Salmonella aortitis without surgery or fluoroquinolones: Complete resolution with sequential antibiotic therapy

Salmonella aortitis is a rare, life-threatening infection historically associated with near-universal mortality without surgery. When surgery is not possible, the choice of oral agent, particularly when fluoroquinolones cannot be used, and the conduct of long-term suppression are guided by few reported cases.

An 85-year-old man with diabetes mellitus, coronary artery disease, and atrial fibrillation presented in septic shock from Salmonella Enteritidis bacteremia with infrarenal aortitis. Bacteremia cleared by hospital day 2 on intravenous ceftriaxone. Because operative risk was prohibitive and the patient preferred non-operative care, a multidisciplinary team elected antibiotic therapy alone: six weeks of intravenous ceftriaxone followed by oral trimethoprim-sulfamethoxazole, chosen because the isolate was only intermediately susceptible to ciprofloxacin (minimum inhibitory concentration 0.25 μg/mL). On serial computed tomography angiography, periaortic inflammation was unchanged through week 7 despite clinical improvement, improved at week 15, and resolved completely at approximately 9 months, with no aneurysm, pseudoaneurysm, or periaortic gas on any of eight studies. Inflammatory markers normalized during that time. After radiographic resolution, and with appetite and weight loss possibly related to trimethoprim-sulfamethoxazole, suppression was stepped down to reduced-dose oral amoxicillin, planned to continue for the foreseeable future.

Carefully selected patients with non-aneurysmal native Salmonella aortitis and prohibitive operative risk may achieve clinical and radiographic resolution with antibiotics alone, even when fluoroquinolones are not an option. This case illustrates susceptibility-guided selection of an oral agent and step-down to a better-tolerated agent after resolution. Radiographic response lagged clinical response by months; unchanged early imaging should not by itself be read as treatment failure.