Clinical Picture

Typhoid carriage in the gallbladder Buddha Basnyat, Stephen Baker

The case of Mary Mallon, an asymptomatic carrier who infected 51 people while working as a cook and laundress in New York in 1906–15, showed that Salmonella enterica serovar Typhi (S Typhi) is able to lurk in the gallbladder without overt clinical signs and spread enteric fever through person-to-person transmission. In May, 2009, a 42-year-old man presented to Patan Hospital in Kathmandu, Nepal, with acute, sudden, severe pain in his right upper quadrant lasting for 2 days. We diagnosed cholecystitis and he underwent a cholecystectomy and made a prompt recovery. S Typhi was cultured from the bile in his gallbladder, and the cholecystitis was confirmed histologically. We used immunofluorescent labelling to analyse a section of his gallbladder with a confocal microscope (figure). Initially, we bound primary antibody (O9; Murex, Dartford, UK) to the cellular (bacterial) antigen, which was then specifically bound to a secondary fluorochromeconjugated antibody. The 4ʹ,6-diamidino-2-phenylindole (DAPI) stain (Invitrogen Molecular Probes, Carlsbad, CA, USA) binds to dsDNA and fluoresces blue, showing the

nucleus (white arrow) of the cells of the mucosal layer in the gallbladder (green arrow) that have been stained green with phalloidin. Phalloidin binds to F-actin and is used to identify tissue structure and locations of actin reassortment (green regions) triggered by the infection. The S Typhi (red arrow) can be seen in red (O antigen stain) in a discrete cluster on the outside of the mucosal layer. Although not the only member of the Enterobacteriaceae bearing the O9 antigen, culture isolation of S Typhi from our patient’s bile is strongly suggestive that these microorganisms are also S Typhi. Our patient did not have a documented history of enteric fever. In endemic areas such as Nepal, most people who undergo cholecystectomy for cholecystitis do not give an obvious, recent history of enteric fever, but gallbladder carriage of S Typhi and Paratyphi organisms is a well recognised means of spread. At last follow-up in December, 2013, the patient was doing well.

Published Online April 17, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60029-0 Oxford University Clinical Research Unit–Patan Academy of Health Science, Kathmandu, Nepal (B Basnyat MD); and Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam (S Baker PhD) Correspondence to: Prof Buddha Basnyat, Oxford University Clinical Research Unit/Patan Academy of Health Science, Kathmandu, Nepal [email protected]

Contributors BB cared for the patient and both authors contributed to writing of the report. Written consent to publication was obtained.

100 µm

Figure: Immunofluorescent-labelled section of the gallbladder

www.thelancet.com Published online April 17, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60029-0

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Typhoid carriage in the gallbladder.

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