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A comprehensive review of disseminated Salmonella arizona infection with an illustrative case presentation.

Abstract: Salmonella arizona is known to cause infection in reptiles and other animals. Disseminated human infection is rare, except in the setting of a deficient immune system. The following is a unique account of disseminated infection including pericardial involvement. Unusual features include nonreptile vector transmission and eastern seaboard (rather than southwestern) locale. A comprehensive literature review of disseminated S arizona infections is presented describing the types of infection, sources of exposure, underlying conditions, locale, treatments, and outcomes.

Key Words: Salmonella arizona, pericarditis, rattlesnake


Salmonella arizona is an uncommon human pathogen. Over the last 50 years, approximately 50 case reports and case series have appeared in the literature. Serious human infections have been reported in hosts with impaired immune systems caused by conditions such as collagen vascular diseases requiring immunosuppressive therapy, (1-8) malignancy, (4,9-16) organ transplantation, (6,15) human immunodeficiency virus (HIV) infection, (1,5,17-20) and a young age (16,21-28) (< 7 years old). The majority of cases cited originated from the southwestern United States, primarily in California, (1-6,11-12,15,17,29-31) Arizona, (24,32) and Texas. (2,3,7-9,13,14,19) This geographic region corresponds to a large Latino population known to use folk remedies for a variety of illnesses. In particular, rattlesnake meat, (2,13,18,24) capsules (1,4,5,9-12,14,19,32,33), and powders (3,20) have been linked to infection with S arizona, although other animals or animal products have been implicated, including reptiles, poultry, sheep, rats, dogs, and cats. (34-38) This organism has caused disease in virtually every tissue in the human body and is often difficult to eradicate. Since serious infection has not been documented in a healthy human adult, isolation of S arizona should prompt evaluation of the immune status in apparently healthy individuals.

We present a case of pericardial infection associated with disseminated S arizona infection. Recognition of this unusual infection led to the diagnosis of HIV infection, and prolonged treatment resulted in a full recovery without recurrence.

Illustrative case

A previously healthy, 47-year-old black female presented to the emergency department complaining of progressive dyspnea of 1 week's duration. The patient reported worsening dyspnea on exertion that progressed to frank shortness of breath at rest over the course of 2 days, as well as diaphoresis and new onset pedal edema. She reported no chest pain or similar symptoms in the past. A review of systems revealed complaints of watery diarrhea without melena for 2 weeks before this admission and an approximate 40-pound unintentional weight loss during the preceding 3 months. She reported no fever, nausea, vomiting, dysuria, headache, or dizziness. Furthermore, she reported no previous surgery or travel outside of her hometown in Virginia during the preceding 10 years.

Vital signs included a blood pressure of 114/62 mm Hg, heart rate of 125/min, respiratory rate of 28 breaths/min, rectal temperature of 101.0[degrees]F, and a pulse oximetry of 70% on room air, and 99% while breathing 100% [O.sub.2] by nonrebreather mask. In general, she was a morbidly obese (body mass index = 49.7 kg/[m.sup.2]) female in moderate respiratory distress. Her oropharynx was normal, and mild, clear rhinorrhea was noted. Moderate jugular venous distension was present, and no carotid bruits were heard. She was using accessory muscles of respiration, and the lung examination revealed bilateral crackles in the lower halves of her lung zones with dullness to percussion at the bases. Her cardiovascular examination was significant for tachycardia with a regular rhythm, a prominent [S.sub.2], and a faint systolic ejection murmur at the lower left sternal border, but no rubs or gallops. Her abdomen was protuberant and soft, with normal bowel sounds and a reducible periumbilical hernia without tenderness or distension. A rectal examination showed Hemoccult negative brown stool and normal sphincter tone. Her lower extremities had bilateral pitting edema up to her thighs with faintly palpable peripheral pulses. Skin examination revealed an absence of rashes, tattoos, or areas of skin breakdown. Her neurologic examination was unremarkable.

Admission laboratory data revealed the following: blood urea nitrogen, 43 mg/dL; creatinine, 5.1 mg/dL; glucose, 201 mg/dL; albumin, 2.1 g/dL; aspartate aminotransferase, 69 U/L; international normalization ratio, 1.1; partial thromboplastin time (PTT), 36 seconds; creatine kinase, 641 U/L; creatine kinase-muscle/brain fraction, 4.7 [micro]g/L; troponin I, 2.9 [micro]g/L; erythrocyte sedimentation rate, 71 mm/h; and white blood cell count, 10.1 X [10.sup.6]/mL (75% PMNs). An arterial blood gas revealed a pH of 7.41, pC[O.sub.2] of 34 mm Hg, p[O.sub.2] of 43 mm Hg, and 79% saturation while breathing room air. The electrocardiogram showed sinus tachycardia at 131/min, normal QRS axis, normal intervals, low voltage, and nonspecific ST-T wave changes. Her chest radiograph revealed low lung volumes, a large cardiac silhouette suggesting global chamber enlargement and/or pericardial effusion, mild interstitial edema, and no alveolar infiltrate.

In the emergency department, blood and urine cultures were obtained, and she was given imipenem and levofloxacin as empiric antibiotic treatment. She was admitted to the medical intensive care unit, where a bedside transthoracic echocardiogram showed a left ventricular ejection fraction of 71%, moderate tricuspid regurgitation, moderate pulmonary hypertension, and no evidence of pericardial effusion. Because of the patient's size, a computed tomography scan for pulmonary embolism was deferred and a pulmonary angiogram was performed, which showed multiple bilateral subsegmental basilar emboli. At this point, she was started on unfractionated heparin infusion for treatment of pulmonary embolism. Approximately 6 hours after intravenous heparin therapy was started, the patient had worsening shortness of breath. Physical examination at this time revealed a three-component friction rub heard across the precordium. The heparin infusion was stopped, and an emergent echocardiogram showed a large pericardial effusion with severe right ventricular dysfunction (PTT at this time was 46 seconds). A bedside pericardiocentesis by subxiphoid approach under electrocardiographic and echocardiographic guidance was performed, and approximately 700 mL of bloody, nonclotting fluid was drained and sent for culture.

The following morning, her admission blood cultures were reported as growing Gram-negative bacilli. Empiric antibiotics were changed to ceftazidime and levofloxacin. The following day, the Gram-negative rod was identified as Salmonella arizona (subgroup III, group Y, serotype 48:G, Z51:-), which was sensitive to both ceftazidime and levofloxacin. The same species of bacteria was later isolated from the pericardial fluid, stool, and urine. Because of the known association between this type of disseminated infection and an underlying cell-mediated immunity defect, we pursued evaluation of possible causes. Subsequent serologic testing was negative for antinuclear antibodies and rheumatoid factor. Testing for HIV by enzyme-linked immunosorbent assay returned positive and was confirmed by Western blot for HIV type 1. Later, the patient's absolute CD4 count and HIV viral load returned as 12 mL (normal, 600 to 1500/mL) and 6.97 X [10.sup.5] copies/mL, respectively.

Our patient had multiple medical problems and complications coincident to her hospitalization, including renal failure requiring hemodialysis, shock requiring vasopressive therapy with phenylephrine and norepinephrine, incarcerated periumbilical hernia requiring surgical abdominal herniorrhaphy, and a central line-associated, methicillin-resistant Staphylococcus aureus bacteremia. Her antibiotic coverage for S arizona was changed to ciprofloxacin and ceftriaxone, and she completed a 4-week course.

After a prolonged, complicated hospitalization, she recovered without long-term sequelae and is currently receiving highly active antiretroviral therapy (HAART). Her absolute CD4 count has increased above 300/mL after initiation of HAART therapy, and her HIV viral load is undetectable. At follow-up 18 months after initial presentation, she had no recurrence of infection with S arizona or other opportunistic infections. Interestingly, our patient reported no ingestion of alternative medicines, contact with reptiles, or travel to the southwestern United States. She did, however, describe close contact with approximately 15 chickens that she raised as pets, an association previously reported by others (31) as a possible source of exposure. She said that she had never used recreational drugs, had not received blood products by transfusion, and did not have tattoos. She said that she had no unprotected sexual activity in the 5 years before this admission, and her mode of contraction of HIV remains uncertain.

Discussion and Literature Review

A review of the English language literature available was performed with the use of MEDLINE (National Library of Medicine, Bethesda, MD) to search for publications containing S arizona or Arizona hinshawii, as well as review of the citations listed as references from results of the search. Features of the reported cases, including age, race, sex, type of infection, exposure, underlying immunocompromise, treatment, recurrence, outcome, and locale, are displayed in Table 1.

Salmonella arizona is a facultative anaerobic Gram-negative bacillus of the family Enterobacteriaceae, which has the ability to ferment lactulose and liquefy gelatin; its growth is inhibited by cyante. (1) This bacteria was first isolated from diseased reptiles in Arizona in 1939 (40) and was called "Salmonella. dar-es-saalam variety from Arizona," later Arizona hinshawii, and finally reclassified as Salmonella arizona in 1983. Not long after its discovery, a human case of gastroenteritis caused by S arizona was identified. (41) Since that time, S arizona infection has been documented in a myriad of animals including reptiles, fowl, ducks, rats, dogs, and cats. (35) Additional outbreaks of gastroenteritis have been linked to contaminated dairy and egg products. (34,36,37)

Serious human infections were very rare until multiple cases were identified in the 1980s, associated with widespread use of rattlesnake meat, capsules, and powders in the Latino communities in the southwestern United States as a form of alternative medicinal therapy. (1,2,9-11,17,33) Users of rattlesnake products believed that these preparations were beneficial for many illnesses including arthritis, diabetes mellitus, cancers, and HIV infection. (33,42) Into the 1990s, sporadic cases of disseminated S arizona infection were identified (3-5,12-14,18-20) until the California Public Health Department was instrumental in banning the sale of these preparations in the United States (43) (Table 2).

Infection has been documented in individuals ranging from 8 weeks to 87 years of age. Blacks and whites have been infected, although the majority of cases have occurred in Hispanics in the southwestern United States, probably related to the use of rattlesnake products. Although from one to nine cases per year of S arizona have been reported to the Virginia Department of Health [personal correspondence, Department of Epidemiology, Virginia Department of Health, Richmond, VA] since 1990, isolation from stool was the norm, and none were known to cause serious or disseminated infection.

The portal of entry for the bacteria into a human host is postulated to be the gastrointestinal tract as a result of eating a product that contains the bacteria. Salmonella then is thought to disseminate through the blood and lymphatics, (44) although this has not been evaluated with certainty. The time interval from exposure to development of overt clinical manifestation of infection appears to be variable. In a case series reported by Kraus, the mean time from exposure to infection was 3 months, (45) though Cortes documented a case in which the last known exposure to rattlesnake meat was up to 6 years earlier. (13) Thus, it is possible that colonization occurs for extended periods before the onset of illness.

Common to adults with serious S arizona infection is an impaired cell-mediated immune response. Multiple comorbid conditions have been documented including rheumatoid arthritis (3-5,45) and systemic lupus erythematosus on corticosteroid therapy, (1-27,28) malignancy, (4,9-14) HIV infection, (1,5,17-20) status posttransplantation, (6,15) and others cited in Table 3. Of the cases reviewed in which S arizona caused serious infection in individuals with connective tissue diseases and usual interstitial pneumonia, concomitant corticosteroid therapy was universal, suggesting the infection was a complication of therapeutic immunomodulation, rather than of the condition itself.

Salmonella arizona has been isolated from a variety of biological fluids and tissue, including blood, urine, stool, and others (Table 4). To the best of our knowledge, our case represents the first documented infection in which S arizona was isolated from pericardial fluid reported in the English language literature. The hemorrhagic nature of the pericardial fluid raises the question regarding whether primary infection was present initially with subsequent hemorrhage related to systemic anticoagulation or whether bleeding into the pericardial space was the sole source of bacteria. Confounding issues include renal failure and recent non-Q-wave myocardial infarction. Uremia has been associated with hemorrhagic pericarditis in the presence of anticoagulation with heparin (46); however, our patient's blood urea nitrogen was only 43 mg/dL; thus, frank uremia was not present. Also, as reviewed by Figueras, (47) anticoagulation with unfractionated heparin after myocardial infarction has not been shown to increase the incidence of hemorrhagic pericardial effusions. In a large review of complications of anticoagulation including major bleeding and death, hemorrhagic pericardial effusion was not listed as a complication of anticoagulation with intravenous unfractionated heparin therapy. (48) Moreover, in prior cases described in the literature, when other serous fluids including pleural (15) and peritoneal (12,14,30) fluid were involved, the samples were not noted to be hemorrhagic. Although our patient reported no chest pain on presentation, suppurative pericarditis may present silently, with tamponade as the initial manifestation of infection, and, as in our patient, overshadowed by concomitant systemic illness. (49) Furthermore, infectious pericarditis is usually the result of bacteremia. (50) For these reasons, we believe the hemorrhagic pericarditis was a direct result of disseminated infection with S arizona, while acknowledging that this is not proven.

How S arizona has been able to invade virtually all parts of the human body has been under investigation. Noskin (18) proposed a defect in cell-mediated immunity, as seen with HIV infection, as instrumental in pathogenesis. Salmonella strains are able to invade epithelial cells and macrophages. (44) In the macrophages, the bacteria proliferate and cause cell destruction with subsequent further dissemination of organisms. (49) Libby (51) determined that the virulence associated with S arizona was related to genes in the spv locus on the chromosome of this and other Salmonella species. The spv locus genes encode an ADP ribosyltransferase that is able to modify and destabilize the infected cells due to actin destabilization, therefore, enhancing the organism's growth. (44)

There has not been a uniform therapy for this type of infection. As documented in several of the case reports, this organism appears to be susceptible to commonly prescribed antibiotics. However, due to the critical nature of illness in these patients and their underlying immunocompromise, prolonged courses of therapy have been used. Moreover, recurrence of infection has been documented after apparent clearance of the organism demonstrated by negative cultures. (1-3,7,8,13,14,17,20,26,52) Although incomplete treatment is a possible explanation, reexposure has also been noted, especially when medicinal rattlesnake preparations are causative. (1,2) According to Jacobson, (17) standards of therapy for salmonellosis include ampicillin, trimethoprim/sulfamethoxazole, and chloramphenicol, although other [beta]-lactams, fluoroquinolones, aminoglycosides, and vancomycin in various combinations have also been used with apparent efficacy. Our patient responded to a combination of prolonged therapy (4 weeks) with antibiotics in combination with improved immune status as a result of HAART therapy.


Several important pieces of information can be gleaned from our case and review of the literature regarding S arizona infection. First, disseminated S arizona infection can be found outside of the typical geographic region and may not be associated with typical animal vectors such as snakes and reptiles. Second, the manifestations are protean, including infection of serosal surfaces. Third, the isolation of this organism from blood, tissue, or normally sterile body fluids should prompt an evaluation for underlying immunocompromise, since this is almost universal among patients with invasive disease. In 1987, the Centers for Disease Control and Prevention's National Center for HIV, STD and TB Prevention classified recurrent Salmonella infection as an AIDS indicator. (53) Fourth, although the organism tends to be susceptible to many antibiotics, patients who have serious infections with S arizona require prolonged therapy because of the high risk for recurrence. Finally, a detailed history of exposures to nonmainstream medicinal therapies is important, and education is paramount as reinfection is a real possibility.


The authors thank Dr. Richard Wenzel for his careful scrutiny and assistance with editing.


1. Riley KB, Antoniskis D, Maris R, Leedom JM. Rattlesnake capsule-associated Salmonella arizonainfections. Arch Intern Med 1988;48:1207-1210.

2. Bhatt BD, Zuckerman MJ, Foland JA, Polly SM, Marwah RK. Disseminated Salmonella arizona infection associated with rattlesnake meat ingestion. Am J Gastroenterol 1989;84:433-435.

3. Caravalho J Jr, McMillan VM, Ellis RB, Betancourt A. Endogenous endophthalmitis due to Salmonella arizonae and Hafnia alvei. South Med J 1990;83:325-327.

4. Cone LA, Boughton WH, Cone LA, Lehv LH. Rattlesnake capsuleinduced Salmonella arizonae bacteremia. West J Med 1990;153:315-316.

5. Waterman SH, Juarez G, Carr SJ, Kilman L. Salmonella arizona infections in Latinos associated with rattlesnake folk medicine. Am J Public Health 1990;80:286-289.

6. Quismorio FP Jr, Jakes JT, Zarnow AJ, Barber D, Kitridou RC. Septic arthritis due to Arizona hinshawii. J Rheumatol 1983;10:147-150.

7. Smilack JD, Goldberg MA. Bone and joint infection with Arizona hinshawii: report of a case and a review of the literature. Am J Med Sci 1975;270:503-507.

8. Guckian JC, Byers EH, Perry JE. Arizona infection of man, report of a case and review of the literature. Arch Intern Med 1967;119:170-175.

9. Fainstein V, Yancey R, Trier P, Bodey GP. Overwhelming infection in a cancer patient caused by Arizona hinshawii: its relation to snake pill ingestion. Am J Infect Control 1982;10:147-153.

10. Marzouk JB, Joseph P, Lec TK, Livermore T, Benjamin R. Arizona hinshawii septicemia associated with rattlesnake powder. Calif Mobidity Weekly Report 1983; No. 25.

11. Fleischman S, Haake DA, Lovett MA. Salmonella arizona infections associated with ingestion of rattlesnake capsules. Arch Intern Med 1989;149:701-705.

12. Woolf GM, Runyon BA. Spontaneous Salmonella infection of high-protein noncirrhotic ascites. J Clin Gastroenterol 1990;12:430-432.

13. Cortes E, Zuckerman MJ, Ho H. Recurrent Salmonella arizona infection after treatment for metastatic carcinoma. J Clin Gastroenterol 1992;14:157-159.

14. Sharma J, Von Hoff DD, Weiss GR. Salmonella arizonae peritonitis secondary to ingestion of rattlesnake capsules for gastric cancer. J Clin Oncol 1993;11:2288-2289.

15. Johnson RH, Lutwick LI, Huntley GA, Vosti KL. Arizona hinshawii infections: New cases, antimicrobial sensitivities, and literature review. Ann Intern Med 1976;85:587-592.

16. Fisher RH. Multiple lesions of bone in Letterer-Siwe disease. J Bone Joint Surg 1953; 35A:445-464.

17. Jacobson MA, Hahn SM, Gerberding JL, Lee B, Sande MA. Ciprofloxacin for Salmonella bacteremia in the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 1989;110:1027-1029.

18. Noskin GA, Clarke JT. Salmonella arizonae bacteremia as the presenting manifestation of human immunodeficiency virus infection following rattlesnake meat ingestion. Rev Infect Dis 1990;12:514-517.

19. Casner PR, Zuckerman MJ. Salmonella arizonae in patients with AIDS along the US-Mexican border. N Engl J Med 1990;323:198-199.

20. Babu K, Sonnenberg M, Kathpalia S, Ortega P, Swiatlo AL, Kocka FE. Isolation of salmonellae from dried rattlesnake preparations. J Clin Microbiol 1990;28:361-362.

21. Nowinski RJ, Albert MC. Salmonella osteomyelitis secondary to iguana exposure. Clin Orthop 2000;372:250-253.

22. Buck JJ, Nicholls SW. Salmonella arizona enterocolitis acquired by an infant from a pet snake. J Pediatr Gastroenterol Nutr 1997;25:248-249.

23. Sanyal D, Douglas T, Roberts R. Salmonella infection acquired from reptilian pets. Arch Dis Child 1997;77:345-346.

24. Kelly J, Hopkin R, Rimsza ME. Rattlesnake meat ingestion and Salmonella arizona infection in children: case report and review of the literature. Pediatr Infect Dis J 1995;14:320-322.

25. Ichord R, Brook I, Controni G. Arizona hinshawii bacteraemia and meningitis in a child: a case report. J Clin Pathol 1980;33:848-850.

26. Ogden JA, Light TR. Pediatric osteomyelitis: Arizona hinshawii osteomyelitis. Clin Orthop 1979;139:110-113.

27. Hruby MA, Honig GR, Lolekha S, Gotoff SP. Arizona hinshawii osteomyelitis in sickle cell anemia. Am J Dis Child 1973;125:867-868.

28. Butt E, Morris JF. Arizona paracolon recovered from middle ear discharge. J Infect Dis 1952;91:283-284.

29. Krag D, Shean DB. Serious human infections due to bacilli of the Arizona Group. California Medicine 1959;90:230-233.

30. Lindsay KL, Canawati HN. Spontaneous Arizona hinshawii peritonitis in cirrhosis with ascites. Gastroenterology 1981;81:349-351.

31. Petru MA, Richman DD. Arizona hinshawii infection of an atherosclerotic abdominal aorta. Arch Intern Med 1981;141:537-538.

32. McIntyre KE Jr, Malone JM, Richards E, Axline SG. Mycotic aortic pseudoaneurysm with aortoenteric fistula caused by Arizona hinshawii. Surgery 1982;91:173-177.

33. Ripley GD. Mexican-American folk remedies: Their place in health case. Texas Med 1986;82:41-44.

34. Soloway M. Paracolon organisms in spray dried whole egg powder. J Bacteriol 1947;53:667.

35. Edwards PR. Studies on the Arizona subgroup of enterobactereaceae. Bacteriol Rev 1959;23:155.-

36. Edwards PR, McWhorter AC, Fife MA. The Arizona subgroup of enterobactereaceae. Bull WHO 1956;14:511.-

37. Sechter I. Arizona isolates in Israel (1957-69). Ann Inst Pasteur (Paris) 1970;119:323.-

38. D'Aoust JY, Daley E, Crozier M, Sewell AM. Pet turtles: A continuing international threat to public health. Am J Epidemiol 1990;132:233-238.

39. Croop JM, Shapiro B, Alpert G, Campos JM, Zavod W. Arizona hinshawii osteomyelitis associated with a pet snake. Pediatr Infect Dis 1984;3:188.-

40. Caldwell MC, Hyerson DL. Salmonellosis in certain reptiles. J Infect Dis 1939;65:242.-

41. Seligman E, Saphra I, Wasserman M. Occurrence of some unusual Salmonella types in man including a new type, Salmonella georgia. Am J Hyg 1944;40:227-231.

42. Hentges K, Shields CE, Cantu C. Folk Medicine and Medical Practice. Texas Med 1986;82:27-29.

43. Centers for Disease Control (CDC). Arizona hinshawii septicemia associated with rattlesnake powder: California. MMWR Morb Mortal Wkly Rep 1983;32:464-465.

44. Lesnick ML, Reiner NE, Fierer J, Guiney DG. The Salmonella spvB virulence gene encodes an enzyme that ADP-ribosylates actin and destabilizes the cytoskeleton of eukaryotic cells. Mol Microbiol 2001;39:1464-1470.

45. Kraus A, Guerra-Bautista G, Alarcon-Segovia D. Salmonella arizona arthritis and septicemia associated with rattlesnake ingestion by patients with connective tissue diseases. A dangerous complication of folk medicine. J Rheumatol 1991;18:1328-1331.

46. Dember LM. Critical care issues in the patient with chronic renal failure. Crit Care Clin 2002;18:421-440.

47. Figueras J, Juncal A, Carballo J, Cortadellas J, Soler JS. Nature and progression of pericardial effusion in patients with a first myocardial infarction: Relationship to age and free wall rupture. Am Heart J 2002;144:251-258.

48. Levine MN, Raskob G, Landefeld S, Kearon C. Hemorrhagic complications of anticoagulation treatment. Chest 2001;119:108-121s.

49. Braunwald. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: WB Saunders Company, 2001:1854-1856.

50. Richter-Dahlfors AA, Buchan MJ, Finlay BB. Murine Salmonellosis studied by confocal microscopy: Salmonella typhimurium resides intracellularly inside macrophages and exerts cytotoxic effects on phagocytes in vivo. J Exp Med 1997;186:287-299.

51. Libby SJ, Lesnick M, Hasegawa P, Kurth M, Belcher C, Fierer J, Guiney DG. Characterization of the spv locus in Salmonella enterica serovar Arizona. Infect Immun 2002;70:3290-3294.

52. Keren DF, Rawlings W Jr, Murray HW, Leonard WR. Arizona hinshawii osteomyelitis with antecedent enteric fever and sepsis: A case report with a review of the literature. Am J Med 1976;60:577-582.

53. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36:3-15s.
Never confuse a single defeat with a final defeat.
--F. Scott Fitzgerald

Jeffrey B. Hoag, MD, MS, and Curtis N. Sessler, MD

From the Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, MD; and the Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Medical College of Virginia Hospitals, Richmond, VA.

Reprint requests to Curtis N. Sessler, MD, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Medical College of Virginia Hospitals, Box 980050, Richmond, VA 23298-0050. E-mail:

Accepted April 1, 2005.


* Disseminated Salmonella arizona infection should prompt investigation into underlying immunocompromise.

* Although most cases in the literature have occurred in the southwestern United States, eastern seaboard infections occur.

* Recurrence after adequate antibiotic therapy is common, thus requiring prolonged antibiotic therapy and vigilance in removing possible sources of exposure.
Table 1. Composite data from case reports or series of Salmonella
arizona infection from 1952 to 2004a

 Age, race, Type of Exposure
Reference sex infection

Current 2002 47 yr, B, F Pericarditis, UTI, Chickens?
Nowinski 2000 (21) 7 mo, F Arthritis Pet iguana
Buck 1997 (22) 3 mo, M Gastroenteritis Pet snake
Sanyal 1997 (23) 5 yr, M Gastroenteritis Pet snake
Kelly 1995 (24) 6 yr, H Gastroenteritis Meat
Sharma 1993 (14) 69 yr, H, M Peritonitis Capsules
Cortes 1992 (13) 60 yr, H, M Bacteremia Meat
Waterman 1990 (5) H Pneumonia, UTI Capsules
 H Perirectal abscess Capsules
 H Perirectal abscess Capsules
 H Gastroenteritis Capsules
Cone 1990 (4) 71 yr, H, F Bacteremia "Folk remedy"
 72 yr, H, M Bacteremia Capsules
Caravalho 1990 (3) 55 yr, H, F Endophthalmitis Powder
Woolf 1990 (12) 28 yr, F Peritonitis Capsules
Babu 1990 (20) 25 yr, H, M Bacteremia Powder
Casner 1990 (19) 30 yr, H, M Bacteremia Capsules
Noskin 1990 (18) 57 yr, H, M Bacteremia Meat
Bhatt 1989 (2) 27 yr, H, F Bacteremia, Meat
Fleischman 1989 (11) 38 yr, H, M Bacteremia Capsules
Jakobson 1989 (17) 49 yr, W, F Bacteremia Unknown
Riley 1988 (1) 19 yr, H, F Bacteremia Capsules
 25 yr, H, M Gastroenteritis Capsules
 51 yr, H, M Bacteremia Capsules
Croop 1984 (39) Osteomyelitis Pet snake
Marzouk 1983 (10) 63 yr, H, M Bacteremia Capsules
Quismorio 1993 (6) 31 yr, H, M Arthritis Unknown
 41 yr, A, M Arthritis, UTI, Unknown
 48 yr, H, F Arthritis, Unknown
Fainstein 1982 (9) 66 yr, H, M Bacteremia Capsules
McIntyre 1981 (32) 73 yr, H, M Arthritis, UTI, Capsules
Petru 1981 (31) 53 yr, M Bacteremia Hens at home
Ichord 1980 (25) 8 wk, W, F Bacteremia, Pet turtle,
 meningitis milk
Lindsay 1980 (30) 69 yr, F Peritonitis, Unknown
Ogden 1979 (26) 2 yr, B, M Osteomyelitis Unknown
 1 yr, B, M Osteomyelitis Unknown
Keren 1976 (51) 53 yr, B, M Disseminated Unknown
Johnson 1976 (15) 29 yr, H, F Bacteremia, Raw milk
 54 yr, W, M Gastroenteritis Unknown
 54 yr, W, M Pneumonia Unknown
Smilack 1975 (7) 23 yr, B, F Osteomyelitis, Unknown
Hruby 1973 (27) 2.5 yr, B, F Bacteremia Unknown
Guckian 1967 (8) 52 yr, B, F Arthritis, UTI Unknown
Krag 1959 (29) 87 yr, W, F Abscess Unknown
 63 yr, W, F Osteomyelitis, Unknown
Fisher 1953 (16) 2 yr, B, M Osteomyelitis, Raw milk
Butt 1952 (28) 7 yr, B, F Otitis media Unknown

 Age, race, Underlying
Reference sex condition Antibiotic

Current 2002 47 yr, B, F HIV/AIDS (CD4 12) Cep, Q
Nowinski 2000 (21) 7 mo, F Young age Cep
Buck 1997 (22) 3 mo, M Young age Sal
Sanyal 1997 (23) 5 yr, M Netherton syndrome Q
Kelly 1995 (24) 6 yr, H Young age Cep
Sharma 1993 (14) 69 yr, H, M Metastatic AdenoCa Cep, AG
Cortes 1992 (13) 60 yr, H, M Right Neck Mass AZ, Q
Waterman 1990 (5) H HIV/AIDS
 H RA, Dermatitis
Cone 1990 (4) 71 yr, H, F RA, corticosteroids Cep, Chl
 72 yr, H, M Metastatic melanoma V, AZ
Caravalho 1990 (3) 55 yr, H, F Rheumaroid arthritis Cep, AG
Woolf 1990 (12) 28 yr, F Pregnant, AdenoCa AMP
Babu 1990 (20) 25 yr, H, M HIV/AIDS Q
Casner 1990 (19) 30 yr, H, M HIV/AIDS SMX-
Noskin 1990 (18) 57 yr, H, M HIV (CD4 300) AMP, AG
Bhatt 1989 (2) 27 yr, H, F SLE, corticosteroids AMP
Fleischman 1989 (11) 38 yr, H, M Gastric cancer AMP
Jakobson 1989 (17) 49 yr, W, F HIV/AIDS Q
Riley 1988 (1) 19 yr, H, F SLE, corticosteroids AMP
 25 yr, H, M HIV AMP
 51 yr, H, M CHF, Afib, dilated
Croop 1984 (39)
Marzouk 1983 (10) 63 yr, H, M AdenoCa
Quismorio 1993 (6) 31 yr, H, M SLE, corticosteroids AMP
 41 yr, A, M Renal transplant AMP, Cep
 48 yr, H, F W. Macroglob AMP
Fainstein 1982 (9) 66 yr, H, M Leukemia TIC, AG
McIntyre 1981 (32) 73 yr, H, M DM, HTN AMP
Petru 1981 (31) 53 yr, M UIP on corticosteroids AMP, AG
Ichord 1980 (25) 8 wk, W, F Young age AMP, Chl
Lindsay 1980 (30) 69 yr, F Alcoholic, cirrhosis Cep, AG,
Ogden 1979 (26) 2 yr, B, M SSA Chl
 1 yr, B, M SSA Chl
Keren 1976 (51) 53 yr, B, M Alcohol abuse AMP, AG
Johnson 1976 (15) 29 yr, H, F Hodgkin disease Cep, AG,
 54 yr, W, M Heart transplant
 54 yr, W, M Mental retardation Cep, AMP
Smilack 1975 (7) 23 yr, B, F Sickle cell trait, AMP
Hruby 1973 (27) 2.5 yr, B, F SSA AMP, AG
Guckian 1967 (8) 52 yr, B, F SLE Cep, AMP
Krag 1959 (29) 87 yr, W, F DM, nursing home PCN
 63 yr, W, F ATP, splenectomy
Fisher 1953 (16) 2 yr, B, M Letterer-Siwe Strept
Butt 1952 (28) 7 yr, B, F SSA

 Age, race,
Reference sex Rec O St

Current 2002 47 yr, B, F N S VA
Nowinski 2000 (21) 7 mo, F N S OH
Buck 1997 (22) 3 mo, M N S UK
Sanyal 1997 (23) 5 yr, M N S
Kelly 1995 (24) 6 yr, H N S AZ
Sharma 1993 (14) 69 yr, H, M Y S TX
Cortes 1992 (13) 60 yr, H, M Y S TX
Waterman 1990 (5) H CA
Cone 1990 (4) 71 yr, H, F N S CA
 72 yr, H, M N S CA
Caravalho 1990 (3) 55 yr, H, F Y S TX
Woolf 1990 (12) 28 yr, F N D CA
Babu 1990 (20) 25 yr, H, M Y S IL
Casner 1990 (19) 30 yr, H, M N S TX
Noskin 1990 (18) 57 yr, H, M N S IL
Bhatt 1989 (2) 27 yr, H, F Y S TX
Fleischman 1989 (11) 38 yr, H, M N S CA
Jakobson 1989 (17) 49 yr, W, F Y S CA
Riley 1988 (1) 19 yr, H, F N S CA
 25 yr, H, M Y S CA
 51 yr, H, M N S CA
Croop 1984 (39)
Marzouk 1983 (10) 63 yr, H, M
Quismorio 1993 (6) 31 yr, H, M N D CA
 41 yr, A, M Y D CA
 48 yr, H, F Y D CA
Fainstein 1982 (9) 66 yr, H, M N D TX
McIntyre 1981 (32) 73 yr, H, M N S AZ
Petru 1981 (31) 53 yr, M N S CA
Ichord 1980 (25) 8 wk, W, F N S
Lindsay 1980 (30) 69 yr, F N D CA
Ogden 1979 (26) 2 yr, B, M N S H
 1 yr, B, M N S H
Keren 1976 (51) 53 yr, B, M Y S MD
Johnson 1976 (15) 29 yr, H, F N D CA
 54 yr, W, M N D CA
 54 yr, W, M N CA
Smilack 1975 (7) 23 yr, B, F Y S TX
Hruby 1973 (27) 2.5 yr, B, F N S IL
Guckian 1967 (8) 52 yr, B, F Y S TX
Krag 1959 (29) 87 yr, W, F D CA
 63 yr, W, F
Fisher 1953 (16) 2 yr, B, M N D VA
Butt 1952 (28) 7 yr, B, F N S GA

"Race: A, Asian; B, black; H, Hispanic; W, white. Type of infection:
UTI, urinary tract infection. Exposure: capsules, powder, and meat
refers to rattlesnake preparations. Underlying conditions: AdenoCa,
adenocarcinoma; ATP, autoimmune thrombocytopenia purpura; DM, diabetes
mellitus; HTN, hypertension; RA, rheumatoid arthritis; SLE, systemic
lupus erythematosus; SSA, sickle cell anemia; UIP, usual interstitial
pneumonia; W. Macroglob, Waldenstrom macroglobulinemia. Antibiotics: AG,
aminoglycoside; AMP, ampicillin; AZ, aztreonam; Cep, cephalosporin; Chl,
chloramphenicol; PCN, penicillin; Q, fluoroquinolone; Sal,
sulfasalazine; Strept, streptomycin; SMX-TMP, sulfamethoxazole-
trimethoprim; TIC, ticarcillin; V, vancomycin, Recurrence (Rec): Y, yes;
N, no or not documented. Outcome (O): S, survived; D, died. State or
country (St): AZ, Arizona; CA, California; GA, Georgia; H, Republic of
Haiti; IL, Illinois; MD, Maryland; OH, Ohio; TX, Texas; UK, United
Kingdom; VA, Virginia.

Table 2. Exposures cited as source of Salmonella arizona infection

Pet chickens or hens (31)
Pet iguanas (21)
Pet snakes (22-23,39)
Pet turtles (25,38)
Rattlesnake meat (2,13,18,24)
Rattlesnake capsules (1,4,5,9-12,14,19,32,33)
Rattlesnake powder (3,20)
Unpasteurized milk (15,16,24,25,36)
Egg powder (37)
"Folk remedy" from Mexico (4)
Unknown (6-8,15,17,26-30,52)

Table 3. Underlying medical conditions of patients infected with
Salmonella arizona

Human immunodeficiency virus (2,13,17-19,23, current)
Neoplastic diseases
 Adenocarcinoma (10-12,14)
 Carcinoma (13)
 Melanoma (4)
 Leukemia (9)
 Letterer-Siwe disease (16)
Connective tissue diseases
 Rheumatoid arthritis (3-5)
 Systemic lupus erythematosus (1,2,6-8)
Dermatologic diseases
 Netherton syndrome (23)
Hematologic diseases
 Sickle cell anemia (7,26-28)
 Autoimmune thrombocytopenia purpura, splenectomy (29)
 Waldenstrom macroglobulinemia (6)
Posttransplant, on immunosuppressive medication
 Kidney transplant (6)
 Heart transplant (15)
Other conditions
 Usual interstitial pneumonia (31)
 Cardiac disease (CHF, dilated cardiomyopathy, atrial fibrillation) (1)
 Diabetes mellitus (29,32)
 Alcoholism, cirrhosis (30,52)
 Young age (< 7 yr) (16,21-28)

Table 4. Infection caused by Salmonella arizona and source of bacterial
culture (a)

Type of infection Source of culture

Abscess, hematoma and Tissue (5,6,29,32)
Adenitis Lymph node (1)
Bacteremia, septicemia Blood (1,2,4,9-11,13,15-20,25,30,31,52, current)
Empyema, pleural Pleural fluid (15)
Endophthalmitis Vitreous fluid (3)
Gastroenteritis Stool (1,5,15,22-24,41, current)
Meningitis Cerebrospinal fluid (25)
Osteomyelitis Bone (7,16,26,27,29,39)
Otitis media Ear drainage (28)
Pericarditis Pericardial fluid (current)
Peritonitis Peritoneal fluid (12,14,30)
Pneumonia Sputum (5,15)
Septic arthritis Synovial fluid (6,8,21,32)
UTI, pyelonephritis Urine (5,8,32, current)

(a) UTI, urinary tract infection.
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Title Annotation:Review Article
Author:Sessler, Curtis N.
Publication:Southern Medical Journal
Date:Nov 1, 2005
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