Case Report H. Arentoft, H. SchCnheyder, N. K. SchOnemann Cerebral Salmonella typhimurium Abscess in a Patient with a Stroke Case Report S u m m a r y : A 59-year-old woman with renal failure was admitted in a coma with seizures. Computerized tomography (CT) revealed a frontal mass in the right cerebral hemisphere and on day 12 new low density areas had appeared in both the right and left hemisphere. Blood cultures on day t3 grew Salmonella typhimurium, and the patient died the next day. An autopsy showed cerebral in/3rction with abscess formation. The elusive features of non-typhoid Salmonella infections make it advisable to obtain blood and faecal cultures from susceptible patients with fever or focal disorders of unknown aetiology. Zusammenfassung: Hirnabszefl durch Salmonella typhimurium bei einer Patientin mit Apoplex. Eine 59 Jahre alte Frau mit Nierenversagen wurde im Korea mit Krampfanf~illen eingewiesen. Computertomographisch zeigte sich eine L~ision in der rechten Hemisph~ire frontal; am Tag 12 waren neue Herde geringer Dichte in der rechten und linken Hemisphtire aufgetretcn. Am Tag 13 wurde in der Blutkultur SahnoneIla typhimurium angeztichtet. Die Patientin verstarb am n~ichsten Tag. Autoptisch zeigte sich ein Hirninfarkt mit Abszedierung. Weg c n d e r schwer fal3baren Erscheinungsformen der Infektionen durch nicht-Typus-Salmonellen erscheint es ratsam, bei empP,inglichen Patienten mit Fieber oder ~itiologisch ungekl~irten Herd-Symptomen Blut- und Stuhlkulturen anzulegen. A 59-year-old woman was admitted in a coma with clonic seizures. Chronic interstitial nephritis had been diagnosed 18 years previously and because of chronic pyetonephritis a rightsided nephrcctomy ~had been performed. As renal failure was progressive the patient was seen regularly in the outpatient clinic. The last six months before admission serum creatinine had been stable o_round 400 ~tmol IL During this period the patient had complaints of diarrhoea, nausea, and womiting. On ~u'rival at the hospital blocxt pressure was 130/80 mm Hg, serum creatinine 702 gmol l~, carbamide 25 mmol 1 ~, haemoglobin 5.5 mmql 1 ~ and white blip3 cell count 16.5 x 109 IL Pyrexia was absent and CT revealed a frontal mass in the right cerebral hemisphere compatible with a haematoma, but a neoplasm could not be excluded (Figures l a and lb). Because of uraemia no contrast material was administered. Supportive care and intravenous dexamethasone was given and alter three days the patient was awake with a leftsided hemiparesis. CT on day 12 showed regression of the right frontal mass, but low density areas had appeared in the right hemisphere and close to the lateral ventricle in the left hemisphere (Figures le and ld). During the ensuing 24 h the temperature rose to 38.3 °C. A chest x-ray showed a lung infiltrate and intravenous treatment with ampicillin and gentamicin was begun, but the patient died on day 14. Bacteriology: Blood cultures obtained on day 13 grew gram-negative rods identified as Salmonella serogroup B [7]. The serotype was S. ~phimurium (Statens Seruminstitut, Copenhagen) and S. typhimurium was also recovered from faeces taken on day 13. Autopsy: Macroscopically the brain was edematous with confluent necrosis of the right hemisphere, comprising most of the frontal and parietal lobes. In the center, an abscess 4 cm in diameter was seen. The central arteries showed moderate arteriosclerosis with stenosis of the right middle cerebral artery. The endocardium and the cardiac vah, es were normal. Additional findings included bronchopneumonia and chronic pyelonephritis of the remaining left kidney. Leptomeninges and the underlying brain parenchyma showed infiltration with neutrophilic leukocytes. Numerous gram-negative rods were prescnt in the abscess. Introduction Discussion In Denmark isolates of non-typhoid Salmonella tripled during the years 1983.-1989 [1] and a parallel increase of Salmonella bacteraemia was recorded [2]. A similar trend has been observed in other countries of Western Europe and in the USA [31. In Germany non-typhoid salmonellosis culminated in 1991 at an incidence rate of 140 per I ~ , 0 0 0 [4]. Although clinical awareness is high, the diagnosis may still elude recognition. The spectrum of non-typhoid salmonellosis encompasses extraintestinal focal infection, and in order to draw attention to the diagnostic difficulties we present a case of cerebral infarction with concomitant Salmonella abscess. We are aware of only three cases of cerebral Salmonella typhimurium abscesses, although e m p y e m a and meningitis may be more frequent [5, 6]. Although most non-typhoid Salmonella infections are selflimiting bacteraemia has been documented in 3 - 8 % of patients with faecal isolates [2, 8]. Salmonella bacteraemia may remain unrecognized as pyrexia is absent in up to 46% [8] and gastroenteritis !s recorded in only about half of the patients [21. Bacteraemia may lead to focal metastatic infections of virtually any organ or tissue, and preexistent pathology, e. g., ischaemia or neoplasia, seems to form a Received: I I February/Revisionaccepted: 19 April 1993 tL Arentofi, M.D., N. IC Schonemann, M.D., Dept. of Medicine C. It. SchOnheyder, M. D., Dept. of Clinical Microbiology,Aalborg Hospital, P. O. Box 365, DK-9100 Aalborg, Denmark. Infection 21 (1993) No. 4 © MMV Medizin Verlag GmbH Mtinchen, Mtinchen 1993 251/61 H. Arentoft et al.: Cerebral Salmonella typhimurium Abscess Figure 1: a and b - CT revealed a frontal mass in the right cerebral hemisphere compatible with a haematoma, but a neoplasm could not be excluded, nidus for the bacteria. In our case it is probable that ischaemic cerebral tissue was infected by blood-borne S. typhimurium as a secondary event, but we cannot entirely rule out that Salmonella had a primary role in precipitating cerebral events. No attempt to cultivate microorganisms was made at autopsy, but the bacteriological diagnosis rested on the blood isolate obtained within 24 h before death. There is evidence that focal infections contribute notably to the mortality of non-typhoid sahnonellosis: mnong the approximately 7% of patients in whom SahnonelIa bacteraemia was the immediate cause of death around 70% had focal infections [2]. Thus, in patients who are susceptible to salmonellosis faecal and blood cultures should be included in the work-up of focal disorders of unclear aetiology. Faecal cultures should not be disregarded, as they are positive in 76-86% of bacteraemic patients [5, 9]. The age distribution of patients with Salmonella bacteraemia is bimodal with predominance of patients under 10 and above 60 years of age [10, 11]. Predisposing conditions include AIDS, systemic lupus erythematosus, hepatic and 62/252 gastrointestinal dieseases, alcohol abuse, and malignancy [1 1, 12]. Renal failure, however, is not reckoned with as a risk factor. Non-typhoid Sahnonella serotypes differ in invasiveness, as manifested by the rate of bacteraemia among patients with positive faecal cultures. S. typhimurium (7%) ranks lower than e. g., Salmonella dublin (39%), but because S. typhimurium is a more common isolate it is a leading cause of bacteraemia and focal infections [8] and accounts for up to 50% of Salmonella-associated deaths [ 11]. Besides the elusive features of Salmonella bacteraemia intracranial abscesses may present without pyrexia or leukocytosis [ 13]. CT and nuclear magnetic resonance scan are the mainstay of diagnosis of cerebral abscess, the differential diagnoses being neoplasia and haematoma. A timely diagnosis of a cerebral Sahnonella abscess should lead to antibiotic therapy with chloramphenicol, a third generation cephalosporin, or sulfamethoxazole/trimetroprim [5, 6, 14]. Close clinical and weekly neuroradiological monitoring is indicated and surgical drainage is recommended in patients who fail to respond to antibiotic therapy [14, 15]. Infection21 (1993) No. 4 © MMV McdizinVerlag Gmbtl Miinchen,Mtinchen 1993 H. 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