A 52-year-old male was admitted to our intensive care unit with high grade fever, shortness of breath, hypotension, and urosepsis. Patient had a history of poor oral intake for several weeks with significant weight loss. There was no history of cough, expectoration, nausea or vomiting, dysuria, bleeding, loose bowel movements or alteration of higher mental functions. The patient has been drinking unpasteurized camel milk. Patient had a past medical history of hypertension and diabetes. His social history single and denies sexual activities. He has served in the military. There was no past history of sexual transmitted diseases, blood transfusion, homosexuality, or travel outside the country. On physical examination, he was in moderate distress, febrile (38.1°C), with decreased breath sounds bilaterally and blood pressure of 100/50 mmHg; carotid pulsations were visible with no bruits and non-elevated jugular venous pressure (JVP). Cardiovascular examination showed normal heart sounds. Abdomen was soft, non-tender with no hepatospleenomegaly or pain on deep palpation. No other abnormalities were noted on systemic examination. Laboratory analysis revealed: hemoglobin, 85 g/liter; total leucocyte count, 6200/mm3; normal platelet count (1.6 × 109/liter); C reactive protein, 222 mg/L. No malaria parasites were seen on blood smear. Additionally, colonoscopy and endoscopy showed internal hemorrhoids and gastritis. Gastric biopsy for Helicobacter pylori stain was negative. CT scan revealed no mediastinal, hilar or axillary lymphadenopathy. However, there was 3 cm pleural effusion noted on the right side and 1.4 cm on the left side with minor amount of pericardial effusion noted as well. Additionally, there were no focal changes noted in the liver, pancreas, spleen, kidneys, or adrenals. There was no retroperitoneal or intraperitoneal lymphadenopathy noted. There was minor amount of free abdominal fluid with lesser fluid noted within the pelvis.
Serial cultures of blood and urine revealed the presence of non-typhoidal Salmonella Group D sensitive to piperacillin/tazobactam, ciprofloxacin, and ampicillin, but resistant to cefuroxime, gentamicin, and trimethoprim/sulfamethoxazole. The antimicrobial susceptibility was performed using Kirby Bauer disk diffusion method. Hence, the decision was to investigate for malignancy, tuberculosis, or HIV as a differential diagnosis for the unusual presence of NTS in the blood and urine. A positive ELISA result, followed up with a positive Western blot test, confirmed the diagnosis of HIV. Cytology report was negative for malignancy. Sputum smears and cultures using fluorescence microscopy for acid-fast bacilli were also negative. The patient was treated with ciprofloxacin 200 mg IV twice daily, which was then switched to piperacillin/tazobactam 3 days later with a total duration of 7 days. A urine culture obtained later showed negative growth.