RARE CASE OF SALMONELLA EMPYEMA IN MULTIPLE, LARGE LOCULATED PLEURAL FLUID COLLECTIONS

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Non-typhoidal Salmonella as a cause of empyema is very unusual with approximately 30 cases reported in the literature (1). Salmonella usually causes gastroenteritis while less commonly causing meningitis or osteomyelitis. Here, we present a case of Salmonella empyema due to Salmonella montevideo in an asplenic patient without gastrointestinal symptoms. CASE PRESENTATION: 57 y.o Caucasian male presented with shortness of breath for three weeks that acutely worsened over three days along with pleuritic chest pain and a cough productive of yellow sputum. He denied hemoptysis but reported chills. History also significant for chronic alcoholism and splenectomy at age six. He was noted to be tachycardic and tachypneic on admission along with a WBC of 13.1. He was afebrile. Physical exam was notable for diminished breath sounds over left lung field and presence of digital clubbing along with cachexia. CT chest showed multiple, large, partially loculated fluid collections in the pleural space of the left hemithorax causing almost complete atelectasis of left lung. A left sided chest tube was placed with 550cc output of foul-smelling, frankly purulent fluid; found to be exudative with pH 7.5 and LDH 3,745. Empiric antibiotic coverage was started. Patient did not have any gastrointestinal symptoms. His pleural fluid cultures grew Salmonella montevideo, sensitive to Ampicillin. He was placed on Augmentin for 21 days and discharged with appropriate vaccinations. DISCUSSION: In this case, we showcase the rare presence of Salmonella in a patient with multiple loculated pleural fluid collections. Given his history of chronic alcoholism, it was suspected that he had episodes of micro-aspiration events associated with retching. Our case is unique in comparison to previously documented cases of Salmonella empyema in that our patient presented with left-sided pathology (2). Typically, aspirated contents are most commonly found in the right lung. In the absence of neurological compromise, as well as absence of GI fistulas, the finding of left-sided complicated fluid collections is impressive. We also show unorthodox pleural fluid studies with alkalotic pH levels inconsistent with conventional definitions of empyema (pH less than 7.2) in the setting of frank pus. Of note, all documented cases of Salmonella empyema have also had significantly elevated levels of pleural fluid LDH values in the thousands (3). We pose that there is a possible association between Salmonella metabolism in pleural fluid that influences these unique pleural fluid findings and further research can help elucidate this association. CONCLUSIONS: While the presence of Salmonella in the respiratory tract is unconventional, we recommend a high index of suspicion for this pathogen as as a causative agent in empyemas, particularly in immunocompromised patients. Reference #1: Rodero MR, Martins Immunization for patients with asplenia. Importance and Recommendations. Journal of Blood and Lymph. 2016; 6-149. Reference #2: Shivanshan, Pathmanathan, S. Welagedara, P. Dorrington, S. Sharma. Salmonella empyema: a case report. Pneumonia. 20156:BF03371465. https://doi.org/10.1007/BF03371465 Received: 23 June 2015, Accepted: 4 November 2015, Published: 1 December 2015. BioMedCentral. Reference #3: Kam, Jennifer. Case Report: Pleural Empyema due to Group D Salmonella. Department of Internal Medicine, St. Michael’s Medical Center, School of Graduate Medical Education, Seton Hall University, South Orange, NJ, USA. Copyright © 2012. Case Reports in Gastrointestinal Medicine DISCLOSURES: No relevant relationships by Jared Coe, source=Web Response No relevant relationships by Shashitha Gavini, source=Web Response No relevant relationships by Farheen Shaikh, source=Web Response no disclosure on file for Christopher Wexler