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Thoracic empyema due to Salmonella enteritidis infection in a patient with breast cancer
ARTICLE IN PRESS Respiratory Medicine Extra (2007) 3, 89–91
respiratory MEDICINE Extra
CASE REPORT
Thoracic empyema due to Salmonella enteritidis infection in a patient with breast cancer Hirokazu Tokuyasua,, Ryota Okazakia, Etsuko Watanabea, Yuji Kawasakia, Ryo Maedab, Noritaka Isowab, Yasuto Uedac, Eiji Shimizuc a
Division of Respiratory Medicine, Matsue Red Cross Hospital, 200 Horomachi, Matsue, Shimane 690 8506, Japan Thoracic Surgery, Matsue Red Cross Hospital, 200 Horomachi, Matsue, Shimane 690 8506, Japan c Division of Medical Oncology and Molecular Respirology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan b
Received 23 March 2007; accepted 4 April 2007
KEYWORDS Salmonella enteritidis; Empyema; Breast cancer
Summary We report a rare case of thoracic empyema due to Salmonella enteritidis infection in a 79year-old woman with breast cancer and diarrhea. The presence of the bacteria was determined by culturing the stool, blood, and pleural fluid. Although it is a rare occurrence, Salmonella empyema should be excluded in a febrile cancer patient with pleural effusion and a recent history of enteritis. & 2007 Elsevier Ltd. All rights reserved.
Introduction Salmonella are Gram-negative bacilli belonging to the Enterobacteriaceae family. Nontyphoid Salmonella species commonly cause gastroenteritis. Although immunocompromised hosts sometimes contract focal infection such as appendicitis, cholesystitis, or subphrenic abscess directly or indirectly connected with the gastrointestinal tract due to nontyphoid Salmonella species, very few patients suffer from empyema.1–3 We report an extremely rare case of
Corresponding author. Tel.: +81 852 24 2111;
fax: +81 852 31 9783. E-mail address: [email protected] (H. Tokuyasu). 1744-9049/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmedx.2007.04.001
thoracic empyema due to Salmonella enteritidis infection in a patient with breast cancer and enteritis.
Case report In February 2006, a 79-year-old woman was referred to our hospital due to mild diarrhea and low-grade fever of 3 months duration. She had undergone modified radical mastectomy for right breast cancer in July 2004. Nine months later, she developed liver metastasis, which was under observation without treatment. On admission, she was febrile and her breath sound on the left side was diminished. Laboratory investigations revealed a hemoglobin level of 7.6 g/dL, and a total leukocyte count of 15,300/ mm3 comprising 76% neutrophiles, 14% lymphocytes, 9%
ARTICLE IN PRESS 90
Figure 1 Computed tomographic scan on admission shows left pleural effusion. There are multiple metastases in the liver and no ascites.
monocytes, and 1% eosinophils. The level of C-reactive protein was elevated to 15.6 mg/dL. The levels of the serum enzymes tested were as follows: aspartate aminotransferase, 213 IU/L (normal 11–34 IU/L); alanine aminotransferase, 37 IU/L (normal 7–34 IU/L); alkaline phosphatase, 1304 IU/L (normal 110–340 IU/L); and lactate dehydrogenase, 894 IU/L (normal 110–230 UL). The albumin level was decreased to 1.9 g/dl, and the sodium level was elevated to 154 mEq/L. Chest roentgenogram and computed tomographic (CT) scan demonstrated left pleural effusion (Fig. 1). We aspirated 500 ml of bloody pleural effusion containing no malignant cells, which was subject to culture. She was empirically treated with ciprofloxacin intravenously administered at a dose of 300 mg twice daily. The patient was in the end stage of breast cancer, and on her request, chest tube drainage was not performed. Seven days later, pleural effusion, blood, and stool culture yielded S. enteritidis. The patient remained critically ill, and 11 days after admission, she died due to multiple organ failure. A post-mortem examination was not performed (Fig. 1).
Discussion Clinical forms of salmonellosis are gastroenteritis, sepsis, focal infections, and establishment of the carrier state.3 In
H. Tokuyasu et al. the old analysis of 7779 human salmonellosis identified in the New York Salmonella Center from 1939 to 1955, focal manifestations were present in 572 (7.4%).1 Of 572, the cases of pneumonia or pleurisy were 85 (14.9%). The other authors reported that among 125 cases of extraintestinal infection caused by nontyphoid salmonellae, pleuropulmonary involvements were reported in 11 cases and empyema in only one case.4 Thus, in the focal manifestations, pulmonary infection due to salmonellae is rare. Salmonella species have been classified into approximately 2000 serologic types. S. enteritidis and S. typhimurium are the most common cause of salmonella gastroenteritis.5 These two serotypes are known to cause extraintestinal infections and bacteremia occasionally. Crum reviewed 28 cases of thoracic empyema due to nontyphoid salmonellae reported in English literature from 1946 to 2004. Of 28 cases, 10 were due to S. typhimurium, 6 due to S. enteritidis, and 12 due to others.2 Cachexia, weight loss, and malnutrition shown in advanced cancer patients are linked to alterations in host defenses. Debility and anemia accompanied with progressive malignant diseases predispose the patients to infections. Wolfe reported that 84 (93%) of 95 patients with Salmonella infections had neoplastic diseases.6 Because Salmonella species are intracellular pathogens, the infectious process is affected by the deteriorated lymphocyte or macrophage function in the end-stage cancer patients.7 There are two possible pathways from Salmonella infection to pleural empyema. The first is the aspirated bacteria causing pneumonia and leading the direct intrusion into the pleural space. The second is the invasion of circulated microorganisms into the pleural space in the bacteremia patient. This process is presumably facilitated in the patients under the immunocompromised condition. Our patient possibly developed the empyema through the latter pathway, because the bacteria were cultured in her stool, blood, and the pleural fluid. Fluoroquinolone therapy is the mainstay of salmonellosis. Surgical drainage should be combined with antibiotics therapy for the patient with focal infection such as empyema.8 Our patient was intravenously administered ciprofloxacin without tube drainage since she was in the end stage of breast cancer and refused any surgical treatment. Although it is a rare occurrence, salmonellae empyema should be excluded in a febrile cancer patient with pleural effusion and a recent history of enteritis.9 Antimicrobial therapy alone is insufficient for thoracic empyema, and a surgical intervention should be required for a better outcome.
References 1. Han T, Sokal JE, Neter E. Salmonellosis in disseminated malignant disease: a seven-year review (1959–1965). N Engl J Med 1967;276:1046–52. 2. Crum NF. Non-typhi Salmonella empyema: case report and review of the literature. Scand J Infect Dis 2005;37:852–7. 3. Saphra I, Winter JW. Clinical manifestations of salmonellosis in man: evaluation of 7779 human infections identified at New York Salmonella Center. New Eng J Med 1957;256:1128–34.
ARTICLE IN PRESS Salmonella enteritidis Empyema 4. Aguado JM, Obeso G, Cabanillas JJ, Fernandez-Guerrero M, Ales J. Pleuropulmonary infections due to nontyphoid strains of Salmonella. Arch Intern Med 1990;150:54–6. 5. Darwin KH, Miller VL. Molecular basis of the interaction of Salmonella with the intestinal mucosa. Clin Microbiol Rev 1999;12:405–28. 6. Wolfe MS, Armstrong D, Louria DB, Blevins A. Salmonellosis in patients with neoplastic disease. Arch Intern Med 1971;128:546–54.
91 7. Bodey GP. Infection in cancer patients. A continuing association. Am J Med 1986;81(1A):11–26. 8. Sethia B, Reece IJ, Davidson KG. Empyema, subphrenic abscess and pyaemic splenic necrosis. A rare complication of Salmonella enteritidis infection. J R Coll Surg Edinb 1985;30: 204–5. 9. Gill GV, Holden A. A malignant pleural effusion infected with Salmonella enteritidis. Thorax 1996;51:104–5.
respiratory MEDICINE Extra
CASE REPORT
Thoracic empyema due to Salmonella enteritidis infection in a patient with breast cancer Hirokazu Tokuyasua,, Ryota Okazakia, Etsuko Watanabea, Yuji Kawasakia, Ryo Maedab, Noritaka Isowab, Yasuto Uedac, Eiji Shimizuc a
Division of Respiratory Medicine, Matsue Red Cross Hospital, 200 Horomachi, Matsue, Shimane 690 8506, Japan Thoracic Surgery, Matsue Red Cross Hospital, 200 Horomachi, Matsue, Shimane 690 8506, Japan c Division of Medical Oncology and Molecular Respirology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan b
Received 23 March 2007; accepted 4 April 2007
KEYWORDS Salmonella enteritidis; Empyema; Breast cancer
Summary We report a rare case of thoracic empyema due to Salmonella enteritidis infection in a 79year-old woman with breast cancer and diarrhea. The presence of the bacteria was determined by culturing the stool, blood, and pleural fluid. Although it is a rare occurrence, Salmonella empyema should be excluded in a febrile cancer patient with pleural effusion and a recent history of enteritis. & 2007 Elsevier Ltd. All rights reserved.
Introduction Salmonella are Gram-negative bacilli belonging to the Enterobacteriaceae family. Nontyphoid Salmonella species commonly cause gastroenteritis. Although immunocompromised hosts sometimes contract focal infection such as appendicitis, cholesystitis, or subphrenic abscess directly or indirectly connected with the gastrointestinal tract due to nontyphoid Salmonella species, very few patients suffer from empyema.1–3 We report an extremely rare case of
Corresponding author. Tel.: +81 852 24 2111;
fax: +81 852 31 9783. E-mail address: [email protected] (H. Tokuyasu). 1744-9049/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmedx.2007.04.001
thoracic empyema due to Salmonella enteritidis infection in a patient with breast cancer and enteritis.
Case report In February 2006, a 79-year-old woman was referred to our hospital due to mild diarrhea and low-grade fever of 3 months duration. She had undergone modified radical mastectomy for right breast cancer in July 2004. Nine months later, she developed liver metastasis, which was under observation without treatment. On admission, she was febrile and her breath sound on the left side was diminished. Laboratory investigations revealed a hemoglobin level of 7.6 g/dL, and a total leukocyte count of 15,300/ mm3 comprising 76% neutrophiles, 14% lymphocytes, 9%
ARTICLE IN PRESS 90
Figure 1 Computed tomographic scan on admission shows left pleural effusion. There are multiple metastases in the liver and no ascites.
monocytes, and 1% eosinophils. The level of C-reactive protein was elevated to 15.6 mg/dL. The levels of the serum enzymes tested were as follows: aspartate aminotransferase, 213 IU/L (normal 11–34 IU/L); alanine aminotransferase, 37 IU/L (normal 7–34 IU/L); alkaline phosphatase, 1304 IU/L (normal 110–340 IU/L); and lactate dehydrogenase, 894 IU/L (normal 110–230 UL). The albumin level was decreased to 1.9 g/dl, and the sodium level was elevated to 154 mEq/L. Chest roentgenogram and computed tomographic (CT) scan demonstrated left pleural effusion (Fig. 1). We aspirated 500 ml of bloody pleural effusion containing no malignant cells, which was subject to culture. She was empirically treated with ciprofloxacin intravenously administered at a dose of 300 mg twice daily. The patient was in the end stage of breast cancer, and on her request, chest tube drainage was not performed. Seven days later, pleural effusion, blood, and stool culture yielded S. enteritidis. The patient remained critically ill, and 11 days after admission, she died due to multiple organ failure. A post-mortem examination was not performed (Fig. 1).
Discussion Clinical forms of salmonellosis are gastroenteritis, sepsis, focal infections, and establishment of the carrier state.3 In
H. Tokuyasu et al. the old analysis of 7779 human salmonellosis identified in the New York Salmonella Center from 1939 to 1955, focal manifestations were present in 572 (7.4%).1 Of 572, the cases of pneumonia or pleurisy were 85 (14.9%). The other authors reported that among 125 cases of extraintestinal infection caused by nontyphoid salmonellae, pleuropulmonary involvements were reported in 11 cases and empyema in only one case.4 Thus, in the focal manifestations, pulmonary infection due to salmonellae is rare. Salmonella species have been classified into approximately 2000 serologic types. S. enteritidis and S. typhimurium are the most common cause of salmonella gastroenteritis.5 These two serotypes are known to cause extraintestinal infections and bacteremia occasionally. Crum reviewed 28 cases of thoracic empyema due to nontyphoid salmonellae reported in English literature from 1946 to 2004. Of 28 cases, 10 were due to S. typhimurium, 6 due to S. enteritidis, and 12 due to others.2 Cachexia, weight loss, and malnutrition shown in advanced cancer patients are linked to alterations in host defenses. Debility and anemia accompanied with progressive malignant diseases predispose the patients to infections. Wolfe reported that 84 (93%) of 95 patients with Salmonella infections had neoplastic diseases.6 Because Salmonella species are intracellular pathogens, the infectious process is affected by the deteriorated lymphocyte or macrophage function in the end-stage cancer patients.7 There are two possible pathways from Salmonella infection to pleural empyema. The first is the aspirated bacteria causing pneumonia and leading the direct intrusion into the pleural space. The second is the invasion of circulated microorganisms into the pleural space in the bacteremia patient. This process is presumably facilitated in the patients under the immunocompromised condition. Our patient possibly developed the empyema through the latter pathway, because the bacteria were cultured in her stool, blood, and the pleural fluid. Fluoroquinolone therapy is the mainstay of salmonellosis. Surgical drainage should be combined with antibiotics therapy for the patient with focal infection such as empyema.8 Our patient was intravenously administered ciprofloxacin without tube drainage since she was in the end stage of breast cancer and refused any surgical treatment. Although it is a rare occurrence, salmonellae empyema should be excluded in a febrile cancer patient with pleural effusion and a recent history of enteritis.9 Antimicrobial therapy alone is insufficient for thoracic empyema, and a surgical intervention should be required for a better outcome.
References 1. Han T, Sokal JE, Neter E. Salmonellosis in disseminated malignant disease: a seven-year review (1959–1965). N Engl J Med 1967;276:1046–52. 2. Crum NF. Non-typhi Salmonella empyema: case report and review of the literature. Scand J Infect Dis 2005;37:852–7. 3. Saphra I, Winter JW. Clinical manifestations of salmonellosis in man: evaluation of 7779 human infections identified at New York Salmonella Center. New Eng J Med 1957;256:1128–34.
ARTICLE IN PRESS Salmonella enteritidis Empyema 4. Aguado JM, Obeso G, Cabanillas JJ, Fernandez-Guerrero M, Ales J. Pleuropulmonary infections due to nontyphoid strains of Salmonella. Arch Intern Med 1990;150:54–6. 5. Darwin KH, Miller VL. Molecular basis of the interaction of Salmonella with the intestinal mucosa. Clin Microbiol Rev 1999;12:405–28. 6. Wolfe MS, Armstrong D, Louria DB, Blevins A. Salmonellosis in patients with neoplastic disease. Arch Intern Med 1971;128:546–54.
91 7. Bodey GP. Infection in cancer patients. A continuing association. Am J Med 1986;81(1A):11–26. 8. Sethia B, Reece IJ, Davidson KG. Empyema, subphrenic abscess and pyaemic splenic necrosis. A rare complication of Salmonella enteritidis infection. J R Coll Surg Edinb 1985;30: 204–5. 9. Gill GV, Holden A. A malignant pleural effusion infected with Salmonella enteritidis. Thorax 1996;51:104–5.