Salmonella enterica pneumonia in a patient with lung cancer.

Abstract

A case of life-threatening Salmonella enterica serotype Enteritidis pneumonia in a febrile patient with lung cancer is described. The organism was isolated from the sputum, the protected specimen brush material of bronchial secretions, and the stool. Despite the early administration of appropriate and adequate treatment, the patient died 7 days after the onset of the infection.

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JOURNAL OF CLINICAL MICROBIOLOGY, Dec. 2003, p. 5820–5822
0095-1137/03/$08.00?0DOI: 10.1128/JCM.41.12.5820–5822.2003
Copyright © 2003, American Society for Microbiology. All Rights Reserved.
Vol. 41, No. 12
Salmonella enterica Pneumonia in a Patient with Lung Cancer
George Samonis,* Sofia Maraki, Charalambos Kouroussis, Dimitrios Mavroudis, and
Vassilios Georgoulias
School of Medicine, The University of Crete, Heraklion, Crete, Greece
Received 20 June 2003/Returned for modification 14 August 2003/Accepted 18 September 2003
A case of life-threatening Salmonella enterica serotype Enteritidis pneumonia in a febrile patient with lung
cancer is described. The organism was isolated from the sputum, the protected specimen brush material of
bronchial secretions, and the stool. Despite the early administration of appropriate and adequate treatment,
the patient died 7 days after the onset of the infection.
CASE REPORT
The patient was a 72-year-old white male with small cell lung
cancer, diagnosed 10 months prior to the present admission.
He was initially treated for his cancer with three cycles of
chemotherapy with cisplatin and etoposide, with partial re-
sponse. The therapeutic effort was continued with radiation
treatment of the primary tumor followed by second-line che-
motherapy with cisplatin and paclitaxel. Five weeks after he
completed radiation treatment, radiation pneumonitis was sus-
pected and was treated with corticosteroids (prednisolone, 50
mg/day for 15 days). He continued on corticosteroids in ta-
pered doses, and 20 days prior to the present admission he
received the first cycle of his second-line chemotherapy.
His past medical history was significant for a myocardial
infarction in 1979. He had undergone surgery for coronary
arterial bypass grafting in 1998. He was on proton pump in-
hibitors (omeprazole) for gastric protection during the time he
was receiving steroids for radiation pneumonitis. He was also
on nitrites, calcium channel antagonists, and low-dose acetyl-
salicylic acid.
He was admitted with a low-grade fever of 37.5°C, dyspnea,
tachypnea, chest discomfort, and a productive cough with pu-
rulent sputum. His vital signs on admission were the following:
pulse rate of 126 beats/min, blood pressure of 150/75 mm Hg,
and respiration rate of 20 breaths/min. Examination of the
chest revealed decreased breath sounds and rales over the left
middle and lower lung fields. A chest X-ray showed diffuse
consolidation of the lower lobe of the right lung (Fig. 1). The
white blood cell count was 8,500/mm3with an absolute gran-
ulocyte count of 7,700/mm3and with marked lymphocytopenia
(absolute lymphocyte count, 100/mm3). Serology for human
immunodeficiency virus serotypes 1 and 2 was negative.
Sputum, protected specimen brush (PSB) material of bron-
chial secretions, and three sets of blood specimens were taken
for cultures on admission. He was also started on empirical
antibiotic treatment with trimethoprim-sulfamethoxazole (240/
1,200 mg intravenously [i.v.], four times a day), ceftazidime (2
g i.v., three times a day), and clindamycin (600 mg i.v., three
times a day). He also received bronchodilators.
Twenty-four hours later, sputum and PSB sample cultures
yielded a gram-negative aerobic rod identified as Salmonella
enterica serotype Enteritidis, at a concentration of 2 ? 108
CFU/ml in the sputum and 3 ? 103CFU/ml in the PSB sample,
while all blood cultures were negative. Stool specimens cul-
tured for enteric pathogens also yielded the same organism.
Antimicrobial susceptibility testing was performed by the disk-
diffusion method following the recommendations of the Na-
tional Committee for Clinical Laboratory Standards (12), and
MICs of the antibiotics were determined by the E-test. Sus-
ceptibilities and MICs were identical for all three isolates. The
isolates were sensitive to commonly used antibiotics, such as
ampicillin (MIC ? 0.75 ?g/ml), ceftazidime (MIC ? 0.125
?g/ml), ceftriaxone (MIC ? 0.094 ?g/ml), cefotaxime (MIC ?
0.094 ?g/ml), ciprofloxacin (MIC ? 0.016 ?g/ml), and tri-
methoprim-sulfamethoxazole (MIC ? 0.064 ?g/ml).
Two days after admission, although the patient was receiving
two antibiotics to which Salmonella was sensitive, he developed
a fever of 39°C, his respiratory function worsened (severe dys-
pnea, tachypnea, and oxygen saturation of 70%), and his gen-
eral condition deteriorated. He was transferred to the intensive
care unit (ICU). The patient was initially treated with nonin-
vasive positive-pressure ventilation. Three additional sets of
blood cultures taken while the patient was febrile were nega-
tive. Three days after his admission to the hospital and 24 h
after his admission in the ICU, the patient developed respira-
tory failure due to the extensive pulmonary involvement and
was put on mechanical ventilation via an endotracheal tube.
The clinical course was consistent with acute respiratory dis-
tress syndrome (ARDS), although the tracheal secretion cul-
tures were negative. His condition continued to deteriorate,
and finally he expired 5 days after his transfer to the ICU.
Discussion. Infections due to nontyphoid salmonellae are
increasing worldwide (9, 14). Salmonella enterica has been the
enteropathogen most frequently isolated in Greece, with sero-
type Enteritidis being the most common (10).
Clinical forms of salmonellosis are gastroenteritis, bactere-
mia, focal infections such as septic arthritis, osteomyelitis, cho-
lecystitis, endocarditis, meningitis, and a carrier state (13). An
increased incidence of salmonellosis has been described in
* Corresponding author. Mailing address: Division of Medicine, The
University of Crete, P. O. Box 2203, 71003 Heraklion, Crete, Greece.
Phone: 302810 392747.Fax:
georgsec@med.uoc.gr.
30 2810392802.E-mail:
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patients with impaired cell-mediated immunity because Salmo-
nella is an intracellular pathogen, and an intact cellular immu-
nity is required for its eradication. Hence, conditions predis-
posingtosalmonellosis include
immunodeficiency virus, diabetes mellitus, prolonged cortico-
steroid therapy, alcohol abuse, some types of chemotherapy,
and some types of malignancies, mainly leukemias and lym-
phomas (2–4, 8, 15, 17). Wolfe et al. evaluated salmonella
infections in patients with neoplastic diseases. Among the 86
patients described, more than half had hematologic malignan-
cies (17).
Salmonella pneumonia due to nontyphoid salmonellae is
rare (1, 5). Prior lung disease is associated with a higher risk for
lung involvement. In a review of 36 patients with Salmonella
pneumonia, empyema, or lung abscess, Cohen et al. noted that
13 of them (36%) had prior abnormalities of the lung or
pleura. Among them seven had lung malignancies (5).
The most common serotypes isolated from salmonella pul-
monary infections are S. enterica serotype Typhimurium and S.
enterica serotype Choleraesuis (1, 5, 7). Serotype Enteritidis
has been considered the causative agent in only four cases of
respiratory infection according to the available literature (1).
In the present case the isolation of the bacterium from the
sputum and the PSB samples in high concentrations make the
diagnosis certain. Additionally, the organism was isolated from
stools. Many factors may have contributed to the development
of the infection, such as cancer of the lung, chemotherapy with
paclitaxel, already known to cause lymphopenia and lympho-
cyte dysfunction (16), irradiation of the lung, and prolonged
administration of corticosteroids. The patient had no symp-
toms from the gastrointestinal tract, and the fact that Salmo-
nella was isolated from his stools does not necessarily mean
that he was a carrier. The patient was most likely swallowing
infected respiratory secretions, and this could account for the
positive cultures. Since he was on antacids for a long period, we
hypothesize that the source of the infection could be aspiration
of colonized or infected gastric secretions; due to the de-
creased gastric acidity, Salmonella from the gallbladder and the
upper intestinal tract could have colonized the stomach and
infection withhuman
the esophagus. Alternatively, it could be a self-limited bacte-
remia with seeding of the lung. Other mechanisms known from
the literature to be implicated in the pathogenesis of pulmo-
nary Salmonella infections include extension of the infection
from a nearby site (5).
Salmonella pneumonia requires at least 2 weeks of paren-
teral or oral antibiotic therapy (11). Mortality is high in pa-
tients over the age of 60, with underlying malignancies and
immunosuppression due to antineoplastic treatments (1, 5).
Aguado et al. reported a mortality rate of 63% among immu-
nosuppressed patients with pleuropulmonary diseases caused
by nontyphoid salmonellae (1). In the present case, although
appropriate and adequate antibiotic therapy was instituted
early on, the patient succumbed a week later due to respiratory
failure from extensive pulmonary involvement and develop-
ment of ARDS. ARDS is a very dangerous complication of
severe infection associated with high mortality (6). Addition-
ally, the present patient was debilitated, suffering from pro-
gressive neoplasia and severe lymphopenia due to previous
anticancer treatments. All these adverse factors may account
for the lack of response to two effective antibiotic treatments.
Nontyphoid Salmonella organisms, although uncommon,
should be considered among the pathogens responsible for
gram-negative pneumonia in immunocompromised patients
with lung cancer undergoing immunosuppressive treatment.
The disease is severe and associated with high mortality. How-
ever, early institution of empirical antibiotic treatment for se-
vere pneumonia that includes a third- or fourth generation
cephalosporin, an antipseudomonal penicillin-beta lactamase
inhibitor combination, or a quinolone would be appropriate in
treating nontyphoidal Salmonella pneumonia.
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5822 CASE REPORTS J. CLIN. MICROBIOL.