A Fatal Case of Non- typhoidal Salmonella Pyogenic Pericardial Effusion in an Immunocompetent Adolescent

Abstract

BACKGROUND 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. CASE PRESENTATION 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.