The way to a man’s heart
can in fact be through his
stomach
Cardiology Team Lourdes Hospital
Dr Murphy, Dr Halley, Dr Keelan
Derek Crinion
9th May 2014
Case
• PC: 61 year old gentleman
Diarrhoea 7+/day for 6 days
Abdo cramps
Pyrexic, chills, vomited X1
Malaise, headache
• PMhx: Heavy smoker 30 day/30 years
• Meds Nil, NKDA
Case
• Soc Hx. Lives alone, separated,
daughters nearby
poor social circumstance
?C2H5OH
• Fam Hx. Strong IHD
• SR: Low BMI, ? Weight loss
Cough chronic prod White
?Chest discomfort several weeks prior
Case
• O/E: T 38.1°C, BP 95/67 HR118 (Reg)
RR20 Sat 96%(RA) ,  BMI
• S1S2 no A/M , No fluid overload
• +Rhoncus, mild scattered early insp creps
• Abdo Soft NT ,Borborygmi, small inguinal hernia
• Neuro intact, no meningism
ECG
Lab
• WBC 14.5
91% Neut
PLT 47
Hb 15.5
• CRP 293
• TROPONIN I
(+ >0.1ng/ml)
1.3  1.37
• Urea 14.1
Creat 92
Na 124
K 3.9
• Bili 47
Alp 228
GGT 575
ALT 52
• Mg .97
Phos .82
Ca 2.48
• INR 1.4
• Urine
Na <20
Prot ++
Bld+
Leuk +
CXR
First 48 hrs
• Initially IV Co-amoxiclav + Fluid Support
• Ongoing Temp Spikes 39°C peak
• Diarrhoea, abdo cramps persisted
• Provisional Blood Cultures : G − Bacilli
• Changed to IV Tazocin+ Gentamycin
CT TAP ?Source
Echo
Echo
Echo
Day 3
• Blood Culture Result
Salmonella Typhimurium
(Non-typhoidal)
• Micro Input:
Changed to IV Ceftriaxone
•
Notifiable Disease1 ? Source
- no close contacts unwell
- no restaurants known
- no foreign travel
Source?
Cardiac CT
Cardiac CT
Cardiac CT
Cardiac CT
Cardiac CT
• Coronaries ,
• multiplanar reconstruction
Hypothesis
Prior LAD infarct,
Large Apical Aneurysm ± Mural Thrombus
Salmonella Bacteremia
Seeded apical aneurysm thrombus
Infiltrated myocardium; abscess
±?Pseudoaneurysm formation
Persistent Salmonella Dissemination
Clinical Course
• Ongoing Temp Spikes + Rpt cultures
• Day 5 Micro: Δto IV Ciprofloxacin + Meropenem
• Diarrhoea settled, stool day 8 negative
• WBC 12.2 (N) CRP 146 Plt 121
INR 1.3 Alb 15 Bili 49 ALP 421 ALT 56 GGT 555
•
Liver US, coarse echotex. Mild splenomeg. No stones
• O/E: CCF ,Parox A fib , : Trop 1.4 BNP 1610
• CTC Discussion
Echo
Echo
Repeat Cardiac CT
Rpt Cardiac CT
Clinical Course
• Recurrent temp spikes, never stabilised
• Day 28, further deterioration
Hypothermic , oliguric ,BP
Periph. shut down, Delirium
• Lactate 18 , WBC 30 (N) Plt 56 INR 1.7
Alb 18, CRP 154 Urea 11.8 Creat 121 Na 128 K 6
Bili 88 Alp 549 ALT 1161 GGT 330
•
RIP
P.M.
P.M.
P.M.
P.M.
P.M.
P.M.
Summary
• V. rare presentation, of an unusual organism
• Non-typhoidal Salmonella in Ireland 3
2012: 314 cases , 47% travel associated
< 5% develop NT invasive salmonellosis4,5
RF’S : Immunocomp,
Age extremes4
PPI / Gut Flora6
Summary
• Important Clinical Lessons
- Persistent Pyrexia; ?Heart
- Salmonella: : ? Risk of endovascular inf.
- Dog Food ! Hand Hygiene
- Challenging Management
Med Vs Surg? Timing? High Mortality6,7
• Thank You
References
• 1. Health Protection Surveillance Center.
lnfectious diseases regulation 2011
www.hpsc.ie/NotifiableDiseases
2. Center for disese control and prevention.
salmonella and dry pet food.
www.cdc.gov/features/salmonelladrypetfood
3. National Salmonella Reference Laboratory of
Ireland. Annual Report for 2012.
www.hspc.ie
References
4. Vugia DJ, Samuel M, Farley MM, et al. Invavise Salmonella
Infections in the United States. FoodNet. 1996-1999:incidence,
serotype distribution an outcome. Clin Infect Dis 2004;38
Suppl3:s142
5. Lee WS, Puthucheary SD, Boey CCM. Non-typhoid
Salmonella Gastroenteritis. Journal of Paeiatrics and Child
Health. 1988 33;387-390
6. Zhen Y, Rai MK, Adal A.K. Salmonella infeciton of
a ventricular aneurysm with mural thrombus. Ann
Thorac. Surg. 2000;69:939-40
7. Medical Treatment of a salmonella-infected left ventricular
pseudoaneurysm: a case report. Yu TH, Hung WC, Chiu CA,
Wang CP. Kaohsiung J Md Sci. Jan 2010, Vol 26. No 1.
Pub Med Ref
1: Yu TH, Hung WC, Chiu CA, Wang CP. Medical
treatment of a Salmonella-infectedleft ventricular
pseudoaneurysm: a case report. Kaohsiung Med
Sci. 2010Jan;26(1):35-9. doi: 10.1016/S1607551X(10)70006-1. PubMed PMID: 20040471.
6: de la Fuente C, Llorens V, Banzo I, Carril JM.
Gallium-67 citrate scintigraphy in Salmonella
infected thrombus of a left ventricular aneurysm. J
Nucl Med.1989 Jul;30(7):1277-8. PubMed PMID:
2738709.
2: Mathieu P, Marchand R, Tardif J, Perrault LP.
Ventriculotomy and resection forleft ventricular
thrombus infection with Salmonella. Eur J
Cardiothorac Surg.2000 Sep;18(3):360-2. PubMed
PMID: 10973549.
7: Echevarria S, Arjona R, Alonso J, Riancho JA,
Revuelta JM, Macias JG. False
aneurysm formation after Salmonella virchow
infection of a pre-existent ventricular aneurysm-survival after surgical resection. Postgrad Med J.
1989 Mar;65(761):168-70. PubMed PMID: 2813237;
PubMed Central PMCID: PMC2429238.
3: Zheng Y, Rai MK, Adal KA. Salmonella infection of
a ventricular aneurysm with mural thrombus. Ann
Thorac Surg. 2000 Mar;69(3):939-40. PubMed PMID:
10750793.
4: Amyot R, Girouard Y, Baillot R, Sauvé C.
Salmonella endocarditis of aventricular aneurysm: a
case report and review of the literature. Can J
Cardiol. 1997 Mar;13(3):299-301. Review. PubMed
PMID: 9117919.
5: Utley JR, Story JR, Dandilides PC. Resection of
infected ventricular aneurysm (Salmonella)
following septic saddle embolus. J Card Surg. 1993
Mar 8(2):143-7.PubMed PMID: 8461496.
8: Schofield PM, Rahman AN, Ellis ME, Dunbar EM,
Bray CL, Brooks N. Infection of cardiac mural
thrombus associated with left ventricular aneurysm.
Eur Heart J 1986 Dec;7(12):1077-82. PubMed PMID:
3549314.
9: Catherwood E, Mintz GS, Kotler MN, Kimbiris D,
Lemmon W, Parry WR. Pseudoaneurysm of the left
ventricle complicated by Salmonella typhimurium
infection. Recognition by two-dimensional
echocardiography. Am J Med1980May;68(5):782-6.
PubMed PMID: 6990760.
10: Kortleve JW, Düren DR, Becker AE. Cardiac
aneurysm complicated by Salmonella abscess. A
clinicopathologic correlation in two patients. Am J
Med. 1980Mar;68(3):395-400. PubMed PMID:
6892668.