistent with acute cholecystitis. (Anteroposterior and right lateral views.)
again reported as normal and on a repeated nuclear scan the gallbladder was well visualized (Figure 2). Repeated liver function tests upon discharge showed improvement: alkaline phosphatase 183 units/liter, AST 95 units/liter, and ALT 150 units/liter. DISCUSSION Salmonella infections occur throughout the abdomen but most commonly affect the hepatobiliary system and the spleen (8). Almost half of all patients with salmonella intrabdominal infections have preexisting anatomic anomalies including biliary tract stones, intrahepatic cholestasis, biliary cirrhosis or have infections after endoscopic procedures, mainly ERCP (8). Other predisposing conditions include abdominal tumors, sickle cell disease, history of previous typhoid fever, ethanol abuse, and gastric achlorhydria. Digestive Diseases and Sciences, Vol. 37, No. 11 (November 1992)
Cohen et al (8), in a review of previous studies concerning extraintestinal manifestations of salmonella infections, described the clinical features of salmonella abdominal infections in over 50 patients averaging 35 years of age with almost equal sex distribution. Their mean duration of symptoms before diagnosis was 13 days. In 10 of these patients, acute cholecystitis was the main manifestation. The most common predisposing conditions were anatomical abnormalities of the hepatobiliary system, and biliary stones were found in seven of 10 patients. The most common sites were: gallbladder stones in five patients, stones in the common bile duct in one patient, and intrahepatic stones in one patient. The most common clinical manifestations were fever, abdominal pain, and tenderness in over 50% of patients. Acute cholecystitis due to salmonella has been the most frequent intrabdominal
1773
AVALOS ET AL
Fig 2. Hepatobiliary scan (HIDA scan). Images obtained at 30 and 35 min after injection demonstrate a well outlined liver with adequate extrahepatic excretion through the common hepatic and common bile ducts. The gallbladder is well visualized and small intestinal activity is noted consistent with a normal study. (Anteroposterior and right lateral views.)
manifestation reported in several studies (9-11). Acute cholecystitis in the setting of typhoid fever occurs in up to 3% of patients (7), and most cases occur in the presence of gallbladder stones. Only a few cases of acalculous salmonella cholecystitis have been reported and most of them involved a
1774
variety of serotypes other than Salmonella typhi (12-14). In our case, a patient with an episode of relapse of typhoid fever complicated with acute cholecystitis, gallstones were not found in two ultrasound examinations performed, and the patient responded promptly Digestive Diseases and Sciences, Vol. 37~No. 11 (November 1992)
A C A L C U L O U S A C U T E CHOLECYSTITIS
to medical treatment. Medical treatment with various oral antibiotics such as ampicillin, amoxicillin, ciprofloxacin, and trimethoprim sulfametoxasole for six weeks is recommended if no gallstones are found (16-20). Some authors have suggested prolonged oral therapy up to three months before considering surgery for the patient with stones in the gallbladder (19). Cholecystectomy has been recommended for the chronic cartier state (defined as the excretion of salmonella organisms in the stools for more than a year), which occurs in 3-5% of patients with associated gallstones (15). The patient with salmonella acute cholecystitis who requires surgery is more prone to have multiple postoperative complications. The most common being reported are postoperative wound infections, postoperative bacteremia and, rarely, subphrenic abscess or cholangitis due to recurrent stones (13, 14, 22-27). Our patient most likely had a relapse of typhoid fever, which is reported to be as high as 20% after the first episode. This relapse may occur in patients who receive early and proper antibiotic therapy, which may inhibit the development of an adequate immune response (19). Foreign travel to the Dominican Republic was a predisposing factor for acquiring the infection, and it is related mainly to poor hygiene concerning food and water handling. It is important to note that the patient denied risk factors for AIDS and a serological test for the immunodeficiency virus was refused. In summary this case illustrates the rare complication of acute acalculous cholecystitis associated with an episode of typhoid fever which resolved medically. Surgery was not required. REFERENCES 1. Centers for Disease Control: Update: Milk-borne salmonellosis. MMWR 34:215-216, 1985 2. Taylor DN, Pollard RA, Blake PA: Typhoid in the United States and the risk for the internationaltraveler: J Infect Dis 148:599-603, 1983 3. Glaser JB, Morton-Kute L, Berger SR, Wever J, Siegel FP, Lopez C, Robbins W, Landesman SH: Recurrent Salmonella typhimurium bacteremia associated with AIDS. Ann Intern Med 102:189-193, 1985 4. Jacobs SL, Gold JW, Murray HW, Roberts RB, Armstrong D: Salmonella infections in patients with AIDS. Ann Intern Med 102:186-188, 1985 5. Black PH, Kunz LJ, Swartz MN: Salmonellosis: A review of some unusual aspects. N Engl J Med 262:811-817, 864-870, 921-927, 1960
Digestive Diseases and Sciences, Vol. 37, No. 11 (November 1992)
6. Rubin RH, Weinstein L: Salmonellosis: Microbiologic, Pathologic and Clinical Features. New York, Stratton Intercontinental Medical Book Corp, 1977 7. Stuart BM, Pullen RS: Typhoid: Clinical analysis of three hundred and sixty cases. Arch Intern Med 78:629-661, 1976 8. Cohen JI Bartlett JA, Corey GR: Extra intestinal manifestations of Salmonella infections. Medicine 66:349-388, 1987 9. Koshi G: Uncommon manifestations of Salmonella infections. Indian J Med Res 64:314-321, 1976 10. Saphra I, Wasserman M: Salmonella cholerasuis: A clinical and epidemiological evaluation of 329 infections. Am J Med Sci 228:525-533, 1954 11. Seligmann E, Saphra I, Wassermann M: Salmonella infections in the United States. A second series of 2000 human infections recorded by the New York Salmonella Center. J Immunol 54:68-87, 1947 12. Bonta JA, Lovingood CG: Acute cholecystitis in childhood. Surgery 31:309-311, 1952 13. Campbell CW, Eckman MR: Acute cholecystitis caused by Salmonella indiana. JAMA 233:815, 1975 14. Cooper D: Acute non calculous cholecystitis: A case report. Med J Austr 2:669, 1975 15. Dinbar A, Altman G, Tulcinsky D: The treatment of chronic biliary salmonella carriers. Am J Med 47:236-242, 1969 16. Johnson W, Hook E, Linsey E, Kaye D: Treatment of chronic typhoid carriers with ampicillin. Antimicrob Agents Chemother 3:439-440, 1973 17. Musher D, Rubenstein A: Permanent carriers of non typhosa salmonella. Arch Intern Med 132:869-872, 1973 18. Dichler H, Knothe H, Spitzy K, Vielkind G: Treatment of chronic carriers of Salmonella typhi and Salmonella paratyphi with trimethoprim sulfametoxasole. J Infect Dis 128(suppl):743-744, 1973 19. Keusch GT: Salmonellosis. In Harrison's Principals of Internal Medicine, 12th ed. JD Wilson, E Braunwald, KJ Isselbacher, RG Petersdoff, JB Martin, AS Fauci, RK Root (eds). New York, McGraw-Hill, 1991, Chap. 113, pp 609613 20. Ferreccio C, Morris JG, Valdivieso C, Prenzel I, Sotomayor V, Drusano GL, Levine MM: Efficacy of ciprofloxacin in the treatment of chronic typhoid carriers. J Infect Dis 157:1235, 1988 21. Ryan CA, Hargrett-Bean NT, Blake PA: Salmonella typhi infections in the United States 1975-1984: Increasing role of foreign travel. Rev Infect Dis 11:1, 1989 22. Altemeier WA: Postoperative infections. Surg Clin North Am 25:1202-1228, 1945 23. Langenskiold A: Salmonella paratyphi B in suppurating silk granulomas after cholecystectomy for cartier state. Acta Chir Scand 106:187-191, 1953 24. Penistan JL: Surgical wound infection by salmonella. Can Med Assoc J 97:30-31, 1967 25. Reisig G, Schalfner W: Postoperative detection of Salmonella typhi. Arch Surg 104:349-350, 1972 26. Saik RP: Wound dehiscence after cholecystectomy and salmonella infection. Am Surg 42:350-351, 1976 27. Soley RL, Garloch JH: Unusual wound complications following cholecystectomy for typhoid gallbladder. J Mt Sinai Hosp NY 30:241-245, 1963
1775
