IT LOOKED BLOODY BUT WASN'T: A CASE OF SALMONELLA EMPYEMA

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Non-typhi Salmonella was isolated from sample of pleural empyema of an immunocompromised patient. The patient was treated with prolonged antibiotic course, thoracotomy with decortication, and chest tube placement; endured complications including chest tube induced pleural cutaneous fistula, subcutaneous emphysema, pneumomediastinum, and persistent hydropneumothorax with trapped lung. Pulmonary salmonellosis is a rare infection that generally occurs with history of gastrointestinal symptoms or enterocolitis and should be considered in patients with immunodeficiency, sickle cell anemia, and lung cancer. CASE PRESENTATION: 57-year-old man with PMH of RA and recurrent right sided pleural effusion (PE) presented with right sided pleuritic chest pain. The patient was septic with a leukocytosis of 15.8 10E3/uL. CT chest showed moderate sized, loculated PE with adjacent passive atelectasis [Figure 2]. A thoracentesis was performed with 650 cc bloody fluid drained. Pleural fluid was exudative with glucose less than 10, pH 6.83, and LDH 1175. A chest tube was placed and pleurolysis initiated. He subsequently underwent right thoracotomy decortication with findings of extensive adhesions, trapped middle and lower lobe lung, and thick chronic rind with no dissection plane. Fluid culture speciated to Salmonella group D and ABX were narrowed to ceftriaxone. He was successfully treated with a 65-day course. DISCUSSION: Salmonella is a gram-negative non-spore forming anaerobic motile bacilli of the Enterobacteriaceae family. Clinical presentation of a Salmonella infection depends on the serotype and ranges from sepsis to gastroenteritis. Non-typhi salmonella organisms often produce a localized reaction, most commonly intestinal infections.1 There have been rare cases of pleuropulmonary infections, which are abrupt in onset without gastrointestinal symptoms in two-thirds of cases and incidence is highest in immunosuppressed patients.2 Pathogenesis is unclear, however it is suggested that Salmonella may rest dormant in the reticuloendothelial system. Blood spread may be a consequence of reactivation however due to low bacterial load, blood cultures are often negative.3 Due to Salmonella organisms’ propensity for prolonged infection a 4 to 12-week course of ABX should be anticipated and include a third-generation cephalosporin or fluoroquinolone. CONCLUSIONS: In patient with relapsing infections, drainage of empyema is likely necessary, with the possibility of decortication. Patients without known preexisting conditions should also undergo further testing for associated immunodeficiency including HIV and malignancy as well as investigation for focal gastrointestinal tract infections and fistulas.Lastly, in the setting of an immunocompromised patient with exudative pleural effusions or empyema, non-typhi Salmonella should be considered as a causative agent and investigated as early as possible. Reference #1: Abuhasna S, Al Jundi A, et al. Non-typhoidal Salmonella group D bacteremia and urosepsis in a patient diagnosed with HIV Infection. Journal of Global Infectious Diseases. 2012;4(4):218. Reference #2: Pathmanathan, S., Welagedara, S., Dorrington, P. et al. Salmonella empyema: a case report. Pneumonia 6, 120–124 (2015). Reference #3: Saeed N. Salmonella pneumonia complicated with encysted empyema in an immunocompromised youth: Case report and literature Review. The Journal of Infection in Developing Countries. 2016;10(04):437-444. DISCLOSURES: No relevant relationships by Sarah Luber, source=Web Response no disclosure on file for David Sharpe; No relevant relationships by Abigayle Sullivan, source=Web Response