LETTERS TO THE EDITOR
779
X-ray showed bilateral pleural effusion. The white blood 4. Abramson, S., Kramer, S.B., Radin, A. & Holzman, R. Salmonella bacteremia in systemic lupus erythematosus. Arthcell count was 6.6 x 109/l with 89% neutrophils. Thoraritis Rheum 1985, 28: 75-79. cocentesis yielded 0.5 litres of a yellow fluid, from which 5. de Luis, C., Pigrau, C., Pahissa, A., Fernandez, F. & MartinezS. enteritidis was grown. Blood cultures were sterile. Vazquez, J.M. Infeeciones en 96 casos de lupus eritematoso Repeated X-ray films showed no underlying pulmonary sistemico. Rev Clin Esp 1990, 94: 607-610. involvement. Bilateral thoracostomy tubes were inserted 6. Gosset, S., Goursaud, G., Carjuzan, A., Martin, J. Guigui, J. & and treatment was ampicillin g/4 hours i.v. for 4 weeks Seguin, P. Localisation pleurale d'une salmonella non typhoidique multiresistente. Presse Med 1988, 17: 2200. and oral amoxycillin for 2 weeks more, but pleural fluid drainage persisted. A bilateral chemical pleurodesis was 7. Reddy, K.R., Chan, J.C., Smiley, D., Jeffers, L.J. & Schiff, E.R. Spontaneous group B Salmonella enteritidis peritonitis in performed but a sterile pleural effusion recurred 4 months cirrhotic ascites and AIDS. Am J Gastroenterol 1988, 83: after finishing antibiotic therapy. 882-884. Non-typhoid salmonellae are known to colonize pre- 8. Carel, R., Schey, G., Ma'ayan, M. & Bruderman, I. Salmonella tissues and and non-lupus pleural viously damaged empyema as a complication in malignant pleural effusion. peritoneal effusions have become infected."2'6-8 ExtenRespiration 1977, 34: 232-235. sion from a nearby site, bacteraemic spread from a gastrointestinal source or a dormant focus in the reticuloendothelial system are all pathogenic possibilities. In contrast to other extraintestinal infections, salmonella Spontaneous oesophageal haematoma presenting as pleuropulmonary disease usually has an acute onset with acute myocardial infarction: implications for symptoms lasting less than a week before a diagnosis is thrombolytic therapy established,2 and half the patients have a positive blood or stool culture.2 Sir, Most other Gram-negative pleuropulmonary infec- Retrosternal chest pain of oesophageal origin is well tions are nosocomially acquired; salmonella is frequently known to mimic ischaemic chest pain.' The benefits of community acquired. Prior abnormalities of the lungs thrombolytic treatment in acute myocardial infarction and pleura are found in about 40% of patients, malig- are well established and are reported to outweigh the nancy being the most common predisposing condition risks.2 Speedy thrombolysis has been recommended3 and and 36% are immunosuppressed, including SLE and electrocardiographic changes are not considered to be corticosteroid-treated individuals." 2 mandatory.4 We describe a patient who was a potential Treatment of salmonella empyema resembles that of candidate for thrombolytic therapy but was subsequently other bacterial empyema. Relapse is common and morta- proven to have a spontaneous intramural oesophageal lity may be as high as 15%.2 haematoma. Salmonella empyema should be excluded in febrile A 66 year old woman with a sudden onset of severe lupus patients with pleural effusions. Optimal treatment retrosternal chest pain of 1 hour's duration was referred must include drainage and prolonged parenteral effective with a suspected myocardial infarction. The pain woke therapy with a beta-lactam or fluorquinolone antibiotic. her up from sleep, radiated to her throat and culminated Mortality in salmonella pleuropulmonary infections may in a sensation of choking. She denied recent vomiting, reach 100% when antimicrobial agents not active against retching, dysphagia or dyspepsia. Previously she had been salmonella are used.' fit and well, and was a teetotaller. Clinical examination was normal. The blood count showed a haemoglobin of Alberto Ortiz 13.4 g/l and platelet count and white cell count were Diego Giraldez within normal limits. The electrocardiogram and chest Jesus Egido X-ray were normal. Serial cardiac enzymes and coagulaManuel Fernandez-Guerrero' tion studies were later found to be normal. Departments of Nephrology and Thrombolytic treatment was withheld. The following 'Infectious Diseases, day she complained of dysphagia and pain on swallowing. Fundacion Jimenez Diaz, Endoscopy showed pronounced bulging of the posterior Av Reyes Catolicos 2, oesophageal mucosa extending from the upper oeso28040 Madrid, phagus (approximately 25 cm from the tip of the endoSpain. scope) 5 cm distally. No oesophageal tear, hiatus hernia, gastric or oesophageal lesions were seen. The appearance was that of an intramural oesophageal haematoma and repeat oesophagoscopy at 10 days showed clear signs of it reducing in size. Follow-up endoscopy at 4 weeks revealed almost complete resolution of the haematoma and the References oesophageal mucosa looked normal. She was treated 1. Aguado, J.M., Obeso, G., Cabanillas, J.J., Fernandezconservatively and her recovery was rapid and complete. Guerrero, M. & Ales, J. Pleuropulmonary infections due to Painful dysphagia, haematemesis and retrosternal nontyphoid strains of salmonella. Arch Intern Med 1990, 150: chest pain are well documented as common presenting 54-56. symptoms of spontaneous oesophageal haematoma.5 2. Cohen, J.I., Bartlett, J.A. & Corey, G.R. Extraintestinal manifestations of salmonella infections. Medicine 1987, 66: However, the only presenting symptom may be severe retrosternal chest pain. This patient would have fulfilled 349-388. the criteria for thrombolytic treatment in most institu3. Lovy, M.H., Ryan, P.F.J. & Hughes, G.R.V. Concurrent systemic lupus erythematosus and salmonellosis. J Rheumatol tions where electrocardiographic evidence of myocardial 1981, 8: 605-612. infarction is not essential. The consequences of such 2
780
LETTERS TO THE EDITOR
treatment may have been profound. We advise continued caution in the selection of patients for thrombolytic therapy in the absence of electrocardiographic changes.
R.S. Senarath Yapa G.J. Green Department of Medicine, Glan Clwyd Hospital, Bodelwyddan, Rhyl, Clwyd LL18 5UJ, UK
References 1. Janssens, J. & Vantrappen, G. Angina like chest pain of oesophageal origin. In: Tytgat, G.N.J. (ed.) Clinical Gastroenterology. (International practice and research). Bailliere Tindall, London, 1987, pp. 843-856.
2. Petch, M.C. Dangers of thrombolysis. Br Med J 1990, 300: 483-484. 3. Report of a British Heart Foundation Working Group. Role of the general practitioner in managing patients with myocardial infarction; impact of thrombolytic treatment. Br Med J 1989, 299: 555-557. 4. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187 cases of acute myocardial infarction (ISIS-2). Lancet 1988, fi: 349-360. 5. Shay, S.S., Berendson, R.A. & Johnson, L.F. Oesophageal haematoma. Four new cases, a review and proposed aetiology. Dig Dis Sci 1981, 26: 1019-1024.
779
X-ray showed bilateral pleural effusion. The white blood 4. Abramson, S., Kramer, S.B., Radin, A. & Holzman, R. Salmonella bacteremia in systemic lupus erythematosus. Arthcell count was 6.6 x 109/l with 89% neutrophils. Thoraritis Rheum 1985, 28: 75-79. cocentesis yielded 0.5 litres of a yellow fluid, from which 5. de Luis, C., Pigrau, C., Pahissa, A., Fernandez, F. & MartinezS. enteritidis was grown. Blood cultures were sterile. Vazquez, J.M. Infeeciones en 96 casos de lupus eritematoso Repeated X-ray films showed no underlying pulmonary sistemico. Rev Clin Esp 1990, 94: 607-610. involvement. Bilateral thoracostomy tubes were inserted 6. Gosset, S., Goursaud, G., Carjuzan, A., Martin, J. Guigui, J. & and treatment was ampicillin g/4 hours i.v. for 4 weeks Seguin, P. Localisation pleurale d'une salmonella non typhoidique multiresistente. Presse Med 1988, 17: 2200. and oral amoxycillin for 2 weeks more, but pleural fluid drainage persisted. A bilateral chemical pleurodesis was 7. Reddy, K.R., Chan, J.C., Smiley, D., Jeffers, L.J. & Schiff, E.R. Spontaneous group B Salmonella enteritidis peritonitis in performed but a sterile pleural effusion recurred 4 months cirrhotic ascites and AIDS. Am J Gastroenterol 1988, 83: after finishing antibiotic therapy. 882-884. Non-typhoid salmonellae are known to colonize pre- 8. Carel, R., Schey, G., Ma'ayan, M. & Bruderman, I. Salmonella tissues and and non-lupus pleural viously damaged empyema as a complication in malignant pleural effusion. peritoneal effusions have become infected."2'6-8 ExtenRespiration 1977, 34: 232-235. sion from a nearby site, bacteraemic spread from a gastrointestinal source or a dormant focus in the reticuloendothelial system are all pathogenic possibilities. In contrast to other extraintestinal infections, salmonella Spontaneous oesophageal haematoma presenting as pleuropulmonary disease usually has an acute onset with acute myocardial infarction: implications for symptoms lasting less than a week before a diagnosis is thrombolytic therapy established,2 and half the patients have a positive blood or stool culture.2 Sir, Most other Gram-negative pleuropulmonary infec- Retrosternal chest pain of oesophageal origin is well tions are nosocomially acquired; salmonella is frequently known to mimic ischaemic chest pain.' The benefits of community acquired. Prior abnormalities of the lungs thrombolytic treatment in acute myocardial infarction and pleura are found in about 40% of patients, malig- are well established and are reported to outweigh the nancy being the most common predisposing condition risks.2 Speedy thrombolysis has been recommended3 and and 36% are immunosuppressed, including SLE and electrocardiographic changes are not considered to be corticosteroid-treated individuals." 2 mandatory.4 We describe a patient who was a potential Treatment of salmonella empyema resembles that of candidate for thrombolytic therapy but was subsequently other bacterial empyema. Relapse is common and morta- proven to have a spontaneous intramural oesophageal lity may be as high as 15%.2 haematoma. Salmonella empyema should be excluded in febrile A 66 year old woman with a sudden onset of severe lupus patients with pleural effusions. Optimal treatment retrosternal chest pain of 1 hour's duration was referred must include drainage and prolonged parenteral effective with a suspected myocardial infarction. The pain woke therapy with a beta-lactam or fluorquinolone antibiotic. her up from sleep, radiated to her throat and culminated Mortality in salmonella pleuropulmonary infections may in a sensation of choking. She denied recent vomiting, reach 100% when antimicrobial agents not active against retching, dysphagia or dyspepsia. Previously she had been salmonella are used.' fit and well, and was a teetotaller. Clinical examination was normal. The blood count showed a haemoglobin of Alberto Ortiz 13.4 g/l and platelet count and white cell count were Diego Giraldez within normal limits. The electrocardiogram and chest Jesus Egido X-ray were normal. Serial cardiac enzymes and coagulaManuel Fernandez-Guerrero' tion studies were later found to be normal. Departments of Nephrology and Thrombolytic treatment was withheld. The following 'Infectious Diseases, day she complained of dysphagia and pain on swallowing. Fundacion Jimenez Diaz, Endoscopy showed pronounced bulging of the posterior Av Reyes Catolicos 2, oesophageal mucosa extending from the upper oeso28040 Madrid, phagus (approximately 25 cm from the tip of the endoSpain. scope) 5 cm distally. No oesophageal tear, hiatus hernia, gastric or oesophageal lesions were seen. The appearance was that of an intramural oesophageal haematoma and repeat oesophagoscopy at 10 days showed clear signs of it reducing in size. Follow-up endoscopy at 4 weeks revealed almost complete resolution of the haematoma and the References oesophageal mucosa looked normal. She was treated 1. Aguado, J.M., Obeso, G., Cabanillas, J.J., Fernandezconservatively and her recovery was rapid and complete. Guerrero, M. & Ales, J. Pleuropulmonary infections due to Painful dysphagia, haematemesis and retrosternal nontyphoid strains of salmonella. Arch Intern Med 1990, 150: chest pain are well documented as common presenting 54-56. symptoms of spontaneous oesophageal haematoma.5 2. Cohen, J.I., Bartlett, J.A. & Corey, G.R. Extraintestinal manifestations of salmonella infections. Medicine 1987, 66: However, the only presenting symptom may be severe retrosternal chest pain. This patient would have fulfilled 349-388. the criteria for thrombolytic treatment in most institu3. Lovy, M.H., Ryan, P.F.J. & Hughes, G.R.V. Concurrent systemic lupus erythematosus and salmonellosis. J Rheumatol tions where electrocardiographic evidence of myocardial 1981, 8: 605-612. infarction is not essential. The consequences of such 2
780
LETTERS TO THE EDITOR
treatment may have been profound. We advise continued caution in the selection of patients for thrombolytic therapy in the absence of electrocardiographic changes.
R.S. Senarath Yapa G.J. Green Department of Medicine, Glan Clwyd Hospital, Bodelwyddan, Rhyl, Clwyd LL18 5UJ, UK
References 1. Janssens, J. & Vantrappen, G. Angina like chest pain of oesophageal origin. In: Tytgat, G.N.J. (ed.) Clinical Gastroenterology. (International practice and research). Bailliere Tindall, London, 1987, pp. 843-856.
2. Petch, M.C. Dangers of thrombolysis. Br Med J 1990, 300: 483-484. 3. Report of a British Heart Foundation Working Group. Role of the general practitioner in managing patients with myocardial infarction; impact of thrombolytic treatment. Br Med J 1989, 299: 555-557. 4. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187 cases of acute myocardial infarction (ISIS-2). Lancet 1988, fi: 349-360. 5. Shay, S.S., Berendson, R.A. & Johnson, L.F. Oesophageal haematoma. Four new cases, a review and proposed aetiology. Dig Dis Sci 1981, 26: 1019-1024.
