Nontyphoidal Salmonella as a Cause of Mediastinal Abscess in a Patient With Extensive Cardiac Surgery.

Briana Janelle Dohogne,Anil Potharaju,Sharanyah Srinivasan,Hina Arif-Tiwari

doi:10.7759/cureus.9924

Abstract

Focal infections caused by nontyphoidal Salmonella (NTS) are relatively rare and usually self-limited. Those with cardiac surgical history are predisposed to intrathoracic seeding, including mediastinal infections and abscesses. We report a case of a 39-year-old Hispanic male with a complex past medical history of Tetralogy of Fallot with an initial presentation of Salmonella gastroenteritis and concern for sepsis. The patient did not clinically improve on ceftriaxone despite appropriate cultures and susceptibilities, and another source of infection was speculated. A chest CT scan showed development of a mediastinal abscess with compression of the right ventricular outflow tract. The patient was not deemed an appropriate surgical candidate and was managed conservatively on ceftriaxone and ciprofloxacin. He was discharged in stable condition. This case of NTS infection associated with a mediastinal abscess is a rare occurrence, and management is complicated. To improve morbidity and mortality, early imaging is essential to diagnose distal seeding of the infection in patients with enteral infections who do not show clinical improvement despite appropriate antibiotic treatment. Surgery is the standard of care, but conservative management might be required in certain high-risk cases.

Highlights

Nontyphoidal Salmonella (NTS) are gram-negative bacilli that predominantly cause intra-abdominal infections, the most common being gastroenteritis
We report a case of a 39-year-old Hispanic male with a complex past medical history of Tetralogy of Fallot with an initial presentation of Salmonella gastroenteritis and concern for sepsis
Surgery is the standard of care, but conservative management might be required in certain high-risk cases

Summary

Introduction

Nontyphoidal Salmonella (NTS) are gram-negative bacilli that predominantly cause intra-abdominal infections, the most common being gastroenteritis. The patient’s medical history was significant for Tetralogy of Fallot status post right ventricular pulmonary arterial (RV-PA) conduit in childhood complicated by multiple conduit replacements, history of prosthetic pulmonic valve endocarditis, atrial fibrillation, atrial flutter treated with multiple catheter ablations, heart failure with reduced ejection fraction, hypertension, and dual-chamber pacemaker placement He denied a history of Clostridium difficile infection, antibiotic or antacid use, sick contacts, animal contact, or anal penetration. The patient continued to be febrile after three days of appropriate antibiotics and had worsening dyspnea Due to his lack of clinical improvement, further imaging was obtained including an echocardiogram, given the patient’s extensive cardiac history, and a CT of the chest, abdomen, and pelvis due to the concern for distant seeding of the infection. A CT angiogram of the chest showed a worsening of the anterior mediastinal abscess with a superimposed hematoma that was exerting a significant mass effect on the reconstructed right ventricular outflow tract without extravasation (Figure 2).

Discussion

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Disclosures