SESSION TITLE: Critical Care Student/Resident Case Report Posters I
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Although rare, the range of possible cardiovascular complications by Salmonella spp is quite broad. Anticipation of these effects can be crucial for timely management of life-threatening complications.
CASE PRESENTATION: A 67 year old man with history of hypertension presented with fever and chest pain of three days’ duration. Admission labs showed elevated troponin I (12.8 ng/mL) and EKG with atrial fibrillation. Blood cultures grew Salmonella enteriditis. A 2D echo showed normal structure and function without vegetations. The patient had persistent chest pain, prompting a left heart catheterization that revealed angiographically normal coronary arteries. Troponin elevation was attributed to demand ischemia. Following clearance of bacteremia, the patient was discharged on a course of ciprofloxacin. The patient returned four days following discharge with dyspnea and ongoing chest pain. The patient was tachycardic and hypotensive, a change from prior. EKG now showed low-voltage compelxes, and critical care ultrasound (CCUS) showed tamponade physiology (Fig 1). The patient was admitted to the ICU given risk for cardiovascular decompensation. A pericardial window was performed and drained 300 mL of nonpurulent, culture-negative fluid. The patient recovered from this episode with sequela of uncontrolled atrial fibrillation. A cardiac MRI showed focal myocarditis and pericardial adhesions (Fig 2).
DISCUSSION: While cardiac involvement by nontyphoidal Salmonella species (NTS) is rare in itself, several features about this case are still unique. First, most cases of myocarditis with Salmonella species occur in the context of typhoid fever, complicating 2-7% of all cases of Salmonella typhi infections. In contrast, fewer than 10 cases of myocarditis with Salmonella enteritidis have ever been reported. Additionally, bacterial pericarditis tends not to occur in immunocompetent hosts. In a review of 19 reported cases of NTS pericarditis, 18 cases had underlying autoimmune disease (most commonly systemic lupus erythematosus) or steroid use. The mechanism by which autoimmunity predisposes to infection is unclear, but it has been posited that autoantibodies neutralize cytokines responsible for antimicrobial defense, such as IL-2 and IFN-γ. This patient had positive anti-Ro, but did not meet diagnostic criteria for any specific autoimmune disease.
CONCLUSIONS: Nontyphoidal Salmonella can cause serious cardiac complications, which can be detected by CCUS for appropriate triage. Cardiac involvement by Salmonella warrants screening for predisposing autoimmune conditions.
Reference #1: Ortiz D, Siegal EM, Kramer C, et al. Nontyphoidal Cardiac Salmonellosis: Two Case Reports and a Review of the Literature. Texas Heart Institute Journal. 2014;41(4):401-6.
Reference #2: Maddur MS, Vani J, Lacroix-Desmazes S, et al. Autoimmunity as a Predisposition for Infectious Diseases. PLoS Pathogens 6(11): e1001077. doi:10.1371/journal.ppat.1001077.
DISCLOSURE: The following authors have nothing to disclose: Tanzira Zaman, Ajeet Vinayak, Rajiv Sonti
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