The way to a man’s The way to a man’s heart can in fact be heart can in fact be

through his through his stomach stomach

Cardiology Team Lourdes HospitalDr Murphy, Dr Halley, Dr Keelan

Derek Crinion9th May 2014

CaseCase• 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 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

CaseCase• 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

ECGECG

Lab Lab • Mg .97 Phos .82 Ca 2.48

• INR 1.4

• Urine Na <20 Prot ++ Bld+ Leuk +

• 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

CXR

First 48 hrsFirst 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 ?SourceCT TAP ?Source

Echo Echo

EchoEcho

EchoEcho

Day 3Day 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?Source?

Cardiac CTCardiac CT

Cardiac CTCardiac CT

Cardiac CTCardiac CT

Cardiac CTCardiac CT

Cardiac CTCardiac CT• Coronaries ,• multiplanar reconstruction

HypothesisHypothesis Prior LAD infarct,

Large Apical Aneurysm ± Mural Thrombus

Salmonella Bacteremia

Seeded apical aneurysm thrombus Infiltrated myocardium; abscess

±?Pseudoaneurysm formation

Persistent Salmonella Dissemination

Clinical CourseClinical 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

EchoEcho

EchoEcho

Repeat Cardiac CT Repeat Cardiac CT

Rpt Cardiac CT Rpt Cardiac CT

Clinical CourseClinical 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.

P.M.P.M.

P.M.P.M.

P.M.P.M.

SummarySummary• 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

SummarySummary• 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

ReferencesReferences• 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

ReferencesReferences 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 RefPub Med Ref6: 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.

7: Echevarria S, Arjona R, Alonso J, Riancho JA, Revuelta JM, Macias JG. Falseaneurysm 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.

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.

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/S1607-551X(10)70006-1. PubMed PMID: 20040471.

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.

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.