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
楊
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
鄭
莉 莉*欝
荘
銀清
楊
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