World Heart Journal Volume 9, Number 3
ISSN: 1556-4002 © Nova Science Publishers, Inc.
Salmonella Infection Masquerading as ST Elevation Myocardial Infarction
Alec Kherlopian1,, MD, MPH, Sunita Sharma2, MD, PhD, and Sherif B Labib2, MD 1
Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA 2 Department of Cardiology, Lahey Hospital and Medical Center, Burlington, MA, USA
Abstract Chest pain with associated ST elevation myocardial infarction (STEMI) is a common presentation to the Emergency Department; however, it is uncommon for a diarrheal illness to provoke such an event. In this case report of a young man presenting with chest pain and diarrhea, diagnostic investigations established a diagnosis of non-typhoid Salmonella myocarditis masquerading as a STEMI. Keywords: myocarditis, Salmonella virchow
acute
coronary
syndrome,
Introduction Acute myocarditis is myocardial inflammation commonly caused by a viral infection; it is infrequently caused by bacteria. Of the bacterial causes, Salmonella is a very rare source [1]. Both typhoid and non-typhoid Salmonella have been associated with myocarditis. A recent world-wide literature search by Villablanca and colleagues revealed only 24 cases of non-typhoid Salmonella (NTS) associated myocarditis [1]. Recognition of myocarditis and appropriate subsequent treatment is important as the condition can evolve into dilated cardiomyopathy or ventricular arrhythmias [2, 3]. In this case report, we describe a case of acute myocarditis in a previously healthy, young male infected with non-typhoid Salmonella of Salmonella virchow serotype.
Case Description
Corresponding Author:
[email protected]
A 28-year-old male with a past medical history of hypertension presented to the emergency department
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Alec Kherlopian, Sunita Sharma, and Sherif B Labib
after experiencing acute-onset central, throbbing chest pain with radiation to right and left aspects of his chest. One week prior to the chest pain, the patient had experienced non-bloody diarrhea and nausea, which improved throughout the week. His pain subsided upon arrival to the emergency department after receiving full dose aspirin and sublingual nitroglycerin by Emergency Medical Services. Vital signs were within normal limits. Physical exam was unremarkable; there was no rub or third heart sound. Labs were significant for bandemia of 15%, toxic granulations of white blood cells, elevated initial troponin-I of 14.62 ng/mL (reference range 0.00 – 0.30 ng/mL), and elevated CRP of 73.7 mg/L. Renal function was within normal limits. An electrocardiogram revealed ST elevations in leads II, III, aVF (Figure 1). The patient underwent coronary angiography which showed normal coronary arteries. Urinary drug screen was negative for cocaine. Transthoracic echocardiogram revealed an ejection fraction of 55% and no wall motion abnormalities; there was no pericardial effusion. Troponin-I peaked at 15.38 ng/mL. Repeat vitals during his first hospital day were noteworthy for fever up to 101.7 F and sinus tachycardia up to 106 beats per minute. The stool
sample was positive for non-typhoid Salmonella, which the state lab eventually confirmed as Salmonella virchow serotype. Blood cultures and urine culture were without growth of organisms. Viral work-up was negative for Coxsackie A/B virus antibody, HIV 1 and 2 antibody, Influenza A/B, Herpes Simplex via PCR, Epstein-Barr Virus antibodies, and Respiratory Syncytial Virus via PCR. A working diagnosis of Salmonella myocarditis was thus established. Cardiac magnetic resonance imaging (cMRI) was performed within one day of his chest pain. There was no myocardial edema or delayed gadolinium enhancement. He was discharged on ciprofloxacin for one week. He was advised to avoid competitive sports or heavy lifting for six months. He had no recurrence of diarrhea or chest pain at one-month follow-up after discharge, and a repeat echocardiogram showed slight improvement in global left ventricular contractility. The diagnosis of non-typhoid Salmonella myocarditis was made on the basis of positive stool culture for Salmonella virchow, angiographically normal coronary arteries, negative viral serology, and favorable response to ciprofloxacin.
Figure 1. Electrocardiogram reveals ST elevations in leads II, III, aVF.
Salmonella Infection Masquerading as ST Elevation Myocardial Infarction
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Table 1. Diagnostic Testing
Diagnostic Test CRP Initial troponin-I
Result (normal reference range) 73.7 mg/L (
