A Rare Case of Salmonella Bacteremia in a Patient with Cryptogenic Liver Cirrhosis

Abstract

Introduction: Nontyphoid salmonella infections are most often associated with contaminated food products. Most cases of salmonella bacteremia in liver cirrhosis have been associated with an advanced stage of liver cirrhosis and hepatocellular carcinoma. Case: A 54 year old female with past medical history significant for cryptogenic liver cirrhosis, gastroesophageal reflux disease and hypertension presented with complaint of fever for the last 3 days. She had associated diffuse abdominal pain and 10-15 episodes of non-bloody, non-mucus diarrhea. Her temperature was 39.1 C, BP 134/79 mmHg, pulse 96/min and oxygen saturation 100% on room air. Physical exam was pertinent for soft, moderately distended abdomen with tenderness to deep palpation in all quadrants and 2+ edema in bilateral lower extremities. Lab work revealed a white blood cell count of 7000/μL, platelets 74,000/ μL, creatinine 0.8 mg/dL, albumin 2.2 g/dL, AST 78 IU, ALT 29 IU and total bilirubin 2 mg/dL. Ultrasound abdomen was concerning for hepatic cirrhosis, large amount of ascites and thickened gall bladder wall without stones or sludge. Bedside diagnostic paracentesis was done to evaluate for spontaneous bacterial peritonitis, which revealed only 378 white blood cells (10% polynuclear and 90% mononuclear) but no organisms. However, the blood and the stool cultures drawn at admission were finalized as growing Salmonella species. The patient was then treated with IV ciprofloxacin and responded appropriately. Discussion: Bacteremia is a poor prognostic sign in patients with liver cirrhosis because of its occurrence late in the course of cirrhosis. Escherichia coli and Klebsiella pneumoniae are the most commonly isolated organisms. Only seldom cases of Salmonella bacteremia have been reported. Nontyphoid salmonellosis is associated with immunocompromised conditions, including extremes of age, alteration of the endogenous bowel flora, malignancy, autoimmune disorders and reticuloendothelial blockade. Patients with liver cirrhosis have defects in both humoral and cell-mediated immunity. The rediculoendothelial cells represent a potent filtering mechanism for portal bloodborne pathogens which is impaired in patients with liver cirrhosis. The occurrence of nontyphoid Salmonella bacteremia has been reported patients with an advanced stage of liver cirrhosis and hepatocellular carcinoma. The Model for end stage liver disease score was calculated as 17 in above case.Figure 1