Salmonella typhimurium abscess of the chest wall.

PATIENT: Male, 73 FINAL DIAGNOSIS: Salmonella typhimurium abscess of the chest wall Symptoms: - MEDICATION: Ciprofloxacin Clinical Procedure:- Specialty: Infectious Diseases.
OBJECTIVE: Unusual clinical course.
BACKGROUND: Non-typhoid Salmonella extra-intestinal infections usually develop in infants and in adult patients with pre-existing predisposing conditions. Blood stream infections and urinary tract infections are the most common clinical presentations, but other sites of infection may be involved as well. CASE REPORT: We describe a case of invasive salmonellosis caused by Salmonella typhimurium involving the chest wall in a 73-year-old man. The patient had suffered from gastroenteritis followed by left basal pneumonia with pleural effusion 7 weeks before. The CT scan of the chest wall showed a pericostal abscess with shirt-stud morphology near the left last cartilaginous arch. The abscess was surgically drained and patient was cured after a 40-day ciprofloxacin treatment.
CONCLUSIONS: A review of the literature on extra-intestinal non-typhoid salmonellosis shows that pleuropulmonary and soft-tissue infections are uncommon. We argue that non-typhoid Salmonella might be considered as a possible cause of chest wall abscess in individuals with recent history of gastroenteritis complicated by pneumonia and pleural effusion.

Background

Non-typhoid Salmonella (NTS) can cause not only self-limited acute gastrointestinal infections, but also bacteremia with or without extra-intestinal focal infections. Such complications usually develop in children, or in adults with predisposing conditions or underlying diseases that compromise host defenses. Here, we describe a case report of an unusual site of NTS infection in a patient with diabetes mellitus.

Case Report

A 73-year-old man was admitted to our hospital for left chest pain, diarrhea, and fever. His past medical history was remarkable for hypothyroidism, arterial hypertension, and insulin-dependent diabetes mellitus. Seven weeks before the hospital admission, the patient had gastroenteritis followed by left basal pneumonia with pleural effusion. At that time, he received a 2-week regimen of amoxicillin/clavulanate and seemed to be eventually cured.

At hospital admission, physical examination was unremarkable except for a pasty and floating swelling, 4 cm in diameter, on the left side of his fifth intercostal space. Blood examinations were normal except for neutrophil leucocytosis (white blood cells 16 560/mm3 – normal values 4000–10 000/mm3; neutrophils 13 910/mm3 – normal values 2000–7500/mm3) and elevation of C-reactive protein and erythrocyte sedimentation rate (ESR) (142.1 mg/L – normal value <5 mg/L – and 99 mm/h, respectively).

Chest X-ray showed a small left basal consolidation with little concomitant pleural effusion, while CT scan of the thoracic wall (Figure 1) showed an 8×5 cm abscess with sand-glass morphology near the last cartilaginous arch on the left, without signs of bone involvement. Percutaneous incision of the lesion revealed the abscess was extending into the endothoracic space through a perforation of the intercostal muscles. The culture from the drained pus was positive for Salmonella typhimurium, which was sensitive to fluoroquinolones and trimethoprim-sulfamethoxazole, but was resistant to ampicillin. Treatment with ciprofloxacin by intravenous route was given, with clinical improvement. After 20 days, culture of swab from the chest wall lesion was negative, the chest wall breach was surgically sealed, and antibiotic therapy switched to oral ciprofloxacin for a further 20 days because of the persistence of fever. At 2-month follow-up, the chest X-ray showed a nearly total resolution of the lesion and pleural effusion, and the patient was fully recovered, with no evidence of disease persistence or recurrence.

Figure 1.

(A) Chest CT scan showing a pericostal mass in the left anterior chest wall. (B) Chest CT scan revealing the shirt-stud morphology of a pericostal mass measuring 8×5 cm.

Discussion

NTS are gram-negative bacilli of the family of Enterobacteriaceae, which can be acquired from multiple animal reservoirs. Human transmission occurs by many routes, including consumption of food animal products, especially eggs, poultry, undercooked meat and dairy products, fresh produce contaminated with animal waste, contact with animals or their environment, and contaminated water [1]. Salmonellosis may present in different clinical forms, ranging from asymptomatic chronic carrier to gastroenteritis, bacteriemia, and extra-intestinal infections [1]. In recent years, several case series of NTS infection with extra-intestinal localizations have been reported in many countries (Table 1) [2-10]. Among the extra-intestinal localizations of NTS, blood stream infections are the most common, representing the 94.3% in a case series in the USA between 1996 and 2006 [2] and 82% in a Danish case series of 135 patients observed between 1991 and 1999 [3]. Other reported extra-intestinal localizations of NTS include: urinary tract infection, endovascular infection and endocarditis, meningitis, osteomyelitis, pneumonia, and soft-tissue and other visceral involvement. Pneumonia, with or without pleural empyema, and soft-tissue abscesses represent uncommon complication of NTS infection, accounting for 10% [4] and from 3.7% [3] to 7.3% [5], respectively, of extra-intestinal focal infections. To the best of our knowledge, chest wall abscesses caused by non-NTS have been reported only in 6 patients between 1990 and 2011: 4 of them had no underlying disease or predisposing condition [11-14] and 2 patients had AIDS [15,16]. Most extra-intestinal localizations of NTS infections develop in pediatric patients and in patients with underlying diseases or predisposing conditions, such as malignancies, diabetes mellitus, immunosuppressive therapies, liver cirrhosis, renal insufficiency, or HIV infection [4-9]. Indeed, our patient had diabetes mellitus.

Table 1.

Case series of extra-intestinal localizations of NTS** infections.

Authors	Country and period of observation	Number of cases of invasive Salmonellosis	Clinical presentation/extra-intestinal localizations	Most common isolated Salmonella species	Underlying diseases or predisposing conditions
Arshad M.M. et al. 2008 [10]	USA1995–2001	347	341 positive blood cultures 6 positive cultures from CSF	S. heidelberg 19.3%	Age <4 years
				S. typhimurium 18.7%
				S. enteritidis 16.7%
				Other species 45.3%
Chen P.L. et al. 2007 [4]	Taiwan199–2005	130	130 positive blood cultures of whom: extra-intestinal focal infections 39.5% presenting as: mycotic aneurysm, pneumonia/empyema, spinal osteomyelitis, spontaneous bacterial peritonitis, liver abscess, splenic abscess, septic arthritis	Serogroups	Malignancy, diabetes mellitus, immunosuppressive therapy, renal insufficiency hypertension, human immunodeficiency virus infection, connective tissue disorders,liver cirrhosis, coronary heart disease, congestive heart failure, chronic lung disease
				B 43.3%
				C/C1a 34.9%/31.8%
				D 20.2%
				E 1.6%
Jones T.F. et al. 2008 [2]	USA1996–2006	2676	Blood cultures	S. dublin 64%	Not reported
			cultures from abscess	S. cholaresius 57%
			cultures from bone or joint fluid	S. poona 17%
			cultures from CSF	S. schwarzengrund 15%
				S. heidelberg 13%
				S. enteritidis 7%
				S. typhimurium 6%
Heyd J. et al. 2003 [6]	Israel1990–2000	112	112 patients with positive blood cultures of whom 2 patients with psoas absess	S. enteritidis isolated from the 2 patients with psoas absess: from blood cultures of 1 patient and from the dreined abscess of the other patient	Idiopathic thrombocytopenic purpura treated with steroids and intravenous gammaglobulin Myasthenia gravis treated with steroids
Kedzierska J. et al. 2008 [7]	Poland2000–2006	30	22 blood stream infections and 8 non bacteriemic focal infections of which: 1 retrocecal abscess, 1 subphrenic absess, 1 abscess of the spleen, 1 pneumonia, 4 urinary infections	S. enteritidis 86.7%	Haematologic malignancy, liver chirrosis, renal failure, HIV infection, cancer, SLE*
				S. hadar 6.7%
				S. Infantis 3.3%
				S. braenderup 3.3%
Fisker N. et al. 2003 [3]	Denmark1991–1999	135	Bacteremia, heart or great artery, meningitis, osteomyelitis/bacterial arthritis, cellulites, pleural empyema urinary tract, subcutaneous abscess	S. typhimurium	Diabetes mellitus, hepatic cirrhosis, immunosuppression, acid reducing treatment, age >65 years
				S. enteritidis
				Others
Dhanoa A. et al. 2009 [5]	Malaysia2002–2006	55	Bacteriemia, lung, soft tissue, bone and joint, meningitis, mycotic aneurism, urynary tract, peritonitis	S. enteritidis 72.7%	Malignancy, AIDS, SLE*, hypogammaglobulinemia atherosclerotic conditions, hypertension, diabete mellitus, ischeamic heart disease, stroke, liver cirrhosis, renal disease
				S. corvallis 7.2%
				S. blegdam 5.5%
				S. paratyphi b 5.5%
				Others 9.1%
Asseva G. et al. 2012 [8]	Bulgaria2005–2010	33	Sepsis, septic shock, meningitis, subphrenical abscess, empyema, acute cholecystitis, appendicitis, perianal abscess, pyelonephritis, pneumonia	S. enteritidis 63%	Chronic liver deseases, diabetes mellitus, organ abscess, hypertension, AIDS, liver cirrhosis, gastric hypoacidity
				S. typhimurium 18%
				S. choleraesuis 9%
				Others 12%
Zaidenstein R. et al. 2010 [9]	Israel1996–2006	1415	Blood stream infection, urinary tract infections, abscesses, respiratory infections, meningitis, intra-abdominal sources (bile and peritoneal fluid)	S. enteritidis 31.6%	The incidence of extra-intestinal NTS infection is higher in childhood and in patients >60 years
				S. virchow 20%
				S. typhimurium 14%
				Others 35%

SLE – systemic lupus erythematosus;

NTS – non typhoid Salmonella.

Regarding the different Salmonella species isolated in systemic and extra-intestinal focal infections, S. enteritidis has been reported as the most common in the majority of the studies [5,7-9], followed by S. typhimurium and S. heidelberg, but the frequency of the different isolated Salmonella species varies geographically (Table 2).

Table 2.

Literature case reports of chest wall abscesses caused by Non Typhoid Salmonella (NTS) spp.; all the cases were treated with surgical drainage.

Reference	Age/sex	Underlying condition	Isolated organism	Treatment	Outcome
Raffi 1990 [15]	36/M	AIDS	Salmonella typhimurium	Ofloxacine	Cured
Suganuma 1993 [16]	18/F	AIDS	Salmonella newport		Cured
Porcalla A.R. 2001 [11]	11/F	Healthy condition	Salmonella enterica serogroupp C	CefotaximeCeftriaxoneAmoxicilline	Cured
Gupta S.K. 2003 [12]	48/M	Healthy condition	Salmonella enteritidis	CefuroximeCiprofloxacine	Cured
Vazquez E.G. 2005 [13]	55/M	Healthy condition	Salmonella enteritidis	Ciprofloxacine	Cured
Fajardo Olivares M. 2007 [14]	8/M	Healthy condition	Salmonella enteritidis	Cefotaxime	Cured

Conclusions

Although NTS pleuropulmonary and soft-tissue involvements are quite uncommon, in our case we assume that S. typhimurium caused the gastroenteritis and, by blood stream spread, pneumonia and pleural effusion. Afterwards, the organism entered into the chest wall by contiguity. Alternatively, a non-Salmonella-induced pneumonia with resulting local inflammation might have facilitated a deposition of Salmonella in the nearby chest wall, finally leading to the abscess. Our case suggests that NTS should be considered as a possible cause of chest wall abscess in individuals with recent history of gastroenteritis complicated by pneumonia and pleural effusion.