Case report A 22 year old MSM was diagnosed HIV positive with a CD4 cell count was 475 cells/mm3 (35%). He suffered urinary symptoms and Salmonella typhi was isolated from urine culture. He recalled a self-limiting afebrile diarrhoeal illness 2 weeks earlier. Stool and blood cultures were negative. He completed a one-week course of ciprofloxacin with subsequently negative cultures. He had no past medical history or significant travel history. He reported unprotected anal intercourse one month before HIV diagnosis, and protected anal intercourse with several partners since diagnosis, but no other infections have been reported locally. All named contacts have declined testing.
Discussion The most common manifestation of S.typhi infection is typhoid fever. Most cases in the developed world have been acquired through faeco-oral transmission in endemic areas. Haematogenous dissemination can be widespread and more severe among the immunocompromised. Death ensues in up to 32%. Infection of the genitourinary system is rare. Cases reported have a background of urinary tract abnormalities, invariably with blood and/or stool culture positivity. There are no cases in the literature of sexually acquired S.typhi UTI. Infections were acquired through oro-anal contact and pathogen ingestion. None had UTI. Our patient had repeatedly negative blood and stool cultures, reducing the likelihood that this was a disseminated infection leading to UTI, and raising the possibility that the route of infection was though insertive anal intercourse with direct urethral inoculation with S.typhi. Unfortunately partner notification has not identified an infected sexual contact to add further weight to this theory.