1125

Salmonella-Associated

with

Case

and

Deep

Vein

Review

Ping-I HSU, Yin-Ching

Thrombosis:

of the

CHUANG,

Report

of a

Literature

Chen-Den

YOUNG **,

Lili CHENG * and Ginger HF SHU * From the Section of Infectious Diseases, Department of Internal Medicine and Department of Radiology *, National Cheng Kung University Hospital, Tainan, Taiwan, 70428, Republic of China; Department of Internal Medicine, Yu-Ai Memorial Hospital, Ibaraki, Japan ** Correspondence with Dr. Chen-Den Young, Department of Internal Medicine, Sato Hospital, Ito, Shizuoka, Japan (Received: January 29, 1992) (Accepted: May 10, 1992) Key words:

salmonellosis,

deep vein thrombosis

Introduction While Salmonella infection may produce a variety of clinical pictures, deep vein thrombosis (DVT) is a rare manifestation. To our knowledge, there have been only two reported cases dealing with Salmonellaassociated DVT. In this study, we describe a case recently encountered in our hospital and review the literature. Case A 68-year-old Cheng

Kung

on

left

the

she

lower

became

chills

and

called On

mmHg,

on

our

pulse

98/min,

local

heat

examination

The

initial

form,

gm/dl;

49%

the 26.2

gm/dl,

globulin

serum

total

electrolytes, protein

and

As

on the

chief

chills

the

placed

and

mild

left

lower

some

illness

complaint

and

fever. leg.

swelling

was of an

About On

undefined

painful

showed neutrophil, time,

one

the

oral

next

admitted

week day,

lower

woman

with

swelling

before

admission,

headache,

medicine

of the

to National

erythematous

for

anorexia,

three

extremity

was

a blood

pressure

days

by

a

worsening,

3.3gm/dl;

AST serum

blood

sugar,

on

admission

lesion

white 13%

sec

chemistry

bilirubin,

This

nourished

The

left

was

lower

tender,

extremity

was

especially

in

the

of

diffusely calf

120/90

swollen

region.

with

Otherwise

remarkable.

the

11.6

a well

37.3•Ž.

erythema. nothing

segmented

A blood

revealed

temperature

hemogram

fasting

over

systemic

the

service.

revealed

sec).

was

with with

swelling She

of significant

7,1989,

associated

examination

prothrombin

(control

history

improvement.

emergency physical

physical

was

occurred.

discernible

rate

past August

erythematous

admission,

associated

band

fever no

no on

which

of an

mild with

with Hospital

extremity

aware

physician she

housewife

University

Report

(control study

37.0ƒÊ/l;

9.700/mm3

11.4 revealed

ALT

alkaline serum

count monocyte

with

3%

and

24%

lymphocyte.

sec)

and

the

total

60ƒÊ/l;

phosphatase, alpha-fetoprotein,

serum

LDH blood

myelocyte, The

activated

partial

protein

280ƒÊ/l.

The

urea

of

metamyelocyte,

following

studies

6% was

time,

with

serum antigen,

level

thrombin

6.4gm/dl

nitrogen,

carcinoembryonic

2%

hemoglobin

12.1 30.2%

albumin were

3.1

normal:

creatinine,

serum

antithrombin

III

and

C. The

chest

X-ray

別 刷 請 求先:(〒306)茨

a wedge-shaped

城 県猿 島郡 総和 町関 戸726

友 愛 記念 病 院 平 成4年8月20日

showed



振典

patchy

density

in

the

right

lower

lung

field.

1126

Fig.

Ping-I

1

Venogram

of the

left

lower

revealing

extensive

DVT involving

vein

external

iliac

and

collateral

vein

with

HSU

extremity,

et al

Fig. 2

Lung

perfusion

the femoral

defects

in the superior

prominant

ments

of the right lower

scan

showed

and anterior

perfusion basal

seg-

lobe

circulation

Venogram of the lower extremities demonstrated extensive DVT from the left calf, popliteal and femoral veins to the external iliac vein with abundant collateral circulation in the left thigh and pelvic wall (Fig . 1). Lung perfusion scan revealed two perfusion defects in the superior and anterior basal segments of right lower lobe. (Fig. 2). Blood culture on admission was negative, but when repeated one week later grew Salmonella enteritidis group C1, which was sensitive to ampicillin, chloramphenicol, cephalothin , cefamandol, ceftazidime, gentamicin and tobramycin. Urine and stool cultures were negative . The agglutinin titer for typhoid "H" antigen was reactive at 1:40 while that for typhoid "O" antigen titer was reactive at 1:20. Under the impression of DVT with probable pulmonary embolism, heparinization therapy was initiated on admission with a loading dose of 5,000 units as a bolus injection and followed by about 1,000 units/hour intravenous infusion. As the result the swelling in the left lower extremity improved dramatically. Antibiotic regimen initially consisted of cephalothin and tobramycin , but fever persisted. After Salmonella infection was disclosed in a repeated blood culture , antibiotics were changes to ampicillin 1gm intravenously every 6 hours. The fever subsided gradually and she made a steady progress . The anticoagulant was switched to warfarin on day 12 and dose regulated to maintain the prothrombin time at 1.5-2.5 times the control. On day 23, the patient was discharged with almost completely resolved swelling of the left lower extremity. She received regular follow-up at our outpatient clinic thereafter with continuation of warfarin therapy at the maintenance dose for additional 3 months . No fever or leg swelling has reoccurred ever since. Discussion Genus Salmonella consists of three species i.e. Salmonella typhi, Salmonella choleraesuis and Salmonella enteritidis which include more than 1,700 different serotypes differentiated by O (somatic) and H (flagella) antigens. These pathogens may produce asymptomatic infection of the intestinal tract or 感 染 症学 雑 誌

第66巻

第8号

Salmonella-associated Table

1

Summary

of Clinical

Data

of Three

1127

deep vein thrombosis Reported

Cases with

Salmonella-Associated

DVT

several different clinical syndromes in humans, such as gastroenteritis, enteric fever, bacteremia, and localized infectionsl". The cardiovascular complications of Salmonella infection ranged from endocarditis2'3),myocardial abscess4>,pericarditis5>,mycotic aneurysm6,7>,superficial and deep vein thrombosis8,9,lo).According to the observation of Manson et al.8), minor thromboses of the calf veins appears commonly in salmonellosis. Major thrombosis in the femoral and subclavian veins rarely occur. In reviewing the literatrure, there were only two reports dealing with Salmonella-associated DVT. Verlin et al.9) described the first case in 1987 in an 11-day-old neonate who presented a bilateral renal vein thrombosis in the course of Salmonella ibadan infection. The second case reported by Omer et al.10)in 1988 was a 25-year-old male, who was afflicted by Salmonella enteritidis group Dl infection and presented with intestinal perforation and right polpiteal and femoral vein thrombosis. The case here presented was a 68-year-old female who developed left lower extremity DVT with probable pulmonary embolism during a Salmonella enteritidis group Cl infection. The clinical data of these three cases are summarized in Table 1. We are uncertain that the coincidence of Salmonella sepsis and DVT indicates that the former causes the latter. However, similar to the case reported by Omer, the patient mentioned in our study presented with no obvious predosposing factors of DVT, such as oral contraceptive use, malignant neoplasm, immobilization, intrinsic anticoagulant deficits or previous surgeries. Therefore, we reserve a high index of suspicion that DVT may be triggered by Salmonella sepsis. In our speculation, Salmonella endotoxin or the presence of severe dehydration associated with salmonellosis may be responsible. More reported cases and further investigations are necessary to render this assumption more convincing. In the past, hundreds of mycotic aneurysms associated with Salmonella infection have been reported and Paul et al.11)summarized the pathogenesis of this complication as intravascular or extravascular origin. Those intravascular sources may arise from (i) the vegetations of endocarditis or (ii) bloodstream dissemination of bacteria to the intima surface of the artery or the vasa vasorum. Without surgical intervention, mycotic aneurysms in Salmonella infection almost all resulted in rupture of involved vessels1,12): in view of the good clinical response in all these 3 cases with antibiotics, anticoagulant and/or thrombolytic therapy alone, we speculate the venous thrombosis is likely to be non-suppurative. Because DVT is sometimes present in the abscence of clinical symptoms and signs, the true incidence of this complication in Salmonella sepsis remains to be determined. In the treatment of DVT in Salmonella infection, anticoagulant therapy with or without thrombolytic agents seemed effective and usually could yield satisfactory initial results, but the recurrence rate of DVT is unknown still. In summary, Salmonella-associated DVT may be present in previously healthy persons. It usually responds well to anticoagulant and antibiotic therapy. The true incidence and exact pathogenesis of this serious condition have not yet been established. To clarify these issues, more case reports and further 平 成4年8月20日

1128

investigations

Ping-I

HSU

et al

are necessary. References

1) Cohen, J.I., Bartlett, J.A. & Corey, G.R.: Extra-intestinal manifestations of salmonella infections. Medicine 66: 349-388, 1987. 2) DeSwiet, J.: Subacute bacterial endocarditis due to Salmonella typhimurium. Br. Med.J. 2: 1155, 1949. 3) Verhaegen, D.F., Pelemans, W., Vandepitte, J.: Salmonella infections of the mitral valve and abdominal aorta. J. Infect. 9: 87-92, 1984. 4) Kortleve, J.W., Duren, D.R. & Becker, A.E.: Cardiac aneurysm complicated by salmonella abscess. Am. J. Med. 68: 395-400, 1980. 5) Levin, H.S. & Hosier, D.M.: Salmonella pericarditis. Ann. Int. Med. 55: 817-823, 1961. 6) Carthcart, R.: False aneurysm of the femoral artery following typhoid fever. South. Med.J. 2: 593-594, 1909. 7) Parsons, R., Gregory, J. & Palmer, D.: Salmonella infecteons of the abdominal aorta. Rev. Infect. Dis. 5: 227-231, 1983. 8) Manson, P.E.C.: Manson's Tropical Diseases, 18th ed. In: Salmonellosis. England: Bailliere Tindall, 382-384,1982. 9) Velin, P., Oupont, D., Messa J.L. & Kubar, J.: Neonatal bilateral renal venous thrombosis and Salmonella ibadan infection; cure with thrombolytic agents. Arch. Fr. Pediatr. 44: 287-289, 1987. 10) Omer, A.H., Twum-Danso, K., Grant, C.S. & Hemed, T.B.: Unusual complications of Salmonella enteritidis group D infection. J. Trop. Med. Hyg. 91: 181-182, 1988. 11) Black, P.H., Kunz, L J. & Swartz, M.N.: Salmonellosis-a review of some unusual aspects. New. Eng. J. Med. 262: 811-817, 1960. 12) Wilson, S.E., Gordon, H.E. & Van Wagenen, P.B.: Salmonella arteritis . A precursor of aortic repture and pseudoaneurysm formation. Arch. Surg. 113: 1163-1166, 1978. サ ル モ ネ ラ に よ る深 部 静 脈 血 栓 一 症 例 報 告 及 び 文 献 検 索 一 台湾国立成功大学 内科,*同 放射線科 **日本茨城県猿島郡総和町友愛記念病院内科 許

乗毅



莉 莉*欝



銀清



振 典**

恵 芳*

(平成4年1月29日 受付) (平成4年4月10日 受理) 68歳 の女 性,発 熱,戦 脹 に て 入 院.下

りつ,左 下 肢 の 紅 斑 性腫

か った.健 常 人 は 動 脈 炎,心

内 膜 炎 等 の 患 者 と同

肢 静 脈 造 影 お よ び肺 シ ン チ を施 行

様 に サ ル モ ネ ラ菌 血 症 の 時 に 深 部 静脈 血 栓 症 を 起

し,深 部 静 脈 血 栓 お よ び肺 塞 栓 を認 め た.血 培 に

こす か が 不 明 で あ る.し か し なが ら,本 症 例 の様

てSalmoNella

に深 部 静 脈 血 栓 症 を 起 こす 素 因 が な く,サ ル モ ネ

enteritidis groupC1を

検 出 した.

抗 凝 固 剤 と抗 菌 製 剤 を投 与 し,軽 快 退 院 とな った. 我 々は 英 文 献 を 調 べ た 限 り,今 ま で サ ル モ ネ ラ 菌 血 症 を 伴 った 深 部 静 脈 血 栓 症 が2例

にす ぎな

ラ菌 血 症 で 深 部 静脈 血 栓 症 を 起 こ した こ とが 示 唆. され た.今 後 症 例 を 重 ね て検 討 し て い く必 要 が あ る と思 わ れ る.

感染症学雑誌

第66巻 第8号

Salmonella-associated with deep vein thrombosis: report of a case and review of the literature.

1125 Salmonella-Associated with Case and Deep Vein Review Ping-I HSU, Yin-Ching Thrombosis: of the CHUANG, Report of a Literature Chen-...
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