Salmonella pneumonia and empyema in a patient with end-stage liver disease

Salmonella infections usually present as self-limiting gastrointestinal illnesses. Salmonella pneumonia is an uncommon infection that should be considered in immunodeficient individuals originally presenting with enterocolitis. With fewer than 40 reported cases, salmonella pneumonia can rarely lead to empyema (1. Abdelhafiz, 2020).This case report highlights an unusual presentation of a focal metastatic salmonella pneumonia complicated by an empyema in an immunocompromised host.

An elderly Hispanic gentlemen with history of end stage liver disease, hepatocellular carcinoma, diabetes mellitus type 2, and malnutrition presents with left upper extremity weakness along with four days of generalized weakness, diarrhea, nausea and vomiting. He later developed cough and leukocytosis. Chest X-ray revealed a right sided diaphragmatic hernia. He subsequently had an episode of hemoptysis which led to further imaging. CT Chest revealed a 14 cm loculated right lower lung pleural air fluid filled collection. Thoracentesis with pleural fluid analysis revealed a 200 mL of frank pus, lactate dehydrogenase of 22,182 U/L, protein 3.2 g/dL, WBC 295,503/mm^3, RBC 34,583/mm^3.Cultures revealed a non-typhi Salmonella species. Patient was started on Piperacillin-tazobactam. Infectious disease, pulmonary and cardiothoracic surgery were consulted to ensure interdisciplinary treatment strategy and optimize patient outcome. Treatment course was complicated by inadvertent chest tube dislodgment. Cardiothoracic surgery decided against surgical intervention. Patient was subsequently transitioned to oral levofloxacin with 2 month treatment course as well as regular follow up with pulmonology and infectious disease. Repeat Chest CT after antibiotic treatment was remarkable for a 6.6 cm right lower lobe abscess.