Case Report of International Journal of Case Reports
A Fatal Case of Non- typhoidal Salmonella Pyogenic Pericardial Effusion in an Immunocompetent Adolescent
Teh CY1, Ahmad Kashfi AR2
1Department of Internal Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu.
2Infectious Disease Unit, Department of Internal Medicine, Hospital Sultanah Nur Zahirah, Kuala Terengganu.
Salmonella infection is common in tropical countries including Malaysia. It is invasive in immunocompromised and those of extreme ages. It typically presents with gastrointestinal symptoms such as diarrhea, abdominal pain or vomiting. Extra-intestinal manifestations are seen in 30% of salmonellosis cases. These atypical manifestation leads to difficulty and delay diagnosis thus poorer outcome. Pericardium involvement is estimated to be less than 2% of all cases and has mortality rate as high as 50%1. As high as 70% of pericarditis cases were identified to be immunosuppressed2; these include chronic immunosuppressant usage, autoimmune disease, end stage renal failure, malignancy and etc. Herein, we report a fatal case of pyogenic pericardial effusion by Salmonella enteritidis in an immunocompetent adolescent.
A 16-years-old Malay boy was referred from GP to our centre in April 2015 with CXR finding suggestive of pericardial effusion. He had prolonged cough for 8 months, associated with breathlessness and failure symptoms. He had on and off fever but denied gastrointestinal symptom. He had multiple visits to private practitioners and was investigated for Tuberculosis, which yielded negative result. His condition continued to deteriorate.
Of note, he had no significant medical and surgical illness. There was no history of contact with tuberculosis patients, recent travelling history or high risk behaviour.
Upon admission, he was tachypnea and in shock. His blood pressure was 90/56mmHg with a pulse rate of 102bpm. His JVP was raised and heart sound was muffled. Lung examination revealed reduced breath sound bilaterally with generalized rhonchi. Initial blood investigations revealed leukocytosis with predominant neutrophils (16 x 109/L). ABG showed type 1 respiratory failure. ESR was raised, 100mm/hour. Chest X-ray showed a congested lung field consistent with pulmonary oedema. Bedside echocardiogram revealed a large pericardial effusion with diastolic right atrium and ventricle collapsed, indicating temponade effect. Emergency pericardialcentesis drained 1.3L of frank pus. IV Augmentin (Amoxicillin and calvulanate potassium) was empirically started.
Pericardial fluid culture grew Salmonella Enteritidis which was sensitive to ceftriaxone and ciprofloxacin, thus antibiotic was switch to Ceftriaxone. Despite given targeted therapy, his general condition did not improve; pericardial pus re- accumulates, causing temponade thus requiring second drainage. Antibiotic was switch to ciprofloxacin and later meropenem in worried of poor pericardium penetration. Average daily drainage was 25 to 35ml. Repeated Echocardiogram showed loculated collection of pus in pericardium. HIV screening and autoimmune screenings were negative. Full blood picture was normal. No screening of malignancy done.
His condition continued to deteriorate, requiring ventilator and inotropic support. He succumbed to death on third week of admission.
Keywords: Fatal Case, Non- typhoidal Salmonella Pyogenic Pericardial Effusion, an Immunocompetent Adolescent
How to cite this article:
Teh CY, Ahmad Kashfi AR. A Fatal Case of Non- typhoidal Salmonella Pyogenic Pericardial Effusion in an Immunocompetent Adolescent. International Journal of Case Reports, 2019 4:62. DOI: 10.28933/ijcr-2019-02-1208
1. Manisa S, Sistla S etc al. Pericardial effusion- an unusual manifestation of salmonellosis: a case report. Cases J.2008;1:375.
2. Daniel O, Eric MS etc al. Nontyphoidal Cardiac Salmonelolosis: Two case reports and review of the literature. 2014;41(4):401-406.
3. Hsu RB, Lin FY. Risk factors for bacteraemia and endovascular infection due to non-typhoid salmonella: a reappraisal. QJM. 2005;98(11):821–827.
4. 10. Cohen PS, O’Brien TF, Schoenbaum SC, Medeiros AA. The risk of endothelial infection in adults with salmonella bacteremia. Ann Intern Med. 1978;89(6):931–932.
5. Doig J.C., Hilton C.J., Reid D.S. Salmonella: a rare cause of subacute effusive-constrictive pericarditis. Br. Heart J. 1991;65(5):296–297.
6. Gaurav C, Ruby J, Kumar S etc al. Pericardial salmonella with cardiac tamponade and ventricular wall rupture: a case report. 2016;7:83-86
7. Fernandez Guerrero ML, Aguado JM, Arribas A, Lumbreras C, de Gorgolas M. The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome. Medicine (Baltimore) 2004;83(2):123–38.
8. Hsu RB, Tsay YG, Chen RJ, Chu SH. Risk factors for primary bacteremia and endovascular infection in patients without acquired immunodeficiency syndrome who have nontyphoid salmonellosis. Clin Infect Dis. 2003;36(7):829–34.
9. Muller AJ, Hoffmann C, Galle M, Van Den Broeke A, Heikenwalder M, Falter L et al. The S. Typhimurium effector SopE induces caspase-1 activation in stromal cells to initiate gut inflammation. Cell Host Microbe. 2009;6(2):125–36.
10. Brown M, Eykyn SJ. Non-typhoidal Salmonella bacteraemia without gastroenteritis: a marker of underlying immunosuppression. Review of cases at St. Thomas’ Hospital 1970–1999. J Infect. 2000;41(3):256–9.
11. CC Kuo, WL Yu, CH Lee et al. Purulent constrictive pericarditis caused by Salmonella enteritis in a patient with adult-onset still’s disease. Medicine (Baltimore). 2017; 96(50): e8949.
12. Maisch B, Seferovic PM, Risitc AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary. The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004;25:587–610.