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 Table of Contents  
Year : 2019  |  Volume : 35  |  Issue : 1  |  Page : 129-132

Submandibular abscess caused by Salmonella spp. in a diabetic patient: a case report

Department of Craniomaxillofacial Surgery, Hamad Medical Corporation, Doha, Qatar

Date of Submission03-Jul-2017
Date of Acceptance03-Jul-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Abdul-Aziz Alaqeeli
Hamad Medical Corporation, Arab Board of Oral and Maxillofacial Surgery, PO box 3050, Alrayyan Street, Doha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejo.ejo_54_17

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Head and neck infections normally arise from Streptococcus, Staphylococcus, or other anaerobic species, and infection by Salmonella spp. is rare. Patients with significant underlying conditions are at increased risk for the development of focal infection. This has been observed in patients with HIV, diabetes, and malignancy.

Keywords: Salmonella spp. in the neck

How to cite this article:
Alaqeeli AA, Alani B, Al Khalil M. Submandibular abscess caused by Salmonella spp. in a diabetic patient: a case report. Egypt J Otolaryngol 2019;35:129-32

How to cite this URL:
Alaqeeli AA, Alani B, Al Khalil M. Submandibular abscess caused by Salmonella spp. in a diabetic patient: a case report. Egypt J Otolaryngol [serial online] 2019 [cited 2020 Jun 4];35:129-32. Available from: http://www.ejo.eg.net/text.asp?2019/35/1/129/251315

  Introduction Top

Head and neck infections normally arise from Streptococcus, Staphylococcus, or other anaerobic species, and infection by  Salmonella More Details spp. is rare. Nontyphoidal  Salmonellosis More Details, which is increasing nowadays in the developed countries, is manifested as enteritis in most cases, but it also encompasses bacteremia, intra-abdominal infections, and bone, joint, and soft tissue infections. These rare diseases are known to result from primary gastrointestinal infection and subsequent bacteremia with or without symptoms [1].

Salmonella spp. infections are typically classified into four categories: gastroenteritis, enteric fever, focal disease, and chronic carrier state. The infection may be localized to the gastrointestinal tract or may disseminate via the blood or lymphatic system. Focal salmonellosis is thought to be secondary to a brief episode of bacteremia after infection from the gastrointestinal tract.

Patients with significant underlying conditions are at increased risk for the development of focal infection. This has been observed in patients with HIV, diabetes, and malignancy [2].

According to a recent review, there have been approximately 10 cases of neck abscesses with soft tissue involvement by various nontyphoidal Salmonella reported worldwide in the past 10 years [3].

  The case Top

A 26-year-old male patient with no known medical history, presented to the emergency department in Hamada general hospital on august 2016 complaining of a progressively enlarging swelling of the right upper side of the neck with pain, fever, and reduced oral intake since 7 days.

On examination, the patient was conscious, alert, and oriented, and not in distress; vitals were within the normal range and had raised body temperature to 38°, with no history of recent trauma, dental pain or treatment, any abdominal pain, or abnormal bowel motion.

A swelling of the 5*4 cm right submandibular swelling was clinically evident, erythematous overlying skin, indurated and tender to palpation; trachea was central, and he was able to move the neck freely, with no trismus, no sublingual or parapharyngeal swelling, with odynophagia, and without intraoral focus of infection.

Blood workups were done. Complete blood count revealed leukocytosis (white blood cells 15 000/dl) and high random blood sugar (260 mg/dl); accordingly, hemoglobin A1c was requested, and the result was 11% to confirm undiagnosed non insulin dependent diabetes mellitus (NIDDM).

Intravenous normal saline, amoxiclav antibiotics 1.2 g three times daily and insulin to control blood glucose were initiated immediately.

A computed tomography scan of the neck with contrast was done, which revealed a multilocular collection seen in the right submandibular region (level 2a and 2b) beneath the sternocleidomastoid muscle measuring 4.5×3.5×4.5 cm in dimension with marginal enhancement ([Figure 1] and [Figure 2]).
Figure 1 Coronal view.

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Figure 2 Axial view.

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The patient was taken to the operating room, and incision and drainage was done under general anesthesia; significant amount of pus was evacuated, more than 25 ml, corrugated rubber drain inserted and specimens for culture and sensitivity and TB PCR were sent for laboratory investigations.

On the second day, the patient showed improvement of the symptoms, normal body temperature, reduced count of white blood cells and controlled blood glucose.

After 24 h, the laboratory result for tuberculosis PCR was negative, and after 72 h, the culture diagnosed Salmonella enterica, subtype Enteritidis, as the causative organism and sensitive to penicllin, ceftriaxone, ampicillin, ciprofloxacin, ceftrixone and ertapenem.

Infectious disease team was consulted, and advised to continue on co-amoxiclav for a total of 2 weeks.

On the fourth postoperative day, there was almost total resolution of the swelling, good oral intake, and vitally stable with no fever. So, the drain was removed, and he was discharged home with oral antibiotics, diabetes medications as per the endocrinology team advice, and daily wound care.

A follow-up on weekly basis appointment for 2 months showed great improvement at the surgical site, and well-controlled blood glucose.

  Microbiology Top

The pus sample was cultured in a blood agar medium, thereafter on a MacConkey agar medium, which is selective for gram-negative bacilli and differential based on lactose fermentation, where the formation of white/colorless colonies on the petri plate indicated non-lactose fermenting bacteria such as Salmonella, Shigella, Psuedomonas, Proteus species [4], and then on a Hektoen enteric agar medium, which is primarily used to differentiate Salmonella spp. and Shigella spp., as Salmonella spp. produces black precipitate in the presence of hydrogen sulfide, and Shigella spp. does not produce it and precipitates green colonies [5].

  Discussion Top

Submandibular space infection by Salmonella spp. is rare [6]. The condition usually originate from oral mucosal infections, dental infections, submandibular salivary gland infection, blunt or penetrating trauma to the region, and spread from adjacent spaces, and commonly lead to culture of anaerobic bacteria: Bacteroides spp. and Peptostreptococcus spp. Staphylococcus aureus and Streptococcus species dominate among the aerobic bacteria. Other changes include the emergence of gram-negative organisms, primarily Klebsiella spp. as important pathogens [7]; unusual presentation of actinomycosis of the submandibular gland had been also reported [8].

Salmonella spp. is a gram-negative rod-shaped organism acquired by oral route. In human beings, it causes enteric fever, systemic infection and enteritis, and very rarely it causes focal infections like neck abscess, lung abscess, and bone infection [9]. Conditions associated with higher risk of Salmonella spp. infection are gastrectomy; achlorhydria; antacid medicine use; impaired bowel motility, which allows the bacterial entry and survival more easily; hemolytic anemia; and immunocompromise status, such as patients with diabetes mellitus, connective tissue disorders, or use of immunosuppressive agents for many different diseases. On the contrary, uncontrolled diabetes can contribute to compromise of humoral-mediated and cell-mediated immunity for Salmonella spp. clearance, and these might act as risk factors for the present patient [10].

Other types of neck abscesses involving Salmonella spp. have been described in the literature. A recent report by Luo and Liu demonstrated two cases of neck abscess and necrotizing fasciitis caused by Salmonella enterica serotype Enteritidis in diabetic patients [11].

Proposed mechanisms for diabetes as a risk factor for infection include decreased gastric acidity and an autonomic neuropathy of the small bowel that reduces intestinal motility and prolongs gastrointestinal transit time [9].

  Conclusion Top

Submandibular abscess was caused by Salmonella spp. serotype Enteritidis in a patient with previously undiagnosed diabetes, and treated with surgical drainage and antibiotics. He completely recovered without sequelae. Salmonella spp. infection is a rare disease, but it should be suspected in neck abscess in patients with risk factors like diabetes or immunosuppression, which makes it possible to be successfully treated with surgical drainage and antibiotics therapy.


Organization interdepartmental meeting: HMC Craniomaxillofacial Surgery Department meeting room. Date 1 May 2017.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Reynolds SC, Chow AW. Severe soft tissue infections of the head and neck: a primer for critical care physicians. Lung 2009; 187:271–279.  Back to cited text no. 1
Patrick ME, Adcock PM, Gomez TM, Altekruse SF, Holland BH, Tauxe RV, Swerdlow DL. Salmonella enteritidis infections, United States, 1985–1999. Emerg Infect Dis 2004; 10:1–7.  Back to cited text no. 2
Kwon MH, Kang MI, Chun JY, Lim HW, Yeum YS, Kang YW et al. A case of neck abscess caused by Salmonella serotype D in a patient with liver cirrhosis. Yonsei Med J 2010; 51:128–130.  Back to cited text no. 3
Anderson C. Great adventures in the microbiology laboratory. 7th ed. California, USA: Pearson; 2013. 175–176.  Back to cited text no. 4
Hudzicki J. Hektoen Enteric Agar Protocol. American Society for Microbiology Microbe Library. Retrieved January 2013.  Back to cited text no. 5
Luo CW, Liu CJ. Neck abscess and necrotizing fasciitis caused by Salmonella infection: a report of 2 cases. J Oral Maxillofac Surg 2007; 65:1032–1034.  Back to cited text no. 6
Stalfars J, Adielsson A, Ebenfelt A, Nethander G, Westin T. Deep neck infections remains a surgical challenge. A study of 72 patients. Acta Otolaryngol 2004; 124:1191–1196.  Back to cited text no. 7
Bubbico L, Carartozzolo M, Nard F, Ruoppolo G, Greco A, Venditti M. Actinomycosis of the submandibular gland: an unusual presentation. Acta Otorhinolaryngol Italy 2004; 24:27–34.  Back to cited text no. 8
Brooks GF, Butel JS, Morse SA. Enteric gram-negative rods. In Brooks GF, Butel JS, Morse SA, Melinick & Adelberg’s medical microbiology. 23rd ed. Boston: McGrow-Hill Companies; 2004. 248–260  Back to cited text no. 9
Minohara Y, Kato T, Chiba M, Doi K, Kurihara Y, Kusakado M et al. A rare case of Salmonella soft-tissue abscess. J Infect Chemother 2002; 8:185–186.  Back to cited text no. 10
Lin CH, Chou JC, Lin TL, Lou PJ. Spontaneous resolution of internal jugular vein thrombosis in a Salmonella neck abscess patient. J Laryngol Otol 1999; 113:1122–1124.  Back to cited text no. 11


  [Figure 1], [Figure 2]


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