arizonae exhibiting hydrogen sulfide production and lactose fermentation on XLD agar after 18 hours at 35☌ (A). arizonae compared to other Salmonellae (B). Lactose-fermentation is a unique hallmark of S. arizonae exhibiting lactose fermentation on MacConkey agar after 18 hours of incubation at 35☌ (A). arizonae (IIIa 14:z4,z23) by whole genome sequencing. The organism was submitted to the Texas Department of Health laboratory where the isolate was definitively identified as Salmonella enterica subsp. Hydrogen sulfide production is typical of Salmonellae, and lactose fermentation, a trait unique to some isolates of S. Xylose Lysine Deoxycholate (XLD) agar was set up to confirm the unusual identification (Image 2). However, MALDI-TOF MS provided the surprising identification of Salmonella enterica subsp. Given this biochemical pattern, a member of the Enterobacterales was suspected as typically seen in urine cultures. Urine received in the microbiology laboratory was plated on Blood and MacConkey/CNA agars and grew non-hemolytic, lactose-fermenting gram negative rods (Image 1). A urinalysis was performed as part of the evaluation for his AKI that showed 100 WBC/HPF, > 187 RBC/HPF, and moderate bacteria which triggered a urine culture. He also had acute kidney injury (AKI) thought to be secondary to hepatorenal syndrome leading to the development of anasarca. Admission hemoglobin was 4.3 mg/dL (4.0-11.0 mg/dL) and bilirubin, both total and direct, were 6.3 mg/dL (0.2-1.3 mg/dL) and 2.9 mg/dL (0.0-0.5 mg/dL), respectively. On presentation he was found to have jaundice due to hemolytic anemia secondary to spur cell anemia. A 32 year old male with alcoholic cirrhosis presented to the emergency department with progressive lower extremity swelling.
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