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The way t o a man’s h eart can in fact be through his stomach

The way t o a man’s h eart can in fact be through his stomach. Cardiology Team Lourdes Hospital Dr Murphy, Dr Halley, Dr Keelan Derek Crinion 9 th May 2014. Case. PC: 61 year old gentleman D iarrhoea 7+/day for 6 days Abdo cramps Pyrexic , chills, vomited X1

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The way t o a man’s h eart can in fact be through his stomach

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  1. The way to a man’s heart can in fact be through his stomach Cardiology Team Lourdes Hospital Dr Murphy, Dr Halley, Dr Keelan Derek Crinion 9th May 2014

  2. Case • PC: 61 year old gentleman Diarrhoea 7+/day for 6 days Abdo cramps Pyrexic, chills, vomited X1 Malaise, headache • PMhx: Heavy smoker 30 day/30 years • Meds Nil, NKDA

  3. Case • Soc Hx. Lives alone, separated, daughters nearby poor social circumstance ?C2H5OH • FamHx. Strong IHD • SR: Low BMI, ? Weight loss Cough chronic prod White ?Chest discomfort several weeks prior

  4. Case • O/E: T 38.1°C, BP 95/67 HR118 (Reg) RR20 Sat 96%(RA) ,  BMI • S1S2 no A/M , No fluid overload • +Rhoncus, mild scattered early inspcreps • Abdo Soft NT ,Borborygmi, small inguinal hernia • Neuro intact, no meningism

  5. ECG

  6. Lab • WBC 14.5 91% Neut PLT 47 Hb 15.5 • CRP 293 • TROPONIN I (+ >0.1ng/ml) 1.3  1.37 • Urea 14.1 Creat 92 Na 124 K 3.9 • Bili47 Alp 228 GGT 575 ALT 52 • Mg .97 Phos .82 Ca 2.48 • INR 1.4 • Urine Na <20 Prot++ Bld+ Leuk +

  7. CXR

  8. First 48 hrs • Initially IV Co-amoxiclav + Fluid Support • Ongoing Temp Spikes 39°C peak • Diarrhoea, abdo cramps persisted • Provisional Blood Cultures : G − Bacilli • Changed to IV Tazocin+ Gentamycin

  9. CT TAP ?Source

  10. Echo

  11. Echo

  12. Echo

  13. Day 3 • Blood Culture Result Salmonella Typhimurium (Non-typhoidal) • Micro Input: Changed to IV Ceftriaxone • Notifiable Disease1 ? Source - no close contacts unwell - no restaurants known - no foreign travel

  14. Source?

  15. Cardiac CT

  16. Cardiac CT

  17. Cardiac CT

  18. Cardiac CT

  19. Cardiac CT • Coronaries , • multiplanar reconstruction

  20. Hypothesis Prior LAD infarct, Large Apical Aneurysm ± Mural Thrombus Salmonella Bacteremia Seeded apical aneurysm thrombus Infiltrated myocardium; abscess ±?Pseudoaneurysm formation Persistent Salmonella Dissemination

  21. Clinical Course • Ongoing Temp Spikes + Rpt cultures • Day 5 Micro: Δto IV Ciprofloxacin + Meropenem • Diarrhoea settled, stool day 8 negative • WBC 12.2 (N) CRP 146 Plt121 INR 1.3 Alb15 Bili 49 ALP 421 ALT 56 GGT 555 • Liver US, coarse echotex. Mild splenomeg. No stones • O/E: CCF ,Parox A fib , : Trop 1.4 BNP 1610 • CTC Discussion

  22. Echo

  23. Echo

  24. Repeat Cardiac CT

  25. Rpt Cardiac CT

  26. Clinical Course • Recurrent temp spikes, never stabilised • Day 28, further deterioration Hypothermic , oliguric ,BP Periph. shut down, Delirium • Lactate 18 , WBC 30 (N) Plt56 INR 1.7 Alb18, CRP 154 Urea 11.8Creat121 Na 128 K 6 Bili88 Alp 549 ALT 1161 GGT 330 • RIP

  27. P.M.

  28. P.M.

  29. P.M.

  30. P.M.

  31. P.M.

  32. P.M.

  33. Summary • V. rare presentation, of an unusual organism • Non-typhoidal Salmonella in Ireland 3 2012: 314 cases , 47% travel associated < 5% develop NT invasive salmonellosis4,5 RF’S : Immunocomp, Age extremes4 PPI / Gut Flora6

  34. Summary • Important Clinical Lessons - Persistent Pyrexia; ?Heart - Salmonella: : ? Risk of endovascular inf. - Dog Food ! Hand Hygiene - Challenging Management Med VsSurg? Timing? High Mortality6,7

  35. Thank You

  36. References • 1. Health Protection Surveillance Center. lnfectious diseases regulation 2011 www.hpsc.ie/NotifiableDiseases 2. Center for disese control and prevention. salmonella and dry pet food. www.cdc.gov/features/salmonelladrypetfood 3. National Salmonella Reference Laboratory of Ireland. Annual Report for 2012. www.hspc.ie

  37. References 4. Vugia DJ, Samuel M, Farley MM, et al. Invavise Salmonella Infections in the United States. FoodNet. 1996-1999:incidence, serotype distribution an outcome. Clin Infect Dis 2004;38 Suppl3:s142 5. Lee WS, Puthucheary SD, Boey CCM. Non-typhoid Salmonella Gastroenteritis. Journal of Paeiatrics and Child Health. 1988 33;387-390 6. Zhen Y, Rai MK, Adal A.K. Salmonella infeciton of a ventricular aneurysm with mural thrombus. Ann Thorac. Surg. 2000;69:939-40 7. Medical Treatment of a salmonella-infected left ventricular pseudoaneurysm: a case report. Yu TH, Hung WC, Chiu CA, Wang CP. Kaohsiung J Md Sci. Jan 2010, Vol 26. No 1.

  38. Pub Med Ref 1: Yu TH, Hung WC, Chiu CA, Wang CP. Medical treatment of a Salmonella-infectedleft ventricular pseudoaneurysm: a case report. Kaohsiung Med Sci. 2010Jan;26(1):35-9. doi: 10.1016/S1607-551X(10)70006-1. PubMed PMID: 20040471. 2: Mathieu P, Marchand R, Tardif J, Perrault LP. Ventriculotomy and resection forleft ventricular thrombus infection with Salmonella. Eur J Cardiothorac Surg.2000 Sep;18(3):360-2. PubMed PMID: 10973549. 3: Zheng Y, Rai MK, Adal KA. Salmonella infection of a ventricularaneurysm with mural thrombus. Ann Thorac Surg. 2000 Mar;69(3):939-40. PubMed PMID: 10750793. 4: Amyot R, Girouard Y, Baillot R, Sauvé C. Salmonella endocarditis of aventricular aneurysm: a case report and review of the literature. Can J Cardiol. 1997 Mar;13(3):299-301. Review. PubMed PMID: 9117919. 5: Utley JR, Story JR, Dandilides PC. Resection of infected ventricular aneurysm (Salmonella) following septic saddle embolus. J Card Surg. 1993 Mar 8(2):143-7.PubMed PMID: 8461496. 6: de la Fuente C, Llorens V, Banzo I, Carril JM. Gallium-67 citrate scintigraphyin Salmonella infected thrombus of a left ventricular aneurysm. J Nucl Med.1989 Jul;30(7):1277-8. PubMed PMID: 2738709. 7: Echevarria S, Arjona R, Alonso J, Riancho JA, Revuelta JM, Macias JG. False aneurysm formation after Salmonella virchowinfection of a pre-existentventricularaneurysm--survivalaftersurgicalresection. Postgrad Med J. 1989 Mar;65(761):168-70. PubMed PMID: 2813237; PubMed Central PMCID: PMC2429238. 8: Schofield PM, Rahman AN, Ellis ME, Dunbar EM, Bray CL, Brooks N. Infection of cardiacmuralthrombusassociated with leftventricularaneurysm. Eur Heart J 1986 Dec;7(12):1077-82. PubMed PMID: 3549314. 9: Catherwood E, Mintz GS, Kotler MN, Kimbiris D, Lemmon W, Parry WR. Pseudoaneurysmof the leftventriclecomplicated by Salmonella typhimuriuminfection. Recognition by two-dimensional echocardiography. Am J Med1980May;68(5):782-6. PubMed PMID: 6990760. 10: Kortleve JW, Düren DR, Becker AE. Cardiac aneurysm complicated by Salmonella abscess. A clinicopathologic correlation in two patients. Am J Med. 1980Mar;68(3):395-400. PubMed PMID: 6892668.

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