An Unforgettable Salmonella Illness

Source of Article:  http://www.foodpoisonjournal.com/2009/08/articles/foodborne-illness-outbreaks/an-unforgettable-salmonella-illness/

 

Posted on August 7, 2009 by Drew Falkenstein

This post is about a brutal illness caused by Salmonella.  It happened to one of our clients several years ago.  Don't stop reading just because you think you've seen, or heard about, every varient of a Salmonella illness. I assure you that you've never seen one quite like this before.

At the request of our former client, I have changed the names and locations in this narrative:

Our client, Ron, was infected with Salmonella during a sporting banquet in Indiana. His illness began on July 27, 2004. At first, he suffered from predominantly gastrointestinal symptoms that were, in light of what was to come, relatively mild.

By August 1, Ron was in the emergency room at a nearby hospital The attending physician there noted repetitive diarrhea and, though the vomiting had subsided, that Ron continued to feel “somewhat nauseous and gaggy.” Ron was re-hydrated with a liter of normal saline, and twenty-five milligrams of Phenergan, an anti-nausea medication, were introduced intravenously. He was discharged several hours later with a prescription for Ciprofloxacin, an antibiotic.

Ron’s course over the next two months is one that defies clever adjectival description: He felt generally ill pretty much all of the time. He did manage to return to work after a couple of day’s absence, but he struggled to be as productive as usual, was frequently irritable, and seemed constantly besieged by abdominal discomfort. It was during this time that Ron learned that his stool sample had cultured positive for Salmonella, group D.

The same state of ill health persisted throughout August and September. “Then,” as Ron recalls, “came the first weekend in October,” and “any thoughts I had that the first bout in July was the sickest I’d ever been faded quickly.”

Ron’s memory of the onset of symptoms is vivid:

I returned from a short shopping trip and sat in my favorite chair to look at the printer I bought for my digital camera. While I was sitting there I was suddenly taken very ill. I don’t know how to explain it other than it was as sudden as if a bone were broken or a switch was flipped. I had very severe pain in my lower abdomen and started vomiting. I felt just like I did in July, only worse.

The symptoms persisted for the next two days, while Ron tried treating himself with simple, over-the-counter remedies. He had no reason to suspect that his intestines had started to rot. By Tuesday, October 5, the pain turned frighteningly severe, and Ron drove himself, once again, to the hospital emergency room.

The hours that Ron spent waiting to be seen he describes as “the most uncomfortable [] of my life.” He was eventually seen and admitted soon after, the attending physician having become concerned at the intensity of the sub-umbilical pain that “spread across [Ron’s] entire abdomen,” which suggested acute appendicitis. A CT scan revealed some inflammation in the small bowel mesentery, but “no convincing inflammatory changes around the appendix to confirm the diagnosis of acute appendicitis.”

Afterward, Ron was wheeled to his own room, where he slept intermittently throughout the night. By morning, he was running a high fever, had become nauseated, and his stomach was plagued by intense cramps and pains.

Shortly before noon, Ron met a gastroenterologist in consultation. The gastroenterologist’s note presciently draws the first link to Ron’s recent bout with Salmonella, Group D. The doctor stated, “other than the bout of Salmonella noted above, he never had problems with chronic diarrhea or abdominal pain. There is no family history of inflammatory bowel disease or colitis.” The doctor decided to do laparascopic/exploratory surgery to address the worsening fluid collection and inflammation of Ron’s small intestine.

What was found on introduction of the exploratory laparoscope was not what was expected: “upon induction . . . there were multiple socked-in small bowel loops that were adherent to the anterior abdominal wall as well as to each other.” The surgeon was unable to detach and mobilize the small bowel and consequently had to convert to laparotomy.

Upon exploratory laparotomy, the small bowel had a densely fibrotic reaction throughout most of its length. There was one area in particular, it was in the distal ileum, that had the appearance of a chronic perforation that was very diseased. This was not salvageable.

The surgeon stopped the operation at this point, preferring an intraoperative consultation with yet another surgeon, who noted:

The small bowel was also examined in its entirety from the ligament of teitz to the ileocecal valve. The small bowel in general was very inflamed and beefy red. There were areas of dusky serosa. There was one loop of small bowel, however, that appeared near-necrotic. This loop had been involved with the abscess. It was inflamed and stuck to itself. The mesentery of this portion of the small bowel was also thickened and inflamed . . . It was felt that this portion of the small bowel was the primary process and cause of the peritonitis and abscess.

The doctors concurred that removal of the “near-necrotic” portion of Ron’s small intestine—between twelve and sixteen inches—was required. This was done with no complication and, after copious abdominal irrigation, the functional ends of Ron’s resected intestine were stapled and sutured. And as if this alone was not enough, Ron’s appendix was noted to be “inflamed throughout its course.” Accordingly, the surgeon removed the appendix as well. The surgery concluded with the placement of a Penrose drain in the subcutaneous fat.

Afterward, in search of an infectious cause, the surgeon sent the resected intestine and appendix to pathology; he also ordered that tissue samples from Ron’s abdomen be sent to the lab for culture. The pathology report states, in part:

The morphologic findings . . . confirm the clinical impression of intra-abdominal abscess formation. Although acute inflammation is present in the wall of the appendix, it may be secondary to intra-abdominal inflammatory process. The patient has a previous history of Salmonella infection (July 2004) and correlation with the pending culture results is essential.

The culture report from Ron’s abdominal tissue sample would return later in the month with a positive result for Salmonella enteritidis, group D1.

In the days following Ron’s surgery, his wife Mary spent most of every waking hour at the hospital by her husband’s side, leaving only to sleep or get the kids to their various after-school activities. The kids were required, by parental rule, to stay out of the hospital room. Mary thought that they had enough to endure at present without having to see their incapacitated father in a hospital bed with tubes down his throat and sticking out of his abdomen. But dad was not far from everybody’s thoughts. Ron soon had a large mail delivery, which consisted of get-well-soon cards from every boy and girl in his ten-year-old son’s class.

Meanwhile, Ron’s treatment continued with Ciprofloxacin, Zosyn, Zofran, and repeat dosages of morphine, which was available to Ron, in regulated amounts, at the touch of a button.

Until October 11, with a few minor bumps along the way, Ron progressed well. But that day, a Monday, Ron began to suffer greater pains in his abdomen than he had since surgery. Ron was wheeled to radiology that afternoon for another CT scan of his abdomen and pelvis. The exams showed increased fluid collection in Ron’s abdomen, most prominently in the paracolic gutter region in the lower left quadrant.

The next day, a drainage catheter was installed. In detail not meant for the squeamish, Ron recalls the process by which this drain, and others, was inserted. Beginning with the following caveat, “When [doctors] say they are sorry they have to hurt you as part of the treatment—they mean it,” he states:

The process of inserting a drain, at least in my case, was one of technology and brute force. It is done while lying on the movable platform of a CT machine. First, they run a CT scan to determine the best spot to drain the fluid. Then they prepare the area and push a wire through your side into the abdomen. The first time I had this done I think they went in 11cm. I think that’s a little more than 4 inches. With the wire inserted they run you through the CT machine again to make sure it’s properly placed. If it is in place they then push a larger tube over the wire until it is in place, run the CT again, and try to draw off as much fluid as they can. After that’s done they attach a collection bag that is Velcroed to your leg, and tape the tube to your side. I’ve never been stabbed by a knife or run-through with a sword but I think I can imagine the feeling. Unfortunately a couple of days later, while hauling myself out of bed, I snagged the tube and pulled it out.

In addition to the drain difficulties, Ron continued to suffer a variety of complications from his illness. He was confirmed with a Clostridium difficil infection around October 13, for which he was given another antibiotic called Flagyl. He also experienced a dramatic loss of appetite, which would plague him for months afterward. Fluid and gas continued to accumulate in the area of Ron’s bowel resection, requiring the placement of another catheter on October 15—another unwelcome, painful procedure.

Not all was pain and misery, however. The consensus amongst the doctors was that, under the circumstances, their patient had progressed well. Ron had, after all, had nearly twelve inches removed from his small intestine, and had lost one organ entirely, to say nothing of the gastrointestinal discomfort he suffered for two months prior to hospitalization. Also, Ron’s diarrhea had slowed significantly, and he felt far less fevered.

After nearly two weeks hospitalization, Ron was finally discharged on Saturday, October 16, 2004. The principal diagnosis was intra-abdominal abscess, and the principal procedures were noted to be “1. Exploratory laparotomy [] with a partial small bowel resection. 2. Antibiotic therapy. 3. CT-guided intra abdominal drain placement times two.” As for the resected portion of Ron’s small bowel, the pathology report concludes as follows: “Small bowel with subserosal abscess formation with extensive acute inflammation, acute serositis, fat necrosis, foreign body giant cell reaction and serosal adhesions.”
 

 

 

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