Salmonella pericarditis with tamponade in systemic lupus erythematosus

Purulent constrictive pericarditis caused by Salmonella enteritidis in a patient with adult-onset Still's disease: A case report

RATIONALE

Purulent pericarditis is a rare and usually fatal disease. Immunodeficiency state and preexisting pericardial effusion can predispose patients to infections. However, we are not aware of similar cases in patients with adult-onset Still's disease (AOSD). In addition, it is seldom caused by Salmonella bacteria.

PATIENT CONCERNS

We report a 30-year-old woman with dyspnea on exertion and epigastric fullness. She was newly diagnosed with AOSD 4 months previously and medicated with prednisolone.

DIAGNOSES

Transthoracic echocardiography (TTE) and computed tomography revealed a thickened pericardium with loculations in the pericardial space, consistent with purulent constrictive pericarditis. Subsequent cultures of blood and pericardial fluid yielded S enteritidis.

INTERVENTIONS

She underwent subtotal pericardiectomy through a limited median sternotomy, and antibiotic therapy (ceftriaxone) for 1 month.

OUTCOMES

The New York Heart Association functional classification downgraded from class III to class I. There was no recurrence during the 1-year follow-up.

LESSONS

This case presents an opportunity to highlight the importance of considering purulent pericarditis in patients previously diagnosed with AOSD. High clinical suspicion, early diagnosis, and prompt management can result in a better outcome in purulent pericarditis.

Paratyphoid fever: splicing the global analyses

The incidence of enteric fever caused by Salmonella enterica serovar Paratyphi A (S. Paratyphi A) is increasing in many parts of the world. Although there is no major outbreak of paratyphoid fever in recent years, S. Paratyphi A infection still remains a public health problem in many tropical countries. Therefore, surveillance studies play an important role in monitoring infections and the emergence of multidrug resistance, especially in endemic countries such as India, Nepal, Pakistan and China. In China, enteric fever was caused predominantly by S. Paratyphi A rather than by Salmonella enterica serovar Typhi (S. Typhi). Sometimes, S. Paratyphi A infection can evolve into a carrier state which increases the risk of transmission for travellers. Hence, paratyphoid fever is usually classified as a "travel-associated" disease. To date, diagnosis of paratyphoid fever based on the clinical presentation is not satisfactory as it resembles other febrile illnesses, and could not be distinguished from S. Typhi infection. With the availability of Whole Genome Sequencing technology, the genomes of S. Paratyphi A could be studied in-depth and more specific targets for detection will be revealed. Hence, detection of S. Paratyphi A with Polymerase Chain Reaction (PCR) method appears to be a more reliable approach compared to the Widal test. On the other hand, due to increasing incidence of S. Paratyphi A infections worldwide, the need to produce a paratyphoid vaccine is essential and urgent. Hence various vaccine projects that involve clinical trials have been carried out. Overall, this review provides the insights of S. Paratyphi A, including the bacteriology, epidemiology, management and antibiotic susceptibility, diagnoses and vaccine development.

Definite and probable septic pericarditis in hemodialysis

INTRODUCTION

Although the incidence of septic pericarditis in hemodialysis populations is less frequent in the modern antibiotic era, it is still a cause of death partly because diagnosis is sometimes difficult and uncertain.

METHODS

From 2002 to 2006, 12 out of a total of 12,213 maintenance hemodialysis patients were referred for management of septic pericarditis. Patients were diagnosed as either definite or probable septic pericarditis. A definite diagnosis of septic pericarditis is based on the discovery of pathogenic bacteria in pericardial effusion, whereas a probable diagnosis is based on the proof of bacterial infection elsewhere in a patient with otherwise unexplained pericarditis, or appropriate response to a trial of systemic antibiotics.

RESULTS

Four (33.3%) patients were diagnosed as definite pericarditis, whereas eight (66.7%) patients as probable pericarditis. It was found that although oxacillin-resistant Staphylococcus aureus (ORSA) (4/12 or 33.3%) and tuberculous (4/12 or 33.3%) pericarditis were common, salmonella pericarditis (2/12 or 16.7%) was also not uncommon. Pericardiocentesis, or pericardial window with pericardiectomy, was performed in three (25%) and two (16%) of patients with cardiac tamponade, respectively. Two patients died because of severe ORSA (1/12 or 8%) and salmonella (1/12 or 8%) sepsis. Finally, there were four (33%) patients who developed constrictive pericarditis after follow-up.

CONCLUSIONS

These data are important because the spectrum of septic pericarditis was clearly different between Taiwan and other developed countries. Furthermore, it is the only report in which patients were diagnosed as either definite or probable septic pericarditis, therefore improving the sensitivity of diagnosis as in the case of tuberculous pericarditis.

Pericardial effusion - an unusual manifestation of salmonellosis: a case report

Background

Nontyphoidal salmonellae are important food-borne pathogens that are usually associated with self-limiting gastroenteritis. Occurrence of extra-intestinal non-typhoidal salmonellosis in humans is increasing in many developing countries. The risk of extra-intestinal nontyphoidal salmonellosis is higher in patients with impaired cell mediated immunity, lympho-proliferative disorders and IL-12 deficiencies. Pericardial involvement is one of the rare manifestations accounting for <2% cases but the mortality is very high.

Case presentation

A 23 year old male was admitted in the medicine ward with complaints of fever, chest pain with non-productive cough, not associated with hemoptysis for past 3 weeks. He was a known case of Hodgkin's lymphoma and was treated with complete course of chemotherapy. Cardiovascular examination, chest X-ray and ECG findings suggested this to be a case of pericardial effusion. The causative agent of this purulent pericardial effusion was identified as Group B Salmonella following isolation from the pericardial fluid.

A purulent pericarditis caused by Salmonella typhimurium

A case of Salmonella typhimurium pericarditis is reported. The diagnosis was based on blood and pericardial effusion cultures.

Haemophilus influenzae pericarditis with tamponade as the initial presentation of systemic lupus erythematosus

Although cardiac tamponade is an important and emergent complication of systemic lupus erythematosus (SLE), purulent pericarditis is rare despite the high frequency of pericardial effusion in SLE. We describe the first SLE case of Haemophilus influenzae type-f pericarditis with cardiac tamponade with SLE as the initial presentation. The pathophysiology and therapy are discussed.

Infections in the immunocompromised rheumatologic patient

Immunocompromised patients with rheumatic diseases have an increased risk of infections. A major risk factor for infection seems to be the immunosuppressive therapy used. Newer therapies for RA may lead to increased rates of infection by opportunistic pathogens such as Mycobacteria tuberculosis. Because disease manifestation may mimic signs and symptoms of infection, prompt diagnosis may be difficult. Familiarity with the likely infections and their causes should aid in obtaining the appropriate culture specimens.

Systemic lupus erythematosus in the intensive care unit

SLE causes significant morbidity and mortality by multisystem organ involvement. Infections are the leading cause of morbidity and mortality in patients with SLE. Meticulous exclusion of infection is mandatory in patients with SLE, because infections may masquerade as exacerbation of underlying disease; and the immunosuppression used to treat severe forms of exacerbation of lupus can have catastrophic consequences in patients with infections. Corticosteroids are the first-line therapy for most noninfectious complications of SLE, with various adjuvant immunosuppressive agents such as cyclophosphamide being increasingly used in combination with plasmapheresis. Some recent series have shown an improved survival rate, but this improvement needs to be confirmed by further studies. Controlled trials comparing various therapeutic options are lacking, and optimal therapy has not been defined.

[Paraneoplastic rheumatism--musculoskeletal diseases as a first sign of hidden neoplasms]

Malignancy-associated musculoskeletal syndromes can present in a variety of ways which are not distinguishable from idiopathic rheumatic diseases. Furthermore, there are some rare, but typical syndromes with a high association with neoplasms. To perform a quick and exact diagnosis while avoiding useless invasive and expensive diagnostic procedures is a major challenge for the clinician. This article focuses on the clinical features of paraneoplastic musculoskeletal syndromes and theories about the underlying pathogenesis. We try to highlight those clinical and laboratory aspects which could be a clue to hidden malignancies. Paraneoplastic rheumatic syndromes are rare conditions, but timely recognition can save lives.

Non-thyphoidal salmonellosis in patients with systemic lupus erythematosus. A study of fifty patients and a review of the literature

The objective of this study was to characterize the clinical profile of lupus patients with non-typhoidal salmonellosis. A retrospective review of the clinical charts of lupus patients diagnosed with bacteriologically proven non-typhoidal salmonellosis over the last 20 y was undertaken, paying special attention to risk factors, clinical presentation and treatment outcome. Most episodes were bacteraemic without a localizing focus; and some patients were afebrile. They usually occurred in patients prone to opportunistic infections, and at times of increased immunosuppression given for lupus flares (especially nephritis). However, salmonellosis also occurred in some patients presenting with lupus. The C-reactive protein level was found to be significantly higher during the infective episodes compared to episodes of non-infective febrile lupus flare. All isolates were sensitive to the usual first-line antibiotics and eminently treatable with 3 weeks of appropriate antibiotics without recurrence/persistence or significant morbidity/mortality, the exceptions being spinal osteomyelitis and septic arthritis involving deformed joints requiring surgical debridement and prolonged antibiotic therapy for eradication. Mortality occurred in the setting of septic shock from mixed-microbial sepsis and major organ failure from active lupus. There is a high association of non-epidemic, non-typhoidal salmonellosis with SLE, especially in patients with active disease on intensified immunosuppression. The C-reactive protein value may be helpful in distinguishing between fever from a pure lupus flare and one complicated by infection.

Infections in systemic lupus erythematosus and rheumatoid arthritis

Patients with systemic lupus erythematosus have a higher infection rate than the general population. It is estimated that at least 50% of them will suffer a severe infectious episode during the course of the disease. Improvements in the control of the disease are discussed in this article.

Lupus patients in an emergency unit. Causes of consultation, hospitalization and outcome. A cohort study

The objectives were to determine causes of consultation, hospitalization and outcome in a cohort of lupus patients in an emergency unit. Patients with systemic lupus erythematosus (SLE) who visited the emergency department for consultation from 1 September 1996 to 17 May 1997 were included in the study. They were evaluated during the visit by looking at 100 variables such as demographic, socioeconomic, clinical, therapeutical, behavioral, (compliance), emotional (Beck depression inventory), disease activity, (Mex-SLEDAI), disease severity (Lupus SDI), chronic damage (SLICC-ACR), and physician's and patient's global assessments of severity. All causes of consultation, hospitalization and outcome were registered. Descriptive statistics, univariate analysis and multiple logistic regression were used for analysis. Significance was set at the 0.05 level. 180 patients were included. 164 were female, mean age 31.7/11.39 y, mean Mex SLEDAI score 3.8, mean SLICC-ACR 1.3. Fever, poliarthralgia and abdominal pain were the main causes of consultation with 26, 25 and 18 cases each. 49 patients were hospitalized and these were statistically different than non-hospitalized patients in level of formal education (10.2 vs 11.8, P=0.03); compliance (7.6 vs 9, P=0.0001); malar rash (57% vs 82%, OR, 95% CI=0.28, 0.13-0.62, P=0.0008), chloroquine daily dose intake (45 vs 77 mg, P=0.04); disease severity in physician's global assessments (5.6 vs 2.1, P=0.0001) and Beck depression inventory (21 vs 16, P=0.01). Multiple logistic regression identified physician's global assessment, fewer ACR criteria and higher SLICC-ACR scores as the main variables associated with hospitalization. Five patients died; two with community acquired pneumonia, one with pancreatitis, multiple thromboses, and sepsis, one with pulmonary hemorrhage; and one with pulmonary thromboembolism. In conclusion, poor compliance, low level of formal education, severity, depression, lower ACR criteria and higher SLICC-ACR scores were important variables identified with hospitalization. Chloroquine use seemed to have a protective effect. Causes of death were related to infections and antiphospholipid syndrome.

Purulent pericarditis with tamponade caused by Salmonella enteritidis

The incidence of purulent pericarditis has declined. However, mortality remains high. We describe a case of purulent pericarditis with tamponade caused by Salmonella enteritidis, and emphasize the importance of early recognition, prompt institution of appropriate antibiotic therapy, and early surgical drainage for survival.

Acinetobacter pericarditis with tamponade in a patient with systemic lupus erythematosus

We describe a case of active systemic lupus erythematosus (SLE) complicated with a large amount of pericardial effusion with diastolic collapse of right ventricle suggestive of tamponade. Isolates from surgical drainage of pericardial fluid showed Acinetobacter baumannii exhibiting multiple antibiotics resistance. Despite the high frequency of both pericardial involvement and of infection complications in SLE, septic pericarditis and tamponade is considered rare. Most of the reported cases of septic pericarditis in SLE were due to Staphylococcal aureus, and Acinetobacter baumannii has never been reported before.

Recurrent salmonella sepsis with different species in a systemic lupus erythematosus patient

Infections are a common cause of morbidity and mortality in systemic lupus erythematosus (SLE) patients. The primary disease process and complications of drug management may contribute to this increased susceptibility. A high incidence of salmonella infections have been reported in SLE patients. We report an unusual case of a SLE patient who developed recurrent salmonella sepsis. The first episode with salmonella typhimurium was followed a few months later by an episode of salmonella enteritides sepsis.

Salmonella infection in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) are susceptible to infections, notably salmonellosis. We report 37 cases of salmonella infection in 24 patients with SLE. These cases were detected in a group of 770 patients with SLE. All the patients were women, with a mean age of 25.6 years. At the onset of salmonella infection, 81% were taking prednisolone and 27% were taking cytotoxic drugs. Renal involvement was present in 75% of patients, which was approximately the same as in other SLE patients. Bacteremia, arthritis, osteomyelitis and rare manifestations of salmonellosis, including pulmonary and urinary tract involvement, were encountered. Diagnosis was based on isolation of the microorganism, mostly from blood cultures. Salmonella species other than typhi and paratyphi were often responsible. Widal agglutination test was positive in less than half the cases, and leukopenia was not seen frequently. Recurrence of infection in 29% of the patients and the high mortality rate (28.5%), despite the conventional period of appropriate antimicrobial treatment, show a poor prognosis of salmonellosis in SLE patients. This special picture of salmonellosis argues for a much longer period of treatment in these patients.

The spectrum of pericardial tamponade in systemic lupus erythematosus. Report of ten patients

OBJECTIVE

To describe the range of clinical manifestations and the outcome of pericardial tamponade in patients with systemic lupus erythematosus (SLE).

METHODS

Patients with pericarditis and with pericardial tamponade were identified from our computerized database of 395 SLE patients. Medical records were reviewed to establish activity of SLE at the time of tamponade, as well as clinical and laboratory features, treatment, and outcome of the tamponade.

RESULTS

Pericarditis occurred in 75 patients (19%), with 11 episodes of tamponade in 10 of them (13%; 2.5% of entire series). Tamponade was the initial manifestation of SLE in 4 patients. Seven episodes occurred during active lupus, with nephritis present in 6. Signs of venous congestion, including ascites and facial or peripheral edema, were the most common manifestation of tamponade. Pericardial fluid was exudative, and pericardial tissue demonstrated a range of findings including fibrinous and fibrotic changes, acute and chronic inflammatory infiltrates, and vascular proliferation. Tamponade was fatal in 1 patient, and 2 patients each had recurrent effusions and pericardial thickening.

CONCLUSION

Pericardial tamponade may occur at any point in the course of SLE, and should be considered in patients with unexplained signs of venous congestion. The differential diagnosis includes active SLE, uremia, and infection. Treatment with high-dose steroids and either pericardiocentesis or placement of a pericardial window is indicated, but recurrent effusions or pericardial thickening may develop.