Ann Thorac Surg 2000;69:939-940
© 2000 The Society of Thoracic Surgeons
Case Reports
Salmonella infection of a ventricular aneurysm with mural thrombus
Yunli Zheng, MDa,
Mandeep K. Rai, MDa,
Karim A. Adal, MDa
a Department of Infectious Disease, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Address reprint requests to Dr Adal, Department of Infectious Disease, The Cleveland Clinic Foundation, Desk S32, 9500 Euclid Ave, Cleveland, OH 44195
e-mail: adalk{at}cesmtp.ccf.org
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Abstract
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We describe a case of salmonella infection of a left ventricular aneurysm with a mural thrombus and review 12 cases described in the literature. This entity should be looked for in any patient with persistent or relapsing salmonella bacteremia in whom an intracardiac thrombus is demonstrated. Nuclear imaging may help in the diagnosis. A combined medical and surgical approach should be aggressively pursued because patients who do not undergo an aneurysmectomy are unlikely to survive.
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Introduction
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Salmonellae have a propensity for infection of vascular sites such as the aorta and other large- and medium-sized vessels. Infection of the heart is rare, but cases of salmonella endocarditis, myocarditis, and pericarditis have been described. A recent case of salmonella infection of a left ventricular aneurysm with a mural thrombus at our institution prompted us to review the literature on that entity. A Medline search was performed going back to 1966, and the bibliographies of relevant articles were reviewed. We included only cases with a demonstrated thrombus in a left ventricular aneurysm. Care was taken to ensure that the same patient was not included twice in our analysis, as some patients were described more than once in the literature.
A 76-year-old woman was transferred to the Cleveland Clinic Foundation for evaluation and treatment of a left ventricular aneurysm. Her past medical history was significant for gastritis, for which she took ranitidine. In November 1994, she suffered an inferior wall myocardial infarction and underwent percutaneous angioplasty. During that admission, she developed fever and chills, and blood cultures grew Salmonella enteritidis. She was treated with intravenous ciprofloxacin and ampicillin for 4 weeks. An abdominal ultrasound revealed gallstones. During the following months, she complained of persistent lethargy, fatigue, poor appetite, night sweats, and a 10- to 15-pound weight loss. In August 1995, these symptoms worsened and she was readmitted. Blood cultures again yielded S enteritidis. The patient was started on intravenous ampicillin. An echocardiogram showed a posterior wall aneurysm of the left ventricle and mitral regurgitation. A gallium-67 citrate scan indicated increased uptake within the posterior portion of the left ventricle. The patient was transferred to our hospital. Petechiae were noted on the conjunctiva of the left lower eyelid and on the left sole, and she had splenomegaly. Her sedimentation rate was 51 mm/hour (normal < 30 mm/hour). A computed tomography scan of the chest revealed a large aneurysm of the left ventricle with thrombus formation. Our clinical diagnosis was salmonella infection of the left ventricular aneurysm mural thrombus, and on the ninth hospital day, she underwent combined cholecystectomy and left ventricle aneurysmectomy. Intraoperatively, a large posterior left ventricular aneurysm was found and its volume exceeded that of both the right and left ventricular cavities. The aneurysm had ruptured into the left lung through the pericardium posterior to the phrenic nerve. The thrombus was liquefied with a small amount of purulence. The bleeding was noted to be intense during surgery, and it was almost impossible to maintain systemic vascular resistance, presumably secondary to manipulation of the thrombus with resulting endotoxemia. The patient remained hemodynamically unstable in the intensive care unit and expired. Pathologic examination of the surgical specimen revealed a left ventricular aneurysm with an organizing clot with acute inflammation. Gram stain was negative but cultures from the aneurysm grew S enteritidis.
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Comment
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We found 12 additional cases of salmonella infection of a lft ventricular aneurysm mural thrombus, dating back to 1959 [1–12]. Of the total of 13 cases, our patient was the only woman, perhaps reflecting the higher incidence of coronary artery disease in men. The median age was 64 years, with a range of 52 to 84 years. Not surprisingly, 10 patients (77%) had evidence of a prior myocardial infarction, and 2 additional patients had asymptomatic coronary artery disease. Six patients (46%) had gastritis, peptic ulcer disease, or prior gastric surgery, an interesting finding because lack of gastric acidity through surgery or antiacid medications decreases the infectious dose of salmonella. Surprisingly, only our patient was reported to have gallstones. Gastrointestinal manifestations were common, occurring in 9 patients (69%). One patient had documented salmonella gastroenteritis 3 weeks before his presentation, and another had a febrile diarrheal episode for a few days while on a trip to Columbia 6 months prior. Two patients had embolic phenomena, 1 who presented with a stroke, and the other with an abdominal aortic embolus. Eleven of the 13 patients had positive blood cultures, 8 had a positive aneurysm culture, and an additional patient had a positive culture from an abdominal aortic embolus [10]. Six patients had a positive stool culture.
As part of the diagnostic workup, an abdominal ultrasound should be done to evaluate for the presence of gallstones because a cholecystectomy may be warranted if the patient has cholelithiasis and is thus potentially a chronic carrier. Indium or gallium scanning was positive in our patient and three additional cases [7, 9, 11]. Nuclear testing can be a useful method for distinguishing between infected and uninfected thrombi, is invaluable when positive, and can help determine whether additional occult foci of infection are present or not, such as atheromatous aortic plaques [11].
Overall survival was better in more recent years, but only 6 of the 13 patients (46%) survived. All 4 patients treated only medically expired. The survival rate in the 9 patients in whom an aneurysmectomy was performed was 67%. The three deaths in this subgroup occurred intraoperatively or immediately postoperatively, including the 2 patients who had rupture of the aneurysm into the left lung and died of circulatory collapse. The outcome was thus clearly better when surgery was performed as opposed to medical therapy alone.
Transient salmonella bacteremia in patients with gastroenteritis can result in seeding of extraintestinal (both extravascular and intravascular) sites. The incidence of endovascular infection in patients with bacteremia ranges from 9% to 17%, with higher incidences (up to 35%) in older patients. Salmonellae have a predilection for diseased vascular walls, and it is not surprising that mural thrombi would provide an ideal environment for seeding and growth of the organism. The presence of persistent or relapsing salmonella bacteremia after an apparently adequate course of treatment should arouse suspicion of an infected intravascular lesion. We believe that an intracardiac thrombus should be added to the list of underlying endovascular abnormalities that have the potential to be seeded by salmonellae and that should be looked for in these patients.
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References
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McNally E.M., Kennedy R.J., Grace W.R. Salmonella infantis infection of a pre-existent ventricular aneurysm. Am Heart J 1964;68:541-548.
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Accepted for publication July 13, 1999.
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Abstract
Introduction
