S5133 Myocarditis and Salmonella—A Rare Yet Deadly Combination

Introduction: Myocarditis is a rare extra-intestinal manifestation of non-typhoid Salmonella (NTS) infection. Salmonella enteritidis was the most common pathogen identified with myocarditis and is associated with a high mortality rate. Case Description/Methods: A 25-year-old man with a past medical history positive for chronic sinusitis s/p balloon sinuplasty presented to an outside hospital with severe chest pain with radiation to the neck and nausea. He recalled myalgias, fever and diarrhea several days prior to admission and history of eating eggs and sushi from a local restaurant prior to the onset of diarrhea. On admission his vitals were as follows: BP 112/65 mmHg, HR 101/min, temperature 37.3°C and respiratory rate 18 breaths/min with oxygen saturation of 97% on room air. Physical examination was unremarkable. Initial electrocardiogram (EKG) showed diffuse, concave-upwards ST-segment elevation. Initial troponin was markedly elevated at 40,000 K (normal 0.000-0.034 ng/mL). CBC showed Hb of 18.5, white blood cell of 14.6 and Platelet count 252,000. He underwent a CTA without evidence of aortic dissection. He was subsequently transferred to the cardiac intensive care unit (ICU). Transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction (EF) of 50-55% with mildly enlarged left ventricle. Due to suspicion for myocarditis, a cardiac magnetic resonance was done which showed extensive areas of multifocal mild myocardial and subepicardial early and late gadolinium enhancement near circumferentially involving the myocardium in multiple segments especially in the mid and apical segments overall felt to be most consistent with myopericarditis and was started on colchicine. Blood cultures from the outside hospital grew Salmonella enteridis- susceptible to rocephin and ciprofloxacin. The patient improved and was discharged home on cardiac medications and a 2 week course of ciprofloxacin. Repeat TTE at 3 months showed LVEF had normalized to 70%. Discussion: Bacterial myocarditis is uncommon with a prevalence ranging from 0.2% to 1.5%. However, it should always be considered in patients with sepsis and ventricular dysfunction. NTS are food-borne pathogens that are responsible for diarrheal illness. There is about a 5% incidence of invasion beyond the gastrointestinal tract present most commonly in immunocompromised hosts. A large study of over 7000 human Salmonella infections noted cardiac involvement in the form of endocarditis in 20 patients all of whom had a rapidly fatal outcome.