Non-typhoidal Salmonella causing urinary tract infection in a young male with renal calculi – a case report and comprehensive review
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Introduction. Non-typhoidal Salmonella (NTS) causes urinary tract infections infrequently and are usually associated with presence of genitourinary abnormalities.
Case presentation. We report a case of immunocompetent male in his early 20 s with phimosis presented with history of dysuria and burning micturition for 4 months. A renal ultrasonography showed presence of bilateral intrarenal calculi. Urine analysis revealed presence of non-typhoidal Salmonella. Automated identification systems performed poorly in identification of serotype. On serotyping, it was identified as Salmonella enteritidis in the referral centre. The patient was managed with oral antibiotics.
Conclusion. This report highlights the issues of inaccurate identification of NTS even with advanced automated systems and early initiation of therapy based on the knowledge of local susceptibility patterns. UTI in immunocompetent individuals by non-typhoidal Salmonella should always be investigated further to rule out genitourinary abnormalities and appropriate antibiotics must be started to avoid chronicity and complications.
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Thank you very much for submitting your revised manuscript to Access Microbiology and address the suggested changes. I am pleased to inform you that this work is now accepted for publication. Congratulations to all authors!
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Thank you very much for submitting this revised manuscript to Access Microbiology and addressing the reviewer suggestions. I would like to commend your efforts for improving this report. However, the text still needs some minor amendments prior to acceptance. These include: -Use of italics in the "et al" contractions in citations and bacterial genera and species names (e.g. Salmonella). Please correct this throughout the text. -L56-58: "Urinary tract infection due to NTS infrequently, is predominantly observed in elderly patients with underlying diseases, diabetes mellitus, urologic abnormalities and immunosuppression." This sentence reads incomplete, please reword. -L152: "non typhoidal 'Salmonalla'" can be abbreviated to NTS throughout the text once the this acronym has been defined. -L155: change "be one of the most" to "be among …
Thank you very much for submitting this revised manuscript to Access Microbiology and addressing the reviewer suggestions. I would like to commend your efforts for improving this report. However, the text still needs some minor amendments prior to acceptance. These include: -Use of italics in the "et al" contractions in citations and bacterial genera and species names (e.g. Salmonella). Please correct this throughout the text. -L56-58: "Urinary tract infection due to NTS infrequently, is predominantly observed in elderly patients with underlying diseases, diabetes mellitus, urologic abnormalities and immunosuppression." This sentence reads incomplete, please reword. -L152: "non typhoidal 'Salmonalla'" can be abbreviated to NTS throughout the text once the this acronym has been defined. -L155: change "be one of the most" to "be among the most" -L158: "urinary infection", do you mean "urinary tract infection"? In that case it can be abbreviated to UTI as in other references to this term in the text -L191,193: Would "male" be a more appropriate terminology than "boy"?
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In this manuscript, Sriramajayam et al. describe a Salmonella urinary tract infection and its relationship with renal calculi and phimosis. The case is well described and the text can be easily followed. The manuscript has now been reviewed by two experts in the field, who have raised several issues and suggested multiple changes to the manuscript. Please take these comments into account carefully, especially those concerning: • The perspective to describe the novelty of the case, including the proposed amendments to the title • Discussing the renal calculi as a risk factor and the limitations in the diagnosis • Discussing the methods for Salmonella typing and their applicability As an additional suggestion, please provide a comprehensive literature review on the subject to better understand the case and its novelty. Please …
In this manuscript, Sriramajayam et al. describe a Salmonella urinary tract infection and its relationship with renal calculi and phimosis. The case is well described and the text can be easily followed. The manuscript has now been reviewed by two experts in the field, who have raised several issues and suggested multiple changes to the manuscript. Please take these comments into account carefully, especially those concerning: • The perspective to describe the novelty of the case, including the proposed amendments to the title • Discussing the renal calculi as a risk factor and the limitations in the diagnosis • Discussing the methods for Salmonella typing and their applicability As an additional suggestion, please provide a comprehensive literature review on the subject to better understand the case and its novelty. Please provide a revised version of the manuscript, as well as a point-by-point response to the reviewers’ comments, within 2 months.
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Comments to Author
The case is well described and the results are clearly presented and coherent. However, the reviewer disagrees with the title as well as several points raised in the conclusion. The phimosis is highly unlikely to have contributed in any way to the urinary tract infection (UTI). Unless the phimosis is extreme enough to inhibit urinary flow or voiding of the bladder, it is not a risk factor for UTI. Therefore phimosis should be omitted from the title. However, renal calculi are a well known factor predisposing to UTI, including with Salmonella (check MEDLINE with the keywords nephrolithiasis and Salmonella). The case description is suggestive since the symptoms were present for several months before admission of the patient. The "absence" of gastroenteritis is therefore no surprise and the patient may …
Comments to Author
The case is well described and the results are clearly presented and coherent. However, the reviewer disagrees with the title as well as several points raised in the conclusion. The phimosis is highly unlikely to have contributed in any way to the urinary tract infection (UTI). Unless the phimosis is extreme enough to inhibit urinary flow or voiding of the bladder, it is not a risk factor for UTI. Therefore phimosis should be omitted from the title. However, renal calculi are a well known factor predisposing to UTI, including with Salmonella (check MEDLINE with the keywords nephrolithiasis and Salmonella). The case description is suggestive since the symptoms were present for several months before admission of the patient. The "absence" of gastroenteritis is therefore no surprise and the patient may well have failed to remember an episode of diarrhea shortly before onset of his urinary symptoms. Of notice, the infection tends to be chronic in the presence of urinary stones as shown in the case described. Identification of nontyphoidal Salmonella: this has been well done in the paper. Serotyping of Salmonella isolates in a reference laboratory is always mandatory for isolates from urine. Identification with commerial biochemical tests will usually be reliable in excluding Salmonella ser. Typhi; MALDI is not suitable as a replacement for serotyping (as shown by your results: Samonella ser. Choleraesuis is definitely a misleading result of MALDI and the BRUKER database should not contain this host-specific serovar). However, there is no necessity for serotype identification and this should be omitted from the title. All Salmonella serovars are "equal" (with the exception of S. typhi and other host-adapted serovars of course) . It is a pity that the patient was lost to follow-up because recurrence of Salmonella is possible if nephrolithiasis is not treated.
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
This case report recalls the possibility that phimosis is a risk factor for non-typhoidal Salmonella urinary tract infection. We noticed small slip-up when typing in the written form of this paper that we will enumerate below: Line 32, change " immunocompetant " to immunocompetent ; Line 39, change " the issues inaccurate " to the issues of inaccurate; Line 69, change " complains " to complaints (substantive); Line 133, change " his symptoms has resolved " to his symptoms had resolved "; Line 145, change " include" to including (adjective); Line 138, change " and usually is associated ", to is usually associated Line 149, change " clinical examination of genitourinary " to clinical examination of the genitourinary; Line 157,change "Salmonella isolated on urine" to Salmonella isolated in urine ; Line …
Comments to Author
This case report recalls the possibility that phimosis is a risk factor for non-typhoidal Salmonella urinary tract infection. We noticed small slip-up when typing in the written form of this paper that we will enumerate below: Line 32, change " immunocompetant " to immunocompetent ; Line 39, change " the issues inaccurate " to the issues of inaccurate; Line 69, change " complains " to complaints (substantive); Line 133, change " his symptoms has resolved " to his symptoms had resolved "; Line 145, change " include" to including (adjective); Line 138, change " and usually is associated ", to is usually associated Line 149, change " clinical examination of genitourinary " to clinical examination of the genitourinary; Line 157,change "Salmonella isolated on urine" to Salmonella isolated in urine ; Line 179, change "pathogen causing " to pathogens causing "; Line 184 , change "geographic area is must before " to geographic area is a must before . We need to change the introduction to Non-typhoidal salmonellosis (NTS) is a disease of great public health importance. Urinary tract infection due to NTS infrequently, is predominantly observed in elderly patients with underlying diseases, diabetes mellitus, urologic abnormalities and immunosuppression. It would be interesting to note in the text the limitation of this report case of urinary tract infection due to NTS.
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Dear Authors, Thank you very much for submitting this case report to Access Microbiology. However, although it presents interesting findings, several points need improvement before progressing to peer review. Please consider the following points for a revised version of the manuscript: • There is a Table 1 cited in L108 and L114 which does not appear in the section dedicated to contain figures and tables (L131). • Bacterial species names need to be in italics. • It is stated that this is the first case report on salmonellosis in an adult with phimosis (L57-59). However, L79 mentions phimosis is a congenital condition, which makes it coincidental to occur with Salmonella UTI rather than being directly related, as it is conveyed by the report. Similarly, the renal calculi found in the patient do not seem to show any relation …
Dear Authors, Thank you very much for submitting this case report to Access Microbiology. However, although it presents interesting findings, several points need improvement before progressing to peer review. Please consider the following points for a revised version of the manuscript: • There is a Table 1 cited in L108 and L114 which does not appear in the section dedicated to contain figures and tables (L131). • Bacterial species names need to be in italics. • It is stated that this is the first case report on salmonellosis in an adult with phimosis (L57-59). However, L79 mentions phimosis is a congenital condition, which makes it coincidental to occur with Salmonella UTI rather than being directly related, as it is conveyed by the report. Similarly, the renal calculi found in the patient do not seem to show any relation with the infection as the manuscript reads. Additionally, Yeung (2021, 10.3390/idr13010023) already mentions (without detailed description) a patient with phimosis presenting a Salmonella enteritidis infection, but it is not mentioned in the references. • There are multiple abbreviations without definition (e.g., BD, URS, DJ, OPD…) • The highlight of the case report is the issues in identifying and serotyping the Salmonella isolate. However, the descriptions of these (L110-120) do not reflect that hindrance and are lacking some more elaboration and context to comprehensively address this problematic. Later on, the Discussion section does not elaborate on it either. • In the Discussion section, there is a paragraph dedicated to AMR issues with Salmonella isolates (L165-172). However, the case does not present any issue related to this, which makes it hard to reconcile this paragraph with the rest of the manuscript. • There are multiple sentences that are hard to understand as they read. This would require a revision of the writing to make them more readable. Specific examples are: o L50-51: “Hematogenous spread from gastroenteritis and in women, more commonly through direct urethral invasion has been observed as modes of infection”. o L65-67: “He gave history of intravenous antibiotic administration for his symptoms of UTI in another medical facility and details of which were not available with the patient”. o L67-68: “No history of any co morbidities like diabetes, hypertension or any other chronic illness”. o L76-77: “Abdomen was soft and non-tender without any organomegaly and on palpation and normal bowel sounds were heard”. o L110-112: “Automated identification revealed the identification as Salmonella enterica Group B or Group D (98% probability) with excellent identification confidence using Vitek 2 automated identification system (bioMerieux SA, France)”. o L144-147: “Our patient had phimosis, this further emphasizes that a thorough clinical examination of genitourinary system is mandatory especially when the predisposition to chronic UTI is unlikely such as our patient who is an immunocompetant young male”. o L176: “…hence strong suspicion is the key”. Please provide a revised version of this manuscript within 1 month together with a point-by-point response to these comments. Additional practical information on case report writing and good practice can be found in the CARE checklist (https://www.care-statement.org/checklist). Do not hesitate to contact me or the Access Microbiology Editorial Office if you need any assistance during the process.
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