The Risk of Immunosuppression: A Case of Salmonella Meningitis
The Risk of Immunosuppression: A Case of Salmonella Meningitis
Joshua Dower,1 David P. Lerner,2 Tamar Geva,2 and Kenneth Wener2
1Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
2Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA 01805, USA
Correspondence should be addressed to Joshua Dower; moc.liamg@rewodauhsoj
Received 21 December 2017; Revised 10 April 2018; Accepted 10 May 2018; Published 21 May 2018
Academic Editor: Tomoyuki Shibata
Copyright © 2018 Joshua Dower et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Salmonella meningitis is a rare infection, particularly in adults. We report the case of a 75-year-old female with a history of rheumatoid arthritis on TNF-antagonist immunosuppressive therapy who initially presented to the hospital for management of back and leg pain and was ultimately diagnosed with bacterial meningitis secondary to Salmonella species infection. She was treated with ceftriaxone with slow improvement in neurological function. Though the source of infection was never clearly identified from multiple imaging studies, we suspect the severity of her presentation was due to her history of TNF-antagonist use.
1. Introduction
Immunosuppressive agents are widely available and utilized medications in the treatment of rheumatological diseases. Prior to the introduction of adalimumab, patients with resistant rheumatoid arthritis had few options to help manage their disease activity, leading to significant disability and poor quality of life. The introduction of additional tumor necrosis factor (TNF) antagonists has changed the management of rheumatoid arthritis as they have been shown to be more effective and safer in the treatment of rheumatological disease than nonbiologic disease modifying antirheumatic drugs (DMARDs) [1]. However, while these agents have proven to be beneficial, they do carry the risk of serious infections. This case report presents a patient with a history of rheumatoid arthritis on TNF-antagonist immunosuppressive therapy who ultimately was diagnosed with Salmonella meningitis.
2. Case Report
The patient is a 75-year-old female with a history of rheumatoid arthritis originally diagnosed at age 31 and treated with various DMARDs. She had been well managed on etanercept but was transitioned to a regimen of leflunomide and inflixamab six years prior to presentation. Approximately seven months prior to presentation, the patient was transitioned back to etanercept due to worsening disease activity. In addition, the patient had a history of spinal stenosis, treated with two L4-L5 epidural steroid injections two years prior to presentation.
The patient was initially admitted to the medical floor for management of severe back and right leg pain. Her remaining review of systems was negative with the exception of nausea and an episode of emesis en route to the hospital, and initial presenting vital signs were all within normal limits. On the evening of her admission, the patient was found somnolent with expressive aphasia. Blood pressure at that time was elevated to 188/90 mmHg. Stroke evaluation was initiated. Head CT was negative for intracranial hemorrhage, and tPA was administered within 3 hours of symptom onset. The patient remained neurologically unchanged over the next 36 hours, complaining only of a mild headache. She remained hypertensive and required a nicardipine infusion to maintain a blood pressure less than 180/105 mmHg.
On day 3 of admission, she developed an acute change in mental status. She then experienced rigors and a fever of 103°F (39.4°C). Exam at that time was notable for nuchal rigidity. A set of two blood cultures were drawn at this time, and she was then started on vancomycin, cefepime, ampicillin, and acyclovir as there was concern for a central nervous system infection. Lumbar puncture revealed 493 white blood cells/µL (90% neutrophils), 377 red blood cells/µL, glucose <5 mg/dL, and protein 410 mg/dL, and Gram staining demonstrated rare Gram-negative rods. Cultures from the lumbar puncture ultimately grew Salmonella species, and on day 4 of hospitalization, the patient was transitioned to ceftriaxone 2 grams twice daily. Stool cultures were sent to the laboratory at this time, 24 hours after initiating antibiotics. The patient also underwent HIV testing, which was negative for HIV1 and HIV2 antibodies.
Due to worsening mental status and inability to protect her airway, she was intubated. She developed hypothermia to 95.2°F (35.1°C), progressive elevation in white blood cell count to 14.0 cells/µL, and a new right lower lobe consolidation on chest X-ray. She was transitioned from ceftriaxone to vancomycin and cefepime. She completed treatment for aspiration pneumonia, was extubated, and was transitioned back to ceftri (...truncated)
