Myocarditis associated with bacterial enteritis has only rarely been described in literature.
The clinical manifestation of the disease is often oligosymptomatic, so the real incidence could
be underestimated. A case of myocarditis in a 31-year-old male patient having Salmonella
enteritidis infection is reported. The clinical course and problems concerning the diagnosis
are discussed. The possibility of myocardial infection should be considered in any patient with
cardiac complaints during gastrointestinal infection. (Cardiol J 2007; 14: 589-591

Franczuk, Paweł

Grodzicki, Tomasz

Rewiuk, Krzysztof

English

Via Medica Journals

589www.cardiologyjournal.orgCASE REPORTCardiology Journal2007, Vol. 14, No. 6, pp. 589–591Copyright © 2007 Via MedicaISSN 1897–5593Address for correspondence: Pawel Franczuk, MD, PhDDepartment of Internal Medicine and GerontologyJagiellonian University Medical CollegeŚniadeckich 10, 31–531 Kraków, PolandTel: +48 12 424 88 00, fax: +48 12 424 88 54e-mail: franczuk@mp.plReceived: 12.05.2007 Accepted: 16.06.2007Myocarditis related toSalmonella enteritidis infectionPaweł Franczuk, Krzysztof Rewiuk and Tomasz GrodzickiDepartment of Internal Medicine and Gerontology,Jagiellonian University Medical College, Cracow, PolandAbstractMyocarditis associated with bacterial enteritis has only rarely been described in literature.The clinical manifestation of the disease is often oligosymptomatic, so the real incidence couldbe underestimated. A case of myocarditis in a 31-year-old male patient having Salmonellaenteritidis infection is reported. The clinical course and problems concerning the diagnosisare discussed. The possibility of myocardial infection should be considered in any patient withcardiac complaints during gastrointestinal infection. (Cardiol J 2007; 14: 589–591)Key words: myocarditis, Salmonella enteritidis infectionIntroductionMyocarditis is defined clinically as inflamma-tion of the heart muscle. The postmortem studiessuggest that myocarditis is a major cause of sud-den unexpected death in young adults (20% of cas-es) [1]. The viruses are the most significant causeof myocarditis in Europe. Bacterial diseases are lesscommon causes of myocarditis. We present the casereport of a patient with myocarditis early in thecourse of Salmonella enteritidis.Case presentationA 31-year-old, previously healthy man present-ing with a five-hour history of moderate morning,chest pain with dyspnoea was admitted to the hos-pital. The pain was spontaneous, was constant, ret-rosternal and non-radiating. Besides smoking tencigarettes a day, the patient did not have any othercoronary artery disease risk factors. Two days pri-or to admission, he developed watery diarrhoea (notbloody) and a fever (38.5°C). Two days before theonset of the diarrhoea he had eaten dumplings ina Chinese restaurant. Physical examination on ad-mission to hospital revealed: blood pressure 140/85,heart rate 85 beats per minute, respiratory rate14 per minute and temperature 37°C. The cardiacexamination was normal (no murmurs or pericardialrub). Respiratory, abdominal and musculoskeletalexaminations were normal. The laboratory investi-gations revealed: creatine kinase (CK) and creatininekinase isoenzyme MB (CK-MB) were elevated to407 U/L and 54 mg/L (norm: CK < 190 and CK-MB< 23, respectively), troponin I was 5.19 mg/L (norm< 0.1). WBC 13310. The electrocardiogram (ECG)showed: heart rate 50/min, high J point with STsegment elevation in limb and precordial leads(2 mm), high T wave amplitude in V2–V5, and PQand QT intervals within normal limits. The echocardio-graphy (ECHO) showed hypokinetic areas in theposterior, inferior and lateral walls with left ventri-cle ejection fraction 46% (Simpson). The initial di-agnosis was acute myocarditis. The patient wasadmitted to the coronary care unit for intensivecardiac monitoring. The chest pain resolved within2 hours of admission. Due to infectious diarrhoea,590Cardiology Journal 2007, Vol. 14, No. 6www.cardiologyjournal.orgtreatment with nifuroxazide (4 × 200 mg p.o.) andciprofloxacin (2 × 500 mg p.o.) was initiated. Fecalcultures yielded growth of Salmonella enteritis. Thediarrhoea resolved and troponin normalized on thefifth day. The controlled ECHO showed normal leftventricle function (EF = 65%). ECG on dischargerevealed ST segment normalisation, biphasic Twaves in I, II, III, aVF, V4 and negative T waves inV5–V6.The final diagnosis of Salmonella enteritidisinfection and related myocarditis was made basedon the clinical and echocardiographical findings andlaboratory results. The patient was discharged fromthe hospital in a stable condition after 8 days of treat-ment. At one-year follow up, the patient was well.DiscussionAs clinical manifestation of myocarditis is usu-ally oligosymptomatic, the real incidence of the dis-ease remains underestimated. Nevertheless, myo-cardial inflammation has been identified in 9% ofroutine postmortem examinations [1]. The spec-trum of potential causative agents includes: virus-es, bacteria, protozoa, fungi, parasites as well astoxins and autoimmunological reactions. In Europeand North America the most common cause of my-ocarditis are enteroviruses, whereas in SouthAmerica Trypanosoma cruzi is more often found [2].Bacterial infections of the gastro-intestinalsystem are rarely reported as a cause of myocardi-tis [3–9]. On the other hand, signs of the diseasecould easily be obscured by symptoms from the al-imentary tract. In one study of 100 patients withbacteriologically or serologically documented enter-ic fever, the authors found 7 cases with clinical ev-idence of myocarditis but as many as 46 cases withECG abnormalities suggesting myocarditis [10].The pathogenicity of non-typhoid Salmonella seemsto be limited, although in the study of Theler-Ballmeret al. [11] 8 of 103 patients with salmonellosis pre-sented clinical, laboratory or ECG findings suggest-ing myocarditis. The pathophysiology of myocardialinflammation accompanying gastrointestinal infec-tions is not understood well. The potential mecha-nisms include: direct invasion of myocardium, in-fluence of toxins and immunologically mediatedmyocardial damage.In the case presented, the diagnosis of Salmo-nella enteritidis enteritis and related myocarditiswas made based on the clinical, laboratory, ECG andechocardiographical results. The appearance ofchest pain, arrhythmia or congestive heart failurein young patients, without a history of heart disease,especially when it is concurrent with infection,should arouse suspicion of myocarditis. In our pa-tient, chest pain developed within two days after theonset of diarrhoea, similarly to the cases describedin literature, in which cardiac symptoms occurred2 or 3 days after the first gastrointestinal complaints [9],which suggests direct bacterial invasion of themyocardium. The causative role of Salmonella en-teritidis was determined based on the stool culturesand the absence of any other potential pathogensin the remaining bacteriological examinations. TheSalmonella enteritidis is the most common causa-tive factor of food poisoning in Poland [12], espe-cially connected with the use of raw or undercookedeggs. In the presented case, the suspected sourceof the bacteria was the dish from the Chinese res-taurant.The ECG abnormalities with transient butwidespread changes of ST-T segments are typicalin myocarditis, but may require to be distinguishedwith acute coronary events, including the need ofcoronary angiography [2]. The rise of CK and tro-ponin I is noted in myocardial damage of any cause;however, Smith et al. [13] found CK elevation inonly 5.7% and troponin I elevation in 34% of pa-tients with autoimmune myocarditis. Finally,echocardiographic abnormalities with global hypo-kinesia are reported in myocarditis and could helpin differentiation with myocardial infarction. Theabsence of left ventricular dilatation and full returnof ventricular function (presented by our patient)are characteristic of fulminant course of myocardi-tis, with low risk of progression to dilatated cardio-myopathy, whereas acute myocarditis with less se-vere hemodynamic compromise more often leadsto persistent cardiac dilatation [14]. The completerestoration of cardiac function after antimicrobialtherapy confirmed the diagnosis of heart inflamma-tion related to Salmonella enteritidis.In several cases, the diagnosis of myocarditisrequired an endomyocardial biopsy. Although, thisinvasive examination is recommended only whenthe disease cannot be diagnosed clinically or withroutine biochemical tests. Moreover, the Dallas cri-teria used for the histological evaluation of biopsyspecimens probably underestimates the true inci-dence of myocarditis [1]. In our case, we did not findan indication for this examination.Summing up: temporal coincidence with gastroin-testinal complaints, lack of any unknown myocardialdisease, transient laboratory, ECG and echocardio-graphic abnormalities and quick and full recovery af-ter antibiotic therapy allowed us to make a diagno-sis of myocarditis caused by Salmonella enteritidis.591Paweł Franczuk et al., Salmonella related myocarditiswww.cardiologyjournal.orgConclusionsMyocarditis can be a complication of infectious,enteric disease. Patients with chest pain duringdiarrhoea should be diagnosed for myocarditis.ECG, cardiac enzymes, echocardiography and judi-cial use of coronary angiography may be necessaryto reach proper diagnosis.References1. Feldman AM, McNamara D. Myocarditis. N EnglJ Med, 2000; 342: 1388–1398.2. Braunwald E, Zipes DP, Libby P. Heart disease.WB Saunders Company, Philadelphia 2001.3. Martinez-Martinez L, Mesa E, Rodriguez JE et al.Bacteriemia associated with mycotic aneurysm of thetransversal aortic arch and myocarditis caused bySalmonella enteritidis. Enferm Infecc Microbiol Clin,1989; 7: 97–99.4. Burt CR, Proudfoot JC, Roberts M, Horowitz RH.Fatal myocarditis secondary to Salmonella septicemiain a young adult. J Emerg Med, 1990; 8: 295–297.5. Oziol E, Bonal J, Chauveau E, Talard P, Carli P,Chagnon A. Acute myocarditis in non-typhoid Salmo-nella infection. Arch Mal Coeur Vaiss, 1995; 8: 99–101.6. Neuwirth C, Francois C, Laurent N, Pechinot A.Myocarditis due to Salmonella Virchow and suddeninfant death. Lancet, 1999; 354: 1004.7. Wanby P, Olsen B. Myocarditis in a patient with Sal-monella and Campylobacter enteritis. Scand J InfectDis, 2001; 33: 860–862.8. Cunningham C, Lee CH. Myocarditis related toCampylobacter jejuni infection: a case report. BMCInfect Dis, 2003; 17:16.9. Hannu T, Mattila L, Rautelin H, Siitonen A,Leirisalo-Repo M. Three cases of cardiac complica-tions associated with Campylobacter jejuni infectionand review of the literature. Eur J Clin MicrobiolInfect Dis, 2005; 24: 619–622.10. Mohanan PA, Pereira P, Raghuveer CV. Myocar-ditis in enteric fever. Indian J Med Sci, 1995; 49:28–31.11. Theler-Ballmer D, Noseda G, Reiner M, Keller H.Pericarditis and myocarditis in salmonellosis. Sch-weiz Med Wochenschr, 1980; 110: 1394–1401.12. Mach T. Zatrucie pokarmowe. In: Szczeklik A (ed.)Choroby wewnętrzne. Medycyna Praktyczna,Kraków 2005: 850–851.13. Smith SC, Ladenson JH, Mason JW, Jaffe AS. Evalu-ation of cardiac troponin I associated with myocardi-tis. Experimental and clinical correlates. Circulation,1997; 95: 163–168.14. Felker GM, Boehmer JP, Hruban RH et al. Echocardio-graphic findings in fulminant and acute myocarditis.J Am Coll Cardiol, 2000; 36: 227–232.

Myocarditis related to Salmonella enteritidis infection

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Myocarditis related to Salmonella enteritidis infection

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