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Salmonella enterica serovar Enteritidis brain abscess mimicking meningitis after surgery for glioblastoma multiforme: a case report and review of the literature

Journal of Medical Case Reports201610:192

https://doi.org/10.1186/s13256-016-0973-9

Received: 9 March 2016

Accepted: 3 June 2016

Published: 7 July 2016

Abstract

Background

Salmonella brain abscess associated with brain tumor is rare. Only 11 cases have been reported to date. Here we report a case of brain abscess caused by Salmonella enterica serovar Enteritidis mimicking post-surgical meningitis in a patient with glioblastoma multiforme.

Case presentation

A 60-year-old Algerian woman was admitted through an emergency department for a 4-day history of headache, nausea and vomiting, and behavioral disorders. Surgery for cerebral tumor excision was performed and histopathological analysis revealed glioblastoma multiforme. On the seventh day post-surgery, she presented a sudden neurological deterioration with a meningeal syndrome, confusion, and fever of 39.8°C. Her cerebrospinal fluid sample and blood cultures were positive for S. enterica Enteritidis. She was treated with ceftriaxone and ciprofloxacin. On the 17th day post-surgery, she presented a new neurological disorder and purulent discharge from the surgical wound. Brain computed tomography revealed a large cerebral abscess located at the operative site. Surgical drainage of the abscess was performed and microbial cultures of surgical deep samples were positive for the same S. enterica Enteritidis isolate. She recovered and was discharged 6 weeks after admission.

Conclusions

In this case report, a brain abscess was initially diagnosed as Salmonella post-surgical meningitis before the imaging diagnosis of the brain abscess. The diagnosis of brain abscess should be considered in all cases of non-typhoidal Salmonella meningitis after surgery for brain tumor. Surgical brain abscess drainage followed by prolonged antibiotic treatment remains a major therapeutic option.

Keywords

Brain abscess Glioblastoma Post-surgery meningitis Salmonella Salmonella enterica MALDI-TOF Bacteria Infection Human

Background

Salmonella species are mainly known as common agents of gastroenteritis worldwide. Invasive Salmonella infections have been reported due to their potential to cause focal suppurative complications in urinary tract infection, osteoarticular infection and liver abscess [1]. Central nervous system Salmonella infection is rare and occurs primarily in young children [2] and immunocompromised adults, including human immunodeficiency virus (HIV) infection and co-infected patients [3] and chronic granulomatous disease [4]. Here, we report a case of brain abscess caused by S. enterica subspecies (subsp.) enterica serovar Enteritidis mimicking post-surgical meningitis in a patient with glioblastoma multiforme. We also review cases of Salmonella brain abscess in patients with cerebral tumors.

Case presentation

In September 2015, a 60-year-old Algerian woman was seen in the emergency department in Marseille, France for a 4-day history of headache, nausea and vomiting, and behavioral disorders. She had an unremarkable medical history apart from obesity (body mass index at 30.9 kg/m2). Brain magnetic resonance imaging (MRI) revealed a single 40×35 mm tumor in her right mesial temporal region and a mass effect compression of her right lateral ventricle with transtentorial herniation (Fig. 1). She was transferred to our neurosurgery department, where levetiracetam and methylprednisolone led to neurological improvement. At that time, her leukocyte count was elevated at 22×109/L (neutrophil count was 21×109/L, lymphocytes were decreased at 0.47×109/L, and her platelet count was 291×109/L). Surgery for tumor removal was performed on day 5 of her admission. A histological examination revealed glioblastoma multiforme (Fig. 2). No bacteria were seen on histological analysis.
Fig. 1

Brain magnetic resonance imaging revealed a single 40×35 mm tumor in the right mesial temporal region and a mass effect compression of the right lateral ventricle with transtentorial herniation

Fig. 2

A histological examination revealed glioblastoma multiforme without any microorganism identified on histological analysis

On the seventh day post-surgery, she presented a sudden neurological deterioration with a meningeal syndrome, confusion and fever of 39.8 °C. Laboratory investigations revealed an elevated leukocyte count at 13×109/L, elevated neutrophils at 12.62×109/L, low lymphocytes at 0.15×109/L, normal platelets at 154×109/L, and elevated C-reactive protein at 304 mg/L. Cerebrospinal fluid (CSF) sample analysis revealed an elevated protein level of 2.93 g/L, a low glucose level of 0.1 mmol/L, and a leukocyte count of 5400 cells/mm3 with 80 % neutrophils. CSF cultures and blood cultures were positive for S. enterica. The isolates from the CSF and blood were further identified as S. enterica subsp. enterica serotype Enteritidis as identified by our national reference center for Salmonella (Institut Pasteur, Paris). The isolates were susceptible in vitro to amoxicillin, ceftriaxone, imipenem/cilastatin, gentamycin, co-trimoxazole and fluoroquinolone.

A diagnosis of Salmonella meningitis was made and she was treated with ceftriaxone administered intravenously 2 g/day and oral ciprofloxacin 500 mg every 8 hours. On the 17th day post-surgery, she presented a new neurological disorder and purulent discharge from the surgical wound. Brain computed tomography (CT) revealed a large cerebral abscess located at the operative site (Fig. 3). Surgical drainage of the abscess was performed by craniotomy, which confirmed the diagnosis of intraparenchymal abscess located at the glioblastoma resection site. Microbial cultures of surgical deep samples were positive for S. enterica subsp. enterica serovar Enteritidis, which were susceptible to all antibiotics tested above. She was discharged 6 weeks after admission. Prolonged 10-day anaerobic bacterial cultures of her CSF, bloodstream and brain abscess were negative. A combination of ceftriaxone-ciprofloxacin was given for 6 weeks, and ciprofloxacin treatment was prolonged for 3 months because of the infectious risk due to chemotherapy immunosuppression. No neurological sequelae were noted. Evaluation of the immune system remained normal and HIV serology was negative.
Fig. 3

Computed tomography reveals a large cerebral abscess located at the operative site

Discussion

Here we report a case of brain abscess due to S. enterica subsp. enterica serovar Enteritidis mimicking meningitis occurring after surgery for glioblastoma. Salmonella brain abscesses are rarely reported. Only a few cases of typhoidal Salmonella brain abscess have been reported in immunocompetent adults, usually related to situations promoting their incidence, including recent travel in endemic areas [5], typhoid fever [6], or ingestion of contaminated milk [7]. To the best of our knowledge, only 11 cases of Salmonella brain abscess associated with brain tumor have been reported [818]. Most of these cases (nine cases) were caused by non-typhoidal Salmonella, including eight cases of S. enterica Enteritidis and one case of Salmonella enterica Typhimurium. However, S. enterica Typhimurium is usually responsible for invasive human salmonellosis [19]. Glioblastoma is the main type of brain tumor that has been associated with Salmonella brain abscess (four cases), and all of these cases were caused by S. enterica Enteritidis (Table 1).
Table 1

Review of 12 cases of Salmonella brain abscess related to brain tumors reported in the literature and in our case

Cases

Age, sex, geographical origin

Cerebral tumor

Tumor surgery before diagnosis of brain abscess

Patients under systemic corticosteroid treatment

Clinical symptoms

Surgical drainage

Antibiotic treatment

Salmonella species

Clinical outcome

Our case (2015)

60 years, female, Algeria

Yes, multiforme glioblastoma

Yes

Yes

Sudden neurological deterioration, meningeal syndrome

Yes

Yes, 3 months

Salmonella Enteritidis (CSF, blood, pus, brain abscess)

Good

Rodriguez, Valero, and Watanakunakorn 1986 [8]

28 years, male, Ohio (USA)

Yes, metastatic carcinoma

No

Yes

Per orbital pain, nausea, papilledema

Yes

Yes, 6 weeks (radiotherapy)

Salmonella Enteritidis (brain tissue and blood)

Good

Sharma, Raja, and Shivananda 1986 [9]

32 years, male, India

Yes, malignant astrocytoma

Yes

No

Headache, vomiting, somnolence

Yes

Yes, unknown duration

Salmonella Typhi

Good

Noguerado et al. 1987 [10]

78 years, male, Spain

Yes, multiforme glioblastoma

No

Yes

General conditions deteriorated, fever, meningeal syndrome, septic shock

No

Yes

Salmonella Enteritidis (CSF and blood)

Died

Bossi et al. 1993 [11]

24 years, male, Tunisia

Yes, multiforme glioblastoma

Yes

Yes

Fever, confusion

Yes

Yes, unknown duration

Salmonella Enteritidis (CSF, blood and brain abscess)

Good

Shanley and Holmes 1994 [12]

28 years, female, Hawaii (USA)

Yes, craniopharyngioma

No

Not mentioned

Sudden loss of vision

Yes, Hypophysectomy to decompress optic chiasm

Not mentioned

Salmonella Typhi (pus, brain abscess)

Good

Fiteni et al. 1995 [13]

49 years, female, France

Yes, astrocytoma

Yes

Yes

Fever, confusion

Yes

Yes, 9 weeks

Salmonella Enteritidis (CSF, blood and brain abscess)

Residual hemiparesis

Sarria, Vidal, and Kimbrough Iii 2000 [14]

58 years, female, Texas (USA)

Yes, multiforme glioblastoma

No

Yes

Fever, meningeal syndrome, hemiparesis, coma

Yes

Yes, 6 weeks and local application

Salmonella Enteritidis (material)

Died

Kumari and Kan 2000 [15]

59 years, male, Washington (USA)

Yes, metastatic adenocarcinoma

Yes

Yes

Fever, tachycardia, confusion

Yes

Yes, 6 weeks

Salmonella typhimurium (cerebral abscess)

Good

Schröder et al. 2003 [16]

46 years, female, Germany

Yes, craniopharyngioma

Yes

Yes

Tension, headache at craniotomy site

Yes

Yes, duration not known

Salmonella Enteritidis (pus, brain abscess)

Coxitis abscess

Aissaoui et al. 2006 [17]

72 years, male, Morocco

Yes, oligodendroglioma

Yes

Yes

Fever, neurological deterioration

No

Yes, 8 days then patient died

Salmonella Enteritidis (CSF and blood)

Died

Sait et al. 2011 [18]

57 years, male, not known

Yes, multiforme glioblastoma

Yes

No

Headache, discharge wound, meningeal signs

Yes

Yes, 4 weeks

Salmonella Enteritidis (material and blood)

Good

CSF cerebrospinal fluid

Symptoms of Salmonella brain abscess associated with brain tumor are heterogeneous. Most cases (six cases) have occurred after surgical resection of a brain tumor, initially indicated by fever or neurological deterioration and confusion. However, meningeal signs were noted in three reported cases. In our case, the brain abscess was initially diagnosed as Salmonella post-surgical meningitis before imaging diagnosis of the brain abscess. In our case, the diagnosis of glioblastoma multiforme was suggested by brain MRI and confirmed by a histological examination of the surgical biopsy. In vivo imaging technology, such as molecular imaging, is useful in the diagnosis of brain tumors [20] and might be helpful to differentiate bacterial abscess from tumoral tissues and underlying primary disease [21].

In the literature, Salmonella species have been identified in purulent exudates from brain abscesses (six cases) and in blood cultures (six cases) and CSF cultures (four cases). In our case, Salmonella isolates were identified in the blood, CSF and brain abscess. Most cases in the literature were treated with systemic corticosteroids for brain tumor (eight cases) when the Salmonella brain abscess was diagnosed. The prognosis is relatively good with antibiotic treatment. There is no comparative study on the use of dual antibiotic therapy rather than single antibiotic for this indication. Nevertheless, we decided to treat our case initially with a 6-week combination of ceftriaxone-ciprofloxacin due to a significant risk of immunosuppression related to treatment of the glioblastoma multiforme and the large brain abscess. The duration of antibiotic treatment in the literature varied from 4 weeks to 3 months. Most cases in the literature (nine cases) were treated surgically for the brain abscess. However, three patients died and two patients had complications, including residual hemiparesis in one case and a hip abscess in one case.

Chronic carriage of Salmonella, primarily biliary, may persist after infection (about 1 % of cases) [22]. In our case, septic signs and digestive symptoms such as gastroenteritis were absent on admission and the clinical symptoms of brain abscess such as fever, meningeal signs, and neurological deterioration occurred only at 1 week post-surgery for glioblastoma. These phenomena might be explained by Salmonella’s tropism for necrotic tissue [23], and the central nervous system infection could be secondary to blood dissemination of Salmonella from digestive reservoirs in the bile or intestine. Unfortunately, this hypothesis is difficult to confirm due to the transitory carriage and because a stool culture had unfortunately not been performed.

Conclusions

Salmonella brain abscess is rare but can occur in apparently immunocompetent adult patients with brain tumor. The diagnosis of brain abscess should be considered in all cases of non-typhoid Salmonella meningitis after surgery for brain tumor. Prolonged antibiotic treatment after surgical brain abscess drainage remains a major therapeutic option.

Declarations

Acknowledgements

We thank the house officers and medical staff for their confidence in our management of the patient.

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. No assistance was utilized in the writing of this manuscript.

Availability of data and supporting materials

Medical imaging data will not be shared because it is not fully anonymous.

Authors’ contributions

LL: 1st author, clinical data collection; he was involved in drafting the manuscript. GD: 2nd author, microbiological data collection, manuscript revision. TG: 3rd author, clinical data verification and manuscript revision. EH: 4th author; surgical data verification and manuscript revision. HL: 5th author, histological analysis, manuscript revision, and discussion section. MD: 6th author, microbiological data verification and manuscript revision. PS: first final author and corresponding author; he made substantial contributions to study conception and design, clinical data verification, discussion section, and manuscript revision. AS: second final author, clinical data verification, discussion section, and final approval of the version to be published. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095
(2)
Pôle de Maladies Infectieuses, Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille, Institut Hospitalo-Universitaire Méditerranée Infection
(3)
Service de neurochirurgie, Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille
(4)
Service des Maladies Infectieuses, Hôpital de la Conception
(5)
Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, Faculté de Médecine, Aix Marseille Université

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Copyright

© The Author(s). 2016

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