The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome

Mycotic Aortic Aneurysm Secondary to Salmonella enterica Infection: A Case Report and Treatment Approach

Mycotic (infected) aortic aneurysm is a severe clinical condition with high morbidity and mortality. Salmonella spp. is a Gram-negative, rod-shaped bacteria that is typically limited to the gastrointestinal tract and resolves spontaneously but can progress to invasive infections such as bacteremia. Serious complications may arise, particularly in debilitated, elderly, and neonatal patients. We describe the case of a 74-year-old female with a history of diabetes and hypertension who presented with shortness of breath, fever, chills, abdominal pain, vomiting, and diarrhea. The patient's blood culture tested positive for Salmonella enterica, and she was given ceftriaxone based on the results, but he remained symptomatic. A computed tomography scan of the chest with contrast revealed a mycotic aneurysm of the thoracic aorta. The patient was urgently transferred to a higher level of care and underwent emergency thoracic endovascular aortic repair with stenting and intravenous antibiotics. The presence of an infected aneurysm and associated abscess formation in such high-risk patients makes the endovascular approach more suitable than other options such as open surgery, aneurysmal excision and ligation without arterial reconstruction, excision with immediate reconstruction, and excision with interval reconstruction.

Staphylococcus aureus sepsis and hemoptysis as messengers of a rather impractically located mycotic aneurysm

BACKGROUND

Mycotic aortic aneurysms (MAA) arise due to infection of a pre-existent aneurysm or aneurysmal degeneration of an infected vascular wall. MAA of the thoracic aorta are relatively rare. Treatment is mainly guided by clinical experience as there are no large randomized trials available.

CASE PRESENTATION

A 79-year-old patient was hospitalized with staphylococcus aureus sepsis and MAA originating from the ostium of the left common carotid artery (CCA). Initial treatment consisted of high-dose antibiotics and blood pressure control. After 48 hours, a CT-angiography revealed rapid growth of the MAA with imminent rupture. Various treatment options were considered: a covered stent in the left CCA, a carotid-subclavian bypass with ligation of the left CCA ostium or arch replacement, or an extra-anatomical transposition of the supra-aortic vessels combined with a thoracic endoprosthesis. The last option was selected and, combined with six weeks of antibiotics, proved successful in controlling the impending rupture and treating the MAA.

CONCLUSIONS

Endovascular techniques are used if open surgery is refused, when surgical risks are prohibitively high (as definitive or palliative treatment), or as an emergency temporary treatment until definitive surgical treatment is feasible. Our high-risk patient underwent endovascular treatment for MAA as a definitive treatment. Endovascular treatment is increasingly becoming the treatment of choice due to the high morbidity and mortality of open surgical repair. Although the main concern using endovascular treatment is absence of debridement, recent studies show that combining endovascular treatment and long-term antibiotic therapy represents a potentially durable treatment and viable alternative to open surgical repair.

'From Gut to Heart': A rare case of Salmonella Typhimurium Bacteremia and native valve endocarditis

Background

Salmonella species are very rarely associated with infective endocarditis, accounting for less than 0.01-2.9 % of total bacterial endocarditis cases. Since 1976, there have less than 90 reported cases of non-Typhoidal Salmonella bacteremia and endocarditis.

Case presentation

We present the case of a 57-year-old homeless man with a past medical history significant only for polysubstance abuse. He presented to the emergency department with a 3-day history of severe, non-bloody diarrhea, nausea, chills, and oliguria. Due to the patient's history of substance use, screening laboratory tests were conducted and were positive for rapid plasma reagin, treponemal antibodies, and hepatitis C. For the profuse diarrhea and severe volume loss, C. difficile, stool white blood cells and stool ova and parasites were ordered but were ultimately negative. Both sets of blood cultures were found to be positive for Salmonella Typhimurium bacteremia. Further workup with transthoracic and transesophageal echocardiogram displayed small mobile masses attached to the aortic surface of the right and non-coronary cusps, confirming endocarditis on the aortic valve. Treatment included penicillin-G once a week for 3 weeks for latent syphilis and ceftriaxone and levofloxacin for bacteremia and endocarditis.

Conclusions

Patients with Salmonella typically present early with gastrointestinal symptoms, but clinicians should consider cardiovascular imaging if blood cultures are found to be positive in order to potentially identify and promptly treat highly fatal Salmonella endocarditis.

Non-typhoid Salmonella endocarditis complicated by cardiac failure and acute limb ischaemia in a person living with HIV and hepatitis C: A Case Report and literature review

Salmonella infections are responsible for a large burden of disease worldwide. Non-typhoidal Salmonella (NTS) species cause a myriad of disease manifestations, particularly amongst severely immunocompromised individuals. We present a rare case of endocarditis caused by the NTS species Salmonella Enteritidis in an individual living with HIV and hepatitis C. In this case, endocarditis was complicated by embolization and acute arterial occlusion of the left arm, as well as mitral valve perforation resulting in cardiac failure. A review of the available literature shows few cases of NTS causing endocarditis in people living with HIV, with the earliest reported case in 1983. Our case demonstrates the potential complications of NTS endocarditis and highlights the importance of evaluating patients with NTS-associated blood stream infection for cardiovascular involvement. Prompt surgical intervention in addition to appropriate antimicrobial therapy is essential to reduce the high morbidity and mortality associated with NTS endocarditis.

Cellular mechanisms and molecular pathways linking bitter taste receptor signalling to cardiac inflammation, oxidative stress, arrhythmia and contractile dysfunction in heart diseases

Heart diseases and related complications constitute a leading cause of death and socioeconomic threat worldwide. Despite intense efforts and research on the pathogenetic mechanisms of these diseases, the underlying cellular and molecular mechanisms are yet to be completely understood. Several lines of evidence indicate a critical role of inflammatory and oxidative stress responses in the development and progression of heart diseases. Nevertheless, the molecular machinery that drives cardiac inflammation and oxidative stress is not completely known. Recent data suggest an important role of cardiac bitter taste receptors (TAS2Rs) in the pathogenetic mechanism of heart diseases. Independent groups of researchers have demonstrated a central role of TAS2Rs in mediating inflammatory, oxidative stress responses, autophagy, impulse generation/propagation and contractile activities in the heart, suggesting that dysfunctional TAS2R signalling may predispose to cardiac inflammatory and oxidative stress disorders, characterised by contractile dysfunction and arrhythmia. Moreover, cardiac TAS2Rs act as gateway surveillance units that monitor and detect toxigenic or pathogenic molecules, including microbial components, and initiate responses that ultimately culminate in protection of the host against the aggression. Unfortunately, however, the molecular mechanisms that link TAS2R sensing of the cardiac milieu to inflammatory and oxidative stress responses are not clearly known. Therefore, we sought to review the possible role of TAS2R signalling in the pathophysiology of cardiac inflammation, oxidative stress, arrhythmia and contractile dysfunction in heart diseases. Potential therapeutic significance of targeting TAS2R or its downstream signalling molecules in cardiac inflammation, oxidative stress, arrhythmia and contractile dysfunction is also discussed.

In situ repair or reconstruction of the abdominal aorta-iliac artery by autologous fascia-peritoneum with posterior rectus sheath for the treatment of the infected abdominal aortic and iliac artery aneurysms: A case series and literature review

Background

Infected abdominal aortic and iliac artery aneurysms are considered acute and severe diseases with insidious onset, rapid development, and high mortality in vascular surgery. Currently, there is no better treatment, either anatomic or extra-anatomical repair.

Case presentation

From February 2018 to April 2022, 7 patients with infected abdominal aortic and iliac artery aneurysms did not have sufficient autologous venous material for repair. With the consent of the Ethics Committee of the hospital, it uses the autologous peritoneal fascial tissue with rectus sheath to repair or reconstruct the infected vessels in situ. There were 5 cases of infected abdominal aortic aneurysm, 1 case of an infected common iliac aneurysm, and 1 case of the infected internal iliac aneurysm. Aortoduodenal fistula was found in 3 cases, all of them were given duodenal fistula repair and gastrojejunostomy and cholecystostomy. Three cases of infected abdominal aortic aneurysms were repaired with the autologous peritoneal fascial tissue patch, and 2 cases of infected abdominal aortic aneurysms were reconstructed by the autologous peritoneal fascial tissue suture to bifurcate graft in situ, the autologous peritoneal fascial tissue suture reconstructed the rest 2 cases of infected iliac aneurysm to tubular graft in situ. It was essential that Careful debridement of all infected tissue and adequate postoperative irrigation and drainage. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics based on bacterial culture and susceptibility results of infected tissues and blood. All 7 patients had underwent surgery successfully. But there were 2 cases died of anastomotic infection or massive hemorrhage after the operation, the other 5 cases survived. The follow-up time was 2–19 months. The enhanced CT of postoperation showed that the reconstructed arteries were smooth without obvious stenosis or expansion, and no abdominal wall hernia occurred.

Conclusion

In situ repair or reconstruction with autologous peritoneal fascial tissue with rectus sheath is a feasible treatment for the infected aneurysm patients without adequate autologous venous substitute, but it still needs long-term follow-up and a large sample to be further confirmed.

Refractory Salmonella Prosthetic Valve Endocarditis Complicated by Splenic Infarction and Aortic Pseudoaneurysm in a Patient with Double Prosthetic Valves: A Case Report

Endocarditis is an extremely rare complication of Salmonellosis with an incidence of 0.2–0.4%. It is a destructive and invasive infection that follows a highly complicated course and carries a high mortality rate that exceeds 45%. Multiple predisposing factors for Salmonella endocarditis have been described in the literature, including human immunodeficiency virus infection, congenital heart diseases, and the presence of a prosthetic valve. Herein, we report a case of Salmonella prosthetic valve endocarditis complicated by splenic infarction and aortic pseudoaneurysm presenting as a month-long history of fluctuating fever, chills, and rigors, accompanied by occasional cough and shortness of breath in a 55-year-old female with aortic and mitral valves replacement and multiple comorbidities. She was diagnosed by multiple radiographic studies and successfully treated with the Commando procedure and a long course of IV antibiotics.

Infectious Aortitis: Case Report and Literature Review

Aortitis is the inflammation of the aorta secondary to either infectious or non-infectious etiologies. Infectious aortitis is a rare but potentially life-threatening condition. It is more common among older patients with preexisting pathology. Clinical presentation is variable, therefore, a high index of suspicion is required for timely diagnosis and management. We report a case of aortitis which was complicated with the development of a saccular abdominal aortic aneurysm. A 76-year-old male presented to the Emergency Department with two days of right lower quadrant abdominal pain. Clinical evaluation and imaging studies revealed abdominal aortitis, which progressed to a saccular abdominal aortic aneurysm. We highlight a unique presentation of infectious aortitis to raise awareness among physicians. We also reviewed the available literature on infectious aortitis to illustrate the importance of early diagnosis and appropriate treatment to improve the patients' outcomes.

Mimickers of Large Vessel Giant Cell Arteritis

Giant cell arteritis (GCA) is a large-vessel granulomatous vasculitis occurring in patients over 50-year-old. Diagnosis can be challenging because there is no specific biological test or other diagnoses to consider. Two main phenotypes of GCA are distinguished and can be associated. First, cranial GCA, whose diagnosis is usually confirmed by the evidence of a non-necrotizing granulomatous panarteritis on temporal artery biopsy. Second, large-vessel GCA, whose related symptoms are less specific (fever, asthenia, and weight loss) and for which other diagnoses must be implemented if there is neither cephalic GCA nor associated polymyalgia rheumatica (PMR) features chronic infection (tuberculosis, Coxiella burnetti), IgG4-related disease, Erdheim Chester disease, and other primary vasculitis (Behçet disease, relapsing polychondritis, or VEXAS syndrome). Herein, we propose a review of the main differential diagnoses to be considered regarding large vessel vasculitis.

Invasive Non-typhoidal Salmonella (iNTS) Infections

Salmonella enterica invade the host via the intestinal tract. There are ~ 2 thousand distinct serovars of non-typhoidal Salmonella (NTS) that can cause gastroenteritis in normal hosts, but bacteremia is an uncommon complication of gastroenteritis except at the extremes of age [1]. In contrast, enteric fever and invasive NTS infections (iNTS) are each caused by only a few serovars of S. enterica (Table 1), and bacteremia not gastroenteritis is their principal manifestation.

Medically managed prosthetic valve endocarditis caused by Salmonella enteritidis

Infective endocarditis is associated with morbidity and mortality even when appropriately treated. It can be more complicated to treat when prosthetic material is present, often necessitating surgical revision as well as antimicrobial therapy. Endocarditis caused by gram-negative bacilli is a rare occurrence, with some literature and expert opinion suggesting superior outcomes with combined surgery and antibiotics when a prosthetic valve is involved. In cases where the prosthetic valve is well-functioning and undamaged, or cardiothoracic surgery represents a significant operative risk, it can be unclear how best to proceed. This report documents a case of Salmonella enterica subspecies enterica serovar enteritidis endocarditis of a mechanical mitral valve. The patient was managed with 6 weeks of intravenous antibiotics followed by suppressive oral antibiotic therapy. They remain in good health at 24 months.

Aortitis - An Interdisciplinary Challenge

The term 'aortitis' comprises a heterogeneous spectrum of diseases, with varied etiology and clinical presentations, whose common characteristic is the inflammation of the aortic wall. Since aortitis can mimic almost all common cardiovascular disorders, its clinical recognition remains a challenge. Some cases of aortitis remain undetected for a long time and may be diagnosed after severe life-threatening complications have already arisen. The diagnosis of aortitis is based on the presence of homogeneous circumferential thickening of the aortic wall detected on aortic imaging, or typical histological features in combination with clinical findings and laboratory parameters. Management of aortitis is usually conservative (immunosuppressive drugs in noninfectious aortitis; antimicrobial drugs in infectious). However, if vascular complications such as aortic aneurysm, rupture, or steno-occlusive events appear, aortic surgery or endovascular therapy may be required. This review article summarizes the current knowledge regarding the etiology, clinical presentation, diagnosis, and treatment of inflammatory diseases of the aorta to promote better clinical management of these entities.

Pathogenicity of clinical Salmonella enterica serovar Typhimurium isolates from Thailand in a mouse colitis model

Salmonella enterica serovar Typhimurium (S. Typhimurium [STM]) is a leading cause of nontyphoidal salmonellosis (NTS) worldwide. The pathogenesis of NTS has been studied extensively using a streptomycin-pretreated mouse colitis model with the limited numbers of laboratory STM strains. However, the pathogenicity of the clinically isolated STM (STMC) strains endemic in Thailand in mice has not been explored. The aim of this study was to compare the pathogenicity of STMC strains collected from Northern Thailand with the laboratory STM (IR715) in mice. Five STMC isolates were obtained from the stool cultures of patients with acute NTS admitted to Maharaj Nakorn Chiang Mai Hospital in 2016 and 2017. Detection of virulence genes and sequence type (ST) of the strains was performed. Female C57BL/6 mice were pretreated with streptomycin sulfate 1 day prior to oral infection with STM. On Day 4 postinfection, mice were euthanized, and tissues were collected to analyze the bacterial numbers, tissue inflammation, and cecal histopathological score. We found that all five STMC strains are ST34 and conferred the same or reduced pathogenicity compared with that of IR715 in mice. A strain-specific effect of ST34 on mouse gut colonization was also observed. Thailand STM ST34 exhibited a significant attenuated systemic infection in mice possibly due to the lack of spvABC-containing virulence plasmid.

Iron-Uptake Systems of Chicken-Associated Salmonella Serovars and Their Role in Colonizing the Avian Host

Iron is an essential micronutrient for most bacteria. Salmonella enterica strains, representing human and animal pathogens, have adopted several mechanisms to sequester iron from the environment depending on availability and source. Chickens act as a major reservoir for Salmonella enterica strains which can lead to outbreaks of human salmonellosis. In this review article we summarize the current understanding of the contribution of iron-uptake systems to the virulence of non-typhoidal S. enterica strains in colonizing chickens. We aim to address the gap in knowledge in this field, to help understand and define the interactions between S. enterica and these important hosts, in comparison to mammalian models.

Etiology, Diagnosis and Management of Aortitis

Aortitis includes conditions with infectious or non-infectious etiology, characterized by inflammatory changes in one or more layers in aortic wall. Age at onset, geographic predilections, distribution and pattern of involvement in aorta, its branches and pulmonary arteries, and systemic associations provide a clue to etiology. Clinical presentations are often non-specific. An integrated approach including clinical, laboratory and imaging assessment is essential to confirm diagnosis and plan treatment. Assessment of disease activity is the key as it influences timing and outcome of treatment. Markers of activity include clinical, laboratory and imaging. Medical management remains the first-line therapy. Revascularization is indicated in the presence of hemodynamically significant stenosis and inactive disease. In the presence of flash pulmonary edema, left ventricular dysfunction or hypertensive encephalopathy, revascularization is performed irrespective of disease activity. Endovascular management is favored over surgery due to its high success and low restenosis rates. Symptomatic aneurysmal disease is usually managed by surgery.

Mycotic abdominal aortic aneurysm complicated by infective spondylitis due to P seudomonas aeruginosa

A 67-year-old man with diabetes and hypertension presented with complaints of abdominal pain and lower back ache for 7 months, with intermittent episodes of fever. On examination, there was an expansile mass in the upper abdomen with bruit on auscultation. He also had tenderness in the L1-L2 vertebral space with paraspinal fullness, causing painful restriction of lower limb motor functions but without affecting sensation. On evaluation, he was found to have an abdominal aortic aneurysm with infective lumbar spondylodiscitis. The aspirate from the paravertebral infected tissue and cultures from blood grew Pseudomonas aeruginosa, a rare causative agent of mycotic aortic aneurysm. Whether the infective spondylitis spread to the abdominal aorta causing the mycotic aneurysm or vice versa is a dilemma in such a case. However, the mainstay of treatment remains adequate source control and repair of the aneurysm with appropriate antibiotic therapy. Our patient received intravenous antibiotics for P . aeruginosa based on sensitivity, following which he underwent debridement of the infective spondylodiscitis with aneurysmorrhaphy. He had an uneventful recovery and was well at 3-month follow-up.

Salmonella typhimurium myopericarditis: A case report and review of literature

BACKGROUND

Non-typhoidal salmonella (NTS) is a rare, but well-established cause of myopericarditis. Presenting symptoms may be varied, however often revolve around the dual presentation of both myopericarditis and infectious diarrhoea. Given the rarity of NTS related myopericarditis, we conducted a systematic review of the literature, identifying 41 previously reported cases.

CASE SUMMARY

We present the case of an otherwise healthy 39-year old male, presenting with chest pain in the setting of documented Salmonella typhimurium infection. After further investigation with echocardiogram and laboratory blood tests, a diagnosis of NTS associated myopericarditis was made, and the patient received antibiotic treatment with an excellent clinical outcome. Overall, myopericarditis is rare in NTS. Although treatment for myopericarditis has not been well established, there are guidelines for the treatment of NTS infection. In our review, we found that the majority of NTS cases has been pericarditis (27/42, 64.3%), with an average age of 48.3 years, and 71.4% being male. The average mortality across all cases was 31%.

CONCLUSION

Myopericarditis is a rare, but potentially serious complication of NTS infection, associated with an increased morbidity and mortality.

Endocarditis following Consumption of Cereal Associated with Salmonella enterica Subtype Mbandaka Outbreak

A 69-year-old immunocompromised man developed mitral valve endocarditis due to Salmonella enterica serotype Mbandaka, contracted from the cereal outbreak. The patient had a history of HLA-matched related hematopoietic stem cell transplant with persistent graft-versus-host disease (GVHD). This case report discusses prior international outbreaks that occurred due to Salmonella enterica subtype Mbandaka, the risks of developing endovascular infections from salmonellosis, and persistent infections that may develop more frequently with S. enterica serotype Mbandaka. The patient received a six-week course of intravenous antibiotics and remains on oral suppressive antibiotics, with his length of therapy to be determined based on his GVHD treatment.

Epidemiology and antimicrobial resistance of invasive non-typhoidal Salmonellosis in rural Thailand from 2006-2014

INTRODUCTION

Invasive salmonellosis is a common cause of bloodstream infection in Southeast Asia. Limited epidemiologic and antimicrobial resistance data are available from the region.

METHODS

Blood cultures performed in all 20 hospitals in the northeastern province of Nakhon Phanom (NP) and eastern province of Sa Kaeo (SK), Thailand were captured in a bloodstream infection surveillance system. Cultures were performed as clinically indicated in hospitalized patients; patients with multiple positive cultures had only the first included. Bottles were incubated using the BacT/Alert system (bioMérieux, Thailand) and isolates were identified using standard microbiological techniques; all Salmonella isolates were classified to at least the serogroup level. Antimicrobial resistance was assessed using disk diffusion.

RESULTS

Salmonella was the fifth most common pathogen identified in 147,535 cultures with 525 cases (211 in Nakhon Phanom (NP) and 314 in Sa Kaeo (SK)). The overall adjusted iNTS incidence rate in NP was 4.0 cases/100,000 person-years (95% CI 3.5-4.5) and in SK 6.4 cases/100,000 person-years (95% CI 5.7-7.1; p = 0.001). The most common serogroups were C (39.4%), D (35.0%) and B (9.9%). Serogroup D predominated in NP (103/211) with 59.2% of this serogroup being Salmonella serovar Enteritidis. Serogroup C predominated in SK (166/314) with 84.3% of this serogroup being Salmonella serovar Choleraesuis. Antibiotic resistance was 68.2% (343/503) for ampicillin, 1.2% (6/482) for ciprofloxacin (or 58.1% (280/482) if both intermediate and resistant phenotypes are considered), 17.0% (87/512) for trimethoprim-sulfamethoxazole, and 12.2% (59/484) for third-generation cephalosporins (cefotaxime or ceftazidime). Multidrug resistance was seen in 99/516 isolates (19.2%).

CONCLUSIONS

The NTS isolates causing bloodstream infections in rural Thailand are commonly resistant to ampicillin, cefotaxime, and TMP-SMX. Observed differences between NP and SK indicate that serogroup distribution and antibiotic resistance may substantially differ throughout Thailand and the region.

Mycotic aneurysm due to Salmonella species: clinical experiences and review of the literature

The mortality of patients with mycotic aneurysms is high, especially in East Asia, and infection by Salmonella species is the most common. Our study aimed to improve prognosis of adult mycotic aneurysms with early diagnosis and accurate treatment. Four adult patients with mycotic aneurysm caused by Salmonella were included and analyzed by single-center retrospective analysis. Cases reported in the literature during the past 10 years were also summarized. The average age of the 4 male patients was 61.25 years, while that of the 53 cases reported in the literature was 65.13 years. Hypertension, diabetes, and atherosclerosis were common complications. Most patients presented fever and experienced pain at the corresponding position of the aneurysm. Laboratory examination found an increased number of white blood cells accompanied by an increase in inflammatory markers. Most aneurysms were found in the abdominal aorta, while the rupture of an aneurysm was the most common complication. The mortality rates were 21.43 and 7.14% after open surgery or endovascular aneurysm repair (EVAR) intervention, respectively. The recurrence rates of infection were 0 and 17.85% for both treatments, respectively. The mortality rate of mycotic aneurysm caused by Salmonella infection was high in middle-aged males with hypertension, diabetes, and atherosclerosis. The possibility of a Salmonella-infected aneurysm should be considered in these high-risk groups presenting chills, fever, chest, and back pain. Open surgery was superior to EVAR treatment in the clearance of infected foci and the reduction of postoperative recurrence. The recurrence of postoperative infection can be prevented by intravenous antibiotic therapy for 6 weeks post-surgery.

Infectious Aortitis: A Life-Threatening Endovascular Complication of Nontyphoidal Salmonella Bacteremia

A 65-year-old Japanese man living in the United States presented with pyrexia and chills associated with intermittent lower abdominal and back pain for 5 days. He denied recent travel, rash, diarrhea, or rectal bleeding. Physical examination revealed spiking pyrexia, and routine laboratory tests revealed mild leukocytosis and neutrophilia. Abdominal CT with contrast showed findings highly compatible with aortitis. Comprehensive autoimmune evaluation was negative. Salmonella enterica serotype Enteritidis was isolated from blood cultures. IV antibiotics were administered, but the patient continued to experience low-grade pyrexia and mild leukocytosis, and follow-up abdominal CT showed progressive aortic inflammation. The patient therefore underwent resection of the affected aortic segment with in-situ graft replacement and lifelong suppressive antibiotics. The patient is asymptomatic with no complications at 18 weeks of follow-up. This case report illustrates that patients with infectious aortitis from nontyphoidal Salmonella may (1) present with nonspecific and nonlocalizing symptoms and signs except for sepsis; (2) have diagnostic blood cultures and abdominal CT findings; and (3) typically require aggressive, prolonged IV antibiotic therapy and surgery for potential cure of this life-threatening infection.

An Uncommon Cause of Deep Vein Thrombosis: Mycotic Aneurysm Secondary to Salmonella Arteritis

Mycotic aneurysm is an uncommon surgical emergency with high mortality. Endovascular infection due to salmonella is the commonest cause of intra-abdominal mycotic aneurysm. We report a rare presentation of mycotic aneurysm in a 78-year-old man who presented to the accident and emergency department with deep vein thrombosis due to compression of the iliac vein by a mycotic aneurysm arising from the internal iliac artery and an adjacent abscess. A comprehensive review of the aetiology, clinical presentation and management of mycotic aneurysm secondary to salmonella arteritis is presented.

Non-infectious aortitis in an immunosuppressed renal transplant recipient with IgA nephropathy

A 54-year-old woman presented with atypical chest pain, fever and malaise. She was immunosuppressed with three agents following a living-donor kidney transplant 1 year previously. Her native kidney failure was secondary to biopsy-demonstrated crescentic IgA nephropathy, with systemic involvement. A CT pulmonary angiogram revealed an inflammatory cuff of soft tissue around the descending thoracic aorta suggesting aortitis. Inflammatory markers were elevated. Given her immunosuppression, the patient was screened extensively for infective causes and was empirically commenced on intravenous meropenem. After 72 hours of no clinical or serological response to antibiotic therapy, negative microbiological investigations and worsening inflammation on serial imaging, she was commenced on high-dose methylprednisolone for presumed inflammatory aortitis. Symptoms and inflammatory markers rapidly normalisedand the patient was discharged home on oral prednisolone. A clinical diagnosis of IgA-related aortitis was made. Imaging 3 months later showed complete resolution of the aortitis.

Multidrug Resistant Invasive Nontyphoidal Salmonella Isolated from and Masquerading Healed Tubercular Constrictive Pericarditis and Study of Virulence Markers

Among the infectious causes of pericarditis are various bacteria, viruses, fungal and parasitic infections. The course disease may progress to a chronic constrictive pattern especially with tubercular etiology. Non-typhoidal Salmonella has rarely been reported as a cause of pericarditis. We describe here a case from which the pericardial fluid from an old case of tubercular pericarditis sent for culture to microbiology laboratory grew a Salmonella typhimurium. We studied the antibiotic resistance pattern, phage type and virulence factors playing a role in the invasive nature of the pathogen since no such study from pericardial fluid was found in the literature. The isolate was sensitive only to cephalosporins and it was untypable. It showed amplification for five fimbrial operons, three colonization factors, and other genes (pef operon), gog B(Gifsy-1 encoded effector), sseI (Gifsy-2 encoded effector), sodC ( the periplasmic [copper and zinc Cu, Zn ]-superoxide dismutase) & sopE (a guanine nucleotide exchange factors). The present case highlights the need for early detection of the exact causative agent and serovar in management, the likelihood of a different etiological agent other than the original to be kept in mind for timely management and the highly resistant pattern of non-typhoidal Salmonella (NTS) limiting the therapeutic options as in our case to only cephalosporins. The genes encoded from the NTS might be required for invasive cardiac manifestation in humans.

Cross-sectional imaging of aortic infections

Aortic infections are uncommon clinical entities, but are associated with high rates of morbidity and mortality. In this review, we focus on the cross-sectional imaging appearance of aortic infections, including aortic valve endocarditis, pyogenic aortitis, mycotic aneurysm and aortic graft infections, with an emphasis on CT, MRI and PET/CT appearance. Teaching Points • Aortic infections are associated with high morbidity and mortality. • CT, MRI and FDG PET/CT play complementary roles in aortic infection imaging. • Radiologists should be vigilant for aortic infection manifestations to ensure timely diagnosis.

Nontyphoidal Salmonellosis, Human Immunodeficiency Virus Infection, and Ischemic Stroke

Nontyphoidal Salmonella infection and stroke are major causes of morbidity and mortality worldwide, with increased risk in the human immunodeficiency virus (HIV)-infected population. We report a rare case of ischemic stroke associated with Salmonella enteritidis subdural empyema in an older HIV-infected patient with multimorbidity, despite surgery and treatment with susceptible antimicrobial drugs.

Aortitis

Aortitis encompasses all conditions, infectious or non-infectious, leading to different types of inflammation of the aortic wall. The clinical manifestations are usually nonspecific, as are laboratory findings, and sometimes may mimic other diseases. Imaging modalities can help in the assessment of these patients and are often required for making the final diagnosis. It is extremely important to establish an early diagnosis in order to treat timely potentially life-threatening conditions. Anti-inflammatory drugs, antibiotics, sometimes in combination with surgical or endovascular therapies, are proposed according to etiology and disease severity. This review focuses on the classification, epidemiology, diagnostic approach, and management of aortitis with which physicians should be familiar.

Mycotic aneurysm in a turtle hunter: brief review and a case report

Salmonella-associated mycotic aneurysm is a rare, but dreaded, complication of salmonellosis. Immunocompromised and elderly populations are more susceptible to develop this extra-intestinal complication. Salmonella is spread via fecal–oral and vehicle-borne routes. Reptiles, especially small pet turtles, have been linked with an increased risk of Salmonella infection. Diagnosis of mycotic aneurysm is a challenge due to atypical presentations. Recently, widespread use of CT scan imaging to evaluate for unexplained abdominal pain and sepsis has led to early identification of mycotic aneurysms. Antibiotic therapy and surgical intervention are the cornerstones of management. Open surgery has been the gold standard of treatment but is associated with increased morbidity and mortality. A relatively new alternative to open surgery is endovascular aneurysm repair (EVAR). It is comparatively less invasive and is associated with reduced early morbidity and mortality in the setting of mycotic aneurysm. However, there is a risk of late infection. Here, we present a patient with Salmonella mycotic aneurysm initially treated conservatively with antibiotic therapy who later underwent successful interval EVAR with no complications to date. Also included is a brief review of Salmonella-associated mycotic aneurysms.

Vasculitis related to viral and other microbial agents

Vasculitis due to infection may occur as a consequence of the inflammation of vessel walls due to direct or contiguous infection, type II or immune complex-mediated reaction, cell-mediated hypersensitivity, or inflammation due to immune dysregulation triggered by bacterial toxin and/or superantigen production. As immunosuppressive therapy administered in the absence of antimicrobial therapy may increase morbidity and fail to effect the resolution of infection-associated vascular inflammation, it is important to consider infectious entities as potential inciting factors in vasculitis syndromes. The causality between infection and vasculitis has been established in hepatitis B-associated polyarteritis nodosa (HBV-PAN) and hepatitis C-associated (cryoglobulinemic) vasculitis (HCV-CV). The review summarizes the recent literature on the pathophysiological mechanisms and the approaches to the management of HBV-PAN and HCV-CV. Roles of other viral and microbial infections, which either manifest as vasculitic syndromes or are implicated in the pathogenesis of primary vasculitides, are also discussed.

Salmonella infective endocarditis

OBJECTIVE

Salmonella endocarditis is so rarely reported that its clinical features, prognosis, and optimal treatment remain unclear. In this paper, we report a female with nontyphoid Salmonella endocarditis complicated with perivalvular abscess. We also review and summarize other cases reported in the English literature.

METHODS

Using the key words "Salmonella", "infective endocarditis", and "mural endocarditis" to search the PubMed database, we reviewed case reports on Salmonella endocarditis published between 1976 and 2014 and case series of infective endocarditis that included at least 500 cases.

RESULTS

Salmonella species were rare infective endocarditis pathogens. Among 16 large case series, they accounted for less than 0.01% and up to 2.9% of bacterial endocarditis cases. From 1976 to 2014, a total of 87 cases of typhoid and nontyphoid Salmonella endocarditis were reported, which included 42 cases in 1976-1984, 30 cases in 1986-2002, and 15 cases in 2003-2014. Men predominated among the cases (58.6%), and the mean age was approximately 50-60 years. The major affected valves were the mitral valves (33.3%). Mural endocarditis was common (26.4%). Perivalvular abscess was only reported in 10.5% (6 cases) of 57 cases. The overall mortality rate was 42.5% and decreased over time from 69.0% to 13.3% during the three study periods.

CONCLUSION

Salmonella endocarditis, although rare, may cause purulent infections in the perivalvular area or myocardium and lead to substantial mortality.

Nontyphoidal cardiac salmonellosis: two case reports and a review of the literature

Nontyphoidal Salmonella, especially Salmonella enterica, is a rare cause of endocarditis and pericarditis that carries a high mortality rate. Proposed predisposing conditions include immunodeficiency states, congenital heart defects, and cardiac valve diseases. We present 2 cases of cardiovascular salmonellosis. The first case is that of a 73-year-old woman with mechanical mitral and bioprosthetic aortic valves who died from sequelae of nontyphoidal Salmonella mitral valve vegetation, aortic valve abscess, and sepsis. The second case is that of a 62-year-old man with a recent systemic lupus erythematosus exacerbation treated with oral steroids, who presented with obstructive features of tamponade and sepsis secondary to a large S. enteritidis purulent pericardial cyst. He recovered after emergent pericardial drainage and antibiotic therapy. Identifying patients at risk of cardiovascular salmonellosis is important for early diagnosis and treatment to minimize sequelae and death. We reviewed the literature to identify the predisposing risk factors of nontyphoidal Salmonella cardiac infection.

Concurrent Salmonella mycotic abdominal aneurysm and empyema thoracis: a rare coincidence

OBJECTIVE

To present a case of Salmonella bacteremia with a rare metastatic focus.

CLINICAL PRESENTATION AND INTERVENTION

A 61-year-old male presented with a suicide attempt after ingestion of half a bottle of toilet cleaner. He had a medical history of intravenous drug abuse and major depression. Persistent Salmonella enteritidis bacteremia occurred during his hospitalization, and a search for the primary source of infection disclosed a mycotic abdominal aortic aneurysm. A suppurative lesion was also noted over the left pleural space, and Salmonella empyema was confirmed after thoracentesis. He underwent video-assisted thoracoscopic surgery and endovascular repair of the abdominal aortic aneurysm and was placed on long-term antibiotics, without recurrence.

CONCLUSION

S. enteritidis involvement of the cardiovascular system is a rare coincidence and results in significant morbidity and mortality. In addition, the phenomenon of secondary metastatic infective foci involving the pleural space has an even lower frequency than that of cardiovascular involvement. Therefore, a high index of suspicion and prompt treatment from the treating physicians are strongly recommended.

Treatment of infected abdominal aortic aneurysm caused by Salmonella

BACKGROUND

We reviewed the outcomes of patients treated for nontyphoidal Salmonella-infected abdominal aortic aneurysm (AAA) treatment at a single center.

METHODS

This was a retrospective chart review of 26 patients with nontyphoidal Salmonella-infected AAA. Four patients underwent medical therapy alone, while 22 patients underwent surgical therapy. Revascularization method selection was dependent on preoperative antibiotic response in the surgical therapy group.

RESULTS

The in-hospital mortality rate for the surgical therapy group was 14%, while the rate for the medical therapy group was 100%. Overall survival for the surgical therapy group was 82%, while the reinfection rate was 9%. In the surgical therapy group, 2 patients had periaortic abscesses and underwent in situ prosthetic graft replacement; none developed graft-related complications or died in the hospital. Kaplan-Meier analysis and log-rank testing revealed no significant differences in graft-related complication and overall survival rates between in situ prosthetic graft group and extra-anatomic bypass group. Salmonella choleraesuis had a higher antimicrobial resistance rate than other isolates. The predictors of survival were clinical presentation of abdominal pain and receiving surgical therapy.

CONCLUSIONS

If patients with Salmonella-infected AAAs have good responses to preoperative antibiotic therapy, in situ prosthetic graft replacement is a viable revascularization method, even in the situation of periaortic abscess presentation formation.

Salmonella mycotic thoracoabdominal aortic aneurysm associated with chronic lymphocytic leukemia

Non-typhoidal Salmonella infections typically cause self-limiting gastroenteritis. However, extraintestinal focal infections, including mycotic aneurysms of the aorta, can also occur. We present the case of a 71-year-old man with chronic lymphocytic leukemia (CLL) and a large type V thoracoabdominal mycotic aneurysm infected with Salmonella enteritidis, complicated by thoracolumbar spondylodiscitis, paravertebral collections, and epidural abscess. This is the first report of Salmonella aortitis in the setting of CLL, and the unusual extent of local infective invasion seen here with Salmonella enteritidis infection raises a suspicion of CLL-related immunosuppression as a direct predisposing factor. This case illustrates the need to consider the possibility of an immune defect, even in CLL patients with normal leukocyte counts. The underlying mechanisms are unclear, but are likely to involve defects in cell-mediated immunity, thought to be of particular importance in invasive infections with intracellular pathogens such as Salmonella spp.

Infective endocarditis at autopsy: a review of pathologic manifestations and clinical correlates

The frequency of autopsies appears to be declining, and the usefulness has been challenged. We reviewed cases of autopsied active infective endocarditis (IE) during 2 periods based on the availability of high-tech 2-dimensional echocardiograms: Period 1 (P1) included 40 cases studied from 1970 to 1985, and Period 2 (P2) included 28 cases seen from 1986 to 2008--that is, before and after the introduction of echocardiograms in our institution. We conducted the study to reassess the pathology of IE and to determine how frequently diagnosis is not made during life.The age of patients increased 10 years on average between the 2 periods, and comorbidities were significantly more frequent in P2. While the frequency of rheumatic valve disease and prosthetic valve endocarditis (PVE) decreased, degenerative valve disease increased. Isolated mitral or aortic valve IE was most common. Right-sided IE was observed in patients with Staphylococcus aureus bacteremia from infected venous lines. In most cases IE involved only the cusps of cardiac valves. "Virulent" microorganisms caused ulcerations, rupture, and perforation of the cusps and necrosis of chordae tendiniae and perivalvular apparatus. In PVE the lesions were located behind the site of attachment, and vegetations were seen on the sewing ring in both metallic and biologic prostheses. Infection spread to adjacent structures and myocardium with ring abscess observed in 88% of cases. Prosthetic detachment causing valve regurgitation was associated with abscesses in 76% of cases; these patients developed persistent sepsis and severe cardiac failure. Obstruction occurred in patients with PVE of the mitral valve. Acute purulent pericarditis was observed in 22% of cases, mainly in patients with aortic valve IE and myocardial abscesses.Gross infarcts were seen in 63% of cases but were asymptomatic in most instances. The spleen, kidneys, and mesentery were the sites most frequently involved. Myocardial infarctions were found in less than 10% of cases. Abscesses were also frequently found and were a common source of persistent fever and bacteremia. Glomerulonephritis was more common in the first period. Brain pathology consisted of ischemic and hemorrhagic infarcts and abscesses. Cerebral bleeding was more frequent in patients with PVE on anticoagulant therapy. Neutrophilic meningitis was observed in S. aureus IE.Diagnosis of IE was not made during life in 14 (35%) cases during P1 and 12 (42.8%) cases in P2. Overall, diagnosis was missed until autopsy in 38.2% of cases. IE was hospital acquired in 28 instances. While a clinical diagnosis was made in all but 4 cases of early-onset PVE (23.5%), the diagnosis was not made during life in 22 of 51 patients with native-valve IE (43.1%). Of these 22 patients, IE was hospital acquired in 11 (50%). The absence of fever, cardiac murmurs, and many of the typical stigmata of endocarditis may have led to the diagnosis being overlooked clinically.Brain bleeding, cardiac failure and less frequently acute myocardial infarct were the most common causes of death.IE continues to be missed frequently until autopsy. Postmortem examination is an important tool for evaluating the quality of care, and for guiding teaching and research related to cardiovascular infections.

Non-typhoidal Salmonella bacteraemia in elderly patients: an increased risk for endovascular infections, osteomyelitis and mortality

Non-typhoidal Salmonella (NTS) is a common pathogen causing foodborne infections, bacteraemia, and extra-intestinal focal infections (EFIs) in humans. The study compares the clinical characteristics of elderly patients with NTS bacteraemia with those of young adults. Of 272 adults with NTS bacteraemia identified in this study, 162 (59·6%) were aged ⩾55 years. EFIs were observed in 36% of the 162 patients. The most common EFIs in the elderly patients (⩾55 years) was mycotic aneurysm, followed by pulmonary infections and bone/joint infections. Elderly patients more often had chronic heart, lung, renal and malignant diseases, had more EFIs, and a higher 30-day mortality rate. Independent factors of 30-day mortality in elderly patients were solid-organ tumour [adjusted odds ratio (aOR) 4·4, P=0·003], mycotic aneurysm (aOR 3·7, P=0·023) and shock (aOR 12·1, P<0·0001). HIV infection, autoimmune diseases, and receipt of immunosuppressive therapy were more often observed in young patients.

Management of the infected aortoiliac aneurysms

PURPOSE

We have reviewed ruptured and nonruptured infected aortoiliac aneurysms to study the clinical presentation, management and eventual outcome of patients managed with in situ prostheses, axillofemoral prostheses grafts and endovascular reconstruction.

DESIGN

A retrospective chart review of 16 cases treated at a single institution.

METHODS

From January 2007 to March 2008, a total of 93 patients with aortoiliac aneurysms underwent surgical repair at our institution. Among these, 16 patients (17.2%) were shown to be infected aneurysms of the infrarenal (n = 6), juxtarenal (n = 2), and pararenal aorta (n = 1); the others were 5 common, 1 external, and 1 internal iliac arteries. Fourteen patients were male and 2 were female with the mean age of 66 years (range, 45-79). In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered at least 1 week, unless in patients need emergency operations. At the time of an operation, all were saccular and were classified as primary infected aortoiliac aneurysms. Thirteen patients had surgical debridement with in situ graft interposition and omental wrapping, 2 underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass, 1 underwent aneurysmectomy of left external iliac artery and polytetrafluoroethylene (PTFE) graft interposition, and 1 underwent endovascular exclusion. The parenteral antibiotics were continued in the postoperative period for 4-6 weeks. Chronic renal disease was present in 37.5% (6/16), with diabetes mellitus present in 31.25% (5/16). The most common pathogen was Salmonella sp. (n = 6) and E. coli (n = 5). Thirty-seven percent (6/16) of the patients presented late, with a 37.5% (6/16) incidence of ruptured (4 contained, 2 free ruptured) that needed emergency surgery.

RESULTS

Disease-specific mortality was 31.25% (5/16). The 30-day mortality rate of ruptured cases is high 67% (4/6), because patients present late in the course of the disease. One patient who underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass died 6 months later from burst aortic stump. Salmonella and E. coli are the most common pathogens.

CONCLUSIONS

Early diagnosis followed by surgical intervention with proper antibiotic coverage provides the best results. Mortality rate was still high in patients with sepsis and rupture. An in situ graft interposition and omental wrapping is a safe option for revascularization of infected aneurysms of the iliac arteries and infrarenal aorta.

Predictors for pathologically confirmed aortitis after resection of the ascending aorta: a 12-year Danish nationwide population-based cross-sectional study

Introduction

Assessing the prevalence of, and predictors for, pathologically-confirmed inflammation of the aorta in Denmark, using a nationwide population-based study design.

Methods

We identified all adults with first-time surgery on the ascending aorta between January 1, 1997 and March 1, 2009 in Denmark. Presence of aortic inflammation was ascertained through linkage to a nationwide pathology registry. We used logistic regression to compute prevalence odds ratios (ORs) for sex, age at surgery, cardiovascular risk factors, cancer, connective tissue disease, and infectious diseases associated with the presence of aortitis.

Results

A total of 1,210 adults underwent resection of the ascending aorta, of who 610 (50.4%) had tissue submitted for pathological examination. Aortitis was found in 37 (6.1%) patients whose tissue was examined. Ten of the 37 patients were diagnosed with conditions known to be associated with aortitis or aortic aneurysm: five patients with temporal arteritis, one with Crohn's disease, one with rheumatoid arthritis, one with systemic lupus erythematosus, one with infectious aortitis, and one with Marfan's disease. Twenty-seven patients had idiopathic aortitis. Predictors of aortitis included history of connective tissue disease (adjusted OR 4.7, 95% confidence interval (CI) 1.6, 13.6), diabetes (OR 5.2, 95% CI 0.9, 29.7), advanced age (> 67 years OR 2.5, 95% CI 0.8, 7.6), and aortic valve pathology (OR 2.3, 95% CI 1.1, 4.9).

Conclusions

Aortitis was present in 6.1% of adults in Denmark who had pathological examination after resection of the ascending aorta. Predictors of inflammation included connective tissue disease, diabetes, advanced age, and aortic valve pathology.