VA AM Report 12.18.17: Salmonella and splenic abscess in a returning traveler

Case summary: Thanks to Luis Rubio for staying post-nights to present a 30M with recent very adventurous travel to India (with exposure to rodents, street food, dogs, agriculture, and dirty water!), who presented with nausea, vomiting, diarrhea and fevers, and was found to have GNR bacteremia, splenic abscess, and stool culture positive for Salmonella.

Takeaways:

  1. Recall this great intern report post from 9/2017 about fever in a returning traveler, and recall that incubation period is key to building your differential (< or > 21 days).
  2. Impress your friends on rounds by discussing the age-old phenomenon of pulse-temperature dissociation: for each degree Celsius increase in temperature, HR should increase by 8bpm, and if it doesn’t, this is called pulse-temperature dissociation. The most common etiology in the modern era is beta blockade, but Salmonella is another common offender
  3. Splenic abscess should raise your suspicion for bacterial endocarditis or other endovascular source of infection and cause you to consider obtaining a TTE.

Pulse-temperature dissociation

  1. Impress your friends on rounds by discussing the age-old phenomenon of pulse-temperature dissociation: for each degree Celsius increase in temperature, HR should increase by 8bpm, and if it doesn’t, this is called pulse-temperature dissociation.
  2. Certain conditions break this rule
    • Salmonella typhoid is the classic case
    • Brucellosis
    • Leptospirosis
    • Acute rheumatic fever with conduction abnormalities
    • Viral myocarditis
    • Endocarditis with perivalvular abscess with conduction abnormalities
    • Beta blockers

 


 Splenic abscess 101

  1. Splenic abscess should raise your concern for endocarditis or other endovascular infection leading to seeding.
  2. Other good facts to store in  your illness script:
    • Most commonly presents with fever, abd pain, L pleural effusion, splenomegaly, leukocytosis/leukopenia
    • 2/3 have positive blood cultures
    • Most common pathogens GPCs (Strep and staph) and GNRs (Klebsiella, E coli)
    • TTE is warranted in most,though data is lacking
    • Treatment includes ABX +/- splenectomy or percutaneous drainage
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